Gender differences in correlates of recent physical assault among untreated rural and urban at-risk drinkers: role of depression

This study examined gender-specific correlates of past 6-month physical assault victimization among 468 men and 229 women at-risk drinkers recruited from both urban and rural settings. Both alcohol dependence and depression were associated with physical assault, but there were differences for women and men in the pattern of significant correlates. Specifically, for women the presence of alcohol dependence, depression or their comorbidity all were associated with physical assault. For men, depression by itself was not associated with physical assault, but alcohol dependence and especially alcohol dependence comorbid with depression were significant predictors. Further, there were stronger relationships between demographics and physical assault for men. The results have implications regarding identification of risk factors for physical assault victimization among at-risk drinkers. Overall, the results of this study suggest that screening and prevention interventions for physical assault among at-risk drinkers should target both alcohol use disorders and depression.

Variations in drinking patterns in the rural South: joint effects of race, gender, and rural residence

OBJECTIVES

To understand the relative contribution of gender, race (African-American vs. Caucasian), and rural residence on variations in drinking patterns, including past year abstinence, at-risk drinking, and recent drinking quantity and frequency for drinkers only.

METHODS

A brief health survey was administered by telephone to a probability sample of 11,529 residents of six southern states, over-sampling rural inhabitants.

RESULTS

Drinking patterns varied by gender, race, and rural residence in bivariate analysis. Gender effects were independent of rural residence, but race effects on abstinence and at-risk drinking were found only in urban residents and race differences in drinking quantity only in rural residents. Multivariate analysis, controlling for age and education, found gender and rural residence to be the strongest predictors, as well as being an African-American female.

CONCLUSIONS

Female gender, African-American race, and rural residence appear protective for at-risk drinking but rural residence dominates racial differences.

Characteristics of cocaine users presenting to an emergency department chest pain observation unit

OBJECTIVES

This report examines the sociodemographic and substance use characteristics, co-occurring psychological status, substance abuse consequences, and prior experiences with substance abuse treatment among patients with cocaine-associated chest pain presenting to an emergency department chest pain observation unit.

METHODS

This was a consecutive cohort of patients in the emergency department chest pain observation unit aged 18-60 years with low to moderate risk for acute coronary syndrome and recent cocaine use. Responses on standardized and validated instruments were used to examine demographic and clinical characteristics of the sample and to compare patients who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for past three-month substance abuse or substance dependence with patients who did not.

RESULTS

Of 145 eligible patients identified between June 1, 2002, and February 29, 2004, 86% met criteria for a lifetime DSM-IV substance use disorder and 50% met past three-month criteria. Approximately one half of the total sample reported substantial symptoms of depression. Substance use frequency and consequences, depression, and psychological distress were significantly more severe among those with past three-month substance use diagnoses; however, most sociodemographic characteristics were not associated with substance use diagnoses. Interest in treatment services and treatment history was also significantly associated with the presence of a substance use disorder diagnosis.

CONCLUSIONS

Findings regarding diversity in alcohol and drug involvement, current level of psychological functioning, depressive symptomatology, and interest in treatment services provide useful information for designing emergency department-based interventions for this population.

Gang and multiple rapes during military service: health consequences and health care

OBJECTIVES

We aimed to determine whether there were differences in women veteran's health status and use of health care services by type of rape that occurred during military service.

METHODS

We conducted a national cross-sectional survey of women veterans who served in Vietnam and subsequent eras and were listed in Department of Veterans Affairs comprehensive women's health care registries. We used structured telephone interviews to gather socioeconomic information, violence history, use of outpatient health care services, and health status for a random sample, stratified by region and era of service.

RESULTS

Five hundred forty women completed the interview, 28% of whom reported being raped during military service. Nineteen percent reported a single rape, 5% reported repeated rape (range 2-36), and 5% reported gang rape. Women who reported repeated and gang rapes had significantly impaired physical and emotional health compared with women with a single or no rape (p < or = .05). Repeatedly raped women were more likely to use inpatient and outpatient mental health services (p < or = .05). Gang-rape survivors reported the most severe impairment in physical functioning and general health and demonstrated a trend to seek outpatient medical services.

