Readiness to change as a mediator of the effect of a brief motivational intervention on posttreatment alcohol-related consequences of injured emergency department hazardous drinkers

Kawasaki disease: patients' transition journey and recommendations for adult care

BACKGROUND

Children who develop coronary artery aneurysms after Kawasaki disease are at risk for cardiovascular morbidity, requiring health care transition and lifelong follow-up with an adult specialist. Follow-up losses after health care transition have been reported but without outcome and patient experience evaluation.

OBJECTIVE

The Theoretical Domains Framework underpinned our aim to explore the required self-care behaviours and experiences of young adults' post-health care transition.

METHODS

A qualitative description approach was used for virtual, 1:1 interviews with 11 participants, recruited after health care transition from a regional cardiac centre in Ontario. Directed content analysis was employed.

RESULTS

Health, psychosocial, and lifestyle challenges were compounded by a sense of loss. Six themes emerged within the Theoretical Domains Framework categories. Participants offered novel health care transition programme recommendations.

CONCLUSIONS

The realities of health care transition involve multiple, overlapping stressors for young adults with Kawasaki disease and coronary artery aneurysms. Our findings will inform a renewed health care transition programme and will include outcome evaluation.

Measurement Invariance of the Readiness to Change Questionnaire Among Injured Patients Who Received a Brief Intervention for Alcohol Use

We tested measurement invariance of the Readiness to Change Questionnaire (RCQ) to evaluate its utility in assessing the stages of change in the context of brief intervention for alcohol use in opportunistic settings. Participants (N = 596) were patients admitted from three Level I trauma centers who were randomly assigned to one of three brief alcohol interventions. The RCQ was administered at baseline and 3-month follow-up. The RCQ was scalar invariant across biological sex and partially scalar invariant across race/ethnicity and alcohol use severity. Hispanic participants were higher on contemplation and action and Black participants were higher on action than White participants. Hazardous drinkers were lower in precontemplation and higher in contemplation and action than nonhazardous drinkers. The RCQ was scalar invariant across intervention conditions and time. Brief motivational intervention with a booster increased action from baseline to 3 month. These findings provide further support for the use of the RCQ.

Treatment-As-Usual Control Groups in Brief Alcohol Intervention Trials: A Systematic Review and Meta-Analysis

OBJECTIVE

Brief alcohol interventions (BAIs) are evidence-based practices that can help reduce hazardous drinking among patients in medical settings. However, descriptions of the treatment-as-usual (TAU) control groups that BAIs are compared to in clinical trials often lack clarity and detail. This systematic review and meta-analysis quantified and compared descriptions of intervention and TAU control arms within reports of randomized controlled trials and examined whether treatment effects were affected by level of detail in narrative descriptions.

METHOD

A systematic literature search to identify eligible articles was performed. Studies were rated on methodological quality, and the Template for Intervention Description and Replication (TIDieR) checklist was used to rate the level of clarity and detail included in descriptions of the intervention and TAU conditions in eligible articles. Data were extracted from articles for use in meta-analysis and meta-regression.

RESULTS

Twenty-one studies met inclusion criteria. Across the studies, TIDieR ratings for intervention arms were higher than ratings for control arms. BAIs were linked to reductions in drinks per week, heavy drinking episodes, and alcohol consequences over time when compared with TAU. TIDieR ratings for control groups were significantly associated with larger treatment effects on drinks per week and alcohol consequences but were not significant for heavy drinking episodes.

CONCLUSIONS

This meta-analysis reiterated the effectiveness of BAIs in medical settings. Yet the lack of clarity in TAU descriptions raises concerns regarding the validity of BAI trials, suggesting need for more detailed reporting and use of the TIDieR guidelines for support.

Measurement invariance of the University of Rhode Island Change Assessment Scale in Project MATCH: An exploratory structural equation modeling approach

BACKGROUND

Progression through the stages of change is a proposed mechanism underlying the effects of treatment for alcohol use disorder (AUD). However, examining stages of change as a mechanism of treatment effects requires that the measure be invariant across patient subgroups, treatment conditions, and time. In this study, we examined measurement invariance of the University of Rhode Island Change Assessment Scale (URICA) in Project MATCH using an exploratory structural equation modeling (ESEM) approach.

METHODS

We conducted a secondary analysis of data from Project MATCH (N = 1726; M_age  = 40.2, SD = 10.9; 75.7% male; 80% non-Hispanic white), a multisite randomized clinical trial that tested three AUD treatments: Motivational Enhancement Therapy, Cognitive-Behavioral Therapy, or Twelve-Step Facilitation. Participants completed the 24-item URICA for assessing the stages of change in relation to drinking at baseline and post-treatment (3 months after baseline).

RESULTS

A 4-factor ESEM provided a good fit to the data and a better fit to the data than a conventional 4-factor confirmatory factor analysis model. Further, the URICA demonstrated scalar invariance across each patient subgroup at baseline (sex, ethnicity, marital status, education, and parental history of AUD) and treatment condition at follow-up. However, the URICA was not longitudinally invariant as the metric model resulted in a significant decrement in model fit.

CONCLUSIONS

Measurement invariance of the URICA over time was not supported. Longitudinally invariant measures of the stages of change are needed to test the proposal that progression through the stages explains treatment effects.

The Effects of a Brief Motivational Intervention for Alcohol Use through Stages of Change among Nontreatment Seeking Injured Patients

BACKGROUND

Little is known about the mechanisms of change underlying brief interventions and the patient characteristics that may affect them. The present study tested whether the stages of change mediate the effects of a BMI with and without a telephone booster relative to brief advice (i.e., multiple mediation). Further, the present study tested whether the effects of the BMI conditions on the stages of change were contingent on patients' alcohol use severity (i.e., moderated mediation).

METHODS

The present study is a secondary analysis using data from injured adult patients at 3 trauma centers who were screened for inclusion in the study and randomly assigned to brief advice (n = 200), BMI (n = 203), or BMI with a telephone booster (n = 193) (Field et al., 2014). Participants completed a baseline assessment and 3-, 6-, and 12-month follow-up assessments that included self-report measures of the stages of change, alcohol use, and alcohol-related problems, as well as other variables of interest.

RESULTS

The results demonstrated significant and consistent mediation at p < 0.05 wherein BMI with a telephone booster increased action at 3-month follow-up leading to reduced likelihood of at-risk drinking, less alcohol use, and fewer alcohol problems at both 6- and 12-month follow-up. However, moderated mediation analyses suggested that the effects of the BMI conditions on the stages of change were not contingent on patients' alcohol use severity.

CONCLUSIONS

This study contributes to the understanding of stages of change as potential mechanisms of change in BMI. Directions for future research are discussed.

Factor, Concurrent and Predictive Validity of the Readiness to Change Questionnaire [Treatment Version] Among Non-Treatment-Seeking Individuals

AIMS

This study assessed the factor, concurrent and predictive validity of the revised Readiness to Change Questionnaire [Treatment Version] (RCQ[TV]) among non-treatment-seeking individuals.

METHODS

Non-treatment-seeking patients (Mage = 34.8, SD = 12.4) who screened positive for alcohol misuse were recruited from three urban Level I Trauma Centers and completed the RCQ[TV] (Heather et al. [(1999) Development of a treatment version of the Readiness to Change Questionnaire. Addict Res7, 63-83]).

