Patient-treatment matching improves compliance of alcoholics in outpatient treatment

Personality traits and alcohol consumption: Secondary analysis of the Self-Match Study

Background

This secondary analysis of the Self‐Match Study explores whether personality traits affect the treatment outcome for alcohol use disorders (AUD). We designed the Self‐Match Study to investigate whether clients choosing between treatment options improves treatment outcomes. The primary outcome report revealed no difference in the outcome, whether treatment allocation was based on clinician matching or self‐matching. Because willingness to choose, choice of treatment method, and compliance with treatment may be related to personality, this exploratory sub‐study investigated the influence of personality traits on treatment outcome.

Method

We enrolled 402 consecutive clients (female 46.7%, mean age 47.4) seeking treatment at the outpatient alcohol treatment center in Odense, Denmark. Clients were randomized to treatment by expert‐match or self‐matching. Data on alcohol consumption (Timeline Follow Back), personality traits (NEO‐FFI‐3), and retention in care were collected at baseline and 6‐month follow‐up. Outcomes were compliance, sensible drinking (alcohol intake below National Recommendations), and the number of heavy drinking days at follow‐up.

Results

A high neuroticism score was negatively associated with treatment completion. Further, clients with a high score on neuroticism, openness, and extraversion, or a low score on conscientiousness were less likely to reduce their drinking to a sensible level at follow‐up. We also found that low scores on conscientiousness were associated with having more heavy drinking days at follow‐up. The personality traits neuroticism and openness were associated with treatment preferences.

Conclusions

Personality traits influence 6 months drinking outcomes for people receiving AUD treatment.

Personality traits seem to not affect treatment completion. However, a high score on neuroticism, openness, extraversion, or a low score on conscientiousness influence the drinking pattern in different ways at 6‐month follow‐up. The personality traits neuroticism and openness were associated with preferences for specific treatment methods, but further research is needed on this matter. Tentative conclusions are that client‐centered treatment is preferable and shared decision‐making should be considered as part of the treatment regimen.

The impact of free choice in alcohol treatment. Primary outcomes of the self-match study

INTRODUCTION

A paternalistic approach to treatment planning is common, but there is a growing interest in involving clients in the planning of their own treatment, both in medical care and psychotherapy. Several studies on matching patients to treatment have failed to improve outcome. Studies on Shared Decision-Making in mental health are encouraging but somewhat ambiguous in addiction treatment.

OBJECTIVE

This study investigated whether self-matching (Informed Choice) to treatment improves alcohol consumption, retention, and quality of life.

METHOD

402 consecutive clients (female 46.7 %, mean age 47.4) seeking treatment for alcohol use disorder at the outpatient clinic in Odense, Denmark were enrolled in this single-blinded randomized controlled trial. Clients randomized to the intervention group watched an 8-minute video presentation of the treatments and then chose the treatment they preferred. Clients in the treatment as usual (TAU) group were allocated to treatment by an evidence-based algorithm. Measurements on alcohol consumption, quality of life, and retention in care were completed at baseline and 6-month follow-up.

RESULTS

There was no significant difference on primary and secondary outcome measures between the Informed Choice group and TAU group at 6-month follow-up. 80 % of clients in the Informed Choice group were satisfied with being randomized to self-matching whereas 24 % in the TAU group were satisfied with being assigned by expert matching.

CONCLUSION

Our hypothesis, that outcome is improved if clients choose their own treatment, was not supported. However, an important finding is that client self-matching is just as beneficial as expert matching.

Effectiveness of Optional Videoconferencing-Based Treatment of Alcohol Use Disorders: Randomized Controlled Trial

BACKGROUND

Treatment of alcohol use disorders (AUDs) is characterized by an adherence rate below 50%. Clinical research has found that patient adherence enhances treatment effect; hence, health authorities, clinicians, and researchers strive to explore initiatives contributing to patients receiving treatment. Concurrently, videoconferencing-based treatment is gaining ground within other addiction and psychiatric areas.

OBJECTIVE

The aim of this study was to test whether optional videoconferencing increases adherence to and effectiveness of AUD treatment in a randomized controlled trial (RCT). We hypothesized that the intervention would decrease premature dropout (the primary outcome), as well as increase successful treatment termination, treatment duration, and treatment outcome (secondary outcomes).

METHODS

We conducted this study in the public outpatient alcohol clinic in Odense, Denmark, between September 2012 and April 2013. It was an RCT with 2 groups: treatment as usual (TAU) and treatment as usual with add-on intervention (TAU+I). The TAU+I group had the option, from session to session, to choose to receive treatment as usual via videoconferencing. Data consisted of self-reported responses to the European version of the Addiction Severity Index (EuropASI). We collected data at baseline, at follow-up at 3, 6, and 12 months, and at discharge.