CONCLUSIONS

Simply asking a woman if she has been raped is not sufficient to detect the level of consequences. More than a decade after military discharge, women who experienced repeated or gang rape during their military service had significant impairment of physical and emotional health compared with women with no or a single rape. The differential health effects associated with severe violence supports the public health importance of sexual violence screening, treatment, and prevention.

Factors associated with perceived stigma for alcohol use and treatment among at-risk drinkers

This study examined the perceived public stigma for alcohol use and treatment among a sample of 733 at-risk drinkers living in the South. Substantial levels of perceived stigma were reported for the community's judgment about at-risk drinking (86.1%), community's judgment about seeking primary care treatment for alcohol disorders (48.9%), community's judgment about seeking specialty treatment (56.3%), and primary care providers' judgment about their patients who were at-risk drinkers (35.7%). Similarly, respondents perceived a substantial lack of privacy associated with primary care treatment (42.0%) and specialty treatment (45.2%). African Americans were more likely to perceive a lack of treatment privacy but they were less likely to perceive community judgment about seeking specialty treatment. Those with greater social network contact intensity were more likely to perceive community judgment about at-risk drinking and more likely to perceive a lack of treatment privacy. Rural at-risk drinkers were more likely to perceive a lack of privacy in primary care.

Life Span and Repeated Violence against Women during Military Service: Effects on Health Status and Outpatient Utilization

PURPOSE

To determine whether the type or frequency of intentional violence experiences among women during military service influences health status or healthcare utilization. Differences in utilization and health status were also examined while controlling for life span violence exposures and important patient characteristic confounders.

METHODS

A cross-sectional survey of women veterans was conducted using a random sample stratified by region and era of service. Women veterans who served in the Vietnam and subsequent eras (n = 520) were selected from comprehensive women's healthcare centers' registries at Department of Veterans medical centers in Boston, Durham, Tampa, Minneapolis, Chicago, and Los Angeles (n = 8693). Socioeconomic information, violence exposure history, outpatient healthcare utilization, and assessment of health status (measured by the Medical Outcomes Study Short-Form 36) were obtained by structured telephone interview.

RESULTS

The type of violence women experienced was unrelated to differences in medical utilization. Women reporting repeated violence exposures during military service had significantly more outpatient visits in the year preceding the interview than singly or nontraumatized peers (16 vs. 9 and 8 visits, respectively, p < 0.05). Repeatedly assaulted women also had poorer health status (p < 0.05), and more often reported a history of childhood violence (p < 0.001) and postmilitary violence (p < 0.001).

CONCLUSIONS

Repeated violence exposure is a relatively common experience among women in the military, and this has substantial implications for their health.

Predictors of short-term course of drinking in untreated rural and urban at-risk drinkers: effects of gender, illegal drug use and psychiatric comorbidity

OBJECTIVE

The purpose of this study was to examine predictors of changes in drinking and drinking consequences in untreated at-risk drinkers in a community sample.

METHOD

Four waves of telephone interviews were conducted at 6-month intervals with a probability sample of at-risk drinkers in the rural and urban South (initial N = 733). Participants were interviewed at each wave regarding concurrent drug use, psychopathology and social support, as well as alcohol service use. Individuals reporting receiving services for drinking (n = 69) were dropped from the analyses. Longitudinal data were analyzed for predictors of quantity and frequency of drinking, "safe" drinking levels and diagnoses of recent alcohol disorder. Simultaneous and lagged models were fit for each dependent variable.

RESULTS

Over the period of study, drinking quantity and alcohol diagnoses decreased, and safe drinking increased. Only a few variables, including drug use and rural residence, predicted change over time for some outcomes. Remaining significant effects associated with drinking outcomes were constant throughout the study. Women and participants scoring high on religiosity experienced better outcomes; illegal drug use and social consequences of drinking were associated with worse outcomes. Rural residents maintained higher drinking quantity and were less likely to be safe drinkers than urban residents were. Psychiatric comorbidity was significantly associated only with drinking quantity.

