Special Features Influencing Treatment
There is considerable evidence that links the
outcome of alcohol-ism treatment to comorbid psychopathology. General measures
of psychopathology, as well as the specific diagnoses of drug abuse, drug
dependence, antisocial personality disorder and major de-pressive disorder have
been shown to predict poorer outcomes in alcoholics. The extent to which
treatment of concomitant psychopathology enhances alcoholism treatment outcome
is un-clear. Ries (1993) has distinguished among serial, parallel and
integrated models for treating these disorders. The serial model involves the
treatment of one disorder, followed by the treatment of the second disorder.
For example, a psychotic alcoholic might first be treated on a general psychiatric
unit and once his acute psychosis is controlled, transferred to an alcoholism
rehabilita-tion program. The parallel treatment approach involves concur-rent,
but separate, treatment of both the psychiatric and the alco-hol use disorder.
The integrated model involves the treatment of both disorders in a single
treatment setting at the same time. This approach requires that personnel with
expertise in both the addic-tions and psychiatric treatment be available in a
single location. Each of these approaches has advantages and disadvantages. For
example, the integrated model, while it provides the most com-prehensive
approach, is the most difficult and costly to configure and may, therefore, not
be feasible for many treatment providers.
Despite a paucity of controlled, age-specific
treatment outcome studies of adolescents with alcohol use disorders, the need
for prevention and specialized treatment for this group is clear. The
literature indicates that in substance-abusing adolescents some treatment is
better than no treatment, relapse rates are high, and there is no consistent
support for the superiority of any single treatment modality. However, several
factors have been associ-ated with better treatment outcome: later onset of
problem drink-ing, pretreatment attendance at school, voluntary entrance into
treatment, active parental input and availability of ancillary
ado-lescent-specific services, including those pertaining to school,
recreation, vocational needs and contraception.
Because many adolescents have not yet fully
developed formal operational thinking, treatment efforts should be concrete and
goal-oriented. Furthermore, the clinician should consider the potential impact
on treatment of other cognitive problems: learn-ing disabilities,
attention-deficit/hyperactivity disorder and other psychopathology which may
previously have gone undiagnosed. Treatment of the adolescent with an alcohol
use disorder also re-quires an appreciation of the importance of modeling, imitation
and peer pressure, which are intrinsic to identity development. The use of
age-appropriate support groups (e.g., Alateen) may be particularly useful in
this regard.
In addition to the high prevalence of medical
problems, phar-macokinetic and pharmacodynamic variables can affect treat-ment
outcome in elderly alcoholics. For example, Liskow and colleagues (1989) found
that elderly alcoholics, despite having drunk less than younger patients during
the month prior to ad-mission, had more severe alcohol withdrawal
symptomatology and required a higher dosage of chlordiazepoxide. These
inves-tigators speculated that the observed differences might delay the entry
of elderly alcoholics into rehabilitation.
An important question in treating elderly
alcoholics is the extent to which specialized treatment services improve
outcome. Kofoed and colleagues (1987) found that patients treated in spe-cial
elderly peer groups remained in treatment longer and were more likely to
complete treatment than those treated in mixed-age groups. These investigators
concluded that elder-specific treatment has differential therapeutic value.
Recent shifts in the demographic features of AA
partici-pants suggest that the current cohort of elderly alcoholics has less
experience with self-help groups at a time when AA is attracting younger
members who are more likely to have comorbid drug abuse/dependence. As a
consequence, the elderly can be expected to experience increased difficulty
affiliating with AA. This, along with evidence indicating an advantage for
age-specific treatment in the elderly, suggests that special efforts should be
made to help the elderly alcoholic locate AA meetings that include a
substan-tial proportion of older participants. Age-appropriate AA groups may be
especially beneficial to the older alcoholic who is isolated and lonely and for
whom the prospect of helping others may help to combat feelings of uselessness.
As described above, epidemiological and clinical
studies have shown that alcohol abuse and dependence have become quite com-mon
among women, as historical gender differences in drinking problems have
diminished during the past 25 years. This trend has promoted greater awareness
of the impact of alcohol use on women’s health and the importance of gender as
a potential deter-minant of treatment outcome. Nonetheless, the vast majority
of studies related to alcohol use and its effects, including the diag-nosis and
treatment of alcohol dependence, have involved men.
To guide the treatment of alcoholism in women,
Blume (1992) suggests that evaluation should include special attention to the
identification of physical abuse, sexual abuse, medical prob-lems, psychiatric
comorbidity, the presence of alcoholism and drug abuse in spouses, and
alcohol-related birth defects in children. To enable women with children to
participate in treatment, the avail-ability of child care services is critical,
although it must generally be arranged independent of treatment. Blume (1992)
also lists the following special treatment needs of women: information about
the effects of substance use on the fetus, parenting skills, couples and family
therapy, sober female role models, assertiveness train-ing, and an awareness of
sexism and its consequences. Special care must also be taken to avoid creating
iatrogenic drug depend-ence in women (e.g., through the use of benzodiazepines
to treat comorbid anxiety and depressive symptoms). While these are use-ful
guidelines for treating alcoholic women, empirical research is needed to
evaluate these and other issues more systematically.
In 1991 approximately two-thirds of patients in
alcoholism treatment were white, 17% were black and 12% were Hispanic. Although
socioeconomic and cultural issues should be addressed in alcoholism treatment,
guidelines for such treatment are based largely on common sense, rather than
systematic outcome evalu-ation. Obviously, where language barriers exist,
special efforts must be made to ensure adequate communication. Treatment
providers should also be aware of their patients’ traditional pat-terns of
drinking, how drinking may be influenced by accultura-tion, differences among
ethnic groups in their perception of al-cohol-related problems, the impact of
sociocultural differences between patients and providers, and how prevailing
social (e.g., family) relationships can affect treatment outcome.
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