RESULTS

A confirmatory factor analysis supported the three-factor structure of the RCQ[TV]. Observed scores for precontemplation, contemplation and action demonstrated concurrent validity, as they were correlated with drinking and alcohol-related problems prior to baseline assessment. Finally, RCQ[TV] scores at baseline added to the predictability of an alcohol consumption composite score at a 3-month follow-up after controlling for baseline alcohol consumption and randomization to treatment arm.

CONCLUSIONS

The results of the present study suggest that the RCQ[TV] has desirable psychometric properties and supports the use of the RCQ[TV] among non-treatment-seeking patients with alcohol misuse.

An Examination of Motivation to Change and Neural Alcohol Cue Reactivity Following a Brief Intervention

Background: Brief interventions represent a promising psychological intervention targeting individuals with heavy alcohol use. Motivation to change represents an individual's openness to engage in a behavior change strategy and is thought to be a crucial component of brief interventions. Neuroimaging techniques provide a translational tool to investigate the neurobiological mechanisms underlying potential mediators of treatment response, including motivation to change. Therefore, this study aimed to examine the effect of a brief intervention on motivation to change drinking behavior and neural alcohol taste cue reactivity. Methods: Non-treatment-seeking heavy drinkers were randomized to receive a brief drinking intervention (n = 22) or an attention-matched control (n = 24). Three indices of motivation to change were assessed at baseline and after the intervention or control session: importance, confidence, and readiness. Immediately following the intervention or control session, participants also underwent an functional magnetic resonance imaging (fMRI) during which they completed an alcohol taste cues paradigm. Results: There was a significant effect of the brief intervention on increasing ratings of importance of changing drinking behavior, but not on ratings of confidence or readiness to change. Ratings of importance after the intervention or control session were associated with neural alcohol taste cue reactivity, but notably, this effect was only significant for participants who received the intervention. Individuals in the intervention condition showed a positive association between ratings of importance and activation in the precuneus, posterior cingulate, and insula. Conclusions: The brief drinking intervention was successful at improving one dimension of motivation to change among non-treatment-seeking heavy drinkers. The brief intervention moderated the relationship between ratings of importance and brain activation in circuitry associated with interoceptive awareness and self-reflection. Together, findings represent an initial step toward understanding the neurobiological mechanisms through which a brief intervention may improve motivation to change.

Mechanisms of behavior change in a brief dual-target motivational intervention: Reduction in alcohol use mediates intervention effects on risky sex

To examine the mechanisms underlying the efficacy of a dual-target motivational intervention (MI) to reduce heavy drinking and risky sex. A priori hypotheses were that: increases in alcohol-related readiness to change (RTC) and self-efficacy would mediate the effect of MI on alcohol use; increases in sex-related RTC and self-efficacy would mediate the effect of MI on risky sex; and reductions in alcohol use would mediate reductions in risky sex. Patients in Emergency Departments who screened positive for heavy drinking and risky sex were randomly assigned to receive MI or brief advice. RTC and self-efficacy were assessed at baseline and immediately postintervention. Alcohol use and sexual behavior was assessed at baseline, 3-, 6-, and 9-month follow up. Single- and serial-mediation models were tested. Patients who received MI had higher postintervention RTC and self-efficacy, but neither mechanism mediated the effects of MI on behavioral outcomes. Reduction in heavy drinking mediated the effect of MI on frequency of sex under the influence (SUI). Further, the effect of MI on condomless sex was mediated by an indirect path in which reductions in heavy drinking at 3 months predicted less SUI at 6 months, which in turn predicted reduction in condomless sex at 9-months. Although some effect of dual-target MI on risky sex is independent of drinking, treatment-related reduction in heavy drinking does account for a significant portion of reduction in risky sex, providing support for the utility of this intervention in patient populations where heavy drinking and risky sex co-occur. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Testing Mediators of Reduced Drinking for Veterans in Alcohol Care Management

INTRODUCTION

Alcohol Care Management (ACM) is a manualized treatment provided by behavioral health providers working in a primary care team aimed at increasing patients' treatment engagement and decreasing their alcohol use. Research has shown that ACM is effective in reducing alcohol consumption; however, the mechanisms of ACM are unknown. Therefore, the purpose of this study is to examine the mechanisms of change in ACM in the context of a randomized clinical trial evaluating the effectiveness of ACM.

MATERIALS AND METHODS

This study performed secondary data analysis of existing data from a larger study that involved a sample of U.S. veterans (N = 163) who met criteria for current alcohol dependence. Upon enrollment into the study, participants were randomized to receive either ACM or standard care. ACM was delivered in-person or by telephone within the primary care clinic and focused on the use of oral naltrexone and manualized psychosocial support. According to theory, we hypothesized several ACM treatment components that would mediate alcohol consumption outcomes: engagement in addiction treatment, reduced craving, and increased readiness to change. Parallel mediation models were performed by the PROCESS macro Model 4 in SPSS to test study hypotheses. The institutional review boards at each of the participating facilities approved all study procedures before data collection.

RESULTS

As hypothesized, results showed that treatment engagement mediated the relation between treatment and both measures of alcohol consumption outcomes, the percentage of alcohol abstinent days, and the percentage of heavy drinking days. Neither craving nor readiness to change mediated the treatment effect on either alcohol consumption outcome.

CONCLUSIONS

Findings suggest that ACM may be effective in changing drinking patterns partially due to an increase in treatment engagement. Future research may benefit from evaluating the specific factors that underlie increased treatment engagement. The current study provides evidence that alcohol use disorder interventions should aim to increase treatment engagement and reduce barriers to care.

Effectiveness of brief alcohol interventions in primary care populations

BACKGROUND

Excessive drinking is a significant cause of mortality, morbidity and social problems in many countries. Brief interventions aim to reduce alcohol consumption and related harm in hazardous and harmful drinkers who are not actively seeking help for alcohol problems. Interventions usually take the form of a conversation with a primary care provider and may include feedback on the person's alcohol use, information about potential harms and benefits of reducing intake, and advice on how to reduce consumption. Discussion informs the development of a personal plan to help reduce consumption. Brief interventions can also include behaviour change or motivationally-focused counselling.This is an update of a Cochrane Review published in 2007.

OBJECTIVES

To assess the effectiveness of screening and brief alcohol intervention to reduce excessive alcohol consumption in hazardous or harmful drinkers in general practice or emergency care settings.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and 12 other bibliographic databases to September 2017. We searched Alcohol and Alcohol Problems Science Database (to December 2003, after which the database was discontinued), trials registries, and websites. We carried out handsearching and checked reference lists of included studies and relevant reviews.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of brief interventions to reduce hazardous or harmful alcohol consumption in people attending general practice, emergency care or other primary care settings for reasons other than alcohol treatment. The comparison group was no or minimal intervention, where a measure of alcohol consumption was reported. 'Brief intervention' was defined as a conversation comprising five or fewer sessions of brief advice or brief lifestyle counselling and a total duration of less than 60 minutes. Any more was considered an extended intervention. Digital interventions were not included in this review.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We carried out subgroup analyses where possible to investigate the impact of factors such as gender, age, setting (general practice versus emergency care), treatment exposure and baseline consumption.

