Behavioral indices in medical care outcome: the working alliance, adherence, and related factors.

BACKGROUND: The working alliance has been shown to be a consistent predictor of patient outcome and satisfaction in psychotherapy. This study examines the role of the working alliance and related behavioral indices in predicting medical outcome. OBJECTIVE: Cognitive and emotional dimensions of the physician-patient relationship were examined in relation to patients' ratings of physician empathy, physician multicultural competence, perceived utility of treatment, and patients' adherence self-efficacy. These factors were then examined as part of a theoretical framework using path analyses to explain patient self-reported adherence to and satisfaction with treatment. DESIGN: The study was based on an ex-post facto field correlation design. PARTICIPANTS: One hundred fifty-two adult outpatients from a neurology clinic at Bellevue Hospital, a large municipal hospital in New York City, participated in the study. INTERVENTIONS: Surveys given to participants. MEASUREMENTS: We used the following measurements: Physician-Patient Working Alliance Scale, Perceived Utility Scale, Treatment Adherence Self-Efficacy Scale, Medical Outcome Study Adherence Scale, Physician Empathy Questionnaire, Physician Multicultural Competence Questionnaire, Medical Patient Satisfaction Questionnaire. MAIN RESULTS: The effect sizes for adherence are between 0.07 and 0.21 and for satisfaction between 0.10 to >0.50. Regression and path analyses showed that ratings of physician multicultural competence and patient adherence self-efficacy beliefs predicted patient adherence (SB = 0.34) and (SB = 0.30) and satisfaction (SB = 0.18) and (SB = 0.12), respectively. Working alliance ratings also predicted patient satisfaction (SB = 0.49). CONCLUSIONS: Psychological and interpersonal dimensions of medical care are related to patient adherence and satisfaction. Medical care providers may be able to use these dimensions to target and improve health care outcomes.

Is cigarette smoking a gateway to alcohol and illicit drug use disorders? A study of youths with and without attention deficit hyperactivity disorder.

BACKGROUND: The goal of this study was to assess whether cigarette smoking is a gateway drug for subsequent alcohol and illicit drug abuse and dependence in youth with Attention Deficit Hyperactivity Disorder (ADHD), and to test if this association is stronger in ADHD youth relative to controls. METHODS: We used data from a case-control family study of female youth with and without ADHD. We studied 97 ADHD and 203 control youth of both sexes, aged at least 12 years. We assessed ADHD, smoking, and substance use status using structured diagnostic interviews. We tested the association between cigarette smoking and subsequent substance use outcomes using Cox proportional hazard regression models. RESULTS: ADHD youth who smoked cigarettes (n = 15) were significantly more likely to subsequently use alcohol and illicit drugs as well as to develop abuse and dependence compared to ADHD youth who did not smoke (n = 76; p < .05). CONCLUSIONS: These results extend the gateway hypothesis to an ADHD sample and provide evidence that this effect may be particularly robust in ADHD youth. If replicated in larger, community-based samples, these findings have important public health consequences, and underscore the already pressing need to prevent smoking in ADHD children.