One-Year Outcomes among Members of a Dual-Recovery Self-Help Program.

Research Objective: Self-help is gaining increased acceptance among treatment professionals as empirical support for of its effectiveness is growing and the advent of managed care warrants the use of cost-effective modalities. Traditional “one disease-one recovery” self-help programs cannot serve adequately the needs of the dually-diagnosed.

This paper presents one-year outcome data from a longitudinal study of the effectiveness of self-help for the dually-diagnosed.

Subjects are members of Double Trouble in Recovery (DTR), a 12-step self-help program designed to meet the special needs of those diagnosed with both a mental health disorder and a chemical addiction.Study.

Design: The study uses a 12-month prospective longitudinal design with follow-ups at 12 and 24 months after baseline. Subjects (N = 310) were recruited at 25 DTR meeting sites throughout New York City. Semi-structured instruments assess history and current status of mental health and substance abuse, treatment in both areas, and self help participation (DTR as well as traditional 12-step groups such as AA and NA).

Population Studied: Community-based individuals dually-diagnosed with a mental health disorder and substance abuse.

Principal Findings: S’s are mostly members of underserved minority groups with long histories of substance abuse and mental health disorders.

Most S’s attend outpatient treatment (for drug use, mental health or dual-diagnosis – 77%) and take psychotropic medications (87%).

At the 12 months follow-up,

• 76% were still attending DTR;
• 68% were also attending AA or NA.

Mean number of symptoms S’s. experienced in the past year decreased significantly;

• two-thirds (69%) of S’s reported that their mental health was “better” in the past month than it was at baseline.
• One-third (29%) reported substance use in the past year, compared to 42% at baseline (p = .002).

Substance use (less) was significantly associated with DTR attendance:

• Total time abstinent was related to lifetime length of DTR attendance (r = .25, p = .002) and
• past year substance use was related to number of months of DTR attendance in the past year (r = -.17, p = .02).

Conclusions: For dually-diagnosed individuals, continued participation in dual recovery self-help groups plays a significant role in the recovery process, particularly in the area of substance use.

Implications for Policy, Delivery or Practice: Participation in dual-recovery self-help groups, both during and after formal treatment, should be encouraged as part of an integrated lifelong recovery plan for dually-diagnosed individuals.

Research; One-Year Outcomes among Members of a Dual-Recovery Self-Help Program. Laudet A, Magura S, Vogel H, Knight E, Staines G; Abstr Acad Health Serv Res Health Policy Meet. 2000; 17.

More at; Double Trouble in Recovery

See also;

• 12-Step Treatment More Effective than Alternative
• AA and Treatment Work Better Together
• Subscribe to Twelve Step Facilitation by e-Mail

Dual Diagnosis; Counseling the Mentally Ill Substance Abuser by Katie Evans, J. Michael Sullivan Read more about this title…

Depression in 6050 Former Drinkers; Association With Past Alcohol Dependence.

Background; The association between alcoholism and major depression in the general population has been explained as misdiagnosed alcohol intoxication and withdrawal effects mistaken for depressive syndromes.

To investigate whether this could account for the entire relationship, the association of past alcohol dependence with current major depression (ie, non-overlapping time frames) was investigated in individuals who no longer drink or who drink very little.

We conducted the study using data from the National Longitudinal Alcohol Epidemiologic Survey, a representative sample.

Methods; Former drinkers who did not use drugs or smoke in the past year (n = 6050) were divided into those with and without past DSM-IV alcohol dependence. These 2 groups were compared for the presence of current (last 12 months) DSM-IV major depression. The association between prior alcohol dependence and current major depression was tested with linear logistic regression, controlling for other variables.

Prior alcohol dependence increased the risk of current major depressive disorder more than 4-fold.

Results; Prior alcohol dependence increased the risk of current major depressive disorder more than 4-fold. This relationship was not attenuated by control variables.

The majority of subjects with major depression last used substances 2 or more years prior to the interview, which eliminates acute intoxication or withdrawal effects as an explanation of their depressions.

Conclusions; The strong, specific association between prior alcohol dependence and current or recent major depression in a nationally representative sample of former drinkers indicates that the association is not entirely an artifact of misdiagnosed intoxication and withdrawal effects.

A better understanding of the nature of the relationship between the 2 disorders should be sought and will have important public health significance.

Research report; Deborah S. Hasin; Bridget F. Grant.Major Depression in 6050 Former Drinkers; Association With Past Alcohol Dependence. Arch Gen Psychiatry. 2002;59:794-800.

• Alcoholics Have Trouble Identifying Emotions
• Cognitive Behavioral Therapy
• Depressed Men Who Drink More Likely to Commit Suicide
• Depression & 12-Step Programs

Primary Care Clinicians Lack Comfort, Skills in Discussing Alcohol Use

Often, primary care clinicians inadequately address alcohol use with their patients.

