0740-5472/92 $5.00 + .OO Copyright Q 1992 Pergamon Press Ltd.
Journal of Substance Abuse Treattnent, Vol. 9, pp. 59-62, 1992 Printed in the USA. All rights reserved.
INTERNATIONAL
PERSPECTIVE
Demand for Alcohol Treatment by Problem Drinkers AUGUSTINUS
F.I.
BANNENBERG, MD, PhD,* HEIN RAAT, MD, PhD,t AND H. NICO PLOW’,
PhD*
*Department of Social Medicine, Free University, Amsterdam, The Netherlands; TDepartment of Epidemiology, Municipal Health Service, Rotterdam, The Netherlands
Abstract-Problem drinkers applying for treatment at both outpatient and inpatient treatment programs were compared with problem drinkers identified in a genera1 population survey. The characteristics in which these populations differ were interpreted as factors contributing to the demand for treatment and, thus, indicative of the need for alcohol treatment. Older problem drinkers appear to apply for treatment more frequently, and the same is true for divorced and unemployed or d&abled problem drinkers More important, age, marital status, and employment status were found to contribute to the demand for alcohol treatment independent of alcohol consumption. It can be concluded from this study that the demand for alcohol treatment is not determined by alcohol consumption alone, suggesting that alcohol treatment should not only focus on alcohol consumption but also focus on problems related to marital and employment status in order to prevent future need for alcohol treatment. Keywords-alcohol
treatment;
alcohol
problems;
use of treatment
INTRODUCTION
services
ers applying for treatment. The differences between these populations of problem drinkers may be considered as potential aspects of alcohol problems contributing to the need for alcohol treatment. Comparisons between problem drinkers in the general population and in treatment were made in the well-known study by Armor, Polich, and Stambul (1978). Comparable studies have been conducted in The Netherlands (Knibbe, 1982; Raat, 1987). The present study differs from the previous studies on this topic in two ways: (a) Inpatient and outpatient treatment programs were included, and (b) instead of studying problem drinkers in treatment, problem drinkers applying for treatment but not yet in treatment were studied to avoid possible selection by intake staff of problem drinkers in the process of admission to treatment. Thus, this study focused on the total population of problem drinkers applying for treatment, which is thought of as representative for the demand of treatment in a general population.
IN THE TREATMENT of alcohol problems, it is essential to understand what factors contribute to the need for alcohol treatment among problem drinkers in the general population. General population surveys are sometimes used for this purpose, but the interpretation of surveys with respect to the need for alcohol treatment poses some difficulties. For example, what level of alcohol consumption is decisive in the need for alcohol treatment, and what other aspects of alcohol problems should be assessed in general population surveys? An important addition to general population surveys in studying the need for alcohol treatment is to look more closely at the aspects of problem drinking that make problem drinkers seek alcohol treatment: the demand for alcohol treatment. The demand for alcohol treatment can be studied by comparing problem drinkers in the general population and problem drink-
Dr. Bannenberg is currently employed at the Municipal Health Service, Delft, The Netherlands. Requests for reprints should be addressed to Dr. H.N. Plomp, Department of Social Medicine, Free University, v.d. Boechorststraat 7, 1081 BT Amsterdam, The Netherlands.