CONCLUSIONS

These data distinguish which at-risk drinkers might benefit from short or delayed interventions in primary care or community settings, and which should receive more intensive, targeted interventions and be encouraged to enter formal treatment as soon as possible.

Health services utilization and cost for at-risk drinkers: rural and urban comparisons

OBJECTIVE

The purpose of this study was to examine differences between healthcare use and associated costs in rural and urban at-risk drinkers.

METHOD

Primary healthcare utilization and cost data were collected from 1995 to 1998 on rural (n = 215) and urban (n = 228) cohorts of drinkers residing in six southeastern states who met criteria for at-risk drinking. Data were obtained through subject interview and from abstracts of medical and pharmacy records.

RESULTS

Overall healthcare costs were not significantly different between the rural and urban cohorts. For subjects who incurred any hospital costs (including emergency room [ER] visits), however, costs were significantly greater (p < .01) for rural patients (median = dollars 2,561) than for urban patients (median = dollars 865). Hospital costs associated with patients' ER visits and any subsequent admissions were also greater (p < .01) for rural patients (median = dollars 1,004) than for urban patients (median = dollars 512). Use of healthcare services was significantly more likely to occur among women (p < .0001), individuals with lower overall self-reported physical health (p < .01) and individuals with health insurance (p < .0001). Among subjects who used healthcare services, greater costs were significantly associated with older age (p < .05), being female (p <.0001), having lower overall physical health (p < .0001) and having health insurance (p < .01).

CONCLUSIONS

While overall healthcare costs are not significantly different between rural and urban residents in this sample of at-risk drinkers, there are some notable differences in the costs associated with inpatient and ER services.

Rural-urban differences in health care benefits of a community-based sample of at-risk drinkers

CONTEXT

Different types of health plan cost-containment strategies (eg, gatekeeping, selective contracting, and cost-sharing) may affect the utilization of behavioral health services differently in urban and rural areas.

PURPOSE

This research compares the cost-containment strategies used by the health plans of insured at-risk drinkers residing in rural and urban areas.

METHODS

A screening instrument for at-risk drinking was administered by phone to approximately 12,000 residents of 6 southern states; 442 at-risk drinkers completed 4 interviews over a 2-year period and consented to release insurance and medical records. Two thirds of the sample (n=294) were insured during the last 6 months of the study. In 1998, health plan characteristics were successfully collected for 217 (72.3%) of the insured at-risk drinkers, representing 113 different health plans and 206 different policies.

FINDINGS

Compared with urban at-risk drinkers, rural at-risk drinkers were significantly less likely to be enrolled in a health plan with gatekeeping policies for both behavioral health (P = .001), and physical health (P = .031). Compared with urban enrollees, rural enrollees were significantly more likely to pay deductibles (P = .042), to pay coinsurance for physical health services (P = .002), and to have limits placed on physical health services use (P = .067), but they were less likely to pay copayments for physical health (P = .046). Rural enrollees were less likely to face higher copayments (P = .007) and higher coinsurance (P = .076) for mental health than for physical health, compared to urban enrollees.

CONCLUSIONS

Because rural residents were more likely to be enrolled in indemnity plans and less likely to be enrolled in health maintenance organizations, rural at-risk drinkers were enrolled in plans that relied less on supply-side cost-containment strategies and more on demand-side cost-containment strategies targeting physical health service use, compared with their urban counterparts. Rural at-risk drinkers were less likely to be enrolled in health plans with greater cost-sharing for mental health than for physical health compared to urban at-risk drinkers.

Clinical practice variations in prescribing antipsychotics for patients with schizophrenia

