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AM. J. DRUG ALCOHOL ABUSE, 18(2), pp. 223-234 (1992)
Treatment Compliance after Detoxification among Highly Disadvantaged Alcoholics Ricardo Castaneda,* MD Harold Lifshutz, PhD Marc Galanter, MD Division of Alcaholism and Drug Abuse Department of Psychiatry New York University School of Medicine New York, New York
Alice Medalia Department of Psychiatry Albert Einstein College of Medicine New York, New York
Hugo Franco Division of Alcoholism and Drug Abuse Department of Psychiatry New York University School of Medicine New York, New York
*To whom requests for reprints should be addressed at Assistant Professor of Psychiatry and Director, Alcoholism Treatment Unit, Division of Alcoholism and Drug Abuse, New York University School of Medicine, Room 20 North-23, Bellewe Hospital, New York, New York 10016. Telephone: (212) 561-3455.
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ABSTRACT
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An outcome study was carried out on a sene of 109 highly disadvantaged alcoholicsdischarged
from the detoxification unit of a large municipal hospital in New York City. We examined the impact of a variety of clinical and demographic factors on retention in the initial phases of outpatient and inpatient treatment following discharge. Both high school completion and a history of at least 6 months of employment in the two years preceding admission correlated with frequency of registration for continued aftercare. Measurements of cognitive flexibility correlated with frequency of aftercare completion. An association strongly approaching significance was also found between length of hospital stay and aftercare completion. Some suggestions are made as to the assessment and aftercare planning for highly disadvantaged alcoholics.
INTRODUCTION Attention is being paid to the understanding of the variahles which determine outcome among the subpopulation of alcoholics who are highly disadvantaged, generally deprived, and socially disaffiliated [ 11. There is a pressing need to implement follow-up studies on highly disadvantaged alcoholics in order to clarify their clinical course and to determine the value of the treatment modalities currently available to them [ l]. Locating alcoholics during the course of outcome studies has generally proven difficult, with most studies successfully identifying only between 30 and 50% of the patient sample at follow-up [2-41. Inner-city, highly disadvantaged alcoholics, often homeless and typically estranged from social and financial sources of support, represent an even greater challenge to any attempts at follow-up [ 5 ] . The identificationof predictors of treatment outcome in alcoholics would greatly benefit efforts to effectively match specific treatment interventionswith alcoholic subpopulations. There is, however, little consensus on this area of research. For example, a controversy remains over the relative importance of patients’ background on the one hand [6]and the effects of treatment in determining outcome on the other hand [7].Additionally, the applicability of reported outcome predictors to specific alcoholic populations is unclear due to the diversity in methodology and the multiplicity of definitions of “outcome” in the available studies. Outcome has been measured by different and not readily interchangeable yardsticks [8] including “retention in treatment” (9-1I], “abstinence” [12], and “total life adjustment” [13]. Regarding outcome predictors, it has been learned that no single variable consistently predicts outcome in all alcoholic populations. Being married has been associated with a better prognosis, including ability to attain and maintain
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abstinence in several studies [14-161 but not in others [17, 181. Education [ l , 181 and employment histories [15, 16, 191 have been repeatedly found to correlate with overall improvement and quality and length of abstinence. Level of cognitive functioning has been found to correlate with behavior while in treatment and quality of life adjustment [20], and a variety of other variables such as health, amount of drinking, and family adjustment [21]. Finally, associated psychopathology such as depression [22, 231 and personality disorder [23] have been linked to poorer outcome [22] and more frequent relapses [23] in several studies but not in another [101. In this regard, disadvantaged alcoholics may differ from more stable alcoholics in several areas which influence treatment outcome, such as levels of cognitive functioning, associated drug use, limited economic and social supports, and history of educational and vocational functioning. The treatment of such disadvantaged alcoholics is compounded by the magnitude of their social problems [24] and the perpetuating nature of their lifestyle [25-271, factors which further complicate any attempts at evaluating the effects of treatment. Additionally, the drinking patterns of severely disadvantaged, often homeless alcoholics apparently are more severe than those of household alcoholics [2] and may in turn correlate with lower levels of cognitive and social functioning [28]. More severe patterns of alcoholism have been associated with worse treatment prognoses [28, 291 and may warrant more intensive, longer, or different treatment approaches. This study was done in order to assess the value of those variables already reported to correlate with outcome in alcoholic populations, such as demographic and drinking histories and cognitive functioning in a sample of patients representative of the highly disadvantaged population. Because of its clinical utility and easy measurability, initial retention in treatment after detoxification was chosen as the outcome variable.
SUBJECTS AND METHODS
Subjects This investigation was conducted on a consecutive series of 109 primary alcoholic men who completed a detoxification program at the 30-bed alcoholism treatment unit at the Eellevue Hospital Medical Center, a large facility that serves a mostly disadvantaged population in New York City. Patients admitted to the unit include only primary alcoholics in acute alcohol withdrawal who do not require acute treatment for any associated medical or psychiatric conditions.
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Excluded from the study were 22 patients who left the unit before completion of at least 5 days of detoxification.
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Assessment Instruments All patients were assessed between 5 and 9 days after admission, and only when they had completed medical detoxification, had no other acute medical or psychiatric condition, and were not receiving medication that might interfere with neuropsychological testing. Patient interviews and neuropsychological assessments were conducted by trained research assistants. Data generated included sociodemographic information on ethnicity,marital status, income, employment and educational history, housing status, and housing history. Housing status and history of homelessness were assessed by administration of a questionnaire [30] adapted from Susser et al. 151. Substanceuse histories were obtained during structuredinterviews and included age at onset of alcoholism, fresuency and amount of alcohol consumption,and history of all other drug use. The patient’s age at onset of alcoholism was determined by the age at which the patients first met DSM-III-R [311criteria for alcohol dependence. Additiody, a history of alcoholism in first and second degree relatives was assessed. Alcoholism was diagnosed in a relative only when the patient’s description of the relative clearly satisfied DSM-III-R criteria for alcohol dependence. Cognitive functioning was assessed by means of a battery of neuropsychological tests that included the expanded version (3MS) of the Modified Mini-Mental State [32], the Trail Making Test Part B [33], and the Booklet Category Test [34]. The number of days of hospital stay were coded. Follow-up information regarding registration and retention in treatment after discharge from the detoxification ward was obtained through mail communication with those inpatient rehabilitation programs and outpatient clinics where patients were scheduled to continue aftercare treatment following discharge. All patients signed consent for release of information regarding registration, attendance, and completion of treatment from aftercare treatment facilities.
RESULTS Demographic Features Of a total of 109 subjects studied, 47 (43 %) were Black, 36 (33 96) were White, 24 (22%)Hispanic, and 2 (2%)were either American Indian or Asian. The mean (f SD) age for the total cohort was 40.0 (f 9.9 years).
