Effectiveness of brief alcohol interventions for general practice patients with problematic drinking behavior and comorbid anxiety or depressive disorders

doi:10.1016/j.drugalcdep.2007.11.015

Drug and Alcohol Dependence

Volume 94, Issues 1–3, 1 April 2008, Pages 214-220

https://doi.org/10.1016/j.drugalcdep.2007.11.015 Get rights and content

Abstract

Background

Brief interventions (BIs) are effective methods to reduce problematic drinking. It is not known, if the effectiveness of BI differs between patients with or without comorbid depression or anxiety disorders.

Methods

In a randomized controlled BI study with two intervention groups and one control condition, data were collected from 408 general practice (GP) patients with alcohol use disorders, at-risk drinking or binge drinking. 88 participants were diagnosed with comorbid anxiety and/or depressive disorders. The effectiveness of BI was assessed at a 12-month follow-up in relation to the presence and absence of comorbidity. Reduction of drinking in six ordered categories (g/alcohol) between baseline and follow-up served as the outcome variable.

Results

BI were significantly related to reduction of drinking in the non-comorbid (−2.64 g/alcohol vs. −8.61 g/alcohol; p = .03) but not in the comorbid subsample (−22.06 g/alcohol vs. −22.09 g/alcohol; p = .76). Compared to non-comorbid participants, a significantly higher reduction of drinking was found for comorbid individuals (−6.55 g/alcohol vs. −22.08 g/alcohol; p = .01). An ordinal regression analysis revealed comorbidity to be a positive predictor for reduction of drinking (estimator = .594; CI = .175–1.013; p < .01). When entering the variables amount of drinking at baseline, intervention and classification of problematic drinking, these became significant predictors, whereas comorbidity showed only a tendency.

Conclusion

BI did not significantly effect a reduction of drinking in comorbid patients. As BI are known to be less effective for dependent drinkers, a larger proportion of dependents among the comorbid might have limited the effectiveness of BI. Future studies with larger sample sizes of comorbid problem drinkers are necessary to confirm the results.

Introduction

While the majority of alcohol-related harm is not attributable to drinkers with severe alcohol dependence but to a much larger group of excessive or hazardous drinkers whose consumption exceeds recommended drinking limits (Anderson, 1991), brief interventions (BIs) aim to reduce consumption behavior and related harm. Motivational Interviewing (MI; Miller and Rollnick, 1991) poses an effective technique to enhance motivation to change problematic drinking behavior. As the majority of problem drinkers do not seek help (Grant, 1997), primary care settings provide a suitable channel to reach a large number of the target group. A recent Cochrane review provided strong evidence that BI in primary care settings are effective to reduce problematic alcohol consumption (Kaner et al., 2007). However, Kaner et al. (2007) also describe “a clear need to characterise the types of drinkers for whom BI have a positive impact and any subgroups that have not been represented in the trials to date” (p. 3). While high rates of anxiety and depression have been found in various samples of individuals with alcohol use disorders (Kessler et al., 1997, Regier et al., 1990, Wittchen et al., 1996) or at-risk drinking (Bott et al., 2005) as well as within the primary care setting (Üstün and Sartorius, 1995), little is known about the effectiveness of BI for individuals with problematic drinking behavior and comorbid anxiety and/or depressive disorders. Further investigation is needed to improve pro-active intervention strategies for this subgroup.

Regarding the outcome of alcohol specific treatment for comorbid individuals with alcohol use disorders and comorbid depression or anxiety, previous studies have provided heterogeneous results (Greenfield et al., 1998, Hasin and Grant, 2002). On the motivational level, a higher readiness to change problematic drinking behavior has been found for comorbid individuals in an outpatient dual diagnoses sample (Velasquez et al., 1999) and in pro-actively recruited general practice (GP) patients (Grothues et al., 2005). Comorbidity has also been associated with increased utilization of formal help (Lynskey, 1998, Regier et al., 1993). However, previous studies also show increased temptation to drink (Grothues et al., 2005, Velasquez et al., 1999) and lower self-efficacy to abstain from drinking (Grothues et al., 2005).

