Scandinavian Journal of Primary Health Care
ISSN: 0281-3432 (Print) 1502-7724 (Online) Journal homepage: http://www.tandfonline.com/loi/ipri20
Intervention in Alcohol Abuse among Macrocytic Patients in General Practice Kaija Seppä To cite this article: Kaija Seppä (1992) Intervention in Alcohol Abuse among Macrocytic Patients in General Practice, Scandinavian Journal of Primary Health Care, 10:3, 217-222, DOI: 10.3109/02813439209014064 To link to this article: http://dx.doi.org/10.3109/02813439209014064
© 1992 Informa UK Ltd All rights reserved: reproduction in whole or part not permitted Published online: 12 Jul 2009.
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&and J Prim Health Care 1992; 10: 21 7-222
Intervention in Alcohol Abuse among Macrocytic Patients in General Practice KAIJA SEPPA Universiry of Tampere, Department of Public Health, Finland
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SeppH K. Intervention in alcohol abuse among macrocytic patients in general practice. Scand J Prim Health Care 1992; 1 0 217-22. The study examined the effectiveness of routine intervention in alcohol abuse by a general practitioner, with help of a laboratory test. Patients diagnosed as abusers because of high erythrocyte mean cell volume value (MCV) and having no other cause for it were randomly allocated to two groups: 1) an intervention group, comprising 92 patients (69 men and 23 women), who were invited for follow-up at three-monthly intervals for a year; 2) a control (mini-intervention) group, 86 patients (71 men and 15 women), who were followed-up only after 12 months. Follow-up attendance was poor, particularly in the intervention group. In general, MCV-values were unchanged in the groups at the end of the study, though there was a clear trend for the female controls to have lower values (101.9 fl at the start, 98.5 fl at the end, p = 0.06). Altogether 11% (4/38) of the women and 7% (10/140) of the men had clearly reduced their alcohol consumption after one year, and this was also seen in their MCV-values. Mini-intervention, especially in women with an abnormal laboratory value, seems to be, with the help of MCV, at least as effective a way OC counselling nonalcoholic abusers as a more systematic intervention. Key words: erythrocyte mean cell volume (MCV), follow-up, general practitioner, heavy drinking, one-counselling. Kaija Seppa, MD, University of Tampere, Department of Public Health, Box 607, SF-33101 Tampere, Finland.
Heavy drinking and its social and health consequences have in recent years been an increasing problem in many countries (1-3); one of these countries is Finland (4). Growing attention is now being paid to the early identification of heavy drinkers (549, which according to a number of reports is crucial to successful intervention (9-1 1). Since there is a tendency for problem drinkers to hide their problem (12-15), there is also the risk that they are reluctant to meet professional helpers; they may even be afraid of them (16). Therefore the best place for early intervention is not necessarily a clinic for alcoholics or a psychiatric or social clinic, but more probably a general practitioner’s office. Even there the element of fear may undermine the intervention effort, which must seek first and foremost to understand and support the patient. General practitioners normally work alone and therefore cannot spare very much time on one patient; this also applies to
interventions in heavy drinking. The aim of this study was to find out whether an intervention helping heavy drinkers according to standard instructions (17) as soon as the problem is detected with the help of single (mini-intervention) or repeated (intervention) measurements of MCV, can be used in monitoring change in drinking behaviour among macrocytic patients in general practice. PATIENTS A N D METHODS
Patients A total of 300 new consecutive adult patients with an erythrocyte mean cell volume (MCV) of 2 100 fl were examined for the aetiology of macrocytosis in the health centre in Tampere, southern Finland. The patients were normal clients who had come to consult a doctor for some health problem o r symptom and from whom a blood count had been taken. T h e Scand J Prim Health Care 1992; 10
218
K . Seppa
Table I. The Malmo-Modification of the Michigan Alcoholism Screening Test, 1. Do you take a drink before going to a party? 2. Do you usually drink a bottle of wine or corresponding amounts of alcohol over the week-end? 3. Do you drink a couple of drinks (or beers) a day to
4. 5.
6.
