Alcohol dependence: analysis of factors associated with retention of patients in outpatient treatment

Developing a Smoking Cessation Intervention for People With Severe Mental Illness Treated by Flexible Assertive Community Treatment Teams in the Netherlands: A Delphi Study

BACKGROUND

There is still limited evidence on the effectiveness and implementation of smoking cessation interventions for people with severe mental illness (SMI) in Dutch outpatient psychiatric settings. The present study aimed to establish expert consensus on the core components and strategies to optimise practical implementation of a smoking cessation intervention for people treated by Flexible Assertive Community Treatment (FACT) teams in the Netherlands.

DESIGN

A modified Delphi method was applied to reach consensus on three core components (behavioural counselling, pharmacological treatment and peer support) of the intervention. The Delphi panel comprised five experts with different professional backgrounds. We proposed a first intervention concept. The panel critically examined the evolving concept in three iterative rounds of 90 min each. Responses were recorded, transcribed verbatim and thematically analysed.

RESULTS

Overall, results yielded that behavioural counselling should focus on preparation for smoking cessation, guidance, relapse prevention and normalisation. Pharmacological treatment consisting of nicotine replacement therapy (NRT), Varenicline or Bupropion, under supervision of a psychiatrist, was recommended. The panel agreed on integrating peer support as a regular part of the intervention, thus fostering emotional and practical support among patients. Treatment of a co-morbid cannabis use disorder needs to be integrated into the intervention if indicated. Regarding implementation, staff's motivation to support smoking cessation was considered essential. For each ambulatory team, two mental health care professionals will have a central role in delivering the intervention.

CONCLUSIONS

This study provides insight into expert consensus on the core components of a smoking cessation intervention for people with SMI. The results of this study were used for the development of a comprehensive smoking cessation program.

Machine learning prediction of dropping out of outpatients with alcohol use disorders

BACKGROUND

Alcohol use disorder (AUD) is a chronic disease with a higher recurrence rate than that of other mental illnesses. Moreover, it requires continuous outpatient treatment for the patient to maintain abstinence. However, with a low probability of these patients to continue outpatient treatment, predicting and managing patients who might discontinue treatment becomes necessary. Accordingly, we developed a machine learning (ML) algorithm to predict which the risk of patients dropping out of outpatient treatment schemes.

METHODS

A total of 839 patients were selected out of 2,206 patients admitted for AUD in three hospitals under the Catholic Central Medical Center in Korea. We implemented six ML models-logistic regression, support vector machine, k-nearest neighbor, random forest, neural network, and AdaBoost-and compared the prediction performances thereof.

RESULTS

Among the six models, AdaBoost was selected as the final model for recommended use owing to its area under the receiver operating characteristic curve (AUROC) of 0.72. The four variables affecting the prediction based on feature importance were the length of hospitalization, age, residential area, and diabetes.

CONCLUSION

An ML algorithm was developed herein to predict the risk of patients with AUD in Korea discontinuing outpatient treatment. By testing and validating various machine learning models, we determined the best performing model, AdaBoost, as the final model for recommended use. Using this model, clinicians can manage patients with high risks of discontinuing treatment and establish patient-specific treatment strategies. Therefore, our model can potentially enable patients with AUD to successfully complete their treatments by identifying them before they can drop out.

Domiciliary alcohol detoxification outcomes: a study from Goa, India

Alcohol use disorder (AUD) is a significant public health problem across all regions of the world. Overall evidence regarding outcomes is available from western regions. Detoxification is one of the first steps in treating AUDs. The following case note review looks at community detoxification outcomes in a naturalistic setting. We looked at 100 clients with domiciliary detoxification. We found only 35% had a favorable outcome (follow up as advised) while 65% had unfavorable outcomes (lost to follow up or required admission). Trends of higher alcohol use (units/day) were seen in the unfavorable group. We also found that having a medical co-morbidity was associated with unfavorable outcome. In resource poor setting like our country there is a need to look at ways to enhance home detoxification programs; use of technology and supervised monitoring could probably improve the outcomes.

Factors associated with retention in a smoking cessation trial for persons with a mental illness: a descriptive study

Background

Exploring factors associated with retention in randomised trials provides insight into potential threats to internal and external study validity, and may inform the development of interventions to increase retention in future trials. Given a paucity of existing research in the field, a study was conducted to explore factors associated with retention in a smoking intervention trial involving persons with a mental illness, considering demographic and smoking characteristics, treatment condition and engagement in prior follow-up assessments.