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Most subjects were single (64, or 59%)and only 2 (1.8%) were married; 18 (16.5%)were separated; 20 (18.3%)were divorced, and 5 (4.6%)were widowers.
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Employment History Regarding employment history for the 2 y e m preceding hospitalization, 40% either never worked or worked for less than 1 month, only 14%had worked for at least 6 months, 16%had worked for at least 1 full year, and 12%had consistently worked for 2 years. The number of months of employment was significantly associated with the number of completed school grades (r = .30, N = 108, p < .001). Financial instability was also made apparent by yearly income figures. Most subjects (72%) reported income below $10,000, with one-third of patients reporting no income at all or less than $l,OOO in the past year period. Twelve percent of patients earned between $10,000 and $20,000, and 16%reported yearly income above $20,000.
Education History The mean ( f SD) school grade completed was 11 ( f 2.6 years). There was a positive association between the years of school completed and the age at onset of alcoholism (r = .27, n = 108, p < .002), and a negative association between the years of school grade completed and the number of years of alcoholism (DSM111-R)(-r = 0.38, n = 108, p < .0001). The number of school grades completed also correlated with a variety of cognitive measures, including the Mini-Mental scores (r = .30, N = 108, p < .001), the memory section of the Mini-Mental ( r = .23, N = 108, p < .009), and the number of minutes spent in completing the Trail Making Test (r = .27, N = 108, p < .01).
Housing History The housing status on admission and the housing history in the 2 years preceding admission are illustrated in Table 1. A trend of deterioration in the housing history is observed over the 2 years preceding admission. While 2 years prior almost one-third of patients had their own residence (29%),only 9% did so the night prior to admission. A similar phenomenon occurred with patients as guests; while 29% were guests of relatives or friends 2 years ago, only 10% had stayed
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Table 1. Housing Status within 2 Years Prior to Hospitalization of 109 Alcoholics
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Housing status' Night prior to admission (N = 109)
2 months prior to admission (N = 109)
N
96
N
96
N
x
Homeless: street, shelter, or mission
51
46.8
50
46.0
34
31.28
Guests of relatives or friends
11
10. I
28
25.1
39
29.3
Own apartment or house
10
9.1
16
14.7
32
29.3
Institution: hospital emergency, prison, or nursing home
37
34.0
14
12.8
11
10.2
'x
= 105.18, df
2 years prior to admission (N = 109)
= 3, p < .OOO1
at somebody else's house the night before hospitalization. The proportion of homeless patients also increased from 31% 2 years prior to admission to 46% within the 2 months preceding hospitalization (Table 1).
Drinking History Alcoholism was chronic in this population. Patients met criteria for alcoholism for an average of 15.6 years (range: < 1 to 41 years; k9.W years). The scale used to measure alcohol consumption is described in Table 2. Thirtynine percent (38.5%) of the patients consumed the highest amount of alcohol, equivalent to 1 gallon of wine in a typical drinking day. Nearly half of the patients (46.8%) drank at an intermediate level between 1 gallon and 1/5 gallon of wine. About 13% (12.87%) of patients drank the equivalent of 1/5 gallon of wine daily; only 1.87% of the patient sample drank less than 115 gallon of wine daily. Family History of Alcoholism Most patients (61%) had an alcoholic parent, including 45% who had an alcoholic father, 10%an alcoholicmother, and 6% who had a history of almholism in both parents.
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Table 2. Average Daily Alcohol Consumption during Month Prior to Hospitalization in 109 Alcoholics Average consumption
N
%
1 gallon wine, or 1/4 quart whisky, or 3 cases beer Intermediate 112 pint whisky, or 115 gallon wine, or 6 pack beer Less than above
42 51 14 2
38.5 46.8 12.8 1.8
Life Drug Use History A history of prior dependence on cocaine was found in 19% of the sample, opiates in 16 % ,cannabis in 5 % ,amphetamines 2 % ,and benzodiazepines in 2 % . Seventy percent of the total population smoked at least one pack of cigarettes daily.
Cognitive Functioning The level of cognitive functioning was generally low in this patient population. Of the three cognitive instruments administered, only the Mini-Mental Test did not yield mean (k SD) results significantly below normative values (88.7 SD f 9.3 errors vs normative score: 94 f 6 errors). On the Booklet Category Test, patients committed a mean ( f SD) of 73.9 (f28.3) errors. In this test, 50 errors are the cut-off score for impaired functioning [33]. On the Trail Making Test Part B, patients generally took twice the amount of time and made three times more errors than is normative. These results reflected frequent difficulties in abstract thinking, cognitive inflexibility, and slowness of thinking processes, all of which are likely to undermine the subjects’ adaptive abilities and clinical course. There was a significant association between age and the number of errors in the Trail Making Test (r = .17, n = 103, p < .04).
Aftercare Compliance and Completion Of a total of 100 detoxified patients who were followed after discharge from the hospital, 74 accepted aftercare referral; of these, 47 entered their next phase of inpatient (N = 23) or outpatient (N = 24) rehabilitation. The remaining 21 patients were lost to follow-up. Out of 47 patients registered in an aftercare program,a total of 30 patients completed this aftercare phase which included either 42-day-long inpatient rehabilitation (N = 19) or at least 3 months in outpatient
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treatment (N= 11). No differences were found between the frequencies of inpatient and outpatient program completion.
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Variables Associated with Registration for Aftercare Only two variables, education (r = .27, N = 74, p < .01) and employment (r = .26, N = 74, p < .Ol), were associated with compliance with scheduled registration for aftercare. Having completed high school (r = .29, N = 73, p < .007) and having worked for more than 6 months within the past 2 years (r = .26, N = 74, p < .01) were clearly associated with compliance with initial appointment for aftercare.
Variables Associated with Completion of Aflercare Only variables of cognitivemeasurement were significantly associated with aftercare completion. Specifically,measurements of cognitive flexibility such as the Trail Making B (r = .24, N = 45, p < .05) and the generative naming section of the Mini-Mental (r = .25, N = 47, p < .05) had significantassociations with frequency of completion of the initial phases of inpatient and outpatientaftercareprograms. A strong trend toward significance was found between the likelihood of aftercare program completion and the number of days spent on the detoxification unit (r = .25, N = 4 5 , p < .052).
DISCUSSION The data reported here represent a direct measure of the effectiveness of institutional efforts to retain highly disadvantaged alcoholics in treatment after detoxification. The study results reflect a marked tendency for this sample to register for the initial phase of aftercare treatment more often than to complete it as illustrated by the fact that although two-thirds actually accepted aftercare, only a little under half showed up for their initial aftercare appointment, and only onefourth actually completed the initial phase of treatment. The implicationsfor early dropouts from treatment, however, are not obvious since even though dropouts from institutionaltreatment programs are generally expected to have poorer outcomes [3, 41, spontaneous remissions even by skid-row alcoholics have been reported to range between 30 and 50% [35, 361.