MAIN RESULTS

We included 69 studies that randomised a total of 33,642 participants. Of these, 42 studies were added for this update (24,057 participants). Most interventions were delivered in general practice (38 studies, 55%) or emergency care (27 studies, 39%) settings. Most studies (61 studies, 88%) compared brief intervention to minimal or no intervention. Extended interventions were compared with brief (4 studies, 6%), minimal or no intervention (7 studies, 10%). Few studies targeted particular age groups: adolescents or young adults (6 studies, 9%) and older adults (4 studies, 6%). Mean baseline alcohol consumption was 244 g/week (30.5 standard UK units) among the studies that reported these data. Main sources of bias were attrition and lack of provider or participant blinding. The primary meta-analysis included 34 studies (15,197 participants) and provided moderate-quality evidence that participants who received brief intervention consumed less alcohol than minimal or no intervention participants after one year (mean difference (MD) -20 g/week, 95% confidence interval (CI) -28 to -12). There was substantial heterogeneity among studies (I² = 73%). A subgroup analysis by gender demonstrated that both men and women reduced alcohol consumption after receiving a brief intervention.We found moderate-quality evidence that brief alcohol interventions have little impact on frequency of binges per week (MD -0.08, 95% CI -0.14 to -0.02; 15 studies, 6946 participants); drinking days per week (MD -0.13, 95% CI -0.23 to -0.04; 11 studies, 5469 participants); or drinking intensity (-0.2 g/drinking day, 95% CI -3.1 to 2.7; 10 studies, 3128 participants).We found moderate-quality evidence of little difference in quantity of alcohol consumed when extended and no or minimal interventions were compared (-14 g/week, 95% CI -37 to 9; 6 studies, 1296 participants). There was little difference in binges per week (-0.08, 95% CI -0.28 to 0.12; 2 studies, 456 participants; moderate-quality evidence) or difference in days drinking per week (-0.45, 95% CI -0.81 to -0.09; 2 studies, 319 participants; moderate-quality evidence). Extended versus no or minimal intervention provided little impact on drinking intensity (9 g/drinking day, 95% CI -26 to 9; 1 study, 158 participants; low-quality evidence).Extended intervention had no greater impact than brief intervention on alcohol consumption, although findings were imprecise (MD 2 g/week, 95% CI -42 to 45; 3 studies, 552 participants; low-quality evidence). Numbers of binges were not reported for this comparison, but one trial suggested a possible drop in days drinking per week (-0.5, 95% CI -1.2 to 0.2; 147 participants; low-quality evidence). Results from this trial also suggested very little impact on drinking intensity (-1.7 g/drinking day, 95% CI -18.9 to 15.5; 147 participants; very low-quality evidence).Only five studies reported adverse effects (very low-quality evidence). No participants experienced any adverse effects in two studies; one study reported that the intervention increased binge drinking for women and two studies reported adverse events related to driving outcomes but concluded they were equivalent in both study arms.Sources of funding were reported by 67 studies (87%). With two exceptions, studies were funded by government institutes, research bodies or charitable foundations. One study was partly funded by a pharmaceutical company and a brewers association, another by a company developing diagnostic testing equipment.

AUTHORS' CONCLUSIONS

We found moderate-quality evidence that brief interventions can reduce alcohol consumption in hazardous and harmful drinkers compared to minimal or no intervention. Longer counselling duration probably has little additional effect. Future studies should focus on identifying the components of interventions which are most closely associated with effectiveness.

Effectiveness of SBIRT for Alcohol Use Disorders in the Emergency Department: A Systematic Review

INTRODUCTION

Alcohol use disorders (AUD) place a significant burden on individuals and society. The emergency department (ED) offers a unique opportunity to address AUD with brief screening tools and early intervention. We undertook a systematic review of the effectiveness of ED brief interventions for patients identified through screening who are at risk for AUD, and the effectiveness of these interventions at reducing alcohol intake and preventing alcohol-related injuries.

METHODS

We conducted systematic electronic database searches to include randomized controlled trials of AUD screening, brief intervention, referral, and treatment (SBIRT), from January 1966 to April 2016. Two authors graded and abstracted data from each included paper.

RESULTS

We found 35 articles that had direct relevance to the ED with enrolled patients ranging from 12 to 70 years of age. Multiple alcohol screening tools were used to identify patients at risk for AUD. Brief intervention (BI) and brief motivational intervention (BMI) strategies were compared to a control intervention or usual care. Thirteen studies enrolling a total of 5,261 participants reported significant differences between control and intervention groups in their main alcohol-outcome criteria of number of drink days and number of units per drink day. Sixteen studies showed a reduction of alcohol consumption in both the control and intervention groups; of those, seven studies did not identify a significant intervention effect for the main outcome criteria, but nine observed some significant differences between BI and control conditions for specific subgroups (i.e., adolescents and adolescents with prior history of drinking and driving; women 22 years old or younger; low or moderate drinkers); or secondary outcome criteria (e.g. reduction in driving while intoxicated).

CONCLUSION

Moderate-quality evidence of targeted use of BI/BMI in the ED showed a small reduction in alcohol use in low or moderate drinkers, a reduction in the negative consequences of use (such as injury), and a decline in ED repeat visits for adults and children 12 years of age and older. BI delivered in the ED appears to have a short-term effect in reducing at-risk drinking.

Examining motor vehicle crash involvement and readiness to change on drinking and driving behaviors among injured emergency department patients

OBJECTIVE

To measure the effect of motor vehicle crash (MVC) involvement and readiness to change drinking and driving behaviors on subsequent driving and drinking behaviors among injured emergency department (ED) patients who use alcohol at harmful levels.

METHODS

This was a secondary analysis of a randomized controlled trial of injured ED patients who screened positive for harmful alcohol use, who at recruitment reported driving in the past 12 months and received at least one of the intended intervention sessions (brief behavioral intervention versus attention placebo control; N = 407). Outcome variables were as follows: (1) change in 6 impaired driving behaviors and (2) report of MVCs and traffic violations in the 12 months following recruitment; predictor variables were as follows: (1) treatment assignment, (2) MVC involvement at recruitment, and (3) baseline readiness to change alcohol use and drinking and driving.

RESULTS

Modeling of change in the 6 impaired driving variables indicated that neither the recruitment visits being MVC related nor baseline readiness to change alcohol use and drinking and driving behaviors predicted greater changes in impaired driving over time. Baseline reports of past moving traffic violations and the ED visit being MVC related predicted a greater likelihood of each behavior at 12 months following study recruitment.

CONCLUSIONS

This study and others have demonstrated that ED patients with harmful alcohol use are willing to engage in behavioral interventions directed at changing risky behaviors. However, this study did not demonstrate that patients considered having the potential to be more engaged with the intervention because their ED visit was MVC related and/or they had expressed intent to change their risky alcohol use and drinking and driving behaviors were more likely to change these risky behaviors.