Method

A descriptive study was undertaken using data derived from a RCT of a smoking cessation intervention initiated in four adult psychiatric inpatient units in New South Wales (NSW), Australia. Retention assessment was undertaken at 1, 6 and 12-months post-discharge. A Generalised Linear Mixed Model was adopted to explore associations between retention at any follow up time point and demographic and smoking characteristics. Chi square analyses explored the association between retention at all follow up time points and treatment condition, and binary logistic regression analyses assessed for relationships between retention at 12-month follow up and engagement in prior follow up assessments.

Results

Retention rates were 63, 56 and 60% at the 1, 6 and 12-month assessments, respectively. No association was found between retention at any follow-up time point and 13 of 15 demographic and smoking characteristics. Younger participants and those who identified to be Aboriginal and/or Torres Strait Islander were more likely to be retained (both ps > 0.05). Retention rates did not vary according to treatment condition at any follow-up time point. Participants who completed a prior assessment were more likely to complete the 12 month assessment (both prior assessments: OR 10.7, p < 0.001; 6 month assessment: OR 6.01, p < 0.001; and 1 month assessment: OR 1.8, p = 0.002).

Conclusion

The underrepresentation of younger participants and those identifying to be Aboriginal and/or Torres Strait Islander may limit the generalisability of findings. Findings suggest that inclusion of multiple contacts during a trial follow up period may increase retention at the final assessment. Interventions to improve retention, overall and for those sub-groups less likely to be retained, in smoking trials involving persons with a mental illness are needed. Further assessment of sample characteristics, and also trial design factors, associated with retention in this field is warranted.

Effectiveness of community psychosocial and pharmacological treatments for alcohol use disorder: A national observational cohort study in England

BACKGROUND

This was a national English observational cohort study using administrative data to estimate the effectiveness of community pharmacological and psychosocial treatment for alcohol use disorder (AUD).

METHODS

All adults commencing AUD treatment in the community reported to the National Drug Treatment Monitoring System (April 1 2014-March 31 2015; N = 52,499). Past 28-day admission drinking pattern included drinks per drinking day (DDD): 0 ('Abstinent'), 1-15 ('Low-High'), 16-30 ('High-Extreme') and over 30 DDD ('Extreme'). The primary outcome was successful completion of treatment within 12 months of commencement with no re-presentation (SCNR) in the subsequent six months, analysed by multi-level, mixed effects, multivariable logistic regression.

RESULTS

The majority reported DDD in the 'Low-High' (n = 17,698, 34%) and 'High-Extreme' (n = 21,383, 41%) range. Smaller proportions were categorised 'Extreme' (n = 7759, 15%) and 'Abstinent' (n = 5661, 11%). Three-fifths (58%) achieved SCNR. Predictors of SCNR were older age, black/minority ethnic group, employment, criminal justice system referral, and longer treatment exposure. Predictors of negative outcome were AUD treatment history, lower socio-economic status, housing problems, and 'Extreme' drinking at admission. In addition to psychosocial interventions, pharmacological interventions and recovery support increased the likelihood of SCNR. Pharmacological treatment was only beneficial for the 'Low-High' groups with recovery support.

CONCLUSIONS

Over half of all patients admitted for community AUD treatment in England are reported to successfully complete treatment within 12 months and are not re-admitted for further treatment in the following 6 months. Study findings underscore efforts to tailor AUD treatment to the severity of alcohol consumption and using recovery support.

Motivation to change and posttreatment temptation to drink: a multicenter study among alcohol-dependent patients

BACKGROUND

An inpatient 28-day rehabilitation program for alcohol dependence is focused on detoxification, enhancing motivation to change, and coping strategies for the management of emotional distress and temptation to drink. The aims of the present study were to investigate 1) changes over time in motivation to change, anxiety, and depression in individuals undergoing residential rehabilitation treatment for alcohol addiction, and 2) which pretreatment factors are associated with posttreatment temptation to drink.

METHODS

We assessed 432 patients diagnosed with alcohol dependence based on the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision) consecutively recruited from seven residential rehabilitation centers in Northern Italy. Patients were assessed by means of self-report questionnaires at the beginning of rehabilitation (pretreatment) and before their hospital discharge (posttreatment) regarding motivation to change and self-efficacy (motivation assessment of change - alcoholism version), readiness to change and temptation to drink (visual analog scales), and depression and anxiety (cognitive behavioral assessment - outcome evaluation).