Few studies have examined the variations among individual physicians in prescribing antipsychotics for schizophrenia. This study examined clinical practice variations in the route and dosage of antipsychotic medication prescribed for inpatients with schizophrenia by 11 different psychiatrists. The sample consisted of 130 patients with a DSM-III-R diagnosis of schizophrenia who had received inpatient care at a state hospital or Veterans Affairs medical center in the southeastern United States in 1992-1993. Mixed-effects regression models were developed to explore the influence of individual physicians and hospitals on route of antipsychotic administration (oral or depot) and daily antipsychotic dose, controlling for patient case-mix variables (age, race, sex, duration of illness, symptom severity, and substance-abuse diagnosis). The average daily antipsychotic dose was 1092 +/- 892 chlorpromazine mg equivalents. Almost half of the patients (48%) were prescribed doses above or below the range recommended by current practice guidelines. The proportion of patients prescribed depot antipsychotics was significantly different at the 2 hospitals, as was the antipsychotic dose prescribed at discharge. Individual physicians and patient characteristics were not significantly associated with prescribing practices. These data, which were obtained before clinical practice guidelines were widely disseminated, provide a benchmark against which to examine more current practice variations in antipsychotic prescribing. The results raise several questions about deviations from practice guidelines in the pharmacological treatment of schizophrenia. To adequately assess quality and inform and possibly further develop clinical practice guideline recommendations for schizophrenia, well-designed research studies conducted in routine clinical settings are needed.

Service utilization and outcomes in medically ill veterans with posttraumatic stress and depressive disorders

This study examined behavioral health service utilization, health-related quality of life, and psychological distress in medically hospitalized male veterans (N = 743) with and without current or lifetime comorbid posttraumatic stress disorder (PTSD) and depressive disorder. Participants completed psychiatric and psychosocial self-report measures at baseline and follow-up. Clinical/functional status and service utilization rates were compared for patients with PTSD only, depressive disorder only, comorbid PTSD/depressive disorder, and neither disorder. Patients with PTSD/depressive disorder were more likely to use mental health/substance abuse services, have longer lengths of stay, and report more psychological distress than others. Results indicate that screening, early detection, and referral are critical in treating these comorbid patients because of increased psychological distress and high service-use rates.

Vulnerability factors for homelessness associated with substance dependence in a community sample of homeless adults

We studied a community probability sample of 1185 homeless individuals to examine substance dependence in relationship to other personal and social vulnerabilities linked to homelessness, including sociodemographics, childhood/adolescent factors, prehomelessness factors, multiple episodes of homelessness, and the quality of shelter in their current episode of homelessness. These vulnerability factors were significantly concentrated in homeless individuals with lifetime and recent substance dependence, especially among those with both alcohol and drug dependence. In addition, the profiles of the homeless with alcohol dependence alone were distinct from those with drug dependence alone or both, with older age, more males, longer histories of homelessness, and significantly poorer quality shelter during the previous 30 days. Therefore, homeless individuals with substance dependence have many vulnerabilities beyond their substance dependence that should be dealt with in treatment or other service settings before lasting housing can be achieved.

Factors associated with women's risk of rape in the military environment

BACKGROUND

Health hazards specific to women workers have not been adequately documented. This study assessed military environmental factors associated with rape occurring during military service, while controlling for pre-military trauma experiences.

METHODS

A national cross-sectional survey of 558 women veterans serving in Vietnam or in subsequent eras was obtained through structured telephone interviews.

RESULTS

Rape was reported by 30% (n = 151) of participants, with consistent rates found across eras [corrected]. Military environmental factors were associated with increased likelihood of rape, including: sexual harassment allowed by officers (P < 0.0001), unwanted sexual advances on-duty (P < 0.0001) and in sleeping quarters (P < 0.0001).

CONCLUSION

Violence towards military women has identifiable risk factors. Work and living environments where unwanted sexual behaviors occurred were associated with increased odds of rape. Officer leadership played an important role in the military environment and safety of women. Assailant alcohol and/or drug abuse at time of rape was notable. Interventions and policies based on modifiable environmental risk factors are needed to increase protection for women in the workplace.

Differences between physical and behavioral health benefits in the health plans of at-risk drinkers

OBJECTIVE

The goal of this study was to describe the physical and behavioral health benefits of a representative community-based sample of at-risk drinkers potentially in need of behavioral health services.

METHODS

A screening instrument for at-risk drinking was administered by telephone to a random community sample of more than 12,000 adults. A telephone interview was conducted with the health plans of 294 at-risk drinkers who were insured and who consented to the release of their insurance records to collect information about supply-side cost-containment strategies (for example, gatekeeping and restrictions on choice of provider), and demand-side cost-containment strategies (for example, deductibles, limits, coinsurance, and copayments). Information about health plan characteristics was successfully collected for 217 (72 percent) of the insured at-risk drinkers, representing 113 different health plans and 206 different policies.

