Relapse among alcoholics with phobic and panic symptoms

Comorbid social phobia does not predict the outcome in alcohol use disorder outpatient treatment

BACKGROUND

Social phobia (SP) is one of the most prevalent anxiety disorders among patients entering treatment for alcohol use disorders (AUD). However, few studies have examined the association between SP and alcohol-related treatment outcomes in naturalistic settings.

AIMS

The aims of this study were to estimate the prevalence of co-morbid SP and to investigate the impact of the co-morbidity on the treatment course, dropout rates and treatment outcomes in a large sample of AUD patients treated in an outpatient alcohol treatment clinic.

METHODS

The study was conducted as an observational cohort study. A consecutive sample of 3.197 treatment-seeking outpatients, with an AUD diagnosis according to the ICD-10 Diagnostic Criteria for Research, was assessed by means of the Addiction Severity Index at treatment start and at treatment conclusion.

RESULTS

Approximately 15% of the patients suffered from SP when entering treatment and patients with and without SP did not differ on the treatment course, compliance or dropout rates. SP did not predict any alcohol-related treatment outcomes either, where no association was found on change scores for abstinence, drinking days and days with excessive drinking relative to AUD patients without co-morbidity.

CONCLUSION

AUD patients with and without co-morbid SP were equally likely to achieve benefits when treated similarly with evidence-based pharmacological and psychosocial approaches in a naturalistic setting.

The risk for persistent adult alcohol and nicotine dependence: the role of childhood maltreatment

BACKGROUND AND AIMS

Alcohol and nicotine dependence are associated with considerable morbidity and mortality, especially when cases are persistent. The risk for alcohol and nicotine dependence is increased by childhood maltreatment. However, the influence of childhood maltreatment on dependence course is unknown, and is evaluated in the current study.

DESIGN

Physical, sexual and emotional abuse, and physical and emotional neglect, were evaluated as predictors of persistent alcohol and nicotine dependence over 3 years of follow-up, with and without control for other childhood adversities.

SETTING

National Epidemiologic Survey on Alcohol and Related Conditions (NESARC).

PARTICIPANTS

NESARC participants completing baseline and follow-up who met criteria at baseline for past-year alcohol dependence (n = 1172) and nicotine dependence (n = 4017).

MEASUREMENTS

Alcohol Use Disorder and Associated Disabilities Interview Schedule (AUDADIS) measures of alcohol/nicotine dependence, childhood maltreatment and other adverse childhood experiences (e.g. parental divorce).

FINDINGS

Controlling for demographics only, physical, sexual and emotional abuse and physical neglect predicted 3-year persistence of alcohol dependence [adjusted odds ratio (AOR) = 1.50-2.99; 95% CI = 1.04-4.68] and nicotine dependence (AOR = 1.37-1.74; 95% CI = 1.13-2.11). With other childhood adversities also controlled, maltreatment types remained predictive for alcohol persistence (AOR = 1.53-3.02; 95% CI = 1.07-4.71) and nicotine persistence (AOR = 1.35-1.72; 95% CI = 1.11-2.09). Further, a greater number of maltreatment types incrementally influenced persistence risk (AOR = 1.19-1.36; 95% CI = 1.11-1.56).

CONCLUSIONS

A history of childhood maltreatment predicts persistent adult alcohol and nicotine dependence. This association, robust to control for other childhood adversities, suggests that maltreatment (rather than a generally difficult childhood) affects the course of dependence.

Dually diagnosed patients' benefits of mutual-help groups and the role of social anxiety

There is debate about whether dually diagnosed patients benefit from mutual-help groups (MHGs), partly because social anxiety may make participation problematic. We examined dually diagnosed patients' participation in MHGs and outcomes at 6, 12, and 24 months post-treatment, and the extent to which social anxiety was associated with participation. We also examined whether MHG participation and social anxiety were related to outcomes, and whether social anxiety moderated associations between participation and outcomes. We found high rates of MHG participation. Among patients who attended at least one meeting, outcomes were positive. Social anxiety was not associated with levels of MHG participation, but more participation was associated with better outcomes. When social anxiety moderated associations between MHG participation and outcomes, patients with more social anxiety benefited more from participation. Treated dually diagnosed patients participate in, and benefit from, MHGs, and participation and benefits are comparable, or even strengthened, among more socially-anxious patients.