Web-Delivered CBT Reduces Heavy Drinking in OEF-OIF Veterans in Primary Care With Symptomatic Substance Use and PTSD

Veterans from conflicts such as the wars in Iraq and Afghanistan commonly return with behavioral health problems, including posttraumatic stress disorder (PTSD) and hazardous or harmful substance use. Unfortunately, many veterans experience significant barriers to receiving evidence-based treatment, including poor treatment motivation, concerns about stigma, and lack of access to appropriate care. To address this need, the current study developed and evaluated a web-based self-management intervention based on cognitive behavioral therapy (CBT), targeting PTSD symptoms and hazardous substance use in a group of symptomatic combat veterans enrolled in VA primary care. Veterans with PTSD/subthreshold PTSD and hazardous substance use were randomized to primary care treatment as usual (TAU; n = 81) or to TAU plus a web-based CBT intervention called Thinking Forward (n = 81). Thinking Forward consisted of 24 sections (approximately 20 minutes each), accessible over 12 weeks. Participants completed baseline and 4-, 8-, 12-, 16-, and 24-week follow-up assessments. Three primary outcomes of PTSD, alcohol and other drug use, and quality of life were examined. Significant treatment effects were found for heavy drinking, but not for PTSD or quality of life. The effect of the intervention on heavy drinking was mediated by intervening increases in coping, social support, self-efficacy, and hope for the future. These results demonstrate the promise of a web-based, self-management intervention for difficult-to-engage OEF/OIF veterans with behavioral health and substance use concerns.

Readiness to Change Predicts Drinking: Findings from 12-Month Follow-Up of Alcohol Use Disorder Outpatients

AIM

To test whether measures of readiness to change (RTC) re-assessed every 3 months had predictive value for change in alcohol use over 12 months in a sample of adult outpatients with alcohol use disorder (AUD).

METHODS

Of the case, 78 outpatients were followed monthly over one year and averaged 9.0 interviews each (total observations = 704). Alcohol abstinence days and heavy drinking days were assessed monthly using a 30-day timeline follow-back procedure. RTC was assessed using 3 'readiness rulers' (importance, readiness, and confidence to change, measured on a 0-10 visual analog scale). The effect of RTC on alcohol use over time was tested every 3 months using negative binomial generalized estimating equations (GEE), controlling for gender, age, baseline alcohol dependence severity and AUD treatment status (ongoing vs. ceased).

RESULTS

GEE models showed highly significant effects of readiness and confidence to change on respective alcohol outcomes. Effects of importance to change were weaker.

CONCLUSION

As hypothesized, higher RTC scores were associated with improved alcohol use outcomes in this longitudinal study. The strongest effects were for confidence to change. Finding significant predictive validity prospectively is consistent with a theoretical view of RTC as a dynamic construct. Further research might clarify how AUD treatment could actually elicit or increase RTC.

Interventions to reduce college student drinking: State of the evidence for mechanisms of behavior change

Interventions to reduce college student drinking, although efficacious, generally yield only small effects on behavior change. Examining mechanisms of change may help to improve the magnitude of intervention effects by identifying effective and ineffective active ingredients. Informed by guidelines for establishing mechanisms of change, we conducted a systematic review of alcohol interventions for college students to identify (a) which constructs have been examined and received support as mediators, (b) circumstances that enhance the likelihood of detecting mediation, and (c) the extent of evidence for mechanisms of change. We identified 61 trials that examined 22 potential mediators of intervention efficacy. Descriptive norms consistently mediated normative feedback interventions. Motivation to change consistently failed to mediate motivational interviewing interventions. Multiple active ingredient interventions were not substantially more likely to find evidence of mediation than single ingredient interventions. Delivering intervention content remotely reduced likelihood of finding support for mediation. With the exception of descriptive norms, there is inadequate evidence for the psychosocial constructs purported as mechanisms of change in the college drinking literature. Evidence for mechanisms will be yielded by future studies that map all active ingredients to targeted psychosocial outcomes and that assess potential mediators early, inclusively, and at appropriate intervals following interventions.

Randomized Controlled Trial of Mailed Personalized Feedback for Risky Drinkers in the Emergency Department: The Impact on Alcohol Consumption, Alcohol-Related Injuries, and Repeat Emergency Department Presentations

BACKGROUND

Due to the difficulty encountered in disseminating resource-intensive emergency department (ED)-based brief alcohol interventions into real-world settings, this study evaluated the effect of a mailed personalized feedback intervention for problem drinking ED patients. At 6-week follow-up, this intervention was associated with a statistically significant reduction in alcohol consumption among patients with alcohol-involved ED presentations. This study aimed to evaluate the effects of this intervention over time.

METHODS

A randomized controlled trial was conducted among problem drinking ED patients, defined as those scoring 8 or more on the Alcohol Use Disorders Identification Test. Participants in the intervention group received mailed personalized feedback regarding their alcohol consumption. The control group received no feedback. Follow-up interviews were conducted over the phone, postal survey, or email survey 6 weeks and 6 months after baseline screening, and repeat ED presentations over 12-month follow-up were ascertained via linked ED records.

RESULTS

Six-month follow-up interviews were completed with 210 participants (69%), and linked ED records were obtained for 286 participants (94%). The intervention had no effect on alcohol consumption, while findings regarding alcohol-related injuries and repeat ED presentations remain inconclusive.

CONCLUSIONS

Further research in which the receipt of feedback is improved and a booster intervention is provided is recommended.

Lessons learned for follow-up phone booster counseling calls with substance abusing emergency department patients

BACKGROUND

Post-visit "booster" sessions have been recommended to augment the impact of brief interventions delivered in the emergency department (ED). This paper, which focuses on implementation issues, presents descriptive information and interventionists' qualitative perspectives on providing brief interventions over the phone, challenges, "lessons learned", and recommendations for others attempting to implement adjunctive booster calls.

METHOD

Attempts were made to complete two 20-minute telephone "booster" calls within a week following a patient's ED discharge with 425 patients who screened positive for and had recent problematic substance use other than alcohol or nicotine.

RESULTS

Over half (56.2%) of participants completed the initial call; 66.9% of those who received the initial call also completed the second call. Median number of attempts to successfully contact participants for the first and second calls were 4 and 3, respectively. Each completed call lasted an average of about 22 minutes. Common challenges/barriers identified by booster callers included unstable housing, limited phone access, unavailability due to additional treatment, lack of compensation for booster calls, and booster calls coming from an area code different than the participants' locale and from someone other than ED staff.

CONCLUSIONS

Specific recommendations are presented with respect to implementing a successful centralized adjunctive booster call system. Future use of booster calls might be informed by research on contingency management (e.g., incentivizing call completions), smoking cessation quitlines, and phone-based continuing care for substance abuse patients. Future research needs to evaluate the incremental benefit of adjunctive booster calls on outcomes over and above that of brief motivational interventions delivered in the ED setting.

Participant report of therapist-delivered active ingredients in a telephone-delivered brief motivational intervention predicts taking steps towards change

OBJECTIVE

Given the widespread potential for disseminating Motivational Interviewing (MI) through technology, the question of whether MI active ingredients are present when not delivered in person is critical to assure high treatment quality. The Participant Rating Form (PRF) was developed and used to evaluate therapist-delivered active ingredients in phone-delivered MI with hazardous drinking Emergency Department patients.