RESULTS

Results showed an overall improvement in motivation to change and a significant reduction over time in depression and anxiety levels for the total sample, particularly patients with low baseline level of temptation to drink. Multivariate linear regression analysis revealed that significant predictors of posttreatment temptation to drink were polysubstance dependence (p<0.001), readiness to change (p=0.01), and self-efficacy (p=0.05).

CONCLUSION

Inpatients' rehabilitation for alcohol dependence is associated with an overall improvement in motivation to change and a significant reduction of psychological distress. Treatments for alcohol-dependent patients should focus on motivation to change, negative moods, and relapse prevention strategies for the management of craving.

Stratifying delays for assessment by type of substance to improve the probability of attendance in outpatient services

AIMS

1) To confirm the association between delay for assessment (DFA) and probability of first-time attendance in outpatient substance use disorder (SUD) treatment. 2) To evaluate whether this association varies by the type of primary substance for which the assessment was requested. 3) To assess the possibility of estimating differential DFAs to conform to equal probabilities of attendance across various types of primary substance.

METHODS

A prospective observational cohort of consecutive patients (N=1015) who requested a first-time assessment appointment at a publicly funded outpatient SUD treatment center in France between January 2014 and December 2015 was conducted. Logistic regression analyses were performed to evaluate associations between DFA (after log-transformation) and attendance and to provide estimates of attendance probability over time by the type of primary substance.

FINDINGS

After adjusting for gender, age and referral status, the attendance rate was observed to decrease significantly with longer DFA (OR=0.54; 95%CI: 0.44-0.66). The strength of this association differed across types of primary substance (p for heterogeneity <0.0001), with the strongest association being found for opioids (adjusted OR=0.21; 95%CI: 0.10-0.45). DFA was also associated with attendance for alcohol (OR=0.51; 95%CI: 0.37-0.71) and cannabis (OR=0.60; 95%CI: 0.37-0.96), but not for tobacco (OR=0.95; 95%CI: 0.60-1.50). Differential DFAs reflecting equal probabilities of attendance across types of substance could be estimated.

CONCLUSION

Our study suggests that the approach of stratifying DFAs by the type of primary substance could be helpful to improve the probability of first-time attendance in outpatient SUD treatment services.

Treatment outcome, treatment retention, and their predictors among clients of five outpatient alcohol treatment centres in Switzerland

Background

Few studies have reported on the outcomes of outpatient alcohol treatment or the factors associated with effective treatment. We investigated treatment outcome, treatment retention, and their predictors in clients receiving outpatient treatment for alcohol misuse.

Methods

Naturalistic, longitudinal multi-centre study in Switzerland that included 858 clients receiving outpatient treatment for alcohol misuse. Assessments were conducted at treatment admission, discharge, and 6- and 12-month follow-ups. Non-problem drinking was used as an indicator of positive treatment outcome.

Results

Clients admitted to outpatient alcohol treatment were highly heterogeneous in terms of pre-treatment alcohol use and drinking goals. 45 % of clients exhibiting problem drinking at the beginning of treatment showed non-problem drinking at discharge, and 41 % and 43 % showed non-problem drinking at the 6- and 12-month follow-up, respectively; 51 % were discharged regularly and 43 % were discharged irregularly. Non-problem drinking at the 12-month follow-up was more likely in clients with a higher life satisfaction, those with lower alcohol use, those aiming for alcohol abstinence, and those who had been admitted for the first time to a treatment institution, whereas it was less likely in clients with a higher educational level. Treatment retention was higher among older clients, clients with a higher life satisfaction, and clients who subsisted on their own income.

Conclusion

Irregular discharge is high in outpatient alcohol treatment; nevertheless, a substantial portion of clients can achieve and maintain non-problem drinking by a 12-month follow-up.

Predictors of dropout in concurrent treatment of posttraumatic stress disorder and alcohol dependence: Rate of improvement matters

OBJECTIVE

The present study examined predictors and moderators of dropout among 165 adults meeting DSM-IV criteria for posttraumatic stress disorder (PTSD) and alcohol dependence (AD). Participants were randomized to 24 weeks of naltrexone (NAL), NAL and prolonged exposure (PE), pill placebo, or pill placebo and PE. All participants received supportive AD counseling (the BRENDA manualized model).

METHOD

Logistic regression using the Fournier approach was conducted to investigate baseline predictors of dropout across the entire study sample. Rates of PTSD and AD symptom improvement were included to evaluate the impact of symptom change on dropout.