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7. 8. 9.
relax? Do you tolerate more alcohol now than you did ten years ago? Have you difficulties not drinking more than your friends? Do you fall asleep after moderate drinking without knowing how you got to bed? Do you have a bad conscience after drinking? Do you take a drink (a beer) the day after a party? Do you try to avoid alcoholic beverages for a determined period of time e.g. a week?
patients were informed by mzil about the abnormal MCV-value and were at the same time invited for this examination. The invitation was repeated once, when necessary. The patients arrived for this examination about two months after the initial MCV value had been taken. A re-measurement of MCV was then undertaken and this served as the initial value. The exact description of the diagnoses is given in another paper (18). T h e diagnostic criteria applied for alcohol abuse were at least two positive answers to the nine-question Malmo Modified Michigan Alcoholism Screening Test (19) (Mm-MAST, Table I) and macrocytosis for which no other aetiology was found. On the basis of these criteria, 126 male and 33 female macrocytic abusers were diagnosed. As alcohol abuse is a strictly hidden problem, medical history giving clues to alcohol abuse or an alcohol-induced increase in serum gammaglutamyltransferase ( 2 50 U/1) were also taken into account. Thus, in addition t o the questionnaire criterion, 14 men and 9 women were found t o be abusers. All the
140 diagnosed men and 38 of the 42 women agreed to participate in this study. The study protocol was approved by the Ethics Committee of the Town Hospital of Tampere. Intervention and follow-up All the patients were investigated by the same doctor for macrocytosis. After the diagnosis and initial counselling, the abusers were randomly allocated t o the intervention and control groups. T h e patients in the intervention group were asked to visit the doctor at intervals of three months for one year to monitor their MCV-value and long-term alcohol consumption. The sessions were brief: the patients were asked about their alcohol consumption, were informed about the results of their blood test, and encouraged t o minimize consumption. T h e patients in the control group were invited by mail to contact their doctor one year later. MCV-values were measured in all patients after 12 months. The male intervention (n = 69) and control (n = 71) groups were similar to each other in terms of age (p = 0.8, mean ages 53.7 and 54.3 years), S-GGT ( p = 0.1, mean values 153.2 U/I and 156.7 W), and MCV (p = 0.3, mean values 101.5 fl and 100.9 fl). N o statistically significant differences were found between the female intervention (n = 23) and control (n = 15) groups in terms of either age ( p = 0.3, mean ages 52.3 and 47.4 years, respectively), SGGT (p = 0.7, mean values 119.2 UA and 96.3 U/l), or MCV ( p = 0.9, mean values 102.0 fl and 101.7 fl). Outcome Alcohol consumption was considered to be decreased if the patient said that he o r she had reduced consumption, if the patient history during one year showed no signs (e.g. traumas, first-aid contacts while being drunk) of alcohol abuse, and if the
Table 11. MCV-values in male and female intervention and control groups. MCV (fl) k SEM
Intervention group
Control group
p-value
At 12 months Participation rate (%)
101.520.4,(N=69) 101.9k1.0 (N=35) 51
100.9k0.4 (N=71) 101.1k0.8 (N=46) 65
0.3 0.5
Female Initial value At 12 months Participation rate (YO)
102.0t1.0 (N=23) 98.521.8 (N=6) 26
101.7k1.1 (N=15) 98.521.5 (N=8) 53
0.9 1.0
Male
Initial value
Scand J Prim Health Care 1992: 10
lntervention in alcohol abuse
219
Table 111. MCV-values ar the beginning and at the end of the examination in the male and female alcohol abusers who came to the final control. MCV (fl) f SEM
Male Intervention group (N=35) Control group (N=46)
Initial-value
At 12 months
p-value
101.220.7 101.3+0.5
101.9f1.0 10t.120.8
0.5 0.9
99.8k 1.4 101.920.7
98.521.8 98.521.5
0.6 0.06
Female
Intervention group (N=6) Control group (N=8)
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MCV-value was lower than at the beginning of the study.