METHOD

A factor analysis of all PRFs completed after receiving one call (n=256) was conducted. Multiple regression analysis was used to examine whether PRF factors predicted a measure of motivation to change -- taking steps-at the second call (n=214).

RESULTS

The majority of participants were male (65%), with a mean age of 32 years and with an average alcohol ASSIST (Alcohol, Smoking, and Substance Involvement Screening Test) score of 20.5 (SD = 7.1). Results of the factor analysis for the PRF revealed Relational (working collaboration) and Technical (MI behaviors) factors. After controlling for demographics, alcohol severity, and baseline readiness, the technical factor predicted self-report of increased taking steps towards change while the relational factor did not explain any additional variance.

CONCLUSIONS

Our study adds to the growing literature investigating patient perspectives of therapist skill as a source of information to better understand MI active ingredients. The PRF is a feasible instrument for measuring the patient's experience of phone-based MI. Results indicate that MI active ingredients of change (relational and technical components) were present in the telephone intervention as hypothesized. Clinical Trial Registration # 01326169.

Mechanisms of action of brief alcohol interventions remain largely unknown - a narrative review

A growing body of evidence has shown the efficacy of brief intervention (BI) for hazardous and harmful alcohol use in primary health care settings. Evidence for efficacy in other settings and effectiveness when implemented at larger scale are disappointing. Indeed, BI comprises varying content; exploring BI content and mechanisms of action may be a promising way to enhance efficacy and effectiveness. Medline and PsychInfo, as well as references of retrieved publications were searched for original research or review on active ingredients (components or mechanisms) of face-to-face BIs [and its subtypes, including brief advice and brief motivational interviewing (BMI)] for alcohol. Overall, BI active ingredients have been scarcely investigated, almost only within BMI, and mostly among patients in the emergency room, young adults, and US college students. This body of research has shown that personalized feedback may be an effective component; specific MI techniques showed mixed findings; decisional balance findings tended to suggest a potential detrimental effect; while change plan exercises, advice to reduce or stop drinking, presenting alternative change options, and moderation strategies are promising but need further study. Client change talk is a potential mediator of BMI effects; change in norm perceptions and enhanced discrepancy between current behavior and broader life goals and values have received preliminary support; readiness to change was only partially supported as a mediator; while enhanced awareness of drinking, perceived risks/benefits of alcohol use, alcohol treatment seeking, and self-efficacy were seldom studied and have as yet found no significant support as such. Research is obviously limited and has provided no clear and consistent evidence on the mechanisms of alcohol BI. How BI achieves the effects seen in randomized trials remains mostly unknown and should be investigated to inform the development of more effective interventions.

Brief interventions for hazardous and harmful alcohol consumption in accident and emergency departments

The prevalence of alcohol abuse among patients treated in accident and emergency departments (A&E) is considered as substantial. This paper is a narrative review of studies investigating the effectiveness of brief interventions (BI) for hazardous and harmful alcohol consumption in A&E. A&E departments in hospitals (and other health care infrastructures) are commonly the place where serious consequences of alcohol drinking are seen and need to be tackled, supporting the suggested theoretical usefulness of delivering BI in this environment. Available research shows that BI may be considered a valuable technique for dealing with alcohol-related problems. However, it is suggested that the usefulness of BI may depend significantly on the target population to be dealt with. BI have proved to be beneficial for male individuals and those patients who do not abuse other psychoactive substances. In contrast, evidence indicates that BI in A&E settings are not effective at all when dealing with men admitted as a consequence of a violence-related event. In addition, some studies were unable to confirm the effectiveness of BI in female population, in emergency setting. Studies investigating the association between drinking patterns and the effectiveness of BI also present inconsistent results. Most studies assessing the effectiveness of BI in A&E settings only adopted a short perspective (looking at the impact up to a maximum of 12 months after the BI was delivered). When assessing the effects of BI, both the amount of alcohol consumed and expected reductions in alcohol consequences, such as injuries, can be taken into account. Evidence on the implementation of brief intervention in emergency departments remains inconclusive as to whether there are clear benefits. A variety of outcome measures and assessing procedures were used in the different studies, which have investigated this topic.

Efetividade da intervenção breve para o uso abusivo de álcool na atenção primária: revisão sistemática

A pesquisa identificou estudos clínicos acerca das intervenções breves para o uso abusivo de álcool e analisou a eficácia dos aconselhamentos para os consumidores. Estudo bibliográfico sistemático que utilizou artigos publicados no período de 1997 a 2010. Os achados mostraram que a estratégia de intervenção breve é efetiva na redução da frequência e quantidade de álcool, com melhores resultados quando aplicada na atenção primária. Todos os profissionais da área da saúde obtêm bons resultados com o manejo dessa terapia. Não foi possível definir se a estratégia é mais eficaz se aplicada em bebedores de uso nocivo ou em crônicos, uma vez que a intervenção depende da mobilização de recursos motivacionais do paciente e de mudanças de atitude relacionadas ao consumo de álcool.

Dropout among patients in qualified alcohol detoxification treatment: the effect of treatment motivation is moderated by Trauma Load

Background

Motivation to change has been proposed as a prerequisite for behavioral change, although empirical results are contradictory. Traumatic experiences are frequently found amongst patients in alcohol treatment, but this has not been systematically studied in terms of effects on treatment outcomes. This study aimed to clarify whether individual Trauma Load explains some of the inconsistencies between motivation to change and behavioral change.

Methods

Over the course of two months in 2009, 55 patients admitted to an alcohol detoxification unit of a psychiatric hospital were enrolled in this study. At treatment entry, we assessed lifetime Trauma Load and motivation to change. Mode of discharge was taken from patient files following therapy. We tested whether Trauma Load moderates the effect of motivation to change on dropout from alcohol detoxification using multivariate methods.

Results

55.4% dropped out of detoxification treatment, while 44.6% completed the treatment. Age, gender and days in treatment did not differ between completers and dropouts. Patients who dropped out reported more traumatic event types on average than completers. Treatment completers had higher scores in the URICA subscale Maintenance. Multivariate methods confirmed the moderator effect of Trauma Load: among participants with high Trauma Load, treatment completion was related to higher Maintenance scores at treatment entry; this was not true among patients with low Trauma Load.

Conclusions

We found evidence that the effect of motivation to change on detoxification treatment completion is moderated by Trauma Load: among patients with low Trauma Load, motivation to change is not relevant for treatment completion; among highly burdened patients, however, who a priori have a greater risk of dropping out, a high motivation to change might make the difference. This finding justifies targeted and specific interventions for highly burdened alcohol patients to increase their motivation to change.