The key objective of this paper is to assess the effectiveness of BI to reduce problematic drinking behavior on grounds of longitudinal data which has been derived from a sample of pro-actively recruited GP patients with a range of drinking problems and comorbid depressive and/or anxiety disorders. The following aspects are addressed: Does the effectiveness of BI differ according to the presence or absence of comorbid anxiety and/or depressive disorders? Which implication does this yield for the delivery of BI to comorbid individuals who do not seek help for their drinking?

Section snippets

Procedure

Within the randomized controlled BI study “Stepped Interventions for Problem Drinkers (SIP)”, data were collected by trained project staff in 81 general practices in the north German city of Lübeck and its 46 surrounding communities and also in four practices in the north German city of Kiel during the period 2001 and 2003. A power analysis based on data by Fleming (1997) indicated an 80% statistical power for a sample size of 114 participants per group when applying a 5%, one-way significance

Participants

The CONSORT statement is presented in Fig. 2.

In total, 10,803 GP patients were screened (refusal rate: 5.9%). Among these, 2239 (20.7%) were positive according to the AUDIT and/or the LAST criteria. Of these, 1410 patients subsequently agreed to participate further in the study (63.0%). Later, 7% of these withdrew from further participation and 13.6% had to be excluded for other reasons (e.g. no telephone access). With 1119 (79.4%) of positively screened patients with informed consent,

Discussion

This is the first paper examining an interaction between the effectiveness of BI for problematic drinking and comorbid depression and/or anxiety disorders.

Although BI were significantly related to reduction of drinking in non-comorbid participants, this was not found for comorbid individuals. Regardless of the intervention, comorbidity was associated with a stronger drinking reduction than was found for the non-comorbid subsample. When comorbidity was entered as a single independent variable

Conflict of interest

All authors declare that they have not conflict of interest.

Acknowledgements

We thank all participating general practices for enabling data collection on their premises, and all participants for providing their data for our analyses. We thank Mrs. Bluhm, Mrs. Fahndrich, Mrs. Tychsen-Witt, Mrs. Wolf, Mrs. Willudt, Mrs. Madaler, Mr. Kruse, Mrs. Först, Mr. Wüstenberg, Mr. Biedendieck, Mrs. Dybeck, Mrs. Macke, Mr. Mommsen and Mr. Sommer for assisting us with data collection. We thank Mrs. Kreutzer for data entry and correction.

