Carla A. Green

Behavioral Counseling Interventions in Primary Care To Reduce Risky/Harmful Alcohol Use by Adults: A Summary of the Evidence for the U.S. Preventive Services Task Force

Alcohol misuse, including risky and harmful drinking, alcohol abuse, and dependence, is associated with numerous health and social problems and with more than 100 000 deaths per year (1). Risky drinkers consume alcohol above recommended daily, weekly, or per-occasion amounts. Harmful drinkers experience harm associated with their alcohol use but do not meet criteria for alcohol abuse or dependence (2). Persons who misuse alcohol have elevated risks for a host of health problems (3-6), including violence-related trauma and injury (4). Most individuals who consume alcohol do so in moderation and without adverse consequences, however, and observational research suggests light or moderate use may be beneficial for some people (7-20). The assumption underlying brief behavioral counseling interventions in primary care is that, for identified risky or harmful drinkers, reducing overall alcohol consumption or adopting safer drinking patterns (that is, fewer drinks per occasion and not drinking before driving) will reduce the risk for medical, social, and psychological problems (21). Little experimental evidence supports this assumption, and most epidemiologic evidence relates health outcomes to existing drinking behaviors rather than to changes in drinking behaviors. Cross-sectional and cohort studies have consistently related high average alcohol consumption to short- or long-term health consequences (4, 22). A meta-analysis of studies examining the association between all-cause mortality and average alcohol consumption found that men averaging at least 4 drinks per day and women averaging 2 or more drinks per day experienced significantly increased mortality relative to nondrinkers (23). Studies also relate heavy per-occasion alcohol use (binge drinking) to acute injury risks and alcohol-related life problems (4, 22). Injury rates are higher for binge drinkers who consume 5 or more drinks on one occasion as infrequently as 3 to 6 times per year, even when average intake is not excessive (24). In the United States, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) has proposed epidemiologically based alcohol use guidelines to limit risks for short- and long-term drinking-related consequences by establishing age- and sex-specific recommended consumption thresholds (25). Maximum recommended consumption is 1 or less standard drink per day for adult women and for anyone older than 65 years of age and 2 or fewer standard drinks per day for adult men. These guidelines do not apply to persons (such as adolescents, pregnant women, and persons with alcohol dependence or medical conditions or medication use) for whom alcohol intake is contraindicated, or to circumstances (driving) in which no consumption is considered safe. Primary care clinicians commonly see patients with a range of alcohol-related risks and problems. In Wisconsin, about 20% of primary care patients were found to exceed NIAAA guidelines and to qualify as risky drinkers (26). Across multiple primary care populations, 4% to 29% are risky drinkers, 0.3% to 10% are harmful drinkers, and 2% to 9% exhibit alcohol dependence (27). Prevalence of these forms of alcohol misuse generally is higher in males and younger persons of all races and ethnicities (28). The NIAAA and others encourage physicians to identify patients with alcohol-related risks or problems and to provide office-based brief interventions or referrals as needed (25, 29, 30). In everyday practice, screening and screening-related assessment procedures are necessary to identify the range of alcohol users in order to offer appropriate treatment (31, 32). Even so, few primary care clinicians use recommended screening protocols or offer treatment (33). To assist the U.S. Preventive Services Task Force (USPSTF) in updating its 1996 recommendation (34), the Oregon Evidence-based Practice Center systematically reviewed the evidence on primary carebased behavioral counseling interventions for risky/harmful alcohol use; systematic evidence reviews and meta-analyses since the last USPSTF report (35-39) did not adequately address the key questions posed by the USPSTF. This review was exempted by the Institutional Review Board at Kaiser Permanente Northwest (FWA 00002344-IRB 00000405). Our review addressed the following questions: Do behavioral counseling interventions in primary care reduce risky or harmful alcohol use? What are elements of effective interventions? Do such interventions improve health outcomes? What methods were used to identify risky/harmful drinkers for behavioral counseling interventions in primary care? What adverse effects are associated with interventions addressing risky/harmful drinkers in primary care? What health care system influences are present in effective interventions for risky and harmful drinkers in primary care? Methods We concentrated our review on the program