101.6 fl (+ 0.31); this was taken as the initial MCVvalue. Table 11 shows the MCV-values at the start and Laborarory methods and statistical unalysk end of the study for all the groups. With respect to MCV was measured by Coulter Counter S (Coulter the males, there were no significant differences beElectronics Inc, Hialeah, Fla) and serum gammaglu- tween the two groups at 12 months. In the interventamyltransferase according to the recommendations tion group, 46 attended at 3 months, 48 at 6 months, of the Scandinavian Society for Clinical Chemistry and 30 at 9 months. Thirty-five (51%) men in this and Clinical Physiology (20). BMDP software pro- group came to the control examination at the end of grams were used in the statistical analysis of the the follow-up. Twenty-eight men had attended every material (21). Analysis of variance (7D) was used in follow-up. T h e mean MCV-value of these 35 men the comparison of the laboratory values among the was not significantly reduced at the end of the examgroups, and two-way frequency tables (4F) in the ination (101.2 fl and 101.9, respectively: p = 0.5) comparison of the attendance percentages between (Table 111). Case-by-case MCV-values showed that it was unchanged in four ( 1 1Yo)and reduced in 13 men the groups. (37%); six of the latter said they were drinking considerably less than earlier. Forty-six (65%) men in the control group attended the 12-month follow-up. RESULTS No significant changes were observed in the mean When the patients first contacted the health centre, the mean MCV-value (-+ SEM) was 103.2 fl (-+ MCV-values within this group (101.3 fl and 101.1 fl, 0.73). About two months later, when they were in- respectively, p = 0.9, Table 111). In this group, unvited for a closer examination of macrocytosis, it was changed MCV-values were found in four (9%) and decreased values in 24 men (52%). Four of them said that they had markedly reduced their alcohol consumption. Thus, 10/140 men (7%) said that their drinking had decreased, and their MCV-values were lower than at the beginning of the intervention. The difference in the male participation rates at 12 Change 0 months between the intervention group (51%) and the controls (65%) was not significant ( p > 0.1). There were no significant differences in the MCV-10 values between the female groups at the start or end 1 2 3 4 5 6 of the study (Table 11). Attendance of the intervenPatient number tion group at the follow-ups decreased progressively Figure I A . Case-by-case changes in MCV-values among from 11 at 3 months, 8 at 6 months, 7 at 9 months, to women in the intervention group after 12 months. Patient No. 1 said she had significantly reduced her alcohol con- 6 (26%) at the 12 month follow-up. Only 2 women attended every follow-up. The mean MCV-value of sumption.
l-y-r--z-L
Scand J Prim Heulrh Care 1992; I0
220
K . Seppa l6
-16
women's and men's groups, those who were counselt led only once (i.e. control groups) attended in larger
1
L , 1
2
3
4
5
6
7
8
Patient number
Figure 1B. Case-by-case changes in MCV-values among women in the control group after 12 months. Patients Nos. 1, 2 and 8 said they had significantly reduced their alcohol
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consumption. the 6 women who attended at 12 months decreased from the initial value of 99.8 fl to 98.5 fl, but the decrease was not significant (p = 0.6, Table 111). Case-by-case MCV-values for these women are shown in Figure 1A. The value had decreased in four women (67%), but only one (No. 1, Fig. 1A) said that her consumption was significantly reduced. Eight (53%) of the women in the control group attended the one-year control, and the MCV-values at the beginning and at the end of the study were 101.9 fl and 98.5 fl, respectively (p = 0.06), (Table 111). Case-by-case MCV-values for this group are shown in Figure 1B; the value had decreased in seven women (88%). Three of them said that they had significantly cut down on their drinking (Nos. 1, 2, and 8, Fig. 1B). In the whole group of 38 women, four (llYo) reported having reduced their alcohol consumption; in all these cases the MCV-values had also decreased. A higher percentage of control than intervention women attended the follow-up at 12 months, 8/15 (53%) and 6/23 (26%), respectively (p = 0.09). DISCUSSION The group of patients who formed the target of this intervention effort was ideal for the present purposes in that they had at least one abnormal laboratory value (MCV) and their alcohol problem was not profound. In addition, the intervention took place at a health centre, where the patient does not need to fear that he or she will be considered an abuser. That so many of both sexes failed to attend at 12 months means that heavy drinking is a strictly hidden problem. It may also be noted that in both the Scund I Prim Heulth Cure 1992: 10