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We identified several significant correlates of treatment compliance and confirmed the outcome predictive value of level of functioning prior to detoxification [ l , 9, 101. In general, as Slater et al. point out [23], the degree of stability of the alcoholic’s lifestyle prior to admission for treatment is inversely associated with the likelihood of hospital readmission. It is not surprising, in light of similar reports [ 15,37, 381, that in this group of highly disadvantaged alcoholics, employment history also correlated with initial treatment compliance. Consistent with previous investigationson skid-row alcoholics [ 11, in our study the level of education (and high school completion in particular) correlated most closely with the likelihood to show up for aftercare appointments. High school education thus appears to be associated with increased compliance with treatment. These findings illustrate the importance of the incorporation of demographic data into considerations regarding treatment planning. The positive correlations found between level of education and other variables, such as treatment compliance, employment, and cognitive functioning, may reflect the beneficial effects of exposure to school in improving the patient’s ability to absorb the impact of alcoholism. The same factors, however, which mitigate against a good outcome, such as cognitive deficits, social instability, and early onset of drinking, might affect individuals at an early age and prevent them from advancing in their schooling. Other variables associated with treatment compliance were scores on the Trail Making B and the generative naming section of the Mini-Mental. The specificity of these two cognitive variables may be perhaps explained by the cognitive function they measure, mainly cognitive flexibility. Specific rehabilitation efforts aimed at improving alcoholics’ cognitive flexibility have been implemented and have been reported to significantly improve treatment response [39, 401. Cognitive functions related to cognitive shifting have also been identified as outcome predictors. Specifically, more effective “internal scanning” in a sample of 42 male alcoholics proved to be predictive of better adjustment at 2 year follow-up [2 11. Given the studies suggesting a predictive value to specific cognitive functions, it may be justified to implement comprehensive and specific cognitive assessment in large populations of alcoholics in order to determine the potential role of specific cognitive functions as outcome predictors. The Trail Making B has also been found to be sensitive to cognitive deficits and has been recommended as a useful assessment tool in alcoholics [33, 41, 421. Although some kind of cognitive impairment is frequently found not only in alcoholics [43, 441 but also in their children [45], and may indeed precede the onset of alcoholism [41], the frequency and severity of cognitive deficits vary in different alcoholic populations [28, 41, 461. In this group of highly disadvantaged alcoholics, cognitive impairment was more frequent than it was severe. Neuropsychological assessments
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are not routinely camed out in alcoholism treatment settings. Despite abundant evidence supporting the clinical importanceof information on the level of cognitive functioning [47], the cognitive profile of individual alcoholic patients is rarely included in treatment planning. Clearly, studies involving larger samples and longer follow-up are needed in order to better determine the relevance and applicability of our findings. Regarding the management of cognitive deficits in alcoholics [48], additional research attention should be placed on pharmacological [49] and cognitive [21] methods for cognitive improvement and rehabilitation. A strong trend was found between length of hospital stay and aftercare completion. Since patients’ hospital stay ranged only between 1 and 2 weeks, this suggests that even a few additional days of treatment may have an impact on treatment outcome. An association between length of inpatient stay in a rehabilitation program for skid-row alcoholics and subsequent length and quality of abstinence and improvementof level of vocational functioning has been reported [ 11. It may be that a longer period of recuperation from cognitive dysfunction while in the hospital increases aftercare treatment compliance. Alternatively, longer hospital stays may afford the opportunity to better address some of the severe socioeconomic problems prevalent in the study population. Further studies are required to better assess the relationship between length of stay for hospital-based detoxification and subsequent treatment compliance among highly disadvantaged alcoholics.
ACKNOWLEDGMENTS
This project was supported in pan by BRSG SO7 RRO5399-28awarded by the Medical Research Support Grant Propram,Division of Research Resources, National Institutes of Health @r. Castaneda). The study was done at Bellevue Hospital Medical Center, New York, New York. We gratefully acknowledge the valuable research assistance provided by Jephta Tausig-Edwards, BA, Mitra Bassiri, MA, Cindy Weiner, MA, and Kenneth Washington, MA.
REFEWNCES Fagan, R. W.,and Mauss, A. L.,Social margin and social reenby: An evaluation of a rehabilitation program for skid row alcoholics, 1. Srud. Alcohol 47(5):413-425 (1986). [2] Baekeland, F., Lundwall, L., and Shanahan, T., Correlates of patient attrition in the outpatient treatment of alcoholism, J. New. Ment. Dis. 1579-107 (1973). [3] Vanicelli, M., Pfau, B.,and Ryback, R. S., Data attrition in follow-up studies of alcoholics, J. Std. A k ~ h o 37:1325-1330 l (1976). [4] Moos, R., and Bliss, F.,Difficulty of follow-up and outcome of alcoholism treatment, J. Srud. Alcohol 39(3):473-490 (1978). [I]
