Six-month outcomes of hospital-based psychiatric substance use consultations
Alaja R and Seppa K;
Commented by , 30 Apr 2003
Background
Substance use disorders and related health complications are increasingly common in general hospitals. While specialized substance use consultations by general hospital psychiatric consultation teams have previously been described, outcome data are scant.
Purpose
Evaluate the 6-month outcomes of hospital-based psychiatric substance use consultations in a naturalistic setting.
Methods
The sample consisted of 218 inpatients referred for substance use consultations from other specialists at a university general hospital in Finland. A psychiatrist with additional qualifications in addictions, accompanied by a nurse or social worker, conducted the consultations in one or two visits of 1.5-2 hours.
Prior to the consultation, patients completed the Short Alcohol Dependence Data (SADD) and Severity of Dependence Scale self-report questionnaires. During the consultation, alcohol consumption, substance use disorders, severity of dependence, adverse substance use consequences, mental and physical complications and service utilization were assessed using a modification of the European Addiction Severity Index.
A follow-up mail interview 6-months after the initial consultation measured self-reported consumption and SADD scores during the preceding month, and follow-up treatment attendance. Statistical analyses were performed using two-tailed t test for continuous and OR for binary variables.
Results
52% (113/218) of the patients returned the follow-up questionnaire. Those lost to follow-up were younger, more commonly male, had an earlier onset of drinking and more adverse substance use consequences, particularly legal offences.
Continued substance use was assumed of all lost to follow-up, included in intention to treat (ITT) analysis. 37% (81/218) of patients, one out of two women and one out of three men, reported abstinence (11%) or reduction (26%) in substance use. Among this group, the mean reduction in ethanol was significant (P<0.001), >1000 gm/week and 500 gm/week for males and females, respectively. There was also a mean reduction in SADD scores (p<0.001) in these individuals. Female gender and no previous history of substance use or psychiatric treatment at initial consultation predicted abstinence or reduction.
While all patients were provided with “aftercare referral or guidance,” at follow-up only 19% reported treatment attendance. 58% (47/81) of those who reported improvement, i.e., 22% (47/218) of all consultations, improved without further substance use treatment after initial consultation.
Discussion
Several limitations bear consideration. As there was no control group, the impact of a severe medical complication alone on substance use reduction cannot be excluded. As self-report outcome measures are subject to response bias, more objective outcomes such as sensitive laboratory markers would have strengthened the results.
Finally, little is known about the details of the intervention, for example, whether motivational interviewing which has strong empirical support (1, 2), was incorporated into the consultation. This omission limits the study’s generalisability and application in clinical practice.
Losing half of the sample to follow-up reflects the challenge of poor compliance in this population. These dropouts resemble Babor’s Type B drinkers (3), a more treatment-refractory group; thus their inclusion in ITT analysis is a study strength.
Notwithstanding these limitations, the study offers several important insights. Significant improvement reported in 37% of the sample, the majority in the absence of ongoing treatment, highlights the important timing of a substance use consultation in the setting of an acute medical crisis when patients may be more motivated to change (4).
The impact of a single consultation in this study rivals that of more elaborate substance use treatment programs, and challenges our commonly held nihilistic view of this population.
References
1. Miller WR. Motivational interviewing: research, practice, and puzzles.
Addictive Behaviors 1996; 21 (6); 835-842
2. Dunn C, Deroo L, Rivara FP.The use of brief interventions adapted from motivational interviewing across behavioral domains: a systematic review. Addiction 2001; 96 (12); 1725-1742
3. Babor TF, Hofmann M, DelBoca FK, Hesselbrock V, Meyer RE, Dolinsky ZS, Rounsaville B. Types of alcoholics, I. Evidence for an empirically derived typology based on indicators of vulnerability and severity. Archives of General Psychiatry 1992; 49 (8); 599-608
4. Gentilello LM, Donovan DM, Dunn CW, Rivara FP. Alcohol interventions in trauma centers. Current practice and future directions. JAMA; 274 (13); 1043