RESULTS

Both provider choice restrictions and gatekeeping were more likely to be used for behavioral health care than for physical health care. Greater cost-sharing for mental health than for physical health was most often achieved by using additional limits (83 percent) and higher coinsurance (66 percent) and less often achieved by using higher copayments (38 percent) and additional deductibles (13 percent). The greater cost-sharing for behavioral health amounted to a 30 percent ($42) difference in annual out-of-pocket costs for an average user of behavioral health services compared with full parity.

CONCLUSIONS

The results provide information to advocacy groups and policy makers about how much equalization would have to occur in the insurance market before full parity could be achieved between physical health and behavioral health benefits for a population of individuals potentially in need of behavioral health services.

Depressive disorders and alcohol dependence in a community population

This cross-sectional study examines sociodemographic, clinical and func tional correlates of comorbid depression in a community sample of 268 individuals with alcohol dependence. Results of analyses comparing drinkers with either current or past depression to never-depressed drinkers showed that respondents in the former two groups were more likely to be female and report more comorbid drug use disorders. In addition to marked functional impairment for currently depressed drinkers, we also found that respondents with past depression were significantly less likely to have health insurance coverage. This lack of insurance for previously depressed persons calls for future work examining the potential influence of this barrier to access care on both clinical and functional outcomes.

Depressive symptomatology and early attrition from intensive outpatient substance use treatment

This study examines the relationship between depressive symptoms and attrition from outpatient treatment in a Veterans Affairs facility that had recently moved to intensive outpatient-only treatment for substance abuse. This article focuses on 126 consecutively admitted patients who were enrolled on their last day of a 3- to 4-day outpatient detoxification. Results indicate that severe depressive symptomatology presenting at treatment entry is a significant risk factor for early attrition from intensive outpatient substance use treatment but not later attrition. These data indicate that retention efforts should be directed toward the assessment and management of depressive symptoms early in the treatment process, with interventions targeted to those who report severe symptomatology. The results also indicate that future research should focus on potential distinguishing characteristics between early and later attrition.

The impact of drinking and drinking consequences on short-term employment outcomes in at-risk drinkers in six southern states

Alcohol use and misuse impose economic burdens, with over half the total costs estimated associated with lost productivity. Research on labor productivity and alcohol abuse has been limited by methodologic differences, making conclusions equivocal. This study employed two waves of data from a community probability sample of 658 at-risk drinkers. It analyzed the prospective impact of several measures of drinking and drinking consequences on the 6-month follow-up probability of not being employed and fewer weeks of employment if employed. Drinking seven drinks or more on an average drinking day significantly increased the likelihood of not working and, for those who were working, reduced weeks of employment. Thus, productivity benefits may accrue from developing treatments for at-risk drinkers, particularly interventions to reduce drinking.

The impact of problem drinking on employment

Social cost studies report that alcohol use and misuse impose a great economic burden on society, and over half of the total economic costs are estimated to be due to the loss of work productivity. Controversy remains, however, as to the magnitude and direction of the effects of alcohol consumption on productivity. Furthermore, most of the studies have looked at the relationship between problem drinking and wages. This paper investigates the impact of problem drinking on employment by analysing a random sample of men and women of prime working age from six Southern states in the US (Alabama, Arkansas, Georgia, Louisiana, Mississippi and Tennessee). The data set contains 4898 females and 3224 males, with information on both employment and problem drinking. To eliminate the bias that may result from single-equation estimation, we used a bivariate probit model to control for possible correlation in the unobservable factors that affect both problem drinking and employment. We find no significant negative association between problem drinking and employment for both men and women, controlling for other covariates. The findings are consistent with other research and highlight several methodological issues. Furthermore, the study suggests that estimates of the costs of problem drinking may be overstated owing to misleading labour supply relationships.