RESULTS

Among consecutive patients attending the clinic, 128 met the inclusion criteria, and 71 of them were included at baseline. For the primary outcome, after 180 days, 2 of 32 patients (6%) in the TAU+I group and 12 of 39 patients (31%) in the TAU group had dropped out prematurely. The difference is significant (P=.008). After 365 days, 8 patients (25%) in the TAU+I group and 17 patients (44%) in the TAU group had dropped out prematurely. The difference is significant (P=.02). For the secondary outcomes, significantly more patients in the TAU+I group were still attending treatment after 1 year (P=.03). We found no significant differences between the 2 groups with regard to successful treatment termination and treatment outcome.

CONCLUSIONS

The results indicate that offering patients optional videoconferencing may prevent premature dropouts from treatment and prolong treatment courses. However, the small sample size precludes conclusions regarding the effect of the intervention, which was not detectable in the patients' use of alcohol and severity of problems.

TRIAL REGISTRATION

The Regional Health Research Ethics Committee System in Denmark: S-20110052; https://komite.regionsyddanmark.dk/wm258128 (Archived by WebCite at http://www.webcitation.org/6tTL3CO6u).

Characteristics and treatment interests among individuals with substance use disorders and a history of past six-month violence: findings from an emergency department study

The study examined clinical characteristics and treatment interests of individuals identified to have substance use disorders (SUDs) in an urban emergency department (ED) who reported past six-month history of violence or victimization. Specifically, participants were 1441 ED patients enrolled in a randomized controlled trial of interventions designed to link those with SUDs to treatment. To examine factors related to violence type, four groups based on participants' reports of violence toward others were created: no violence (46.8%), partner violence only (17.3%), non-partner violence only (20.2%), and both partner and non-partner violence (15.7%). Four groups based on participants' reports of victimization were also created: no violence (42.1%), victimization from partner only (18.7%), victimization from non-partner only (20.2%), and both partner and non-partner victimization (17.7%). Separate multinomial logistic regression analyses were conducted to examine which variables distinguished the violence and victimization groups from those reporting no violence or victimization. For violence toward others, demographic variables, alcohol and cocaine disorders, and rating treatment for psychological problems were higher for violence groups, with some differences depending on the type of violence. For victimization, demographic variables, having an alcohol disorder, and rating treatment for family/social problems were higher for violence groups, also with some differences depending on the type of violence. Findings from the present study could be useful for designing effective brief interventions and services for ED settings.

Influence of pretreatment coping strategies on the outcome of outpatient treatment of Danish alcohol abusers

An important issue regarding treatment for alcohol abuse is the high rate of relapse following treatment. In the research on treatment of alcohol abuse, the concept of coping has been proposed as a relevant factor in the relationship between relapse crises and treatment outcome. The present study investigated the role of pretreatment coping strategies in outcome of outpatient treatment for alcohol abuse. The pretreatment coping strategies of 136 clients receiving outpatient treatment for alcohol abuse were examined as a predictor of drinking pattern after treatment. The pretreatment coping strategies were assessed by the COPE questionnaire. Drinking pattern after treatment was assessed at follow-up one year after treatment was entered. Results indicated that some pretreatment coping strategies are identifiable as adaptive and maladaptive coping strategies, respectively, regarding successful treatment for alcohol abuse. Restraint coping was found predictive of a positive drinking pattern at follow-up while the use of alcohol to cope was found predictive of a negative drinking pattern. Furthermore, the results showed tendencies towards the possibility that some coping strategies co-operated differently with types of treatment methods.

Unilateral treatment exit: a failure of retention or a failure of treatment fit?

This article highlights perceived weaknesses in the current understanding of unilateral client exit from alcohol and other drug psychosocial treatment. It is argued that unilateral client exit is typically interpreted as a "failure of retention" when it could equally be interpreted as a "failure of treatment fit"; that is, the failure to deliver treatment optimally suited to actual client attendance. The results from an exploratory study conducted within a failure of treatment fit framework are presented. This study explored the possibility that short-term outpatient alcohol and other drug (AOD) treatment attendance may be an intentional service use strategy and that short-term attendees may exit AOD treatment as satisfied, successful, consumers. Standardized questionnaires were administered to clients (n = 109) starting a new treatment episode between June-August 2003 at admission and two-months post admission. Questionnaires explored the accuracy of client estimates of future appointment attendance, the reasons for short-term service exit, the satisfaction and outcome ratings of short-term clients, and the extent to which these compared with their longer-term peers. Findings suggest short-term treatment attendance is not an intentional service use strategy. However, despite attending fewer appointments than intended, most short-term participants reported significant levels of service satisfaction and problem improvement, and at a level comparable with their longer term peers. Problem-improvement was endorsed as the number one reason for short-term service exit. Implications for treatment delivery are discussed in light of these findings.