RESULTS

Trauma type and rates of PTSD and AD improvement significantly predicted dropout, accounting for 76% of the variance in dropout. Accidents and "other" trauma were associated with the highest dropout, and physical assault was associated with the lowest dropout. For participants with low baseline PTSD severity, faster PTSD improvement predicted higher dropout. For those with high baseline severity, both very fast and very slow rates of PTSD improvement were associated with higher dropout. Faster rates of drinking improvement predicted higher dropout among participants who received PE.

CONCLUSIONS

The current study highlights the influence of symptom trajectory on dropout risk. Clinicians may improve retention in PTSD-AD treatments by monitoring symptom change at regular intervals, and eliciting patient feedback on these changes.

Methods to analyze treatment effects in the presence of missing data for a continuous heavy drinking outcome measure when participants drop out from treatment in alcohol clinical trials

BACKGROUND

Attrition is common in alcohol clinical trials and the resultant loss of data represents an important methodological problem. In the absence of a simulation study, the drinking outcomes among those who are lost to follow-up are not known. Individuals who drop out of treatment and continue to provide drinking data, however, may be a reasonable proxy group for making inferences about the drinking outcomes of those lost to follow-up.

METHODS

We used data from the COMBINE study, a multisite, randomized clinical trial, to examine drinking during the 4 months of treatment among individuals who dropped out of treatment but continued to provide drinking data (i.e., "treatment dropouts;" n = 185). First, we estimated the observed treatment effect size for naltrexone versus placebo in a sample that included both treatment completers (n = 961) and treatment dropouts (n = 185; total N = 1,146), as well as the observed treatment effect size among just those who dropped out of treatment (n = 185). In both the total sample (N = 1,146) and the dropout sample (n = 185), we then deleted the drinking data after treatment dropout from those 185 individuals to simulate missing data. Using the deleted data sets, we then estimated the effect of naltrexone on the continuous outcome percent heavy drinking days using 6 methods to handle missing data (last observation carried forward, baseline observation carried forward, placebo mean imputation, missing = heavy drinking days, multiple imputation (MI), and full information maximum likelihood [FIML]).

RESULTS

MI and FIML produced effect size estimates that were most similar to the true effects observed in the full data set in all analyses, while missing = heavy drinking days performed the worst.

CONCLUSIONS

Although missing drinking data should be avoided whenever possible, MI and FIML yield the best estimates of the treatment effect for a continuous outcome measure of heavy drinking when there is dropout in an alcohol clinical trial.

Six-month outcome in bipolar spectrum alcoholics treated with acamprosate after detoxification: a retrospective study

Background: Glutamate system is modified by ethanol and contributes both to the euphoric and the dysphoric consequences of intoxication, but there is now growing evidence that the glutamatergic system also plays a central role in the neurobiology and treatment of mood disorders, including major depressive disorders and bipolar disorders. We speculate that, using acamprosate, patients with bipolar depression (BIP-A) can take advantage of the anti-glutamate effect of acamprosate to “survive” in treatment longer than peers suffering from non-bipolar depression (NBIP-A) after detoxification. Method: We retrospectively evaluated the efficacy of a long-term (six-month) acamprosate treatment, after alcohol detoxification, in 41 patients (19 males and 22 females), who could be classified as depressed alcoholics, while taking into account the presence/absence of bipolarity. Results: During the period of observation most NBIP-A patients relapsed, whereas a majority of BIP-A patients were still in treatment at the end of their period of observation. The cumulative proportion of ‘surviving’ patients was significantly higher in BIP-A patients, but this finding was not related to gender or to other demographic or clinically investigated characteristics. The treatment time effect was significant in both subgroups. The treatment time-group effect was significant (and significantly better) for bipolar patients on account of changes in the severity of their illness. Limitations: Retrospective methodology and the lack of DSM criteria in diagnosing bipolarity. Conclusions: Bipolarity seems to be correlated with the efficacy of acamprosate treatment in inducing patients to refrain from alcohol use after detoxification (while avoiding relapses) in depressed alcoholics. Placebo-controlled clinical trials are now warranted to check the validity of this hypothesis.

Does age at first treatment episode make a difference in outcomes over 11 years?

This study examines the associations between age at first substance use treatment entry and trajectory of outcomes over 11 years. We found significant differences in individual and treatment characteristics between adult intakes first treated during young adulthood (25 years or younger) and those first treated at an older age. Compared to their first treated older age counterparts matched on demographics and dependence type, those who entered first treatment during young adulthood had on average an earlier onset for substance use but a shorter duration between first substance use and first treatment entry; they also had worse alcohol and other drug outcomes 11 years post treatment entry. While subsequent substance use treatment and 12-step meeting attendance are important for both age groups in maintaining positive outcomes, relationships varied by age group. Findings underline the importance of different continuing care management strategies for those entering first treatment at different developmental stages.