MATERIALS
AND METHODS
This study was conducted in the Jellinek Center in Amsterdam, The Netherlands, an alcohol treatment 59
60 center with a regional catchment area. In this study, an outpatient treatment program, a short-term inpatient treatment program, and a long-term inpatient treatment program were included. The outpatient treatment program offered weekly individual counseling and group therapy; the short-term inpatient treatment program offered detoxification followed by a maximum stay of 3 weeks with group therapy, and the long-term inpatient treatment program offered detoxification followed by an average stay of 3 to 4 months with individual counseling and intensive group therapy. All treatment programs could be consulted freely by problem drinkers, and because all payments were reimbursed by health insurance plans, no financial barriers to treatment existed. In structured interviews with problem drinkers, data were collected about problem-drinker characteristics possibly related to application for treatment: sociodemographic characteristics of age, sex, marital and employment status, alcohol problems, other drug use problems, and health status. Health status was measured with the help of the Dutch VOEG scale, which is a subjective judgment of each patient’s health status on 10 items with a maximum score of 21 points. Alcohol problems were measured in this study with the problem-drinking scale developed by Cahalan (1970) and adapted by Garretsen (1983) and Knibbe (1982). This scale consists of two parts: an alcohol consumption index and a problem index. The alcohol consumption index is constructed by asking for the total number of days per month during which alcohol is consumed and the average number of glasses consumed on those days. Alcohol consumption is defined as very excessive when on 21 or more days per month 6 or more glasses are consumed and is defined as excessive when this is the case on 15 or more days per month or when on 21 or more days per month 4 or more glasses are consumed. In the problem index, five problem areas are operationalized, that is, psychological dependence, symptomatic drinking, social problems, health problems/accidents, and frequent drunkennessihangover. In a standardized questionnaire on each problem area, a score is assigned of 2 (serious problems), 1 (moderate problems), or 0 points (slight problems). Thus, the maximum score of the problem index is 10 points. All problem drinkers applying for treatment at the outpatient and inpatient treatment programs of the Jellinek Center from June to September 1985 were invited to participate in the study. Because the Jellinek Center is the only alcohol treatment center in the region, the study population may be regarded as representative for the total demand for alcohol treatment in the region. Altogether, 146 interviews took place, which is a response of almost 61%. Control of the nonresponse did not question the representativeness of the study population. The mean age of the study pop-
A.F.I. Bannenberg et al. ulation was 38 years; 73% were men, 40% were divorced, and 56% were unemployed or disabled. All scored positive on the problem drinking scale. Problem drinkers applying for treatment at the inpatient treatment programs had alcohol problems for a longer period and were more frequently divorced, unemployed, or disabled than were problem drinkers at the outpatient program, but because the study focuses on the total population applying for treatment, no detailed analysis of these differences is presented. Because data on problem drinking in Amsterdam were not available, 153 problem drinkers that were identified in a general population survey in Rotterdam (Garretsen, 1983) served as a reference population. A study by Raat (1987), using different indicators, showed that the problem drinking in Rotterdam, the second largest city in The Netherlands, is comparable to that in Amsterdam. The mean age in the reference population was 35 years, 80% were men; 10% were divorced, and 18% were unemployed or disabled. Because the same questionnaire was used, data for the reference population were available on sociodemographic characteristics, alcohol problems, other drug use, and health status that allowed a comparison with the study population. In the analysis, the characteristics of problem drinkers applying for treatment were compared to characteristics of problem drinkers in the general population.’ RESULTS Almost all of the problem-drinker characteristics that were analyzed relate to application for treatment by problem drinkers. With respect to sociodemographic characteristics, problem drinkers seeking treatment were generally older, more frequently divorced, and unemployed or disabled. Men applied for treatment as frequently as did women, though. Regarding alcohol problems, both alcohol consumption and problem index were related to application for treatment in a dose-response manner: the higher the alcohol consumption and problem index, the higher the odds of seeking treatment. Also, other drug use and health status contributed to application for treatment (Table 1). Age, marital status, and employment status are known to be related to alcohol problems, and, thus, the relation of these characteristics to application for treatment may be confounded by the alcohol problems. For this reason, an additional analysis was performed
‘The analysis was carried out with odds ratios, indicating the odds of a given outcome (application for treatment) with a given characteristic compared to the opposite of that characteristic. Odds ratios higher than 1 point gave a higher chance of the outcome; odds ratios less than 1gave a lower chance. The more an odds ratio departed from 1, the stronger is the relation of a characteristic to the outcome. Ninety percent confidence intervals for the odds ratios are given.
61
Demand for Alcohol Treatment TABLE 1 Odds Ratios (90% Confidence Limits) of Application for Treatment
Odds of Application for Treatment Problem Drinker Characteristics Sociodemographic Characteristics Age: 230 vs. ~30 yr Sex: male vs. female Marital status: divorced vs. other Employment status: unemployed/disabled vs. other Alcohol Problems Alcohol consumption Very excessive vs. excessive or less Excessive vs. moderate or less Problem index 28 vs.