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Susser, E., Struening, E. L., and Conover, S.,Psychiatric problems in homeless men. Lifetime psychosis and substance abuse, current distress in new arrivals at NYC shelters, Arch. Gen. Psychiatry 46:845-850 (1989). Vaillant, G.E., lhe Nururul Hisrory of Alcoholism, Harvard University Press, Cambridge, Massachusetts, 1983. Emrick, C. D., and Hansen J., Assertions regarding effectivenessof treatment for alcoholism: Fact or fantasy, Am. Psychol. pp. 1078-1088 (October 1983). Voris, S. W., Alcohol treatment outcome evaluation: An overview of methodological issues, Am. J. Drug Alcohol Abuse 8(4):549-558 (1981-1982). Clopton, J. R., Alcoholism and the MMPI, J. Stud. Alcohol 39:1540-1558 (1978). McWilliams, J., and Brown, C. C., Treatment termination variables, MMPI scores and frequency of relapse in alcoholics, Q. J. Stud. Alcohol 28:52-58 (1967). Crawford, J. J., and Chalupsky, A. B., The reported evaluation of alcoholism treatments, 1968- 1971: A methodological review, Addicr. Behuv. 2:63-74 (1977). Armor, D. J., Polich, J. M., and Stambul, H. B., Alcoholism and Treutmenr, Rand Corporation, Santa Monica, California, 1976. Belasco, J. A., The criterion question revisited, Br. J. Addict. 66:33-44 (1971). Ritson, B., Prognosis of alcohol addiction, Br. J. Psychiurry 114:1019-1029 (1968). Pokorny, A. D., Miller, B. A,, and Cleveland, S. E., Response to treatment of alcoholism, Q. J. Stud. Alcohol 29:364-381 (1968). McCance, C., and McCance, P., Alcoholism in North East Scotland. It's treatment and outcome, Br. J. Psychiatry 119189-198 (1969). Reed, R., Grant, I., and Adams, K.,Family history does not predict neuropsychologicperformance in alcoholics, Alcoholism: Clin. Exp. Res. 11(4):340-344 (1987). McLelland, A., Luborsky, L., O'Brien, C., et al., Alcohol and drug abuse treatment in 3 different populations: Is there improvement and is it predictable?, Am. J. Drug Alcohol Abuse 12(1&2): 101- 120 (1986). Gillis, L. S., and Keej, M., Prognostic factors and treatment results in hospitalized alcoholics, Q. J. Stud. Alcohol 40:426-437 (1969). Parsons, O., Do neurological deficits predict alcoholics treatment course and postreatment recovery, in Neuropsychology of Alcoholism. Implicutions for Diagnosis and Treutmenr (0. Parsons, N. Butters, and J. Biggs, eds.), Guilford Press, New York, 1987, pp. 273-290. Tarbox, A. R., Weigel, J. D., and Biggs, J. T., A cognitive typology of alcoholism: Implications for treatment outcome, Am. J. Drug Alcohol Abuse 11(1&2):91-101 (1985). Rounsaville, B. S., Dolinsky, Z., Babor, J., and Meyers, R., Psychopathologicalpredictors of treatment outcome in alcoholics, Arch. Gen. Psychiatry 44:505-513 (1987). Slater, E. J., and Lion, M. W., Predictors of rehospitalization in a male alcoholic population, Am. J. Drug Alcohol Abuse 9(2):211-220 (1982-83). Cook, T., Vugronr Alcoholics, Routledge & Kegan Paul, Boston, 1975. Bahr, H. M., Skid Row: An Inrroduction to Disuflliation, Oxford University Press, New York, 1973. Blumberg, L. U., Shipely Jr., T. E., and Shandler, I. W., Skid Row Md Irs Alrem'ves: Research nnd Recommendutionsfrom Philadelphia, Temple University Press, Philadelphia, 1973. Mulford, H. A,, Rethinking the alcohol problem: A natural processes model, J. Drug Issues 14:31-43 (1984). Castaneda, R., and Galanter, M., Ethnic differences in drinking practices and cognitive impairment among detoxifying alcoholics, J. Sfud. Alcohol 49(4):335-339 (1988). Von Knorring, L., Palm, U., and Anderson, H., Relationship between treatment outcome and subtype of alcoholism in men, J. Stud. Alcohol 46:388-391 (1985).
Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by McMaster University on 11/06/14 For personal use only.
234
CASTANEDA ET AL.
Herman,M.,Galanter, M., and Lifshutz, H.,Homelessnessin patients with combdpsychiatric and substance abuse disorders, Am. J. Drug Alcohol Abuse 17(4):415-422 (1991). American Psychiatric Association, Work Group to Revise DSM-III of the American Psychiatric Association,Diagnostic and Sratiktical Manu~lof Mental Disorders, revised 3rd ed., American Psychiatric Association, Washington, D.C., 1987. Teng, E. L., and Chi, H.C., The Modified Mini-Mental State (3MS) Examination, J. Clin. psychiatry 48(8):314-318 (1987). Reitan, R. M., Validity of the Trails Making Test as an indication of organic brain damage, Percept. Moror Skills (8):271-276 (1958). DeFillippis, N. A., McCampbell, E., and Rogers, P., Development of a booklet form of the Category Test. Normative and validity data, J. Clin. Neuropsychol. (1):339-343 (1979). Smart, R. G., Spontaneousrecovery in alcoholics: A review and analysis of the available research, Drug Alcohol Depend. 1:277-285 (1976). Tucffield, B. S., Spontaneous remission in alcoholics: Empirical observationsand theoretical implications, J. Stud. Alcohol 42:626-641 (1981). Bateman, N. E., and Petersen, D. M., Variables related to outcome of treatment for hospitalized alcoholics, Inr. J. Addicr. 6:215-224 (1971). Mindlin, D. F., The characteristics of alcoholics as related to prediction of therapeutic outcome, Q. J. Srud. Alcohol 29:604-619 (1%9). Gordon, S., Kennedy, B., and McPeake, J., NeuropsychologicaUy impamdalcoholics: Assessment, treatment considerations and rehabilitation, J. SubstMce Abuse Treunwnr599-104 (1988). Heilbrun, A. B., and Tarbox, A. R.,Cognitivestructure and behavioral regulation in alcoholics: Implications for treatment outcome, Br. J. Alcohol Alcoholism 13:65-73 (1978). McCrady, B., Implications of neuropsychological research findings for the treatment and rehabilitation of alcoholics, in Neuropsychology of Alcoholism. lmplicaionsfor Diagnosis and Treatment (0.A. Parsons, N. Butters, and P. E. Nathan, eds.), Guilford Press, New York, 1987, pp. 381-391. Parsons, 0. A., and Farr,S. P., The neuropsychology of alcohol and drug use, in Handbook of Clinical Neuropsychology (S. Filskov and T. Boll, eds.), Wiley, New York, 1981, pp. 320-365. Goldman, M. S., Cognitive impairment in chronic alcoholics: Some cause for optimism, Am. Psychol. 38:1045-1054 (1983). Eckardt, M.J., Parker, E.S.,Noble, E. P., Feldman, D. J., and Gottschalk, L. A., Relationship between neuropsychological performance and alcohol consumption in alcoholics, Bid. Psychiatry 13551-565 (1978). Begleiter, H., Poqesz, R., Bihari, B., and Kissin, B., Event-related potentials in boys at risk of alcoholism, Science 225:1493-14% (1984). Parsons, 0. A., Neuropsychological consequences of alcohol abuse: Many questions-some A. answers, in Neuropsychology of Alcoholism. Implications for Diagnosis and Treatment (0. Parsons, N. Butters, and P. E. Nathan, eds.),Guilford Press, New York, 1987, pp. 155-175. Parsons, 0. A., Butters, N., and Nathan, P. E. (eds.), Neurupsychohgy ofAlcoholism. Implications for Diagnosis and Treatmenr, Guilford Press, New York, 1987. Brandy, I., Butters, N., and Ryan, C., Cognitiveloss and recovery in long-term alcohol abusers, Arch. Gen. Psychiatry W.310 (1987). Ternpesta, E., Tronconi, R., Janiri, L., et al., Role of acetyl-L-camitine in the treatment of cognitive deficits in chronic alcoholism, Int. J. Clin. Pharm. Res. 112:lOl-107 (1990).