[Factors Associated With the Temporary Abandonment of Treatment for Disorders Due to Substance Abuse in an Institution in Medellin, Colombia]

OBJECTIVE

To determine the frequency and factors associated withtreatment drop-out in patients from a Substance User Treatment Center in Medellín, Colombia.

METHODS

A case-control study was conducted, with patients with an early treatment dropout as cases, and patients who completed the treatment as controls. Demographic data, substance use pattern, concomitant diseases, and the decision to initiate treatment were compared between cases and controls.

RESULTS

The frequency of early drop-out was 59%, but a high proportion of this drop-out (47.5%) occurred in the transition period between the program stages. The variables associated with drop-out were: psychotic disorder (OR=0.32; 95% CI, 0.11-0.91), bipolar disorder (OR=0.31; 95% CI, 0.12-0.77), heroin as the principal substance compared to alcohol (OR=6.68; 95% CI, 1.52-29.4), decision to initiate the treatment by the family compared to personal decision (OR=3.02; 95% CI, 1.28-7.17), and previous treatments (OR=1.87; 95% CI, 1.02-3.44).

CONCLUSIONS

The drop-out frequency is similar to those reported in other studies. Associated factors were found, which could be considered in order to plan strategies to improve the program results.

Quality of life determinants in patients of a Psychosocial Care Center for alcohol and other drug users

Quality of life assessments in patients receiving treatment for substance dependence can serve as one predictor of response to treatment. This study aimed to identify determinants of quality of life in patients of a Psychosocial Care Center for alcohol and other drug users (CAPSad). The sample consisted of 77 patients with a diagnosis of substance dependence being treated at CAPSad for more than six months. Severity of substance dependence was assessed using the Addiction Severity Index (ASI-6), quality of life was assessed using the World Health Organization Quality of Life assessment instrument-short version (WHOQOL-BREF), and depressive symptoms were assessed by the Beck Depression Inventory (BDI). Data on CAPSad activities, psychiatric diagnoses, and medications used were collected from the medical records. Quality of life was significantly impaired in more severe cases of substance dependence and in those with more severe depressive symptoms. As for other variables, poorer quality of life was significantly associated with a greater number of years of education, unemployment, use of medications, and greater use of individual sessions with the reference professional. Linear regression analysis revealed depressive symptom severity to be an independent determinant of quality of life impairment, accounting for over 50% of the variation in physical and psychological domains. These results demonstrate the need to consider other factors, such as depressive symptoms and quality of life, in the treatment of substance dependence.

Long-term γ-hydroxybutyric acid (GHB) and disulfiram combination therapy in GHB treatment-resistant chronic alcoholics

Leading Italian studies support the use of γ-hydroxybutyric acid (GHB), not only in the treatment of the alcohol withdrawal syndrome, but also in maintaining alcohol abstinence. GHB gives a better result than naltrexone and disulfiram in maintaining abstinence, and it has a better effect on craving than placebo or disulfiram. The problem is that about 30–40% of alcoholics are non-responders to GHB therapy. In our clinical practice, we speculate that by combining disulfiram with GHB treatment we may be able to achieve a kind of ‘antagonist’ effect by using the ‘psychological threat’ of disulfiram (adversative effect) while taking advantage of the anticraving effect of GHB, despite the limitation of its ‘non-blockade’ effect on alcohol. In this context, to improve the outcome in GHB long-term treated alcoholics, we added disulfiram to GHB in the management of GHB treatment-resistant alcoholics. In this study we compared retention in treatment of 52 patients who were treated with the GHB-disulfiram combination for up to six months, with retention for the same subjects considering their most recent unsuccessful outpatient long-term treatment with GHB only. An additional comparison was carried out on the days of complete abstention from alcohol. Thirty four patients (65.4%) successfully completed the protocol and were considered to be responders; 18 (34.6%) left the programme, and were considered to be non-responders. Considering the days of complete abstinence from alcohol, 36 patients stayed in treatment longer with the GHB-Disulfiram combination, 12 stayed for a shorter time and four for the same time. The results of this study seem to indicate a higher efficacy of the GHB-disulfiram association compared with GHB alone. Randomized controlled trials are now needed to verify this hypothesis.