Role of funding source: this study is part of

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For example, online (Montag et al., 2015) and face-to-face or telephone (Satre et al., 2013) BI led to significant improvement in drinking outcomes among patients with co-occurring depression. However, in studies with general practice patients (Grothues et al., 2008) and college students (Geisner et al., 2015), BI was less effective among participants with co-occurring depression. Here our aim is to compare the effect of BI between depressed and non-depressed patients.
The combination of unhealthy alcohol use and depression is associated with adverse outcomes including higher rates of alcohol use disorder and poorer depression course. Therefore, addressing alcohol use among individuals with depression may have a substantial public health impact. We compared the effectiveness of a brief intervention (BI) for unhealthy alcohol use among patients with and without depression.
This observational study included 312,056 adult primary care patients at Kaiser Permanente Northern California who screened positive for unhealthy drinking between 2014 and 2017. Approximately half (48%) received a BI for alcohol use and 9% had depression. We examined 12-month changes in heavy drinking days in the previous three months, drinking days per week, drinks per drinking day, and drinks per week. Machine learning was used to estimate BI propensity, follow-up participation, and alcohol outcomes for an augmented inverse probability weighting (AIPW) estimator of the average treatment (BI) effect. This approach does not depend on the strong parametric assumptions of traditional logistic regression, making it more robust to model misspecification.
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On average, BI is an effective approach to reducing unhealthy drinking, but more research is necessary to understand its impact on patients with depression. AIPW with machine learning provides a robust method for comparing intervention effectiveness across subgroups.
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Depressive symptoms have been commonly related to problematic drinking (Grothues et al., 2008).
This study sought to explore whether individuals who self-medicate with alcohol experience higher levels of depression, and whether symptom level experiences are affected by the behavior of self-medication.
Data were from the Wave I (2001–2002) National Epidemiologic Survey on Alcohol and Related Conditions – NESARC. Only participants who answered affirmatively to either one or both of the two stem questions that highlight the key symptoms of depression were included (n = 13,753).
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The findings aid understanding of the drinking patterns and other mental health correlates of those who engage in the behavior of self-medication. Findings indicate that those who self-medicate are at a higher risk for suicidality, given the same level of depression. These findings highlight the importance of identifying these potentially problematic health behaviors as early as possible, due to these risks.
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Individuals in this age group report the highest rates of hazardous drinking (e.g., misuse, alcohol-related problems; Whiteford et al., 2013) and emotional problems such as depression and anxiety (Ibrahim et al., 2013; Schry & White, 2013). Not surprisingly given the high comorbidity rates, these emotional challenges are likewise related to drinking problems among young adults (Grothues et al., 2008). The impact of both disorders leads to disproportionately greater impairment than either disorder alone, including poor health and treatment outcomes, higher rates of relapse, increased suicidality, relationship difficulties, increased risk of injury or accidents, and early mortality (Beidel et al., 2014; Grant et al., 2015; Lai et al., 2015; Prior et al., 2017).
Many young adults struggle with comorbid alcohol misuse and emotional problems (i.e., depression and anxiety). However, there is currently a paucity of evidence-based, integrated, accessible treatment options for individuals with these comorbidities. The main goal of this study was to examine efficacy of a novel online, minimally guided, integrated program for comorbid alcohol misuse and emotional problems in young adults. Method: The study was an open-label two-arm RCT. Participants (N = 222, M_age = 24.6, 67.6% female) were randomized to one of two conditions: the Take Care of Me program (an 8-week, online integrated treatment condition consisting of 12 modules), or an online psychoeducational control condition. Intervention modules incorporated content based on principles of cognitive behavioral therapy and motivational interviewing. Participants completed assessment data at baseline, at the end of treatment (i.e., 8 weeks), and at follow-up (i.e., 24 weeks). Data were analyzed using generalized linear mixed models. Results: We observed that participants in the treatment condition showed larger reductions in depression, hazardous drinking, as well as increases in psychological quality of life and confidence at the end of treatment. We did not find group differences on total alcohol use at follow-up, but participants in the treatment group reduced their hazardous drinking and improved their quality of life at 24-week follow-up. Conclusions: Our study provides promising initial evidence for the first iteration of the comorbid alcohol misuse and emotional problems online program.
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Effectiveness of brief alcohol interventions for general practice patients with problematic drinking behavior and comorbid anxiety or depressive disorders

Abstract

Background

Methods

Results

Conclusion

Introduction

Section snippets

Procedure

Participants

Discussion

Conflict of interest

Acknowledgements

Drug Alcohol Depend.

Addict. Behav.

Alcohol as a key area

Br. Med. J.

Experimental design and project administration

Brief interventions for alcohol problems: a review

Addiction

Psychiatric disorders among at-risk consumers of alcohol in the general population

J. Stud. Alcohol

Guidelines on Sensible Drinking

The reliability and validity of the alcohol use disorder identification test (AUDIT) in a German general practice population sample

J. Stud. Alcohol

Strategies to increase alcohol screening in health care settings

Alcohol Health Res. World

Barriers to alcoholism treatment: reasons for not seeking treatment in a general population sample

J. Stud. Alcohol

The effect of depression on return to drinking: a prospective study

Arch. Gen. Psychiatry

Intention to change drinking behavior in general practice patients with problematic drinking and comorbid depression and anxiety

Alcohol Alcohol.