To describe alcohol-related discussions in primary care, investigators audiotaped and performed qualitative analysis of outpatient visits involving 14 primary care clinicians (physicians and nurse practitioners) and 29 of their patients.

All patients were male veterans who screened positive for unhealthy alcohol use.*

Three themes emerged:

• Patients often disclosed that they consumed large amounts of alcohol and/or experienced negative health consequences from drinking.
• Clinicians commonly responded by changing the subject, minimizing the significance of their patients’ drinking, or pursuing a nonalcohol-related issue.
• Hesitation, stuttering, inappropriate laughter, and ambiguous statements were apparent when clinicians discussed alcohol but not other topics.
  Advice about drinking was tentative and vague while advice about smoking was more common, decisive, and specific.

Brief alcohol counseling — an evidence-based practice — has been poorly disseminated into primary care practice. This exploratory study suggests that clinicians’ discomfort and limited skills in assessing and advising patients with unhealthy alcohol use are partly to blame.

Although training alone is not sufficient to increase alcohol counseling, these findings indicate that educational initiatives to improve primary care clinicians’ comfort levels and skills are necessary, nonetheless.

Reprinted with permission from Alcohol and Health: Current Evidence.

Reference: McCormick KA, Cochran NE, Back AL, et al. (2006) How primary care providers talk to patients about alcohol: a qualitative study. J Gen Intern Med., 21(9): 966-972.

From Join Together Online

Researchers say that men with clinical depression are more likely to kill themselves if they drink heavily or also suffer from a type of personality disorder known for aggressive and impulsive behavior, Reuters reported Dec. 23.

Researcher Gustavo Turecki and colleagues looked at a group of men with major depressive disorder, including 104 who committed suicide and 74 percent who are living. They found that those who were classified as alcohol abusers or dependent were four times more likely to kill themselves, while those with “Cluster B” personality disorders were 17 times more likely to commit suicide.

“Why some patients with major depressive disorder die by suicide while others with seemingly the same disorder do not, is a question of enormous clinical relevance,” the researchers noted. “…[H]igher levels of impulsive and aggressive behaviors, combined with behavioral disinhibition facilitated by substance use, may mediate suicide in major depressive disorder.”

Drinking and personality disorders were especially dangerous for younger men with depression. “If a clinician has a patient that has major depression and comorbidity with substance-related problems and the presence of cluster B personality trait and is younger, these are patients you want to make sure you pay close attention to,” said Turecki.

The study appears in the November 2005 issue of the American Journal of Psychiatry. Reference; Dumais, A., et al. (2005) Risk Factors for Suicide Completion in Major Depression: A Case-Control Study of Impulsive and Aggressive Behaviors in Men. Am J Psychiatry 162: 2116-2124. From; Join Together

The Practical Art of Suicide Assessment: A Guide for Mental Health Professionals and Substance Abuse Counselors by Shawn Christopher Shea Read more about this title…

Biomarkers in Alcohol Misuse: Their Role in the Prevention and Detection of Thiamine Deficiency

In Western countries alcohol misuse is the most frequent cause of thiamine (vitamin B1) deficiency (TD) and consequent neuro-impairment.

Studies have demonstrated that between 30 and 80% of alcoholics are thiamine deficient, and this puts them at risk of developing the Wernicke–Korsakoff (WK) syndrome.

The relative roles of alcohol and TD in causing brain damage remain controversial and it is important to try to determine the role played by each factor.

Animal studies support an additive effect of alcohol exposure and TD, and indicate the potential for interaction between alcohol and TD in human alcohol-related brain damage.

Early diagnosis of alcohol-related TD is therefore an important aspect of effective intervention and treatment.

Alcohol biomarkers provide a direct and indirect way of estimating the amount of alcohol being consumed, the duration of ingestion and the harmful effects that long-term alcohol use has on body functions.

Appropriate use of these markers is very helpful when considering a diagnosis of alcohol-related TD.

Research report; Rosanna Mancinelli, and Mauro Ceccanti. Biomarkers in Alcohol Misuse: Their Role in the Prevention and Detection of Thiamine Deficiency. Alcohol and Alcoholism 2009 44(2):177-182;

See also;

• 12-Step Treatment More Effective than Alternative
• AA Offers Recovery Not Religion
• AA and Treatment Work Better Together

I’ll Quit Tomorrow: A Practical Guide to Alcoholism Treatment

Women Physicians and Addiction.

Doctors get addicted just like other people and female doctors have earlier addiction and develop worse medical conditions.

Researchers compared case histories of 969 male and female (13%) substance dependent doctors. Their conclusions; “These findings suggest different characteristics between male and female impaired physicians which may have implications for identification and treatment of this population.”