AM. J. DRUG ALCOHOL ABUSE, 18(2), pp. 223-234 (1992)
Treatment Compliance after Detoxification among Highly Disadvantaged Alcoholics Ricardo Castaneda,* MD Harold Lifshutz, PhD Marc Galanter, MD Division of Alcaholism and Drug Abuse Department of Psychiatry New York University School of Medicine New York, New York
Alice Medalia Department of Psychiatry Albert Einstein College of Medicine New York, New York
Hugo Franco Division of Alcoholism and Drug Abuse Department of Psychiatry New York University School of Medicine New York, New York
*To whom requests for reprints should be addressed at Assistant Professor of Psychiatry and Director, Alcoholism Treatment Unit, Division of Alcoholism and Drug Abuse, New York University School of Medicine, Room 20 North-23, Bellewe Hospital, New York, New York 10016. Telephone: (212) 561-3455.
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ABSTRACT
Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by McMaster University on 11/06/14 For personal use only.
An outcome study was carried out on a sene of 109 highly disadvantaged alcoholicsdischarged
from the detoxification unit of a large municipal hospital in New York City. We examined the impact of a variety of clinical and demographic factors on retention in the initial phases of outpatient and inpatient treatment following discharge. Both high school completion and a history of at least 6 months of employment in the two years preceding admission correlated with frequency of registration for continued aftercare. Measurements of cognitive flexibility correlated with frequency of aftercare completion. An association strongly approaching significance was also found between length of hospital stay and aftercare completion. Some suggestions are made as to the assessment and aftercare planning for highly disadvantaged alcoholics.
INTRODUCTION Attention is being paid to the understanding of the variahles which determine outcome among the subpopulation of alcoholics who are highly disadvantaged, generally deprived, and socially disaffiliated [ 11. There is a pressing need to implement follow-up studies on highly disadvantaged alcoholics in order to clarify their clinical course and to determine the value of the treatment modalities currently available to them [ l]. Locating alcoholics during the course of outcome studies has generally proven difficult, with most studies successfully identifying only between 30 and 50% of the patient sample at follow-up [2-41. Inner-city, highly disadvantaged alcoholics, often homeless and typically estranged from social and financial sources of support, represent an even greater challenge to any attempts at follow-up [ 5 ] . The identificationof predictors of treatment outcome in alcoholics would greatly benefit efforts to effectively match specific treatment interventionswith alcoholic subpopulations. There is, however, little consensus on this area of research. For example, a controversy remains over the relative importance of patients’ background on the one hand [6]and the effects of treatment in determining outcome on the other hand [7].Additionally, the applicability of reported outcome predictors to specific alcoholic populations is unclear due to the diversity in methodology and the multiplicity of definitions of “outcome” in the available studies. Outcome has been measured by different and not readily interchangeable yardsticks [8] including “retention in treatment” (9-1I], “abstinence” [12], and “total life adjustment” [13]. Regarding outcome predictors, it has been learned that no single variable consistently predicts outcome in all alcoholic populations. Being married has been associated with a better prognosis, including ability to attain and maintain
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abstinence in several studies [14-161 but not in others [17, 181. Education [ l , 181 and employment histories [15, 16, 191 have been repeatedly found to correlate with overall improvement and quality and length of abstinence. Level of cognitive functioning has been found to correlate with behavior while in treatment and quality of life adjustment [20], and a variety of other variables such as health, amount of drinking, and family adjustment [21]. Finally, associated psychopathology such as depression [22, 231 and personality disorder [23] have been linked to poorer outcome [22] and more frequent relapses [23] in several studies but not in another [101. In this regard, disadvantaged alcoholics may differ from more stable alcoholics in several areas which influence treatment outcome, such as levels of cognitive functioning, associated drug use, limited economic and social supports, and history of educational and vocational functioning. The treatment of such disadvantaged alcoholics is compounded by the magnitude of their social problems [24] and the perpetuating nature of their lifestyle [25-271, factors which further complicate any attempts at evaluating the effects of treatment. Additionally, the drinking patterns of severely disadvantaged, often homeless alcoholics apparently are more severe than those of household alcoholics [2] and may in turn correlate with lower levels of cognitive and social functioning [28]. More severe patterns of alcoholism have been associated with worse treatment prognoses [28, 291 and may warrant more intensive, longer, or different treatment approaches. This study was done in order to assess the value of those variables already reported to correlate with outcome in alcoholic populations, such as demographic and drinking histories and cognitive functioning in a sample of patients representative of the highly disadvantaged population. Because of its clinical utility and easy measurability, initial retention in treatment after detoxification was chosen as the outcome variable.
SUBJECTS AND METHODS
Subjects This investigation was conducted on a consecutive series of 109 primary alcoholic men who completed a detoxification program at the 30-bed alcoholism treatment unit at the Eellevue Hospital Medical Center, a large facility that serves a mostly disadvantaged population in New York City. Patients admitted to the unit include only primary alcoholics in acute alcohol withdrawal who do not require acute treatment for any associated medical or psychiatric conditions.
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Excluded from the study were 22 patients who left the unit before completion of at least 5 days of detoxification.
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Assessment Instruments All patients were assessed between 5 and 9 days after admission, and only when they had completed medical detoxification, had no other acute medical or psychiatric condition, and were not receiving medication that might interfere with neuropsychological testing. Patient interviews and neuropsychological assessments were conducted by trained research assistants. Data generated included sociodemographic information on ethnicity,marital status, income, employment and educational history, housing status, and housing history. Housing status and history of homelessness were assessed by administration of a questionnaire [30] adapted from Susser et al. 151. Substanceuse histories were obtained during structuredinterviews and included age at onset of alcoholism, fresuency and amount of alcohol consumption,and history of all other drug use. The patient’s age at onset of alcoholism was determined by the age at which the patients first met DSM-III-R [311criteria for alcohol dependence. Additiody, a history of alcoholism in first and second degree relatives was assessed. Alcoholism was diagnosed in a relative only when the patient’s description of the relative clearly satisfied DSM-III-R criteria for alcohol dependence. Cognitive functioning was assessed by means of a battery of neuropsychological tests that included the expanded version (3MS) of the Modified Mini-Mental State [32], the Trail Making Test Part B [33], and the Booklet Category Test [34]. The number of days of hospital stay were coded. Follow-up information regarding registration and retention in treatment after discharge from the detoxification ward was obtained through mail communication with those inpatient rehabilitation programs and outpatient clinics where patients were scheduled to continue aftercare treatment following discharge. All patients signed consent for release of information regarding registration, attendance, and completion of treatment from aftercare treatment facilities.
RESULTS Demographic Features Of a total of 109 subjects studied, 47 (43 %) were Black, 36 (33 96) were White, 24 (22%)Hispanic, and 2 (2%)were either American Indian or Asian. The mean (f SD) age for the total cohort was 40.0 (f 9.9 years).