SEQUENTIALLY ADJUSTED RANDOMIZATION TO FORCE BALANCE IN CONTROLLED TRIALS WITH UNKNOWN PREVALENCE OF COVARIATES: APPLICATION TO ALCOHOLISM RESEARCH

AIMS

In treatment outcome studies with small to medium sample sizes (n < 200), the balance of groups with regard to important factors, which sometimes occur at low prevalence, is indispensable for adequate interpretation. This study tested a method for use in clinical alcoholism research, an uncomplicated procedure for satisfactory randomization of patients to different treatments, taking into account relevant background variables.

METHODS

An easily applicable modification of Efron's biased coin method for the randomization of treatments within strata of unknown but low prevalence was compared with the original approach and alternative methods by computer simulation (10,000 runs). An application example for a clinical trial in alcoholism research is given.

RESULTS

The sequentially adjusted randomization procedure revealed results similar to Efron's approach without the necessity for monitoring the assignment history throughout the trial. The new method was slightly superior to Efron's approach in randomizing subjects in strata with n < or = 20, whereas strata with n > 20 favoured randomization with Efron's approach. Taking into account all results from simulation, the new approach reached a proportion of acceptable balanced randomization > 95% in all stratum sizes.

CONCLUSIONS

The approach, a special case of the standard urn design, provides three major advantages in clinical trials: (i) it can be easily implemented in any trial without technical equipment; (ii) it works with high accuracy in trials with a priori unknown but low numbers of subjects (4 < or = n < or = 20) in prognostic relevant strata; and (iii) a deterministic assignment tendency is completely avoided, as a random process takes place throughout the assignment procedure. The modified biased coin method can be recommended as one possible strategy for special purposes, particularly in alcoholism research.

The therapists' experience of alcohol addiction treatment – a qualitative study

The present study is a qualitative study, based on audio-taped interviews with 12 therapists, on how therapists view their own role as therapists within the alcohol treatment areas.

The study describes how the therapists create an image of the patients they treat, and the rationale, they build the treatment on. The analysis of the therapists' stories indicated that therapists based their treatment on a platform that was constructed and negotiated by means of various kinds of information and knowledge. From this stock of information the therapists pulled out and interpreted elements that made coherent sense to them and provided indications about where to go next in the course of treatment.

The stories about treatment were told within the frames of a recognisable structure, consisting of the patient's predisposition to treatment, empowerment, transformation and re-construction. Within this structure, the therapists rhetorically made use of various patterns to describe their communication with the patients. The rhetoric can be regarded as an indication of how the therapists perceive their role as therapist.

As the therapist viewed it, treatment was aimed at helping the patient overcome dependence and at the same time letting the patient be the active decision-maker. The stories about treatment showed how the therapist viewed treatment as an act of balancing between dependence and independence.

Alcohol problems and treatment: the patients' perceptions

The aim of this study is to investigate the patients' perception of their own alcohol problems. It is based on semi-structured, audio-taped interviews with 27 randomly chosen patients at an Alcohol Treatment Centre. Four different ways how alcohol problems were perceived emerged: 'cultural drinking', 'symptomatic drinking', 'pathological drinking' and 'incomprehensible drinking'. The ways of explaining the drinking problems were not related to the duration of the drinking problem, the actual amount of alcohol that the patients drank, or how or when it was drunk. Instead, the patients' perceptions were grounded in the way the drinking pattern was interpreted in relation to concepts like 'normality' and 'deviance'.

Factors associated with compliance of alcoholics in outpatient treatment

Predictors of compliance with psychosocial treatment were examined in a clinical sample of 150 patients seeking outpatient treatment for alcohol problems. Predictor variables were as follows: a) patient characteristics at the beginning of treatment and b) treatment characteristics of a matching model developed from the Conceptual System Theory. This model was based on the conceptual level of patients and therapists, and on the structure of the treatment. Using logistic regression analysis, we identified predictors of compliance in the motivation phase (first four consultations) and the active treatment phase (the remainder of the agreed treatment period of 12 months). Predictors of compliance in the motivation phase were a) therapists with a high conceptual level, characterized by an attitude toward the patients of empathetic and reflective listening; b) disulfiram; and c) psychopharmacological treatment. The only patient-related predictors of compliance in the active treatment phase were a) age below 40 and b) the presence of family and social problems, both factors predicting noncompliance. The only treatment-related predictor variables were a) the matching of patients with the structure of treatment and b) disulfiram during the first month of treatment, both factors predicting compliance. Two years after the beginning of treatment, those patients who completed the motivation phase as well as the active treatment phase had a significantly better psychosocial function than the noncompliant patients.