numbers for the re-examination one year later; this was particularly clear among the women. This suggests that females might be in need of other intervention strategies than males. This also suggests that, unless they specifically ask for it, people do not necessarily want to be advised, at least this strongly, in matters related to their health behaviour. There were n o statistical differences in the MCVvalues of either men or women between the intervention and control groups. From this we may conclude that the attempt to intervene effectively in alcohol problems is a waste of time and resources for both the doctor and the patient; it seems to be sufficient simply to identify the problem, and to remind the patient about it, with laboratory test control only infrequently. MCV was used as the laboratory marker in this study because only macrocytic patients were included. It is clear that, once some alcohol-induced laboratory abnormality has been found, this will also serve as a reference for changes in alcohol consumption. MCV has many limitations when it is used as an alcohol marker. Although it has quite a high specificity, especially among middle aged patients, it is far from being satisfactory in sensitivity (22-24). As a screening method, S-GT is somewhat more sensitive, though still far from ideal. The new biochemical markers, for example serum desialotransferrin (S-CDT), are better both in sensitivity and in specificity (25). Compared with MCV, these also have one benefit; they normalize much more rapidly than MCV (24,26) and thus give more recent information about changes in alcohol consumption. In both female groups MCV-values were lower at 12 months; the decrease was nearly significant in the control group. Although the number of women was small and the result thus tentative, the trend was clear, and the high p-value may be due to the fact that only relatively few women came to the control. No similar decline in the mean MCV-value could be observed among the men. When examined individually, four of the 38 abuser women (11%) said that they had significantly reduced their drinking at the end of the follow-up, and the MCV-value of eleven women had decreased. Among the men 10/140 (7%) said they had cut down on drinking; the MCV-value was decreased in 37/140. All of those patients who were drinking less also showed reduced MCV-values. The minor changes in the MCV-values of abus-
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Intervention in alcohol abuse
ers who had not significantly reduced their alcohol consumption can be explained at least partly by normal variation (1-2 fl). Thus, at the individual level, it seems that many patients benefit from the identification by their doctor of the alcohol problem, and that one-counselling, at least in the present study, is as efficient and possibly more efficient than systematic counselling. It must be taken into account that the patients were not alcoholics, and that they were included in the examination on the basis of one abnormal laboratory value. A central problem in work with heavy drinkers is the motivation not only of patients but also of doctors. In order to be able to encourage that motivation, we need to know what kind of intervention, if any (17, 27), is or can be effective. For instance, should doctors work alone and invite patients to control examinations, or is it more useful to work in groups? Should abusers be seen frequently or infrequently? More research is needed into these questions to make the clinician’s work worthwhile. This study suggests that a mini-intervention, with the help of a laboratory marker, is more useful than more systematic control. This type of work can also be done alone by general practitioners. ACKNOWLEDGEMENTS I am grateful to Dr Matti Saarni for helping me in the original plan of my study on macrocytosis and to Dr Timo Pitkajarvi for allowing me to examine patients from his clinic.
REFERENCES 1 . Consumption statistics. Productschap voor Gedistil-
leerde Dranken, Schiedam, 1988. 2. Royal College of Physicians. A great and growing evil: the medical consequences of alcohol abuse. London: Tavistock. 1987. 3. Andreasson S , Allebeck P, Romelsjo A. Alcohol and mortality among young men: longitudinal study of Swedish conscripts. BMJ 1988; 296: 1021-5. 4. Alcohol statistical yearbook. T-t-print, Helsinki, 1988. 5 . Holt S , Skinner HA, Israel Y. Early identification of alcohol abuse: 2: Clinical and laboratory indicators. Can Med Assoc J 1981; 124: 1279-94. 6 . Lewis KO, Paton A. ABC of alcohol; Tools of detection. BMJ 1981; 283: 1531-2. 7. Stibler H. Borg S, Allgulander C. Clinical significance of abnormal heterogenity of transferrin in relation to alcohol consumption. Acta Med Scand 1979; 206: 275-8 1. 8. Unger KW, Johnson D Jr. Red cell mean corpuscular volume: a potential indicator of alcohol usage in working population. Am J Med Sci 1974; 267: 281-9.
