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Chapter: Essentials of Psychiatry: Substance Abuse: Alcohol Use Disorders

Special Features Influencing Treatment - Alcohol Use Disorders

There is considerable evidence that links the outcome of alcohol-ism treatment to comorbid psychopathology.

Special Features Influencing Treatment


Psychiatric Comorbidity


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.


Demographic Features




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.


Geriatric Patients


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.


Gender (Including Pregnancy)


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.


Ethnic and Cultural Issues and Treatment


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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