Patient attitudes towards change in adapted motivational interviewing for substance abuse: a systematic review

Adapted motivational interviewing (AMI) represents a category of effective, directive and client-centered psychosocial treatments for substance abuse. In AMI, patients' attitudes towards change are considered critical elements for treatment outcome as well as therapeutic targets for alteration. Despite being a major focus in AMI, the role of attitudes towards change in AMI's action has yet to be systematically reviewed in substance abuse research. A search of PsycINFO, PUBMED/MEDLINE, and Science Direct databases and a manual search of related article reference lists identified 416 published randomized controlled trials that evaluated AMI's impact on the reduction of alcohol and drug use. Of those, 54 met the initial inclusion criterion by evaluating AMI's impact on attitudes towards change and/or testing hypotheses about attitudes towards change as moderators or mediators of outcome. Finally, 19 studies met the methodological quality inclusion criterion based upon a Newcastle-Ottawa Quality Assessment Scale score ≥ 7. Despite the conceptual importance of attitudes towards change in AMI, the empirical support for their role in AMI is inconclusive. Future research is warranted to investigate both the contextual factors (ie, population studied) as well as deployment characteristics of AMI (ie, counselor characteristics) likely responsible for equivocal findings.

Readiness to change, drinking, and negative consequences among Polish SBIRT patients

The aim of this study is to examine the longitudinal relationship of readiness to change, drinking pattern, amount of alcohol consumed, and alcohol-related negative consequences among at-risk and dependent drinkers enrolled in a Screening, Brief Intervention and Referral to Treatment (SBIRT) trial in an emergency department in southern Poland. The study examined 299 patients randomized to either an assessment or intervention condition and followed at 3 and 12 months after initial presentation. Patients indicating a readiness or were unsure of changing drinking behavior were significantly more likely to decrease the maximum number of drinks per occasion and the usual number of drinks in a sitting in the 3-months following study entry when compared to those that rated changing drinking behavior as unimportant. Readiness to change was not predictive of outcomes between the baseline and 12-month follow-up. Drinking outcomes and negative consequences by readiness and research condition were non-significant. This is the first Polish study utilizing SBIRT to enable patients to identify their hazardous drinking and reduce alcohol consumption. While some drinking outcomes improved with motivation, these improvements were not maintained at 12-months following SBIRT. Attention to additional constructs of readiness to change and drinking patterns may augment the effectiveness of SBIRT.

Randomized controlled trial of mailed personalized feedback for problem drinkers in the emergency department: the short-term impact

BACKGROUND

Evidence exists for the efficacy of emergency department (ED)-based brief alcohol interventions, but attempts to incorporate face-to-face interventions into routine ED practice have been hampered by time, financial, and attitudinal constraints. Mailed personalized feedback, which is likely to be more feasible, has been associated with reduced alcohol consumption in other settings, but its cost-effectiveness in the ED has not been examined.

METHODS

The intervention was evaluated with a randomized controlled trial of patients presenting to 5 rural EDs in New South Wales, Australia. Patients aged 14 years and older were screened using the Alcohol Use Disorders Identification Test, and those scoring 8 or more were randomly allocated to the intervention or control group. Participants in the intervention group received mailed personalized feedback regarding their alcohol consumption. The control group received no feedback.

RESULTS

Two hundred and forty-four (80%) participants were successfully followed up at 6 weeks. A significant effect of the mailed feedback was observed only in patients with an alcohol-involved ED presentation. Among this subgroup of participants, those in the intervention group consumed 12.2 fewer drinks per week than the control group after controlling for baseline consumption and other covariates (effect size d = 0.59). The intervention was associated with an average cost of Australian $5.83 per patient, and among participants with an alcohol-involved ED presentation, an incremental cost-effectiveness ratio of 0.48.

CONCLUSIONS

Mailed personalized feedback is efficacious in reducing quantity/frequency of alcohol consumption among patients with alcohol-involved ED presentations. Mailed feedback has high cost-efficacy and a low absolute cost, making it a promising candidate for integration into ED care.

The evidence for implementing alcohol screening and intervention in the emergency department - time to act

The harmful effects of alcohol and its contribution to Emergency Department (ED) presentations are evident on a daily basis and undoubtedly add a significant burden on the health care system. Despite alcohol's prevalence in ED presentations, formal screening for alcohol use is not routinely applied in EDs. This paper reviews the evidence supporting the use of screening and the use of brief interventions in the ED. It aims to provide some insights into what may constitute best practice for health workers in relation to identifying and treating patients with problematic alcohol use. Although the burden of alcohol-related presentations is evident and the prevalence of problem acknowledged by health care professionals, the implementation of formal screening and brief interventions is at best inconsistent and sparse. Contemporary screening tools and interventions are critiqued within the ED setting and their advantages and disadvantages discussed. In conclusion, while there is a lack of homogeneity regarding the efficacy of screening tools and brief interventions in the ED setting, there are some promising indications that effectiveness may be enhanced by targeting the interventions at specific patient populations. It may also be possible to start considering innovative information technology applications to screen and intervene.

Six-month follow-up of computerized alcohol screening, brief intervention, and referral to treatment in the emergency department

The goal of this observational study was to measure change in alcohol consumption at 6 months following emergency department computerized alcohol screening brief intervention (CASI) and referral to treatment (ED-SBIRT) with integrated brief negotiated interview (BNI) and computer-generated personal alcohol reduction plans. At-risk patients received a BNI by CASI, including personalized feedback, assessment of readiness to change, reasons for cutting down, goal setting, and a printed personal alcohol reduction plan. Alcohol use was assessed by telephone interview 6 months after CASI. Factors associated with lower alcohol consumption were examined. Of the 385 participants who completed the BNI, were consented, and enrolled, 221 subjects completed the 6-month follow-up interview. Forty-seven percent of the study sample of at-risk patients were no longer drinking over the National Institute on Alcohol Abuse and Alcoholism (NIAAA)-recommended limits. Reductions were greater for patients with Alcohol Use Disorders Identification Test (AUDIT) scores of 1 to 7. Readiness to change was a good predictor of drinking below the recommended limits. The use of computerized ED-SBIRT with integrated personalized messaging and BNI holds promise as a viable screening and intervention modality for a wide range of emergency department patients.

Severity of acute illness is associated with baseline readiness to change in medical intensive care unit patients with unhealthy alcohol use

BACKGROUND

Unhealthy alcohol use predisposes to multiple conditions that frequently result in critical illness and is present in up to one-third of patients admitted to a medical intensive care unit (ICU). We sought to determine the baseline readiness to change in medical ICU patients with unhealthy alcohol use and hypothesized that the severity of acute illness would be independently associated with higher scores on readiness to change scales. We further sought to determine whether this effect is modified by the severity of unhealthy alcohol use.

METHODS

We performed a cross-sectional observational study of current regular drinkers in 3 medical ICUs. The Alcohol Use Disorders Identification Test was used to differentiate low-risk and unhealthy alcohol use and further categorize patients into risky alcohol use or an alcohol use disorder. The severity of a patient's acute illness was assessed by calculating the Acute Physiologic and Chronic Health Evaluation II (APACHE II) score at the time of admission to the medical ICU. Readiness to change was assessed using standardized questionnaires.

RESULTS

Of 101 medical ICU patients who were enrolled, 65 met the criteria for unhealthy alcohol use. The association between the severity of acute illness and readiness to change depended on the instrument used. A higher severity of illness measured by APACHE II score was an independent predictor of readiness to change as assessed by the Stages of Change Readiness and Treatment Eagerness Scale (Taking Action scale; p < 0.01). When a visual analog scale was used to assess readiness to change, there was a significant association with severity of acute illness (p < 0.01) that was modified by the severity of unhealthy alcohol use (p = 0.04 for interaction term).