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Most subjects were single (64, or 59%)and only 2 (1.8%) were married; 18 (16.5%)were separated; 20 (18.3%)were divorced, and 5 (4.6%)were widowers.
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Employment History Regarding employment history for the 2 y e m preceding hospitalization, 40% either never worked or worked for less than 1 month, only 14%had worked for at least 6 months, 16%had worked for at least 1 full year, and 12%had consistently worked for 2 years. The number of months of employment was significantly associated with the number of completed school grades (r = .30, N = 108, p < .001). Financial instability was also made apparent by yearly income figures. Most subjects (72%) reported income below $10,000, with one-third of patients reporting no income at all or less than $l,OOO in the past year period. Twelve percent of patients earned between $10,000 and $20,000, and 16%reported yearly income above $20,000.
Education History The mean ( f SD) school grade completed was 11 ( f 2.6 years). There was a positive association between the years of school completed and the age at onset of alcoholism (r = .27, n = 108, p < .002), and a negative association between the years of school grade completed and the number of years of alcoholism (DSM111-R)(-r = 0.38, n = 108, p < .0001). The number of school grades completed also correlated with a variety of cognitive measures, including the Mini-Mental scores (r = .30, N = 108, p < .001), the memory section of the Mini-Mental ( r = .23, N = 108, p < .009), and the number of minutes spent in completing the Trail Making Test (r = .27, N = 108, p < .01).
Housing History The housing status on admission and the housing history in the 2 years preceding admission are illustrated in Table 1. A trend of deterioration in the housing history is observed over the 2 years preceding admission. While 2 years prior almost one-third of patients had their own residence (29%),only 9% did so the night prior to admission. A similar phenomenon occurred with patients as guests; while 29% were guests of relatives or friends 2 years ago, only 10% had stayed
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Table 1. Housing Status within 2 Years Prior to Hospitalization of 109 Alcoholics
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Housing status' Night prior to admission (N = 109)
2 months prior to admission (N = 109)
N
96
N
96
N
x
Homeless: street, shelter, or mission
51
46.8
50
46.0
34
31.28
Guests of relatives or friends
11
10. I
28
25.1
39
29.3
Own apartment or house
10
9.1
16
14.7
32
29.3
Institution: hospital emergency, prison, or nursing home
37
34.0
14
12.8
11
10.2
'x
= 105.18, df
2 years prior to admission (N = 109)
= 3, p < .OOO1
at somebody else's house the night before hospitalization. The proportion of homeless patients also increased from 31% 2 years prior to admission to 46% within the 2 months preceding hospitalization (Table 1).
Drinking History Alcoholism was chronic in this population. Patients met criteria for alcoholism for an average of 15.6 years (range: < 1 to 41 years; k9.W years). The scale used to measure alcohol consumption is described in Table 2. Thirtynine percent (38.5%) of the patients consumed the highest amount of alcohol, equivalent to 1 gallon of wine in a typical drinking day. Nearly half of the patients (46.8%) drank at an intermediate level between 1 gallon and 1/5 gallon of wine. About 13% (12.87%) of patients drank the equivalent of 1/5 gallon of wine daily; only 1.87% of the patient sample drank less than 115 gallon of wine daily. Family History of Alcoholism Most patients (61%) had an alcoholic parent, including 45% who had an alcoholic father, 10%an alcoholicmother, and 6% who had a history of almholism in both parents.
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Table 2. Average Daily Alcohol Consumption during Month Prior to Hospitalization in 109 Alcoholics Average consumption
N
%
1 gallon wine, or 1/4 quart whisky, or 3 cases beer Intermediate 112 pint whisky, or 115 gallon wine, or 6 pack beer Less than above
42 51 14 2
38.5 46.8 12.8 1.8
Life Drug Use History A history of prior dependence on cocaine was found in 19% of the sample, opiates in 16 % ,cannabis in 5 % ,amphetamines 2 % ,and benzodiazepines in 2 % . Seventy percent of the total population smoked at least one pack of cigarettes daily.
Cognitive Functioning The level of cognitive functioning was generally low in this patient population. Of the three cognitive instruments administered, only the Mini-Mental Test did not yield mean (k SD) results significantly below normative values (88.7 SD f 9.3 errors vs normative score: 94 f 6 errors). On the Booklet Category Test, patients committed a mean ( f SD) of 73.9 (f28.3) errors. In this test, 50 errors are the cut-off score for impaired functioning [33]. On the Trail Making Test Part B, patients generally took twice the amount of time and made three times more errors than is normative. These results reflected frequent difficulties in abstract thinking, cognitive inflexibility, and slowness of thinking processes, all of which are likely to undermine the subjects’ adaptive abilities and clinical course. There was a significant association between age and the number of errors in the Trail Making Test (r = .17, n = 103, p < .04).
Aftercare Compliance and Completion Of a total of 100 detoxified patients who were followed after discharge from the hospital, 74 accepted aftercare referral; of these, 47 entered their next phase of inpatient (N = 23) or outpatient (N = 24) rehabilitation. The remaining 21 patients were lost to follow-up. Out of 47 patients registered in an aftercare program,a total of 30 patients completed this aftercare phase which included either 42-day-long inpatient rehabilitation (N = 19) or at least 3 months in outpatient
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treatment (N= 11). No differences were found between the frequencies of inpatient and outpatient program completion.
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Variables Associated with Registration for Aftercare Only two variables, education (r = .27, N = 74, p < .01) and employment (r = .26, N = 74, p < .Ol), were associated with compliance with scheduled registration for aftercare. Having completed high school (r = .29, N = 73, p < .007) and having worked for more than 6 months within the past 2 years (r = .26, N = 74, p < .01) were clearly associated with compliance with initial appointment for aftercare.
Variables Associated with Completion of Aflercare Only variables of cognitivemeasurement were significantly associated with aftercare completion. Specifically,measurements of cognitive flexibility such as the Trail Making B (r = .24, N = 45, p < .05) and the generative naming section of the Mini-Mental (r = .25, N = 47, p < .05) had significantassociations with frequency of completion of the initial phases of inpatient and outpatientaftercareprograms. A strong trend toward significance was found between the likelihood of aftercare program completion and the number of days spent on the detoxification unit (r = .25, N = 4 5 , p < .052).
DISCUSSION The data reported here represent a direct measure of the effectiveness of institutional efforts to retain highly disadvantaged alcoholics in treatment after detoxification. The study results reflect a marked tendency for this sample to register for the initial phase of aftercare treatment more often than to complete it as illustrated by the fact that although two-thirds actually accepted aftercare, only a little under half showed up for their initial aftercare appointment, and only onefourth actually completed the initial phase of treatment. The implicationsfor early dropouts from treatment, however, are not obvious since even though dropouts from institutionaltreatment programs are generally expected to have poorer outcomes [3, 41, spontaneous remissions even by skid-row alcoholics have been reported to range between 30 and 50% [35, 361.