Pharmacotherapy of alcohol use disorders and concurrent psychiatric disorders: a review

Alcohol use disorders (AUDs) are among the most prevalent psychiatric disorders. Epidemiologic studies have shown a high prevalence of concurrent psychiatric disorders among people with AUDs as well as a higher prevalence of AUDs in people with psychiatric disorders than in the general population. Though psychiatric patients with concurrent AUDs are at increased risk for morbidity and mortality, they are commonly undertreated for their alcohol-related disorders. The efficacy of pharmacotherapy for AUDs is well documented. Our paper reviews the common pharmacotherapies available for AUDs and focuses on the available research regarding treatment of AUDs among psychiatric populations with mood, anxiety, and psychotic disorders. Despite the high prevalence of concurrent AUDs and psychiatric disorders, very limited information has been collected using a randomized controlled trial design targeting those concurrent conditions. Several prevalent psychiatric disorders have not been studied when co-occurring with AUDs. Further research of pharmacological treatments for concurrent AUDs and psychiatric diagnoses is urgently needed.

Predictive value of depression and social support with respect to alcohol abstinence

CONTEXT

Two co-morbid conditions which have been found in high proportions among treatment-seeking alcohol-dependent subjects are depression and low social support.

AIM

We attempted to study both the factors simultaneously in the setting of Alcoholics Anonymous centers in Mumbai. The study intends to understand (1) if pre-existing depression affected the probability of a person abstaining from alcohol and (2) if social support affected the probability of a person abstaining from alcohol. A thorough review of the existing literature was done before initiating the study.

MATERIALS AND METHODS

A single-observer, cross-sectional study was conducted. Subjects with a history of alcohol dependence were included. However, those with other substances abuse and those with a history of anti-depressant usage were excluded. Questionnaires were administered. The Hamilton Depression Scale assessed depression. Similarly, social support was assessed by Social Provisions Scale by Weiss.

RESULTS

According to this study depression does not affect alcohol abstinence as the χ(2) test shows an insignificant result. Social support also showed a negative correlation with alcohol abstinence.

CONCLUSION

This result is consistent with the findings of other studies such as Davidson et al. (1998). However it is not consistent with the results of the studies having a longer follow-up period. The study had some limitations primarily due to time constraints, the main one being that this study would reveal more significant results if done as a longitudinal study as opposed to a cross-sectional study. Also while interacting with subjects in a group like Alcoholics Anonymous it is important to gain the confidence of the group before obtaining confidence of the individual.

Anxiety, Health Risk Factors, and Chronic Disease

Anxiety disorders are the most common mental health condition and frequently co-occur with a variety of health risk factors, such as physical inactivity, cigarette smoking, and alcohol consumption. As such, untreated anxiety and increased risk for engagement in these health risk habits can further increase risk for later-onset chronic disease and complications in disease management. Contemporary studies have identified unique temporal relationships between the onset of specific anxiety disorders with smoking and alcohol use disorders. Incorporating exercise with evidence-based treatments for anxiety is emerging and promising in enhancing treatments for anxiety-related conditions. Likewise, substance use treatment programs may benefit from the detection and management of anxiety. Collaborative care models for anxiety may provide the needed systems-based approach for treating anxiety more effectively in primary and specialty care medical settings. Based on a qualitative review of the literature, this article summarizes the current research on the associations between anxiety, health risk factors, and the risk for chronic diseases. The authors also offer suggestions for future research that would help in better understanding the complex relationships between the role anxiety plays in the vulnerability for and management of physical inactivity and substance use.

Does co-occurring social phobia interfere with alcoholism treatment adherence and relapse?

This study investigates the impact of social phobia on adherence to and outcomes 6 months following standard alcohol treatment and Alcoholics Anonymous (AA) group meetings among alcohol-dependent patients with and without social phobia. In a cohort study, 300 detoxified alcohol-dependent individuals in Porto Alegre, Brazil, were interviewed during, as well as 3 and 6 months after hospital detoxification. At both follow-up points, treatment adherence was low and relapse rates were high among patients with and without social phobia, and no significant differences were seen between the two groups of patients in relapse, adherence to AA, or adherence to psychotherapy. Findings from this sample suggest that although alcohol-dependent patients with social phobia showed a tendency for less adherence at AA and felt less integrated with their AA group, social phobia comorbidity was not a significant risk factor for alcohol use relapse or for nonadherence to AA or psychotherapy.

Social anxiety disorder in 300 patients hospitalized for alcoholism in Brazil: high prevalence and undertreatment

BACKGROUND

Although the frequency of social phobia is high among alcoholic patients, this anxiety disorder is often neglected because treatment tends to be focused exclusively on alcohol dependence.

METHODS

A total of 300 hospitalized alcoholic patients were interviewed using Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition and Liebowitz Social Anxiety Scale as well a questionnaire to check the use of medication for social phobia among alcoholics and the relationship between social phobia and alcohol use.

RESULTS

A prevalence of 30.6% was found for specific phobia, 24.7% for social phobia, 22.2% for anxiety disorder induced by alcohol, 19.3% for generalized anxiety disorder, 5% for obsessive-compulsive disorder, 4.6% for posttraumatic stress disorder, and 2% for panic disorder with agoraphobia. Social phobia preceded alcohol dependence in 90.2% of the patients. The frequency of the use of medication for social phobia among social phobic alcoholics was 20.3%.