elements of brief primary care interventions for risky and harmful drinkers and their effects on alcohol use, health outcomes, and intermediate alcohol-related outcomes. Appendix Figure 1 shows the analytic framework and key questions guiding the entire systematic evidence review. Methods not described in this section appear in the Appendix, Appendix Figures 2 and 3, and Appendix Table 1. Appendix Figure 1. Analytic framework and key questions ( KQs ). Appendix Figure 2. Literature search and retrieval results. Appendix Figure 3. Risky/harmful alcohol use: quality recheck instrument. Definitions No consistent definitions for the drinking patterns that should be the focus of primary care interventions are available from existing guidelines or research; however, it is commonly held that less severe alcohol problems are appropriate for brief interventions in primary care, whereas more severe problems need specialty addiction treatment (41). We adapted the following definitions from a recent systematic review of primary care screening for alcohol problems (2). Risky or hazardous drinkers are at risk from consumption that exceeds daily, weekly, or per-occasion thresholds (other terms further distinguish risky/harmful users who exceed longer-term thresholdshigh-average or heavy usersfrom heavy occasional or binge drinkers, who exceed per-occasion thresholds). Harmful drinkers experience physical, social, or psychological harm from their above-threshold alcohol use without meeting criteria for dependence. Alcohol-abusing/dependent drinkers continue to use alcohol despite significant negative physical, psychological, and social consequences (42); generally meet criteria for abuse or dependence as outlined in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (43); and are candidates for specialty addiction treatment. Our review focuses on studies oriented toward the risky/hazardous/harmful category, which we refer to as risky/harmful drinkers. Fiellin and colleagues (2) similarly divide the literature on screening instruments for alcohol problems into studies that focus primarily on risky, heavy, or harmful drinking and studies that focus on detecting alcohol abuse or dependence. Among the brief intervention studies targeting risky/harmful drinkers selected for this review, we classified intervention groups into 1 of 3 levels of intensity: 1) very brief interventions had 1 session, up to 5 minutes long; 2) brief interventions had 1 session, up to 15 minutes long; and 3) brief multicontact interventions had an initial session up to 15 minutes long, plus follow-up contacts. We used the definition of primary care recommended by the Institute of Medicine (44) (see Inclusion and Exclusion Criteria in the Appendix) to identify relevant medical settings for our review. Inclusion and Exclusion Criteria We included English-language reports of randomized or nonrandomized, controlled clinical trials of nondependent drinkers 12 years of age or older who received a primary care behavioral counseling intervention primarily to reduce alcohol intake. We excluded studies based in hospitals or emergency departments, specialty addiction treatment settings, behavioral health departments, and schools or community agencies without health clinics. We also excluded studies among comorbid patient populations because of limited generalizability to primary care. We excluded studies rated as having poor quality, as described below. Search Strategy We identified 5 recent systematic reviews addressing primary care brief interventions to reduce risky/harmful alcohol use (35-39) and 3 addressing screening (2, 45, 46) from the Cochrane Database of Systematic Reviews and Database of Research Effectiveness (DARE). Relevant trials were identified from searches of MEDLINE, Cochrane Controlled Clinical Trials, PsycINFO, HealthSTAR, and CINAHL databases (1994 to April 2002), reference lists of systematic reviews, the USPSTF 1996 recommendation (34), and experts. We conducted separate searches in MEDLINE and PsycINFO from 1994 through April 2002 to identify any literature on harms related to alcohol screening, screening-related assessment, or intervention. None was found. The Appendix contains further search strategy details, along with information on our abstract and article review processes. We used USPSTF internal validity criteria (40) (Table 1), supplemented by specific quality criteria addressing study randomization, attrition, and intention-to-treat analyses from the Cochrane Drug and Alcohol Group (CDAG) (47) (Appendix Figure 3), to grade the quality of trials that met inclusion and exclusion criteria. We assigned each studys final quality rating according to investigator team consensus. Minimal to no attrition, nondifferential attrition, and replacement of missing values in the outcome analyses were key features of trials rated good quality. Studies receiving a consensus rating of poor quality (n = 27) were excluded from the review (Appendix Table 2). Major quality problems included nonrandom assignment, noncomparable bas