CONCLUSIONS

Medical ICU patients represent a population where brief interventions require further study. Studies of brief intervention should account for the severity of acute illness and the severity of unhealthy alcohol use as potential effect modifiers.

Will emergency and surgical patients participate in and complete alcohol interventions? A systematic review

BACKGROUND

In the everyday surgical life, staff may experience that patients with Alcohol Use Disorders (AUDs) seem reluctant to participate in alcohol intervention programs. The objective was therefore to assess acceptance of screening and intervention as well as adherence to the intervention program among emergency department (ED) and surgical patients with AUDs.

METHODS

A systematic literature search was followed by extraction of acceptance and adherence rates in ED and surgical patients. Numbers needed to screen (NNS) were calculated. Subgroup analyses were carried out based on different study characteristics.

RESULTS

The literature search revealed 33 relevant studies. Of these, 31 were randomized trials, 28 were conducted in EDs and 31 evaluated the effect of brief alcohol intervention. Follow-up was mainly conducted after six and/or twelve months.Four in five ED patients accepted alcohol screening and two in three accepted participation in intervention. In surgical patients, two in three accepted screening and the intervention acceptance rate was almost 100%. The adherence rate was above 60% for up to twelve months in both ED and surgical patients. The NNS to identify one eligible AUD patient and to get one eligible patient to accept participation in alcohol intervention varied from a few up to 70 patients.The rates did not differ between randomized and non-randomized trials, brief and intensive interventions or validated and self-reported alcohol consumption. Adherence rates were not affected by patients' group allocation and type of follow-up.

CONCLUSIONS

Most emergency and surgical patients with AUD accept participation in alcohol screening and interventions and complete the intervention program.

Will emergency and surgical patients participate in and complete alcohol interventions? A systematic review

Background

In the everyday surgical life, staff may experience that patients with Alcohol Use Disorders (AUDs) seem reluctant to participate in alcohol intervention programs. The objective was therefore to assess acceptance of screening and intervention as well as adherence to the intervention program among emergency department (ED) and surgical patients with AUDs.

Methods

A systematic literature search was followed by extraction of acceptance and adherence rates in ED and surgical patients. Numbers needed to screen (NNS) were calculated. Subgroup analyses were carried out based on different study characteristics.

Results

The literature search revealed 33 relevant studies. Of these, 31 were randomized trials, 28 were conducted in EDs and 31 evaluated the effect of brief alcohol intervention. Follow-up was mainly conducted after six and/or twelve months.

Four in five ED patients accepted alcohol screening and two in three accepted participation in intervention. In surgical patients, two in three accepted screening and the intervention acceptance rate was almost 100%. The adherence rate was above 60% for up to twelve months in both ED and surgical patients. The NNS to identify one eligible AUD patient and to get one eligible patient to accept participation in alcohol intervention varied from a few up to 70 patients.

The rates did not differ between randomized and non-randomized trials, brief and intensive interventions or validated and self-reported alcohol consumption. Adherence rates were not affected by patients' group allocation and type of follow-up.

Conclusions

Most emergency and surgical patients with AUD accept participation in alcohol screening and interventions and complete the intervention program.

Change plan as an active ingredient of brief motivational interventions for reducing negative consequences of drinking in hazardous drinking emergency-department patients

OBJECTIVE

Few studies have examined the effects of brief motivational intervention components, such as change-plan completion, on treatment outcomes. This secondary analysis of an opportunistically recruited emergency-department sample of hazardous injured drinkers examines the potential predictive role of an alcohol-related change plan on treatment outcomes after accounting for pretreatment readiness. Written change plans were independently rated.

METHOD

A mediational analysis framework tested directional hypotheses between pretreatment readiness, change plan, and treatment outcomes using linear regressions. The baseline total Drinker Inventory of Consequences (DrInC) score was covaried on 12-month DrInC total score, in all analyses. Participants who completed a brief motivational intervention and a change plan were included (N = 333).

RESULTS

Pretreatment readiness was negatively associated with alcohol consequences at 12 months, (beta = -.09, t(254) = -2.07, p < .05, and good-quality change plans, (beta = .18, t(320) = 4.37, p < .001. With change plan and readiness in the same model, the relationship between readiness and treatment outcomes became nonsignificant, but change plan remained a significant predictor of treatment outcomes in the expected direction, beta = -.17, t(254) = -2.89, p < .01. Follow-up generalized linear modeling including an interaction term (change plan and pretreatment readiness) revealed that those with high readiness and a good-quality change plan versus those with low readiness and a poor-quality change plan had better-than-predicted outcomes for either readiness or change plan alone.

CONCLUSIONS

Study findings suggest that the change plan in brief motivational intervention may be an active ingredient of treatment associated with better outcomes over and above the influence of pretreatment readiness.

Strategies to improve HIV treatment adherence in developed countries: clinical management at the individual level

REMARKABLE ADVANCES IN THE TREATMENT OF HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE HAVE BEEN BLUNTED BY WIDESPREAD SUBOPTIMAL ADHERENCE (IE, NONADHERENCE), WHICH HAS EMERGED AS A MAJOR BARRIER TO ACHIEVING THE PRIMARY GOAL OF ANTIRETROVIRAL (ARV) THERAPY: suppression of HIV viral load. Nonsuppressed HIV viral load is associated with drug resistance, increased morbidity and mortality, and a higher risk of person-to-person HIV transmission. For HIV-infected individuals who are failing HIV treatment due to nonadherence, becoming adherent is a life-saving behavior change. However, overcoming nonadherence is one of the most daunting challenges in the successful management of HIV disease. The purpose of this paper is to provide clinicians with a better understanding of nonadherence to ARV treatment and to review the various factors that have been associated with either adherence or nonadherence. Strategies are presented that may help the nonadherent individual become ready to take HIV medications as prescribed.

Measurement of readiness to reduce driving speed: a pilot study

Speeding is a preventable risky behavior that contributes to risk of accident. Readiness to change reflects an individual's recognition of and desire to change behavior. No measure to identify readiness to change has yet been validated for speeding. The Readiness to Change Questionnaire appraises readiness to change drinking behavior. The questionnaire was adapted to speeding and its psychometric properties examined. Participants (N = 112) completed the questionnaire and reported their usual driving speed. A clear component structure and acceptable internal consistency and test-retest reliability were found. Convergent validity was indicated by an association between higher readiness to change and lower driving speed. Results support the questionnaire's potential as a measure of readiness to change speeding, and advance research into the role of motivation in speeding behavior.

Thinking about going to the dentist: a Contemplation Ladder to assess dentally-avoidant individuals' readiness to go to a dentist

Background

The Transtheoretical Model suggests that individuals vary according to their readiness to change behavior. Previous work in smoking cessation and other health areas suggests that interventions are more successful when they are tailored to an individual's stage of change with regards to the specific behavior. We report on the performance of a single-item measure ("Ladder") to assess the readiness to change dental-avoidant behavior.