CONCLUSIONS

The study confirms the high prevalence of anxiety disorders among alcoholics, particularly of social phobia. It also suggests that social phobia precedes alcohol dependence but shows that the use of medication for social phobia is still infrequent. Further studies are required to check if the failure to identify this comorbidity can make the recovery of alcoholics even more difficult.

Relapse to alcohol and drug use among individuals diagnosed with co-occurring mental health and substance use disorders: a review

This paper reviews the literature investigating relapse to alcohol and drug use among individuals dually diagnosed with a substance use and a co-occurring mood, anxiety, schizophrenia-spectrum, or personality disorder. Prevalence rates for each co-occurring set of disorders are discussed, followed by research studies that examine predictors of relapse to substance use within these groups. Relevant conceptual models well-suited to incorporating relapse as an outcome variable, and psychiatric factors both as predictor and outcome variables, are presented. Suggestions for future studies are provided. A priority area is developing and using consistent and well-articulated definitions of relapse across studies. Several diagnostic issues surfaced such as using structured clinical interviews to determine diagnosis (preferably following detoxification from alcohol and/or drugs), separating individuals with only alcohol use disorders from those with alcohol and drug use disorders in analyses, reporting the rates and types of overlap in mental health diagnoses, and conducting analyses that include and exclude multiply disordered individuals. Finally, future studies that focus on isolating predictors of relapse and abstinence could make substantive contributions to improving treatment for individuals with co-occurring substance use and mental health disorders.

COMORBID PHOBIC DISORDERS DO NOT INFLUENCE OUTCOME OF ALCOHOL DEPENDENCE TREATMENT. RESULTS OF A NATURALISTIC FOLLOW-UP STUDY

AIMS

Despite claims that comorbid anxiety disorders tend to lead to a poor outcome in the treatment of alcohol dependence, the few studies on this topic show conflicting results.

OBJECTIVE

To test whether the outcome of treatment-seeking alcohol-dependent patients with a comorbid phobic disorder is worse than that of similar patients without a comorbid phobic disorder.

METHODS

The probabilities of starting to drink again and of relapsing into regular heavy drinking in (i) a group of 81 alcohol-dependent patients with comorbid social phobia or agoraphobia were compared with those in (ii) a group of 88 alcohol-dependent patients without anxiety disorders in a naturalistic follow-up using Cox regression analysis.

RESULTS

Adjusted for initial group differences, the hazard ratio for the association of phobic disorders with resumption of drinking was 1.05 (95% CI, 0.85-1.30, P = 0.66) and the adjusted hazard ratio for the association of phobic disorders with a relapse into regular heavy drinking was 1.02 (95% CI, 0.78-1.33, P = 0.89).

CONCLUSION

The findings of this study do not confirm the idea that alcohol-dependent patients who have undergone alcohol-dependence treatment are at greater risk of a relapse if they have a comorbid anxiety disorder. No differences were found in abstinence duration or time to relapse into regular heavy drinking between patients with and without comorbid phobic disorders.

Follow-up Study of Anxiety Disorder and Alcohol Dependence in Comorbid Alcoholism Treatment Patients

BACKGROUND

Anxiety disorders are present in a high percentage of alcoholism treatment patients. We tested the prediction that having a comorbid anxiety disorder increases the prospective risk for relapse to drinking after alcoholism treatment. We also explored the prospective associations of specific anxiety syndromes (and depression) with drinking and anxiety outcomes.

METHODS

We assessed the diagnostic status and daily drinking patterns of 82 individuals approximately one week after they entered alcoholism treatment (baseline) and again approximately 120 days later (follow-up) (n=53).

RESULTS

Consistent with study predictions, those with a baseline anxiety disorder (approximately 55%) were significantly more likely than others to meet various definitions of drinking relapse over the course of the follow-up. Regression models showed that baseline social phobia was the single best predictor of a return to any drinking after treatment, whereas panic disorder was the single best predictor of a relapse to alcohol dependence after treatment. Having multiple anxiety disorders (versus any specific anxiety disorder) at the baseline was the strongest predictor of having at least one active ("persistent") anxiety disorder at the follow-up. Cross-sectional analysis at the follow-up showed that anxiety disorder persisted in the absence of a relapse to alcohol dependence far more often than relapse to alcohol dependence occurred in the absence of a persistent anxiety disorder.

CONCLUSIONS

Screening for comorbid anxiety disorder in alcoholism treatment patients is warranted and, where found, should be considered a marker of high relapse risk relative to that of noncomorbid patients. The capacity of specific anxiety treatment to mitigate relapse risk among comorbid patients remains an open question.