Journal of Substance Abuse Treattnent, Vol. 9, pp. 59-62, 1992 Printed in the USA. All rights reserved.
INTERNATIONAL
PERSPECTIVE
Demand for Alcohol Treatment by Problem Drinkers AUGUSTINUS
F.I.
BANNENBERG, MD, PhD,* HEIN RAAT, MD, PhD,t AND H. NICO PLOW’,
PhD*
*Department of Social Medicine, Free University, Amsterdam, The Netherlands; TDepartment of Epidemiology, Municipal Health Service, Rotterdam, The Netherlands
Abstract-Problem drinkers applying for treatment at both outpatient and inpatient treatment programs were compared with problem drinkers identified in a genera1 population survey. The characteristics in which these populations differ were interpreted as factors contributing to the demand for treatment and, thus, indicative of the need for alcohol treatment. Older problem drinkers appear to apply for treatment more frequently, and the same is true for divorced and unemployed or d&abled problem drinkers More important, age, marital status, and employment status were found to contribute to the demand for alcohol treatment independent of alcohol consumption. It can be concluded from this study that the demand for alcohol treatment is not determined by alcohol consumption alone, suggesting that alcohol treatment should not only focus on alcohol consumption but also focus on problems related to marital and employment status in order to prevent future need for alcohol treatment. Keywords-alcohol
treatment;
alcohol
problems;
use of treatment
INTRODUCTION
services
ers applying for treatment. The differences between these populations of problem drinkers may be considered as potential aspects of alcohol problems contributing to the need for alcohol treatment. Comparisons between problem drinkers in the general population and in treatment were made in the well-known study by Armor, Polich, and Stambul (1978). Comparable studies have been conducted in The Netherlands (Knibbe, 1982; Raat, 1987). The present study differs from the previous studies on this topic in two ways: (a) Inpatient and outpatient treatment programs were included, and (b) instead of studying problem drinkers in treatment, problem drinkers applying for treatment but not yet in treatment were studied to avoid possible selection by intake staff of problem drinkers in the process of admission to treatment. Thus, this study focused on the total population of problem drinkers applying for treatment, which is thought of as representative for the demand of treatment in a general population.
IN THE TREATMENT of alcohol problems, it is essential to understand what factors contribute to the need for alcohol treatment among problem drinkers in the general population. General population surveys are sometimes used for this purpose, but the interpretation of surveys with respect to the need for alcohol treatment poses some difficulties. For example, what level of alcohol consumption is decisive in the need for alcohol treatment, and what other aspects of alcohol problems should be assessed in general population surveys? An important addition to general population surveys in studying the need for alcohol treatment is to look more closely at the aspects of problem drinking that make problem drinkers seek alcohol treatment: the demand for alcohol treatment. The demand for alcohol treatment can be studied by comparing problem drinkers in the general population and problem drink-
Dr. Bannenberg is currently employed at the Municipal Health Service, Delft, The Netherlands. Requests for reprints should be addressed to Dr. H.N. Plomp, Department of Social Medicine, Free University, v.d. Boechorststraat 7, 1081 BT Amsterdam, The Netherlands.