The comparison revealed that females;

• Were younger by 4 years (mean 40 years)

• Had 15% more medical problems (49%), and

• 13% more psychiatric issues (76%)

• More past suicidal ideation (52% v 30%), and

• Current suicidal ideation (11% v 5%)

• Had attempted more suicides (20% v 5%) while intoxicated, and

• Had attempted more suicides (14% v 2%) while clean or sober

• Mainly abused alcohol, but

• Were more likely to use hypnotics (11% v 6%)

• Employment and legal problems (65% and 18% respectively) were similar in both genders

Research report; Women Physicians and Addiction. Martha J. Wunsch, Janet S. Knisely, Karen L. Cropsey, Eleanor D. Campbell, Sidney H. Schnoll. Journal of Addictive Diseases, Volume: 26 Issue: 2

Bloggers comment; This research mainly parallels sex differences in the general population which shows that women suffer earlier addiction and greater medical problems.

Alcoholics with cirrhosis of the liver have more brain damage than noncirrhotic alcoholics

• Cirrhosis of the liver is one of the most common and serious medical complications linked to alcoholism.
• Heavy alcohol use can also cause brain damage.
• Cirrhotic alcoholics appear to have even more impaired brain function than non-cirrhotic alcoholics.

Sustained exposure to alcohol can cause scarring and dysfunction of the liver, referred to as cirrhosis. Heavy alcohol use can also cause brain damage. An examination of gene expression in the frontal cortex has found that brain function is even more impaired in cirrhotic than non-cirrhotic alcoholics.

Results are published in the September 2007 issue of Alcoholism: Clinical & Experimental Research.

“The liver’s main function is to remove poisons from the blood,” explained R. Dayne Mayfield, research scientist at the Waggoner Center for Alcohol and Addiction Research at The University of Texas at Austin. “It also helps the body absorb certain nutrients like fats and fat-soluble vitamins. You cannot live without a functioning liver.” Mayfield is also the corresponding author for the study.

He added that about 10 to 20 percent of heavy drinkers develop cirrhosis. It is the seventh leading cause of death among young and middle-aged adults in the United States; approximately 10,000 to 24,000 deaths from cirrhosis each year may be due to alcohol consumption. “Cirrhotic patients [have] dysfunctional livers that cannot remove poisons from the blood stream,” he said. These poisons are able to move into the brain and disrupt normal function.

“When a gene or deoxyribonucleic acid (DNA) is ‘turned on,’” said Mayfield, “it serves as a template for synthesis of ribonucleic acid (RNA), which in turn produces protein, the key element in cell function. These ‘genes’ hold the key or code for the ultimate production of proteins that control all functions of the brain. We know that heavy alcohol drinking changes the regulation of genes in the brain. We predicted that alcohol-related changes in brain genes would be magnified in alcoholics with cirrhosis.”

Researchers obtained brain samples from the Brisbane Node of the National Health & Medical Research Council Brain Bank and the Tissue Resource Centre at the University of Sydney, Australia. They compared roughly 47,000 element cDNA microarrays taken from two groups (n=21): seven cirrhotic and 14 non-cirrhotic alcoholic cases.

“We found that the levels of many important brain genes changed in the cirrhotic patients,” said Mayfield. “These genes are important in regulating cell death and how individual cells in the brain talk to each other in a meaningful way.”

“The level of gene expression differed significantly between tissue from cirrhotic and non-cirrhotic alcoholics,” added John H. Krystal, Robert L. McNeil, Jr. professor of clinical pharmacology and deputy chairman for research in the department of Psychiatry at Yale University School of Medicine and the VA Connecticut Healthcare System. “Out of 1,125 genes, 482 genes showed increased expression and 643 genes showed reduced expression in the cirrhotic individuals. With the levels of so many genes changing, this study suggests widespread effects in many cellular pathways related to cirrhosis in the alcoholic group.” Krystal is also a principal investigator at the NIAAA Center for the Translational Neuroscience of Alcoholism and the VA Alcohol Research Center.

More specifically, those genes involved in neurite growth, neuronal cell adhesion, and synaptic transmission showed greater inhibition at the mRNA level among the alcoholic cases.

“Cells in the brain have to maintain connections in order to operate,” explained Mayfield. “This is similar to the way the internet works to transmit information across the globe. The internet would slow down or stop if enough connections are interrupted or changed. Similarly, the genes outlined above are responsible for proper connections and communication between cells in the brain. Without them, normal function would not be possible.”

Krystal suggested several possible interpretations of the findings. “One, alcoholics who develop cirrhosis likely drink more heavily than those alcoholics who do not develop cirrhosis,” he said. “Therefore, some of the findings may be related to the effects of heavy drinking upon the brain. A second contribution could be the effects of impaired liver function upon the brain. The liver plays a major role in the production and metabolism of a large number of substances that influence brain function, and impaired liver function would be expected to affect the brain. A third possibility is that cellular processes that are stimulated by alcohol consumption might influence both liver and brain. That is, the cirrhotic and non-cirrhotic groups differ in their cellular resilience to the toxic effects of alcohol rather than differences in their level of alcohol consumption. A fourth possible contributing factor could be changes in diet. If patients with cirrhosis have a more profound disruption of their nutrition than patients who do not develop cirrhosis, differences in brain damage may be related to nutritional deficiencies.”