Short-term course of drinking in an untreated sample of at-risk drinkers

OBJECTIVE

We know little about the short-term course of drinking, particularly the stability or instability of at-risk drinking in untreated drinkers. Because few at-risk drinkers obtain help for their drinking, it is important to understand the short-term fluctuations between at-risk drinking and full-fledged alcohol use disorders, as well as remission of at-risk drinking.

METHOD

We used four waves of data (each 6 months apart) from a probability community sample of 733 at-risk drinkers in six states in the southern United States to determine variation in abstinence, drinking patterns and alcohol use disorders over a 2-year period. For this analysis, we excluded those who reported receiving services for drinking during the 2-year study period (retrospectively at baseline), leaving a sample size of 664 (444 male); 479 (306 male) completed all four interviews.

RESULTS

Although the majority (88%) of the sample was nonabstinent throughout the study, we found significant decreases in average number of drinks per drinking day and recent (past 6 months) alcohol disorders, and an increase in 6-month abstinence. Almost 30% of those with no recent alcohol disorder at baseline (n = 280) later met diagnostic criteria in at least one interview. Of those with a recent alcohol disorder at baseline (n = 199), one third met criteria in at least two subsequent interviews.

CONCLUSIONS

There is some evidence for short-term progression from at-risk drinking to alcohol disorder. However, there is stronger evidence for declining problems and a fluctuation in and out of recovery and relapse, which may reflect an effort to maintain controlled drinking. Understanding this short-term course is important for primary and secondary prevention efforts and for screening of at-risk drinking in primary care and in the workplace.

Comparing outcomes of routine care for depression: the dilemma of case-mix adjustment

The purpose of this study was to formulate and test two case-mix models for depression treatment that permit comparisons of patient outcomes across diverse clinical settings. It assessed demographics; eight, diagnostic-specific, case-mix variables; and clinical status at baseline and follow-up for 187 patients. Regressions were performed to test two models for four dependent variables including depression severity and diagnosis. Individual treatment settings were then ranked based on a comparison of actual versus predicted outcomes using regression coefficients and predictor variables. A model inclusive of baseline physical health status and depression severity predicted depression severity, mental health, and physical health functioning at follow-up. A simpler model performed well in predicting depression remission. This study identifies variables to be included in case-mix adjustment models and demonstrates statistical methods to control for differences across settings when comparing depression outcomes.

Correlates and 6-month outcomes for co-occurring cannabis use in rural and urban at-risk drinkers

We know little about the functional correlates of recent cannabis use when such use is additional to an "alcohol disorder" in non-treatment populations. We report on data from a prospective study of a large probability community survey of 733 at-risk drinkers in six Southern U.S. states (Alabama, Arkansas, Georgia, Louisiana, Mississippi, and Tennessee) conducted from 1995 to 1996. Twenty-one percent reported cannabis use during the past six months at the baseline interview. These cannabis users were significantly less likely to be married, employed, or a high school graduate (p < .05). They were also more likely to have a diagnosis of "antisocial personality disorder" or "panic disorder." Recent cannabis users also reported more negative consequences of their alcohol use, including more frequent recent diagnoses of an "alcohol disorder," legal difficulties associated with their drinking, and more social consequences attributed to drinking. At the six-month follow-up interview, negative alcohol outcomes were associated with concurrent cannabis use, including higher frequency and quantity of alcohol consumption, greater frequency of recent "alcohol abuse" and "dependence," and greater social consequences of drinking. These results all point to substantially poorer functioning and experiences of individuals with concurrent at-risk alcohol and cannabis use. We suggest that cannabis use may be a marker for greater impairment associated with at-risk drinking.

Rural-urban differences in service use for memory-related problems in older adults

The reduced availability of providers and travel difficulties in rural areas may thwart older rural adults from getting the care they need for memory-related problems. The purpose of this study was to determine whether rural-urban differences exist in the probability of any service use of primary care physicians and mental health specialists in a full sample of older adults and in a subset of impaired respondents. In the full sample, rural respondents were 0.66 times as likely (p = .06) to have used primary care physicians for memory-related problems compared with urban respondents. In the subgroup, rural individuals were 0.26 times as likely (p = .02). In both groups, there were no rural-urban differences in the probability of mental health specialty use for memory-related problems. Further investigations are necessary to determine the causes.