Purposeful Sampling for Qualitative Data Collection and Analysis in Mixed Method Implementation Research

Purposeful sampling is widely used in qualitative research for the identification and selection of information-rich cases related to the phenomenon of interest. Although there are several different purposeful sampling strategies, criterion sampling appears to be used most commonly in implementation research. However, combining sampling strategies may be more appropriate to the aims of implementation research and more consistent with recent developments in quantitative methods. This paper reviews the principles and practice of purposeful sampling in implementation research, summarizes types and categories of purposeful sampling strategies and provides a set of recommendations for use of single strategy or multistage strategy designs, particularly for state implementation research.

Gender, psychosocial factors and the use of medical services: a longitudinal analysis

Many researchers have reported gender differences in levels of reported symptoms, morbidity, mortality and medical care utilization, but the debate continues about the underlying causes of these differences. Some have argued that women use more medical services because they are more sensitive to symptoms and interested in health, while others believe that womens greater service utilization arises from the fact that women experience more morbidities than do men. To date, these questions have not been studied prospectively. Using data from a household interview survey carried out in 1970-1971 and linked to 22 years of health services utilization records, we explored the effects of gender, self-reported health status, mental and physical symptom levels, health knowledge, illness behaviors and health concerns and interest on the long-term use of health services. After controlling for the aforementioned factors, female gender remained an independent predictor of higher utilization over the 22-year period studied, and psychosocial and health factors measured at the initial interview predicted service use even 19-22 years later. Controlling for factors identified as likely causes of gender-related differences in healthcare utilization, gender remains an important predictor of medical care use before and after removing sex-specific utilization. In addition, the consistent predictive ability of attitudinal and behavioral factors, combined with the finding that health knowledge did not predict utilization, indicates that efforts to help patients assess their service needs should target the attitudinal and behavioral factors that vary with gender, rather than health-related knowledge alone.

Gender differences in predictors of initiation, retention, and completion in an HMO-based substance abuse treatment program

We studied gender differences in treatment process indicators among 293 HMO members recommended for substance abuse treatment. Treatment initiation, completion, and time spent in treatment did not differ by gender, but factors predicting these outcomes differed markedly. Initiation was predicted in women by alcohol diagnoses; in men, by being employed or married. Failure to initiate treatment was predicted in women by mental health diagnoses; in men, by less education. Treatment completion was predicted in women by higher income and legal/agency referral; in men, by older age. Failure to complete was predicted in women by more dependence diagnoses and higher Addiction Severity Index Employment scores; in men, by worse psychiatric status, receiving Medicaid, and motivation for entering treatment. More time spent in treatment was predicted, in women, by alcohol or opiate diagnoses and legal/agency referral; in men, by fewer mental health diagnoses, higher education, domestic violence victim status, and prior 12-step attendance. Clinical implications of results are discussed.

The STRIDE Weight Loss and Lifestyle Intervention for Individuals Taking Antipsychotic Medications: A Randomized Trial

OBJECTIVES The STRIDE study assessed whether a lifestyle intervention, tailored for individuals with serious mental illnesses, reduced weight and diabetes risk. The authors hypothesized that the STRIDE intervention would be more effective than usual care in reducing weight and improving glucose metabolism. METHOD The study design was a multisite, parallel two-arm randomized controlled trial in community settings and an integrated health plan. Participants who met inclusion criteria were ≥18 years old, were taking antipsychotic agents for ≥30 days, and had a body mass index ≥27. Exclusions were significant cognitive impairment, pregnancy/breastfeeding, recent psychiatric hospitalization, bariatric surgery, cancer, heart attack, or stroke. The intervention emphasized moderate caloric reduction, the DASH (Dietary Approaches to Stop Hypertension) diet, and physical activity. Blinded staff collected data at baseline, 6 months, and 12 months. RESULTS Participants (men, N=56; women, N=144; mean age=47.2 years [SD=10.6]) were randomly assigned to usual care (N=96) or a 6-month weekly group intervention plus six monthly maintenance sessions (N=104). A total of 181 participants (90.5%) completed 6-month assessments, and 170 (85%) completed 12-month assessments, without differential attrition. Participants attended 14.5 of 24 sessions over 6 months. Intent-to-treat analyses revealed that intervention participants lost 4.4 kg more than control participants from baseline to 6 months (95% CI=-6.96 kg to -1.78 kg) and 2.6 kg more than control participants from baseline to 12 months (95% CI=-5.14 kg to -0.07 kg). At 12 months, fasting glucose levels in the control group had increased from 106.0 mg/dL to 109.5 mg/dL and decreased in the intervention group from 106.3 mg/dL to 100.4 mg/dL. No serious adverse events were study-related; medical hospitalizations were reduced in the intervention group (6.7%) compared with the control group (18.8%). CONCLUSIONS Individuals taking antipsychotic medications can lose weight and improve fasting glucose levels. Increasing reach of the intervention is an important future step.

The Health and Health Behaviors of People Who Do Not Drink Alcohol

BACKGROUND Compared to abstention, moderate drinking has been linked to better health, and heavy and hazardous drinking to increased morbidity and mortality. Many studies have failed to account for heterogeneity in health and drinking history among nondrinkers, however. If former drinkers quit in response to ill health, this could increase the risk in the nondrinker category and underestimate the effects of alcohol if illnesses leading to abstention are alcohol-related. In addition, health behaviors may vary with drinking status, affecting health outcomes often attributed to drinking. METHODS Survey data were collected from a probability sample of a large health maintenance organizations membership. Regression analyses assess the relationship between drinking status (adjusting for covariates), mental and physical health and functioning, and health behaviors. RESULTS Former drinkers and lifelong abstainers had worse health and functioning than current drinkers and, comparatively, former drinkers had worse health than lifelong abstainers. Former drinkers did not differ from light-to-moderate drinkers in regard to health behaviors (except for smoking), although lifelong abstainers and heavier drinkers were less likely to use preventive care or try to improve their health behaviors. CONCLUSIONS Consistent with hypotheses that former drinkers may stop drinking because of poor health, former drinkers were less healthy than current drinkers and had slightly worse health than lifelong abstainers, compared to light-to-moderate drinkers. Former drinkers did not appear to be at risk because of poorer health behaviors (except smoking), but lifelong abstainers and heavier drinkers might benefit from outreach designed to increase use of preventive care and improve health behaviors.