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We identified several significant correlates of treatment compliance and confirmed the outcome predictive value of level of functioning prior to detoxification [ l , 9, 101. In general, as Slater et al. point out [23], the degree of stability of the alcoholic’s lifestyle prior to admission for treatment is inversely associated with the likelihood of hospital readmission. It is not surprising, in light of similar reports [ 15,37, 381, that in this group of highly disadvantaged alcoholics, employment history also correlated with initial treatment compliance. Consistent with previous investigationson skid-row alcoholics [ 11, in our study the level of education (and high school completion in particular) correlated most closely with the likelihood to show up for aftercare appointments. High school education thus appears to be associated with increased compliance with treatment. These findings illustrate the importance of the incorporation of demographic data into considerations regarding treatment planning. The positive correlations found between level of education and other variables, such as treatment compliance, employment, and cognitive functioning, may reflect the beneficial effects of exposure to school in improving the patient’s ability to absorb the impact of alcoholism. The same factors, however, which mitigate against a good outcome, such as cognitive deficits, social instability, and early onset of drinking, might affect individuals at an early age and prevent them from advancing in their schooling. Other variables associated with treatment compliance were scores on the Trail Making B and the generative naming section of the Mini-Mental. The specificity of these two cognitive variables may be perhaps explained by the cognitive function they measure, mainly cognitive flexibility. Specific rehabilitation efforts aimed at improving alcoholics’ cognitive flexibility have been implemented and have been reported to significantly improve treatment response [39, 401. Cognitive functions related to cognitive shifting have also been identified as outcome predictors. Specifically, more effective “internal scanning” in a sample of 42 male alcoholics proved to be predictive of better adjustment at 2 year follow-up [2 11. Given the studies suggesting a predictive value to specific cognitive functions, it may be justified to implement comprehensive and specific cognitive assessment in large populations of alcoholics in order to determine the potential role of specific cognitive functions as outcome predictors. The Trail Making B has also been found to be sensitive to cognitive deficits and has been recommended as a useful assessment tool in alcoholics [33, 41, 421. Although some kind of cognitive impairment is frequently found not only in alcoholics [43, 441 but also in their children [45], and may indeed precede the onset of alcoholism [41], the frequency and severity of cognitive deficits vary in different alcoholic populations [28, 41, 461. In this group of highly disadvantaged alcoholics, cognitive impairment was more frequent than it was severe. Neuropsychological assessments
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are not routinely camed out in alcoholism treatment settings. Despite abundant evidence supporting the clinical importanceof information on the level of cognitive functioning [47], the cognitive profile of individual alcoholic patients is rarely included in treatment planning. Clearly, studies involving larger samples and longer follow-up are needed in order to better determine the relevance and applicability of our findings. Regarding the management of cognitive deficits in alcoholics [48], additional research attention should be placed on pharmacological [49] and cognitive [21] methods for cognitive improvement and rehabilitation. A strong trend was found between length of hospital stay and aftercare completion. Since patients’ hospital stay ranged only between 1 and 2 weeks, this suggests that even a few additional days of treatment may have an impact on treatment outcome. An association between length of inpatient stay in a rehabilitation program for skid-row alcoholics and subsequent length and quality of abstinence and improvementof level of vocational functioning has been reported [ 11. It may be that a longer period of recuperation from cognitive dysfunction while in the hospital increases aftercare treatment compliance. Alternatively, longer hospital stays may afford the opportunity to better address some of the severe socioeconomic problems prevalent in the study population. Further studies are required to better assess the relationship between length of stay for hospital-based detoxification and subsequent treatment compliance among highly disadvantaged alcoholics.
ACKNOWLEDGMENTS
This project was supported in pan by BRSG SO7 RRO5399-28awarded by the Medical Research Support Grant Propram,Division of Research Resources, National Institutes of Health @r. Castaneda). The study was done at Bellevue Hospital Medical Center, New York, New York. We gratefully acknowledge the valuable research assistance provided by Jephta Tausig-Edwards, BA, Mitra Bassiri, MA, Cindy Weiner, MA, and Kenneth Washington, MA.
REFEWNCES Fagan, R. W.,and Mauss, A. L.,Social margin and social reenby: An evaluation of a rehabilitation program for skid row alcoholics, 1. Srud. Alcohol 47(5):413-425 (1986). [2] Baekeland, F., Lundwall, L., and Shanahan, T., Correlates of patient attrition in the outpatient treatment of alcoholism, J. New. Ment. Dis. 1579-107 (1973). [3] Vanicelli, M., Pfau, B.,and Ryback, R. S., Data attrition in follow-up studies of alcoholics, J. Std. A k ~ h o 37:1325-1330 l (1976). [4] Moos, R., and Bliss, F.,Difficulty of follow-up and outcome of alcoholism treatment, J. Srud. Alcohol 39(3):473-490 (1978). [I]
Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by McMaster University on 11/06/14 For personal use only.