Both Mayfield and Krystal said that the central message of the study is that alcoholism, especially when accompanied by a serious medical complication such as cirrhosis of the liver, can produce widespread changes in the body and brain.

“One hopes that a better understanding of the cellular processes related to the destructive impact of alcoholism upon the brain may help to guide the development of treatments that might protect people from neural damage related to alcoholism, and help them to recover from alcoholism,” said Krystal. “Important questions are: ‘How reversible are the changes in gene expression in the brain when alcoholics stop drinking"’ and ‘How dependent is the recovery of the brain upon the recovery of the liver"’"

Injury Risk Highest Among Binge Drinkers

Binge drinkers have a higher risk of alcohol-related injury than chronic, heavy drinkers, the Health Behavior News Service reported Feb. 22.

Binge-drinking women who otherwise drink in moderation had seven times the risk of injury as nondrinkers, while binge-drinking men increased their injury risk sixfold.

“It’s not only the amount of alcohol consumed that shapes the risk for injury, but also the usual consumption pattern,” said study author Gerhard Gmel of the Swiss Institute for the Prevention of Alcohol and Drug Problems. “At highest risk are those who usually consume moderately but sometimes binge drink. This is true for both sexes.”

The study was based on records from 8,736 people admitted to hospital emergency departments; researchers examined the relationship of injuries to average weekly alcohol consumption, binge-drinking episodes, and the amount of alcohol consumed prior to admission.

Gmel warned against prevention that focuses only on chronic drinkers, saying that many binge drinkers will be missed.

The research appears in the March 2006 issue of the journal Alcoholism: Clinical and Experimental Research. From; Join Together Online

• See also;
• Abstinence Solves Thinking Problems
• Adolescents have deficits in frontal brain activation
• Brain Damage & Cirrhosis

Spirituality/religiosity promotes acceptance-based responding and 12-step involvement.

BACKGROUND: Previous investigations have observed that spirituality/religiosity (S/R) is associated with enhanced 12-step involvement. However, relatively few studies have attempted to examine the mechanisms for this effect. For the present investigation, we examined whether acceptance-based responding (ABR) – awareness or acknowledgement of internal experiences that allows one to consider and perform potentially adaptive responses – accounted for the effect of S/R on 12-step self-help group involvement 2 years after a treatment episode.

METHODS: Data were collected as part of a multi-site treatment outcome study with 3698 substance-dependent male veterans recruited at baseline. Assessments were conducted at baseline, discharge, 1-year follow-up, and 2-year follow-up. We utilized structural equation modeling to examine the relationships among latent variables of S/R, ABR, and 12-step involvement over time.

RESULTS: In the final model, S/R was not directly related to 12-step involvement at 2-year follow-up. However, S/R predicted enhanced ABR at 1-year follow-up after accounting for discharge levels of ABR. In turn, ABR at 1-year follow-up predicted increased 12-step involvement at 2-year follow-up after accounting for discharge levels of 12-step involvement.

CONCLUSIONS: S/R promotes the use of post-treatment self-regulation skills that, in turn, directly contribute to ongoing 12-step self-help group involvement.

Authors: Carrico AW, Gifford EV, Moos RH. Spirituality/religiosity promotes acceptance-based responding and 12-step involvement. Drug Alcohol Depend. 2007 Jun 15;89(1):66-73

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Models of Craving and Implications for Treatment

By Raymond F. Anton, M.D.

Although many alcoholics experience craving, researchers have not yet developed a common, valid definition of the phenomenon. Numerous models of the mechanisms underlying craving have been suggested, however. One of those models-the neuroadaptive model-suggests that the prolonged presence of alcohol induces changes in brain-cell function. In the absence of alcohol, those changes cause an imbalance in brain activity that results in craving. Furthermore, the adaptive changes generate memories of alcohol’s pleasant effects that can be activated when alcohol-related environmental stimuli are encountered, even after prolonged abstinence, thereby leading to relapse.

Similarly, stressful situations may trigger memories of the relief afforded by alcohol, which could also lead to relapse. Neurobiological and brain-imaging studies have identified numerous brain chemicals and brain regions that may be involved in craving. Psychiatric conditions that affect some of these brain regions, such as depression or anxiety, also may influence craving. A better understanding and more reliable assessment of craving may help clinicians tailor treatment to the specific needs of each patient, thereby reducing the risk of relapse.

Alcohol Research & Health Vol. 23, No. 3, 1999