221
9. Kristenson H, Ohlin H , Hulten-Nosslin M-B, Trell E, Hood B. Identification and intervention of heavy drinking in middle-aged men: results and follow-up of 24-60 months of long term study with randomized controls. Alcoholism: Clin Exp Res 1983; 7: 203-9. 10. Chick J, Lloyd G, Crombie E. Counselling problem drinkers in medical wards: a controlled study. BMJ 1985; 290: 965-7. 1. Wallace P, Cutler S , Haines A. Randomised controlled trial of general practitioner intervention in patients with excessive alcohol consumption. BMJ 1988; 297: 663-8. 2. Barrison IG, Viola L, Murray-Lyon IM. Do housemen take an adequate drinking history? BMJ 1980; 281: 1040. 13. Froede CD, Gordon JD. Alcoholism - the second great imitator. Am J Clin Pathol 1980; 74: 719-20. 14. Orrego H, Blendis LM, Blake J E , Kapur BM, Israel Y. Reliability of assessment of alcohol intake based on personal interviews in a liver clinic. Lancet 1979; ii: 1354-6. 15. Keso L, Salaspuro M. Comparative value of self-report and blood tests in assessing outcome amongst alcoholics. Br J Addict 1990; 85: 209-15. 16. Wallace P, Haines A. General practitioner and health promotion: what patients think. BMJ 1984; 289: 5 3 5 6 . 17. Emrick CD. A review of psychologically oriented treatment of alcoholism: 2. The relative effectiveness of different treatment approaches and the effectiveness of treatment versus no treatment. J Stud Alcohol 1975; 36: 88-108. 18. Seppa K, Laippala P, Saarni M. Macrocytosis as a consequence of alcohol abuse among patients in general practice. Alcohol Clin Exp Res 1991; 15: 871-6. 19. Kristenson H, Trell E. Indicators of alcohol consumption; comparison between a questionnaire (MmMAST), interviews and serum gammaglutamyltransferase (GGT) in a health survey of middle-aged males. Br J Addict 1982; 77: 297-304. 20. Scandinavian Society for Clinical Chemistry and Clinical Physiology. Committee on enzymes: recommended method for the determination of gamma-glutamyltransferase in blood. Scand J Clin Lab Invest 1976; 36: 119-25. 21. Dixon WJ. BMDP statistical software. University of California Press, Berkeley, 1983. 22. Wu A, Chanarin I , Levi AJ. Macrocytosis of chronic alcoholism. Lancet 1974; i: 829-30. 23. Chick J , Kreitman N, Plant M: Mean cell volume and gammaglutamyltranspeptidase as markers of drinking in working men. Lancet 1981; i: 1249-51. 24. Morgan MY, Camilo ME, Luck W , Sherlock S , Hoffbrand AV. Macrocytosis in alcohol-related liver disease: its value for screening. Clin Lab Haematol 1981; 3: 35-44. 25. Stibler H, Borg S , Joustra M. Micro anion exchange chromatography of carbohydrate-deficient transferrin in serum in relation to alcohol consumption. Alcohol Clin Exp Res 1986; 10: 535-44. 26. Kapur A, wild G, Milford-Ward A , Triger DR. Carbohydrate deficient transferrin: a marker for alcohul abuse. BMJ 1989; 299: 427-31. Scand I Prim Health Care 1992; 10
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27. Edwards F, Orford J, Egert S, Guthrie S, Hauker A, Henswan C , et al. Alcoholism: A controlled trial of “Treatment and advice”. J Stud Alcohol 1977; 38: 1004-31.
Scand J Prim Health Care 1992; I0
Received December 1990 Accepted January 1992
ISSN: 0281-3432 (Print) 1502-7724 (Online) Journal homepage: http://www.tandfonline.com/loi/ipri20
Intervention in Alcohol Abuse among Macrocytic Patients in General Practice Kaija Seppä To cite this article: Kaija Seppä (1992) Intervention in Alcohol Abuse among Macrocytic Patients in General Practice, Scandinavian Journal of Primary Health Care, 10:3, 217-222, DOI: 10.3109/02813439209014064 To link to this article: http://dx.doi.org/10.3109/02813439209014064
© 1992 Informa UK Ltd All rights reserved: reproduction in whole or part not permitted Published online: 12 Jul 2009.
Submit your article to this journal
Article views: 100
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipri20 Download by: [193.90.12.89]
Date: 23 March 2016, At: 19:46
&and J Prim Health Care 1992; 10: 21 7-222
Intervention in Alcohol Abuse among Macrocytic Patients in General Practice KAIJA SEPPA Universiry of Tampere, Department of Public Health, Finland
Downloaded by [193.90.12.89] at 19:46 23 March 2016
SeppH K. Intervention in alcohol abuse among macrocytic patients in general practice. Scand J Prim Health Care 1992; 1 0 217-22. The study examined the effectiveness of routine intervention in alcohol abuse by a general practitioner, with help of a laboratory test. Patients diagnosed as abusers because of high erythrocyte mean cell volume value (MCV) and having no other cause for it were randomly allocated to two groups: 1) an intervention group, comprising 92 patients (69 men and 23 women), who were invited for follow-up at three-monthly intervals for a year; 2) a control (mini-intervention) group, 86 patients (71 men and 15 women), who were followed-up only after 12 months. Follow-up attendance was poor, particularly in the intervention group. In general, MCV-values were unchanged in the groups at the end of the study, though there was a clear trend for the female controls to have lower values (101.9 fl at the start, 98.5 fl at the end, p = 0.06). Altogether 11% (4/38) of the women and 7% (10/140) of the men had clearly reduced their alcohol consumption after one year, and this was also seen in their MCV-values. Mini-intervention, especially in women with an abnormal laboratory value, seems to be, with the help of MCV, at least as effective a way OC counselling nonalcoholic abusers as a more systematic intervention. Key words: erythrocyte mean cell volume (MCV), follow-up, general practitioner, heavy drinking, one-counselling. Kaija Seppa, MD, University of Tampere, Department of Public Health, Box 607, SF-33101 Tampere, Finland.