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233
Susser, E., Struening, E. L., and Conover, S.,Psychiatric problems in homeless men. Lifetime psychosis and substance abuse, current distress in new arrivals at NYC shelters, Arch. Gen. Psychiatry 46:845-850 (1989). Vaillant, G.E., lhe Nururul Hisrory of Alcoholism, Harvard University Press, Cambridge, Massachusetts, 1983. Emrick, C. D., and Hansen J., Assertions regarding effectivenessof treatment for alcoholism: Fact or fantasy, Am. Psychol. pp. 1078-1088 (October 1983). Voris, S. W., Alcohol treatment outcome evaluation: An overview of methodological issues, Am. J. Drug Alcohol Abuse 8(4):549-558 (1981-1982). Clopton, J. R., Alcoholism and the MMPI, J. Stud. Alcohol 39:1540-1558 (1978). McWilliams, J., and Brown, C. C., Treatment termination variables, MMPI scores and frequency of relapse in alcoholics, Q. J. Stud. Alcohol 28:52-58 (1967). Crawford, J. J., and Chalupsky, A. B., The reported evaluation of alcoholism treatments, 1968- 1971: A methodological review, Addicr. Behuv. 2:63-74 (1977). Armor, D. J., Polich, J. M., and Stambul, H. B., Alcoholism and Treutmenr, Rand Corporation, Santa Monica, California, 1976. Belasco, J. A., The criterion question revisited, Br. J. Addict. 66:33-44 (1971). Ritson, B., Prognosis of alcohol addiction, Br. J. Psychiurry 114:1019-1029 (1968). Pokorny, A. D., Miller, B. A,, and Cleveland, S. E., Response to treatment of alcoholism, Q. J. Stud. Alcohol 29:364-381 (1968). McCance, C., and McCance, P., Alcoholism in North East Scotland. It's treatment and outcome, Br. J. Psychiatry 119189-198 (1969). Reed, R., Grant, I., and Adams, K.,Family history does not predict neuropsychologicperformance in alcoholics, Alcoholism: Clin. Exp. Res. 11(4):340-344 (1987). McLelland, A., Luborsky, L., O'Brien, C., et al., Alcohol and drug abuse treatment in 3 different populations: Is there improvement and is it predictable?, Am. J. Drug Alcohol Abuse 12(1&2): 101- 120 (1986). Gillis, L. S., and Keej, M., Prognostic factors and treatment results in hospitalized alcoholics, Q. J. Stud. Alcohol 40:426-437 (1969). Parsons, O., Do neurological deficits predict alcoholics treatment course and postreatment recovery, in Neuropsychology of Alcoholism. Implicutions for Diagnosis and Treutmenr (0. Parsons, N. Butters, and J. Biggs, eds.), Guilford Press, New York, 1987, pp. 273-290. Tarbox, A. R., Weigel, J. D., and Biggs, J. T., A cognitive typology of alcoholism: Implications for treatment outcome, Am. J. Drug Alcohol Abuse 11(1&2):91-101 (1985). Rounsaville, B. S., Dolinsky, Z., Babor, J., and Meyers, R., Psychopathologicalpredictors of treatment outcome in alcoholics, Arch. Gen. Psychiatry 44:505-513 (1987). Slater, E. J., and Lion, M. W., Predictors of rehospitalization in a male alcoholic population, Am. J. Drug Alcohol Abuse 9(2):211-220 (1982-83). Cook, T., Vugronr Alcoholics, Routledge & Kegan Paul, Boston, 1975. Bahr, H. M., Skid Row: An Inrroduction to Disuflliation, Oxford University Press, New York, 1973. Blumberg, L. U., Shipely Jr., T. E., and Shandler, I. W., Skid Row Md Irs Alrem'ves: Research nnd Recommendutionsfrom Philadelphia, Temple University Press, Philadelphia, 1973. Mulford, H. A,, Rethinking the alcohol problem: A natural processes model, J. Drug Issues 14:31-43 (1984). Castaneda, R., and Galanter, M., Ethnic differences in drinking practices and cognitive impairment among detoxifying alcoholics, J. Sfud. Alcohol 49(4):335-339 (1988). Von Knorring, L., Palm, U., and Anderson, H., Relationship between treatment outcome and subtype of alcoholism in men, J. Stud. Alcohol 46:388-391 (1985).
Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by McMaster University on 11/06/14 For personal use only.
234
CASTANEDA ET AL.
Herman,M.,Galanter, M., and Lifshutz, H.,Homelessnessin patients with combdpsychiatric and substance abuse disorders, Am. J. Drug Alcohol Abuse 17(4):415-422 (1991). American Psychiatric Association, Work Group to Revise DSM-III of the American Psychiatric Association,Diagnostic and Sratiktical Manu~lof Mental Disorders, revised 3rd ed., American Psychiatric Association, Washington, D.C., 1987. Teng, E. L., and Chi, H.C., The Modified Mini-Mental State (3MS) Examination, J. Clin. psychiatry 48(8):314-318 (1987). Reitan, R. M., Validity of the Trails Making Test as an indication of organic brain damage, Percept. Moror Skills (8):271-276 (1958). DeFillippis, N. A., McCampbell, E., and Rogers, P., Development of a booklet form of the Category Test. Normative and validity data, J. Clin. Neuropsychol. (1):339-343 (1979). Smart, R. G., Spontaneousrecovery in alcoholics: A review and analysis of the available research, Drug Alcohol Depend. 1:277-285 (1976). Tucffield, B. S., Spontaneous remission in alcoholics: Empirical observationsand theoretical implications, J. Stud. Alcohol 42:626-641 (1981). Bateman, N. E., and Petersen, D. M., Variables related to outcome of treatment for hospitalized alcoholics, Inr. J. Addicr. 6:215-224 (1971). Mindlin, D. F., The characteristics of alcoholics as related to prediction of therapeutic outcome, Q. J. Srud. Alcohol 29:604-619 (1%9). Gordon, S., Kennedy, B., and McPeake, J., NeuropsychologicaUy impamdalcoholics: Assessment, treatment considerations and rehabilitation, J. SubstMce Abuse Treunwnr599-104 (1988). Heilbrun, A. B., and Tarbox, A. R.,Cognitivestructure and behavioral regulation in alcoholics: Implications for treatment outcome, Br. J. Alcohol Alcoholism 13:65-73 (1978). McCrady, B., Implications of neuropsychological research findings for the treatment and rehabilitation of alcoholics, in Neuropsychology of Alcoholism. lmplicaionsfor Diagnosis and Treatment (0.A. Parsons, N. Butters, and P. E. Nathan, eds.), Guilford Press, New York, 1987, pp. 381-391. Parsons, 0. A., and Farr,S. P., The neuropsychology of alcohol and drug use, in Handbook of Clinical Neuropsychology (S. Filskov and T. Boll, eds.), Wiley, New York, 1981, pp. 320-365. Goldman, M. S., Cognitive impairment in chronic alcoholics: Some cause for optimism, Am. Psychol. 38:1045-1054 (1983). Eckardt, M.J., Parker, E.S.,Noble, E. P., Feldman, D. J., and Gottschalk, L. A., Relationship between neuropsychological performance and alcohol consumption in alcoholics, Bid. Psychiatry 13551-565 (1978). Begleiter, H., Poqesz, R., Bihari, B., and Kissin, B., Event-related potentials in boys at risk of alcoholism, Science 225:1493-14% (1984). Parsons, 0. A., Neuropsychological consequences of alcohol abuse: Many questions-some A. answers, in Neuropsychology of Alcoholism. Implications for Diagnosis and Treatment (0. Parsons, N. Butters, and P. E. Nathan, eds.),Guilford Press, New York, 1987, pp. 155-175. Parsons, 0. A., Butters, N., and Nathan, P. E. (eds.), Neurupsychohgy ofAlcoholism. Implications for Diagnosis and Treatmenr, Guilford Press, New York, 1987. Brandy, I., Butters, N., and Ryan, C., Cognitiveloss and recovery in long-term alcohol abusers, Arch. Gen. Psychiatry W.310 (1987). Ternpesta, E., Tronconi, R., Janiri, L., et al., Role of acetyl-L-camitine in the treatment of cognitive deficits in chronic alcoholism, Int. J. Clin. Pharm. Res. 112:lOl-107 (1990).