The Effectiveness of Anxiety Treatment on Alcohol-Dependent Patients with a Comorbid Phobic Disorder: A Randomized Controlled Trial

OBJECTIVE

Evidence has emerged which indicates that the post-treatment relapse rate for alcohol-dependent patients with a comorbid anxiety disorder is higher than for alcohol-dependent patients without a comorbid anxiety disorder. The question raised by this evidence is whether the relapse rate in these dually diagnosed patients could be reduced if they were given additional treatment for the comorbid anxiety disorder. We attempted to answer this question by conducting a trial among patients with a double diagnosis of alcohol dependence and agoraphobia or social phobia.

METHOD

We conducted a 32-week randomized controlled trial among 96 abstinent patients with a primary diagnosis of alcohol dependence and a comorbid anxiety disorder involving agoraphobia or social phobia. The patients were randomly assigned to an intensive psychosocial relapse-prevention program on its own (n = 49) or in combination with an anxiety treatment program comprising cognitive behavioral therapy (CBT) and optional pharmacotherapy consisting of an SSRI (n = 47). The primary outcome measure was the percentage of patients who suffered an alcohol relapse during a 32-week period. The secondary outcome measures were total abstinence, a reduction in the days of heavy drinking, and less severe anxiety symptoms.

RESULTS

Although the additional therapy clearly reduced the anxiety symptoms, it had no significant effect on the alcohol relapse rates.

CONCLUSION

Anxiety treatment for alcohol-dependent patients with a comorbid anxiety disorder can alleviate anxiety symptoms, but it has no significant effect on the outcome of alcohol treatment programs.

Within-program factors as predictors of drinking outcome following cognitive-behavioral treatment

The relationship between a variety of within-treatment factors and the outcome of treatment for alcoholism was examined. One hundred and twenty-eight male and 68 female participants (consecutive referrals with an ICD-10 diagnosis of alcohol dependence syndrome) were followed at 12 months following in- and day-patient cognitive behavioral treatment on an addiction unit. Within-treatment factors (of self-efficacy, psychological symptoms, expectations for treatment, treatment satisfaction, treatment climate, therapeutic alliance, and treatment evaluation), were assessed to determine their relationship to global outcome categorization into abstinent, nonproblem drinker, drinking but improved, and unimproved participant groups. A logistic regression analysis identified five variables that were predictive of a more favorable outcome: higher self-efficacy in positive social situations, greater treatment program involvement, a lower perception of staff control, a greater perception of treatment as helpful, and a reduction in psychological symptoms during treatment. Findings confirm previous research that pinpoints the importance of self-efficacy as a treatment variable of significance in treatment planning and delivery. It also highlights the prognostic significance of a reduction in psychological distress and, thus, the value of dynamic predictors of treatment outcome. The failure of the therapeutic alliance to predict outcome is discussed. It is concluded that time-limited alcoholism treatment programs need to give equal emphasis to within-treatment change via the promotion of patient confidence and the perception of helpfulness, as well as to skill-based relapse prevention strategies.

A controlled trial of cognitive behavioral treatment of panic in alcoholic inpatients with comorbid panic disorder

Patients entering a 4-week inpatient alcoholism treatment program were screened for anxiety symptoms. Those with panic disorder with or without agoraphobia were randomly assigned to two groups. The treatment group received 12 hours of cognitive-behavioral treatment (CBT) for panic disorder in addition to the regular alcoholism treatment program: the control group received the regular program. Dropouts from the treatment group were also followed. Problem drinking and anxiety symptoms were measured at the start of the study, and at 3, 6, and 12 months posttreatment. Abstinence from drinking, and anxiety and mood symptoms improved after treatment in all of the groups; there were few differences in outcome between the groups. We concluded that this particular intervention had not been more effective than the regular alcohol treatment program in reducing problem drinking in those with panic disorder.

Predictors of in-treatment relapse in perinatal substance abusers and impact on treatment retention: a prospective study

This prospective study investigated in-treatment relapse in a sample of perinatal substance abusers in intensive outpatient treatment. Sixty-four female first-time admissions to a perinatal treatment program completed comprehensive psychological and psychosocial assessment before beginning treatment. Relapse was detected by urine toxicology screening and self-report. A regression analysis resulted in variable reduction, then survival analysis identified the impact of in-treatment relapse and other predictors on treatment length. Fifty-five percent of the subjects were classified as relapsers. Two risk factors for and six protective factors from in-treatment relapse were identified. The survival curves for relapsers and nonrelapsers did not differ until covariates were considered. Subjects with more severe consequences of drug use and less social exposure to drug use during treatment tended not to relapse during treatment, perhaps in order to prevent deterioration such as loss of children or incarceration. Relapse alone did not result in fewer treatment days. Few addiction characteristics were related to either in-treatment relapse or length of treatment. Rather, personality and demographic variables were more salient in both the regression and survival models. Treatment staff may need to reconsider their views of the meaning of relapse and should develop enhanced engagement and retention strategies for women at greater risk of relapse.