Heavy drinking and its social and health consequences have in recent years been an increasing problem in many countries (1-3); one of these countries is Finland (4). Growing attention is now being paid to the early identification of heavy drinkers (549, which according to a number of reports is crucial to successful intervention (9-1 1). Since there is a tendency for problem drinkers to hide their problem (12-15), there is also the risk that they are reluctant to meet professional helpers; they may even be afraid of them (16). Therefore the best place for early intervention is not necessarily a clinic for alcoholics or a psychiatric or social clinic, but more probably a general practitioner’s office. Even there the element of fear may undermine the intervention effort, which must seek first and foremost to understand and support the patient. General practitioners normally work alone and therefore cannot spare very much time on one patient; this also applies to
interventions in heavy drinking. The aim of this study was to find out whether an intervention helping heavy drinkers according to standard instructions (17) as soon as the problem is detected with the help of single (mini-intervention) or repeated (intervention) measurements of MCV, can be used in monitoring change in drinking behaviour among macrocytic patients in general practice. PATIENTS A N D METHODS
Patients A total of 300 new consecutive adult patients with an erythrocyte mean cell volume (MCV) of 2 100 fl were examined for the aetiology of macrocytosis in the health centre in Tampere, southern Finland. The patients were normal clients who had come to consult a doctor for some health problem o r symptom and from whom a blood count had been taken. T h e Scand J Prim Health Care 1992; 10
218
K . Seppa
Table I. The Malmo-Modification of the Michigan Alcoholism Screening Test, 1. Do you take a drink before going to a party? 2. Do you usually drink a bottle of wine or corresponding amounts of alcohol over the week-end? 3. Do you drink a couple of drinks (or beers) a day to
4. 5.
6.
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7. 8. 9.
relax? Do you tolerate more alcohol now than you did ten years ago? Have you difficulties not drinking more than your friends? Do you fall asleep after moderate drinking without knowing how you got to bed? Do you have a bad conscience after drinking? Do you take a drink (a beer) the day after a party? Do you try to avoid alcoholic beverages for a determined period of time e.g. a week?
patients were informed by mzil about the abnormal MCV-value and were at the same time invited for this examination. The invitation was repeated once, when necessary. The patients arrived for this examination about two months after the initial MCV value had been taken. A re-measurement of MCV was then undertaken and this served as the initial value. The exact description of the diagnoses is given in another paper (18). T h e diagnostic criteria applied for alcohol abuse were at least two positive answers to the nine-question Malmo Modified Michigan Alcoholism Screening Test (19) (Mm-MAST, Table I) and macrocytosis for which no other aetiology was found. On the basis of these criteria, 126 male and 33 female macrocytic abusers were diagnosed. As alcohol abuse is a strictly hidden problem, medical history giving clues to alcohol abuse or an alcohol-induced increase in serum gammaglutamyltransferase ( 2 50 U/1) were also taken into account. Thus, in addition t o the questionnaire criterion, 14 men and 9 women were found t o be abusers. All the
140 diagnosed men and 38 of the 42 women agreed to participate in this study. The study protocol was approved by the Ethics Committee of the Town Hospital of Tampere. Intervention and follow-up All the patients were investigated by the same doctor for macrocytosis. After the diagnosis and initial counselling, the abusers were randomly allocated t o the intervention and control groups. T h e patients in the intervention group were asked to visit the doctor at intervals of three months for one year to monitor their MCV-value and long-term alcohol consumption. The sessions were brief: the patients were asked about their alcohol consumption, were informed about the results of their blood test, and encouraged t o minimize consumption. T h e patients in the control group were invited by mail to contact their doctor one year later. MCV-values were measured in all patients after 12 months. The male intervention (n = 69) and control (n = 71) groups were