Outpatient alcoholism treatment: Predictors of outcome after 3 years

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Abstract

Aims:

This prospective study investigated predictors for relapse 3 years after completion of an intensive outpatient treatment programme for alcoholism.

Design:

As previous studies mainly revealed that severity of alcohol dependence, and comorbid psychopathology were predictive for subsequent relapses, the impact of these and other pre-treatment variables on the 36-month outcome was evaluated in a logistic regression analysis. A structured interview was used to assess the variables. Patients were personally interviewed at entry to, and the end of, an outpatient treatment programme, and 6, 12, 24 and 36 months after the end of treatment. One hundred and three alcohol-dependent participants who were taking part in an outpatient treatment were consecutively recruited.

Results:

Seventy-four patients completed the treatment programme. At the follow-up after 36 months, 2 patients had died (after heavy alcohol relapse) and 88 (88%) of the remaining patients could be located and personally re-interviewed. Forty-four (43%) patients were abstinent, 46 (45%) had relapsed and 12 (12%) were classified as improved for the total follow-up period according to the classification proposed by Feuerlein and Küfner. Based on a logistic regression analysis, significant variables for prediction of relapse were treatment drop-outs, female sex and sum of positive life events prior to treatment (relapsers had significantly fewer positive life events).

Conclusions:

In contrast to previous studies we could not confirm the importance of determinants known as risk factors for relapse like severity of alcohol dependence. The strongest predictor for relapsing after treatment is treatment drop-out. Since women were at an increased risk for relapse gender-specific treatment approaches should be considered. In summary, the effectiveness of the studied intensive outpatient treatment programme, with an abstinence rate of 43% for the total follow-up period of 3 years, is favourable although selection criteria of must be taken into account.

Introduction

In Germany, at least 1.6 million persons are currently alcohol-dependent and about 2.7 million abuse alcohol; the overall costs of alcoholism are estimated to be about €20.6 billion per year (Merfert-Diete, 2004). Traditionally, alcohol treatment rehabilitation programmes in Germany and many other European countries have focused almost exclusively on inpatient treatment. The efficacy of inpatient treatment has been addressed in a number of catamnestic studies which indicate a favourable (>40%) abstinence rate at the 4-year follow-up (MEAT study, Feuerlein and Küfner, 1989). Nevertheless, the rising costs of healthcare have led to an increase in the use of outpatient treatment services in the USA and Europe as an alternative treatment modality. Up to now, little national research has focused on this issue and the number of patients included in outpatient rehabilitation programmes is still much smaller than those in special alcohol clinics (12,742 outpatients versus 37,264 inpatients in 2001 (Leune, 2003)).

As early as 1990, an intensive 8-month treatment programme for alcohol-dependent patients, one of the first of this kind in Germany, was initiated in the greater Munich area (Dachau) and a first retrospective 18–24-month follow-up study indicated a favourable treatment outcome (abstinence rate 48%) (Soyka et al., 1997).

On that background, the present prospective study aimed to investigate the effectiveness of a highly structured outpatient treatment programme for alcoholism and to find predictors for relapse after 3 years. Participants were personally interviewed at entry to, and the end of, an outpatient treatment programme, and 6, 12, 24 and 36 months after the end of treatment. Considering that previous studies mainly revealed that sociodemographic variables, severity of alcohol dependence, number of previous treatments, age of onset and comorbid psychopathology were predictive for subsequent relapses (McLellan et al., 1994, Moos et al., 2000, Rounsaville et al., 1987), the impacts of these and other pre-treatment variables on the 36-month outcome of the treatment programme were evaluated in a logistic regression analysis.

Section snippets

Study design

Over a 12-month period, 103 alcohol-dependent patients who began with an intensive outpatient treatment programme were consecutively recruited. The outpatient facility offers a highly structured, intensive, two-phase treatment model with a similar setting to conventional inpatient treatment with respect to intensity and quality of psychotherapy. An initial 12-week motivational phase that has to be completed by all patients is followed by a 8-month rehabilitation phase, which is subject of

Patients’ characteristics at the beginning of the outpatient treatment

One male patient died 2 months after initiation of therapy (not alcohol-related) and was excluded from statistical analyses. Thus, the total sample consisted of 61 male and 41 female alcohol-dependent patients. The youngest was 24 and the oldest was 67 at study entry, the mean age was 45 (±8). Patients were comparatively socially well integrated: 59% of the patients were married, 24% divorced, 15% single and 2% widowed. Seventy-seven percent of the patients were in a stable partnership.

Discussion

The results of this prospective study indicate a favourable outcome: 43% of patients were abstinent, 12% were improved and less than half (46%) had relapsed 36 months after outpatient treatment. Thus, outpatient treatment may be an alternative and effective treatment for serious alcohol-dependent patients: 90% of the patients fulfilled six or more of the eight ICD-10 criteria for alcohol dependence at the start of the programme, and 19% had experienced a delirium tremens prior to treatment.

Acknowledgement

The study was funded by the German Pension Institute for Salaried Employees (Bundesversicherungsanstalt für Angestellte (BfA, Berlin)).

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