Methods

An existing Contemplation Ladder for assessing stage of change in smoking cessation was modified to assess readiness to go to a dentist. The resulting Ladder was administered to samples of English-speaking adolescents (USA), Spanish-speaking adults (USA), and Norwegian military recruits (Norway) in order to assess construct validity. The Ladder was also administered to a sample of English-speaking avoidant adolescents and young adults who were enrolled in an intervention study (USA) in order to assess criterion validity. All participants also had dental examinations, and completed other questionnaires. Correlations, chi square, t tests and one-way ANOVAs were used to assess relationships between variables.

Results

In two samples, participants who do not go to the dentist had significantly more teeth with caries; in a third sample, participants who do not go to the dentist had significantly worse caries. Ladder scores were not significantly related to age, gender, caries, or dental fear. However, Ladder scores were significantly related to statements of intention to visit a dentist in the future and the importance of oral health. In a preliminary finding, Ladder scores at baseline also predicted whether or not the participants decided to go to a dentist in the intervention sample.

Conclusions

The data provide support for the convergent and divergent construct validity of the Ladder, and preliminary support for its criterion validity. The lack of relationship between dental fear and Ladder scores suggests that avoidant individuals may be helped to decide to go to a dentist using interventions which do not explicitly target their fear.

Readiness to change and risk drinking women

The predictive value of the Readiness to Change Questionnaire (RTCQ) for subsequent drinking was evaluated in 499 women. These women had medical problems potentially exacerbated by alcohol use and were enrolled in an intervention study. Correlates and predictors of stage of change were analyzed. Results indicated that the categorical application of the RTCQ did not predict drinking in the 6-12 months after enrollment. Preliminary findings support rescoring the RTCQ into a continuous measure. Following this conversion, situational risks factors for drinking were examined as potential mediators of readiness to change (RTC). Heightened risk for alcohol consumption during argument or boredom was found to attenuate the association between one's RTC and later drinking. Finally, medical condition moderated the association of RTC on later drinking; women with diabetes, infertility, or osteoporosis drank the most in the contemplation stage. In contrast, hypertensive women drank more when action oriented to change. The implications for treating risk drinking in women are discussed.

Prevalence, health and demographics of emergency department patients with diabetes

OBJECTIVE

To determine the prevalence of diabetes in Southern California emergency department (ED) patients and describe the self-reported general health, demographic and social characteristics of these patients with diabetes.

METHODS

Between April 2008 and August 2008, non-critical patients at two Southern California EDs completed a 57-question survey about their chronic medical conditions, general health, social and demographic characteristics.

RESULTS

11.3% of the 1,303 patients surveyed had diabetes. Patients with diabetes were similar to ED patients without diabetes with respect to gender, ethnicity and race. However, patients with diabetes were older (51 vs. 41), less likely to have a high school education (64.0% vs. 84.7%), less likely to speak English (44.9% vs. 55.4%), and less likely to be uninsured (33.3% vs. 49.5%). Additionally, patients with diabetes had markedly lower self-reported physical health scores (37.1 vs. 45.8) and mental component score and mental health scores (42.0 vs. 47.4) compared with ED patients without diabetes.

CONCLUSION

In this study of two Southern California EDs, 11.3% of surveyed patients had diabetes. These patients were often poorly educated, possessed limited English language skills and poor physical health. ED personnel and diabetes educators should be mindful of these findings when designing interventions for ED patients with diabetes.

The mixed evidence for brief intervention in emergency departments, trauma care centers, and inpatient hospital settings: what should we do?

BACKGROUND

This qualitative review is based on a symposia presented at the 2009 annual conference of the Research Society on Alcoholism (Baird et al., 2009; Field et al., 2009; Monti et al., 2009; Saitz et al., 2009a). The purpose is to describe the mixed evidence supporting brief interventions in the emergency department, trauma care, and in-patient medical care settings; examine potential moderators of treatment outcome in light of the mixed evidence; and identify methods to move the research and practice of brief interventions beyond their current state.

METHODS

By drawing upon existing reviews and selected individual studies, we provide examples that reflect the current complexity of research in this area and propose steps for advancing the field.

RESULTS

Emergency departments, inpatient hospital settings, and trauma care settings represent three unique contexts within which brief interventions have been tested. While the general efficacy of brief alcohol interventions in these settings has been recognized, the evidence is increasingly mixed. Recent studies investigating potential moderators of treatment outcomes suggest that a more sophisticated approach to evaluating the effectiveness of brief interventions across varying patient populations is needed to further understand its effectiveness.

CONCLUSIONS

Current dissemination efforts represent a significant advance in broadening the base of treatment for alcohol problems by providing an evidence-based intervention in health care settings and should not be curtailed. However, additional research is required to enhance treatment outcomes, refine current practice guidelines, and continue to bridge the gap between science and practice. Given the current state of research, a multisetting clinical trial is recommended to account for potential contextual differences while controlling for study design.

The route to change: within-session predictors of change plan completion in a motivational interview

This study is the first to examine within-session therapist and client language/process predictors of a client's decision to complete a written Change Plan in an alcohol-focused motivational interview (MI). Data were from an ongoing hospital-based clinical trial (N = 291). Trained raters coded audiorecorded MI sessions using the Motivational Interviewing Skill Code. Logistic regression analyses found that therapist MI-consistent behaviors (b = .023, p < .001) and client change talk (b = .063, p < .001) were positive predictors, and client counter change talk (b = -.093, p < .001) was a negative predictor of the decision to complete a Change Plan regarding alcohol use. Mean comparisons showed that compared to noncompletion, Change Plan completion did not result in significantly greater changes in client motivational readiness. Completion of a Change Plan is a proximal outcome in MI that is associated with client intention to change (change talk) and may predict follow-up alcohol outcomes. Analyses of such theory-driven proximal client mechanisms provide a more complete model of MI process and may inform MI providers of necessary treatment ingredients.

Extended naltrexone and broad spectrum treatment or motivational enhancement therapy

BACKGROUND

Randomized clinical trials on the effectiveness of naltrexone (NTX) in the treatment of alcohol dependence have produced conflicting results. One possible explanation for these discrepancies may lie in the various psychosocial treatments for which NTX is an adjunct. The goal of this study was to examine the interplay between psychosocial treatment and duration of NTX.

METHODS

One hundred and seventy-four alcohol-dependent outpatients participated in a double-blind trial where they were randomly assigned to 12 vs. 24 weeks NTX duration and to one of two psychosocial treatments: motivational enhancement therapy (MET) and broad spectrum treatment (BST), a cognitive behavioral therapy tailored to the patient's specific needs. After an initial 12-week period of NTX and psychosocial treatment, half of each psychotherapy condition was assigned to continue NTX for an additional 12 weeks while the other half was assigned to placebo. Patient drinking outcomes were measured for the year following treatment completion. It was hypothesized that the combination of extended duration of NTX and the moderate intensity of BST would be predictive of longer time to a first heavy drinking day than any of the three alternative combinations: MET with short or extended NTX administration or BST with short NTX administration.

RESULTS

The median time to first drink and time to first heavy drinking day were found to be significantly longer for patients who received BST and extended NTX than for patients in the other three groups.

CONCLUSIONS

These results may suggest that the kind of psychosocial treatment delivered in combination with duration of NTX administration may partially explain the inconsistent findings regarding the efficacy of NTX in the treatment of alcohol dependence.