Development of the Patient Activation Measure for Mental Health

Our objective was to adapt the physical health Patient Activation Measure (PAM) for use among people with mental health conditions (PAM-MH). Data came from three studies among people with chronic mental health conditions and were combined in Rasch analyses. The PAM-MH’s psychometric properties equal those of the original 13-item PAM. Test–retest reliability and concurrent validity were good, and the PAM-MH showed sensitivity to change. The PAM-MH appears to be a reliable and valid measure of patient activation among individuals with mental health problems. It appears to have potential for use in assessing change in activation.

Social Support, Activities, and Recovery from Serious Mental Illness: STARS Study Findings

Research on the role of social support in recovery from severe mental illness is limited and even more limited is research on the potential effects of participating in various activities. This study explores these relationships by analyzing baseline data from a 153-participant subsample in the Study of Transitions and Recovery Strategies. Higher scores on the recovery assessment scale were related to both social support/network size and engagement in more activities. The particular nature of the activities (more/less social, more/less physically active, inside/outside the home) was not important, rather, activities of any type were related to recovery. Furthermore, engagement in activities was more important as levels of social support declined. The results suggest that both social support and activities may promote recovery, and that for persons with poor social support, engagement in a variety of individualized activities may be particularly beneficial.

Impact of attention-deficit/hyperactivity disorder (ADHD) treatment on smoking cessation intervention in ADHD smokers: a randomized, double-blind, placebo-controlled trial.

OBJECTIVE High smoking rates in adults with attention-deficit/hyperactivity disorder (ADHD) and nicotines amelioration of ADHD suggest that effective ADHD treatment might facilitate abstinence in smokers with ADHD. The present study evaluated if using osmotic-release oral system methylphenidate (OROS-MPH) to treat ADHD enhances response to smoking cessation treatment in smokers with ADHD. METHOD A randomized, double-blind, placebo-controlled, 11-week trial with a 1-month follow-up was conducted at 6 clinical sites between December 2005 and January 2008. Adults (aged 18-55 years) meeting DSM-IV criteria for ADHD and interested in quitting smoking were randomly assigned to OROS-MPH titrated to 72 mg/d (n = 127) or placebo (n = 128). All participants received brief weekly individual smoking cessation counseling for 11 weeks and 21 mg/d nicotine patches starting on the smoking quit day (day 27) through study week 11. Outcome measures included prolonged smoking abstinence and DSM-IV ADHD Rating Scale (ADHD-RS) score. RESULTS Of 255 randomly assigned participants, 204 (80%) completed the trial. Prolonged abstinence rates, 43.3% and 42.2%, for the OROS-MPH and placebo groups, respectively, did not differ significantly (OR = 1.1; 95% CI, 0.63-1.79; P = .81). Relative to placebo, OROS-MPH evidenced a greater reduction in DSM-IV ADHD-RS score (P < .0001) and in cigarettes per day during the post-quit phase (P = .016). Relative to placebo, OROS-MPH increased blood pressure and heart rate to a statistically, but not clinically, significant degree (P < .05); medication discontinuation did not differ significantly between treatments. CONCLUSIONS Treatment for ADHD did not improve smoking cessation success; OROS-MPH, relative to placebo, effectively treated ADHD and was safe and generally well tolerated in this healthy sample of adult ADHD smokers. TRIAL REGISTRATION clinical trials.gov Identifier: NCT00253747.

“Being in a Funk”: Teens’ Efforts to Understand Their Depressive Experiences:

Although there is literature about adults’ experiences of depression, little research has focused on teenagers’ experiences. In this article, the authors describe how a sample of adolescents makes sense of depression and responds to a depression diagnosis. Twenty-two adolescents participated in in-depth individual or focus group interviews. Teens discussed their experiences with depression and getting health care for depression, and described a trajectory similar to that found among adults: a slow growth of distress, a time of being in a funk, and a time of consideration of whether they are depressed. Teens who received a diagnosis from a medical provider then sought to make sense of their depression. Teens understood a depression diagnosis as a helpful label, a chronic medical problem, or a significant part of their identity. Understanding the subjective experience of adolescents who are depressed might increase health care providers’empathy and improve their communication with teens.