similar to each other in terms of age (p = 0.8, mean ages 53.7 and 54.3 years), S-GGT ( p = 0.1, mean values 153.2 U/I and 156.7 W), and MCV (p = 0.3, mean values 101.5 fl and 100.9 fl). N o statistically significant differences were found between the female intervention (n = 23) and control (n = 15) groups in terms of either age ( p = 0.3, mean ages 52.3 and 47.4 years, respectively), SGGT (p = 0.7, mean values 119.2 UA and 96.3 U/l), or MCV ( p = 0.9, mean values 102.0 fl and 101.7 fl). Outcome Alcohol consumption was considered to be decreased if the patient said that he o r she had reduced consumption, if the patient history during one year showed no signs (e.g. traumas, first-aid contacts while being drunk) of alcohol abuse, and if the
Table 11. MCV-values in male and female intervention and control groups. MCV (fl) k SEM
Intervention group
Control group
p-value
At 12 months Participation rate (%)
101.520.4,(N=69) 101.9k1.0 (N=35) 51
100.9k0.4 (N=71) 101.1k0.8 (N=46) 65
0.3 0.5
Female Initial value At 12 months Participation rate (YO)
102.0t1.0 (N=23) 98.521.8 (N=6) 26
101.7k1.1 (N=15) 98.521.5 (N=8) 53
0.9 1.0
Male
Initial value
Scand J Prim Health Care 1992: 10
lntervention in alcohol abuse
219
Table 111. MCV-values ar the beginning and at the end of the examination in the male and female alcohol abusers who came to the final control. MCV (fl) f SEM
Male Intervention group (N=35) Control group (N=46)
Initial-value
At 12 months
p-value
101.220.7 101.3+0.5
101.9f1.0 10t.120.8
0.5 0.9
99.8k 1.4 101.920.7
98.521.8 98.521.5
0.6 0.06
Female
Intervention group (N=6) Control group (N=8)
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MCV-value was lower than at the beginning of the study.
101.6 fl (+ 0.31); this was taken as the initial MCVvalue. Table 11 shows the MCV-values at the start and Laborarory methods and statistical unalysk end of the study for all the groups. With respect to MCV was measured by Coulter Counter S (Coulter the males, there were no significant differences beElectronics Inc, Hialeah, Fla) and serum gammaglu- tween the two groups at 12 months. In the interventamyltransferase according to the recommendations tion group, 46 attended at 3 months, 48 at 6 months, of the Scandinavian Society for Clinical Chemistry and 30 at 9 months. Thirty-five (51%) men in this and Clinical Physiology (20). BMDP software pro- group came to the control examination at the end of grams were used in the statistical analysis of the the follow-up. Twenty-eight men had attended every material (21). Analysis of variance (7D) was used in follow-up. T h e mean MCV-value of these 35 men the comparison of the laboratory values among the was not significantly reduced at the end of the examgroups, and two-way frequency tables (4F) in the ination (101.2 fl and 101.9, respectively: p = 0.5) comparison of the attendance percentages between (Table 111). Case-by-case MCV-values showed that it was unchanged in four ( 1 1Yo)and reduced in 13 men the groups. (37%); six of the latter said they were drinking considerably less than earlier. Forty-six (65%) men in the control group attended the 12-month follow-up. RESULTS No significant changes were observed in the mean When the patients first contacted the health centre, the mean MCV-value (-+ SEM) was 103.2 fl (-+ MCV-values within this group (101.3 fl and 101.1 fl, 0.73). About two months later, when they were in- respectively, p = 0.9, Table 111). In this group, unvited for a closer examination of macrocytosis, it was changed MCV-values were found in four (9%) and decreased values in 24 men (52%). Four of them said that they had markedly reduced their alcohol consumption. Thus, 10/140 men (7%) said that their drinking had decreased, and their MCV-values were lower than at the beginning of the intervention. The difference in the male participation rates at 12 Change 0 months between the intervention group (51%) and the controls (65%) was not significant ( p > 0.1). There were no significant differences in the MCV-10 values between the female groups at the start or end 1 2 3 4 5 6 of the study (Table 11). Attendance of the intervenPatient number tion group at the follow-ups decreased progressively Figure I A . Case-by-case changes in MCV-values among from 11 at 3 months, 8 at 6 months, 7 at 9 months, to women in the intervention group after 12 months. Patient No. 1 said she had significantly reduced her alcohol con- 6 (26%) at the 12 month follow-up. Only 2 women attended every follow-up. The mean MCV-value of sumption.