MATERIALS
AND METHODS
This study was conducted in the Jellinek Center in Amsterdam, The Netherlands, an alcohol treatment 59
60 center with a regional catchment area. In this study, an outpatient treatment program, a short-term inpatient treatment program, and a long-term inpatient treatment program were included. The outpatient treatment program offered weekly individual counseling and group therapy; the short-term inpatient treatment program offered detoxification followed by a maximum stay of 3 weeks with group therapy, and the long-term inpatient treatment program offered detoxification followed by an average stay of 3 to 4 months with individual counseling and intensive group therapy. All treatment programs could be consulted freely by problem drinkers, and because all payments were reimbursed by health insurance plans, no financial barriers to treatment existed. In structured interviews with problem drinkers, data were collected about problem-drinker characteristics possibly related to application for treatment: sociodemographic characteristics of age, sex, marital and employment status, alcohol problems, other drug use problems, and health status. Health status was measured with the help of the Dutch VOEG scale, which is a subjective judgment of each patient’s health status on 10 items with a maximum score of 21 points. Alcohol problems were measured in this study with the problem-drinking scale developed by Cahalan (1970) and adapted by Garretsen (1983) and Knibbe (1982). This scale consists of two parts: an alcohol consumption index and a problem index. The alcohol consumption index is constructed by asking for the total number of days per month during which alcohol is consumed and the average number of glasses consumed on those days. Alcohol consumption is defined as very excessive when on 21 or more days per month 6 or more glasses are consumed and is defined as excessive when this is the case on 15 or more days per month or when on 21 or more days per month 4 or more glasses are consumed. In the problem index, five problem areas are operationalized, that is, psychological dependence, symptomatic drinking, social problems, health problems/accidents, and frequent drunkennessihangover. In a standardized questionnaire on each problem area, a score is assigned of 2 (serious problems), 1 (moderate problems), or 0 points (slight problems). Thus, the maximum score of the problem index is 10 points. All problem drinkers applying for treatment at the outpatient and inpatient treatment programs of the Jellinek Center from June to September 1985 were invited to participate in the study. Because the Jellinek Center is the only alcohol treatment center in the region, the study population may be regarded as representative for the total demand for alcohol treatment in the region. Altogether, 146 interviews took place, which is a response of almost 61%. Control of the nonresponse did not question the representativeness of the study population. The mean age of the study pop-
A.F.I. Bannenberg et al. ulation was 38 years; 73% were men, 40% were divorced, and 56% were unemployed or disabled. All scored positive on the problem drinking scale. Problem drinkers applying for treatment at the inpatient treatment programs had alcohol problems for a longer period and were more frequently divorced, unemployed, or disabled than were problem drinkers at the outpatient program, but because the study focuses on the total population applying for treatment, no detailed analysis of these differences is presented. Because data on problem drinking in Amsterdam were not available, 153 problem drinkers that were identified in a general population survey in Rotterdam (Garretsen, 1983) served as a reference population. A study by Raat (1987), using different indicators, showed that the problem drinking in Rotterdam, the second largest city in The Netherlands, is comparable to that in Amsterdam. The mean age in the reference population was 35 years, 80% were men; 10% were divorced, and 18% were unemployed or disabled. Because the same questionnaire was used, data for the reference population were available on sociodemographic characteristics, alcohol problems, other drug use, and health status that allowed a comparison with the study population. In the analysis, the characteristics of problem drinkers applying for treatment were compared to characteristics of problem drinkers in the general population.’ RESULTS Almost all of the problem-drinker characteristics that were analyzed relate to application for treatment by problem drinkers. With respect to sociodemographic characteristics, problem drinkers seeking treatment were generally older, more frequently divorced, and unemployed or disabled. Men applied for treatment as frequently as did women, though. Regarding alcohol problems, both alcohol consumption and problem index were related to application for treatment in a dose-response manner: the higher the alcohol consumption and problem index, the higher the odds of seeking treatment. Also, other drug use and health status contributed to application for treatment (Table 1). Age, marital status, and employment status are known to be related to alcohol problems, and, thus, the relation of these characteristics to application for treatment may be confounded by the alcohol problems. For this reason, an additional analysis was performed
‘The analysis was carried out with odds ratios, indicating the odds of a given outcome (application for treatment) with a given characteristic compared to the opposite of that characteristic. Odds ratios higher than 1 point gave a higher chance of the outcome; odds ratios less than 1gave a lower chance. The more an odds ratio departed from 1, the stronger is the relation of a characteristic to the outcome. Ninety percent confidence intervals for the odds ratios are given.
61
Demand for Alcohol Treatment TABLE 1 Odds Ratios (90% Confidence Limits) of Application for Treatment
Odds of Application for Treatment Problem Drinker Characteristics Sociodemographic Characteristics Age: 230 vs. ~30 yr Sex: male vs. female Marital status: divorced vs. other Employment status: unemployed/disabled vs. other Alcohol Problems Alcohol consumption Very excessive vs. excessive or less Excessive vs. moderate or less Problem index 28 vs.