l-y-r--z-L
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K . Seppa l6
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women's and men's groups, those who were counselt led only once (i.e. control groups) attended in larger
1
L , 1
2
3
4
5
6
7
8
Patient number
Figure 1B. Case-by-case changes in MCV-values among women in the control group after 12 months. Patients Nos. 1, 2 and 8 said they had significantly reduced their alcohol
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consumption. the 6 women who attended at 12 months decreased from the initial value of 99.8 fl to 98.5 fl, but the decrease was not significant (p = 0.6, Table 111). Case-by-case MCV-values for these women are shown in Figure 1A. The value had decreased in four women (67%), but only one (No. 1, Fig. 1A) said that her consumption was significantly reduced. Eight (53%) of the women in the control group attended the one-year control, and the MCV-values at the beginning and at the end of the study were 101.9 fl and 98.5 fl, respectively (p = 0.06), (Table 111). Case-by-case MCV-values for this group are shown in Figure 1B; the value had decreased in seven women (88%). Three of them said that they had significantly cut down on their drinking (Nos. 1, 2, and 8, Fig. 1B). In the whole group of 38 women, four (llYo) reported having reduced their alcohol consumption; in all these cases the MCV-values had also decreased. A higher percentage of control than intervention women attended the follow-up at 12 months, 8/15 (53%) and 6/23 (26%), respectively (p = 0.09). DISCUSSION The group of patients who formed the target of this intervention effort was ideal for the present purposes in that they had at least one abnormal laboratory value (MCV) and their alcohol problem was not profound. In addition, the intervention took place at a health centre, where the patient does not need to fear that he or she will be considered an abuser. That so many of both sexes failed to attend at 12 months means that heavy drinking is a strictly hidden problem. It may also be noted that in both the Scund I Prim Heulth Cure 1992: 10
numbers for the re-examination one year later; this was particularly clear among the women. This suggests that females might be in need of other intervention strategies than males. This also suggests that, unless they specifically ask for it, people do not necessarily want to be advised, at least this strongly, in matters related to their health behaviour. There were n o statistical differences in the MCVvalues of either men or women between the intervention and control groups. From this we may conclude that the attempt to intervene effectively in alcohol problems is a waste of time and resources for both the doctor and the patient; it seems to be sufficient simply to identify the problem, and to remind the patient about it, with laboratory test control only infrequently. MCV was used as the laboratory marker in this study because only macrocytic patients were included. It is clear that, once some alcohol-induced laboratory abnormality has been found, this will also serve as a reference for changes in alcohol consumption. MCV has many limitations when it is used as an alcohol marker. Although it has quite a high specificity, especially among middle aged patients, it is far from being satisfactory in sensitivity (22-24). As a screening method, S-GT is somewhat more sensitive, though still far from ideal. The new biochemical markers, for example serum desialotransferrin (S-CDT), are better both in sensitivity and in specificity (25). Compared with MCV, these also have one benefit; they normalize much more rapidly than MCV (24,26) and thus give more recent information about changes in alcohol consumption. In both female groups MCV-values were lower at 12 months; the decrease was nearly significant in the control group. Although the number of women was small and the result thus tentative, the trend was clear, and the high p-value may be due to the fact that only relatively few women came to the control. No similar decline in the mean MCV-value could be observed among the men. When examined individually, four of the 38 abuser women (11%) said that they had significantly reduced their drinking at the end of the follow-up, and the MCV-value of eleven women had decreased. Among the men 10/140 (7%) said they had cut down on drinking; the MCV-value was decreased in 37/140. All of those patients who were drinking less also showed reduced MCV-values. The minor changes in the MCV-values of abus-
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Intervention in alcohol abuse
ers who had not significantly reduced their alcohol consumption can be explained at least partly by normal variation (1-2 fl). Thus, at the individual level, it seems that many patients benefit from the identification by their doctor of the alcohol problem, and that one-counselling, at least in the present study, is as efficient and possibly more efficient than systematic counselling. It must be taken into account that the patients were not alcoholics, and that they were included in the examination on the basis of one abnormal laboratory value. A central problem in work with heavy drinkers is the motivation not only of patients but also of doctors. In order to be able to encourage that motivation, we need to know what kind of intervention, if any (17, 27), is or can be effective. For instance, should doctors work alone and invite patients to control examinations, or is it more useful to work in groups? Should abusers be seen frequently or infrequently? More research is needed into these questions to make the clinician’s work worthwhile. This study suggests that a mini-intervention, with the help of a laboratory marker, is more useful than more systematic control. This type of work can also be done alone by general practitioners. ACKNOWLEDGEMENTS I am grateful to Dr Matti Saarni for helping me in the original plan of my study on macrocytosis and to Dr Timo Pitkajarvi for allowing me to examine patients from his clinic.
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Received December 1990 Accepted January 1992
