Effects of a drinking event on behavioral skills and condom attitudes in men: implications for HIV risk from a controlled experiment.

This study experimentally tested the effects of a drinking event on HIV-related behavioral skills and condom attitudes. Sixty unmarried, heterosexual men were assigned to 1 of 3 conditions (sober, placebo, or alcohol). Participants who consumed alcohol demonstrated lower skill to negotiate for condom use relative to sober controls. More negative condom attitudes were expressed by participants with stronger sex-related alcohol expectancies, especially when these expectancies were triggered by subjective intoxication. Hierarchical regression analyses revealed that the experimental factors accounted for variance in behavioral skills and condom attitudes beyond that explained by known predictors of sexual risk.

PIP: 60 unmarried, heterosexual men of mean age 24.9 years were recruited from the community through newspaper advertisements and flyers to participate in a study to evaluate the effects of drinking-related and dispositional variables on the antecedents of safer sex behavior. 87% of the men were White, 72% drank alcohol 3-4 times per week, 75% had multiple sex partners in the past year (an average of 3.2 partners), 72% did not always use condoms, and all were told that they would be participating in an alcohol and communication study. The men were assigned to 1 of 3 conditions, sober, placebo, or alcohol, to experimentally test the effects of a drinking event upon HIV-related behavioral skills and condom attitudes. Men in the alcohol group received vodka and tonic drinks, men in the placebo group received all tonic drinks with a bit of vodka rubbed on the glass to make the subjects think that the drinks contained vodka, and men in the sober group received only tonic water. 20 men were in each group. All drinks were made in the presence of the subjects, with the tonic being poured from a vodka-labelled bottle in the placebo group. Participants were instructed to finish their drinks in 30 minutes, after which time they participated in role-play scenarios. The men who consumed alcohol demonstrated lower skill in negotiating condom use relative to sober controls and were more likely to consent to sex without a condom. More negative condom attitudes were expressed by participants with stronger sex-related alcohol expectancies, especially when those expectancies were triggered by subjective intoxication. Regression analyses determined that the drinking event, especially beverage content, accounted for variance in behavioral skills and condom attitudes beyond that explained by known predictors of sexual risk.

Risk for human immunodeficiency virus (HIV) infection among persons with severe mental illnesses.

Individuals diagnosed with a severe mental illness are at significantly enhanced risk for infection with the human immunodeficiency virus (HIV). To better understand elevated seroprevalence in this population, we review the research literature that has investigated HIV-related risk behavior among adults who have a severe and persistent mental illness. This review indicates that 54%-74% of adults report that they have been sexually active in the last year with approximately one third reporting two or more partners. Among those who were sexually active, condom use was inconsistent. A significant minority (4%-35%) of adults also reported a history of injection drug use. Overall, the data indicate that the severely mentally ill engage regularly in practices known to involve increased risk for HIV transmission. We introduce and modify Fisher and Fisher's (1992) theoretical model to organize the possible determinants of HIV-related risk taking among severely mentally ill adults, and encourage use of this model in the design of behavioral epidemiological and risk reduction studies. We also identify several methodological challenges to HIV-related research, including problems associated with the use of self-report measures; diagnostic imprecision; and participant recruitment and retention.

Effects of a brief motivational intervention with college student drinkers.

This study consisted of a randomized controlled trial of a 1-session motivational intervention for college student binge drinkers. Sixty students who reported binge drinking 2 or more times in the past 30 days were randomly assigned to either a no-treatment control or a brief intervention group. The intervention provided students with feedback regarding personal consumption, perceived drinking norms, alcohol-related problems, situations associated with heavy drinking, and alcohol expectancies. At 6-week follow-up, the brief intervention group exhibited significant reductions on number of drinks consumed per week, number of times drinking alcohol in the past month, and frequency of binge drinking in the past month. Estimates of typical student drinking mediated these reductions. This study replicates earlier research on the efficacy of brief interventions with college students and extends previous work regarding potential mechanisms of change.

Stress and unaided smoking cessation: a prospective investigation.

A prospective design was used to determine the outcomes associated with unaided smoking cessation and the influence of stress on cessation. Heavy smokers (N = 308) completed stress-related measures and were then recontacted at 1, 6, and 12 months. At each follow-up, they indicated their smoking status (which was confirmed by collateral report and biochemical tests) and completed several stress-related questionnaires. Results indicated that 33% of subjects smoked continuously throughout the year, 39% quit briefly but subsequently relapsed, and 15% quit (confirmed biochemically). An additional 7% reported that they had quit, but this could not be confirmed, and 6% were lost to follow-up. Compared with nonquiters, quitters reported less perceived stress, greater self-efficacy, greater use of problem solving and cognitive restructuring, and less reliance on wishful thinking, self-criticism, and social withdrawal. A model to forecast quitting was built and cross-validated.

Increasing assertiveness skills to reduce HIV risk among women living with a severe and persistent mental illness.

This study examined whether training women living with a severe mental illness to be assertive in sexual situations would decrease their risk for HIV infection. Twenty female outpatients were randomly assigned to either a 10-session assertiveness training intervention or a waiting-list control condition. All participants completed measures of HIV-related information, motivation, skills, and sexual risk behavior pre- and postintervention and at 2- and 4-month follow-ups. Compared with controls, women in the intervention group increased their assertiveness skill, HIV knowledge, and frequency of condom-protected intercourse. It is concluded that assertiveness training for women living with a severe mental illness can serve as 1 part of a comprehensive HIV-risk-reduction program for this vulnerable population.

Prevalence and correlates of sexual activity and HIV-related risk behavior among psychiatric outpatients.

This study investigates the prevalence and correlates of sexual activity and HIV-risk behavior among adults with a mental disorder. Demographic, psychiatric, sexual behavior, and substance-use data were available for 1,558 outpatients. During the past year, 69% were sexually active and 23% engaged in risky behavior. Risk markers included multiple sexual partners (19%), a sexually transmitted disease (4%), sex trading (3%), injection drug use (1%), and needle sharing (<1%). Being sexually active and being at risk for HIV infection were associated with alcohol and drug use, psychiatric diagnoses other than schizophrenia, and younger age. Married patients were more likely to be sexually active but less likely to engage in risk behavior. Screening for HIV risk in psychiatric settings can identify patients who may benefit from risk reduction programs.

The relation of alcohol use to HIV-risk sexual behavior among adults with a severe and persistent mental illness.

The authors examined the relationship between alcohol use and HIV-risk sexual behavior and tested whether alcohol use immediately prior to sex is related to decreased condom use. The participants were 159 adults living with a severe and persistent mental illness. Each participated in a structured interview to assess all sexual and drug-use behavior over a 3-month period. Analysis of 3,026 sexual behaviors reported by 123 sexually active participants indicated that at the global level, participants who drank more heavily were more likely to have engaged in sexual risk behavior. At the event level, however, alcohol use was not related to condom use during vaginal or anal intercourse; that is, participants who used condoms when sober tended to use them to the same extent when drinking.

Clinically useful assessments: substance use and comorbid psychiatric disorders.

This review addresses the assessment of substance use and related constructs with persons having severe and persistent mental illness. The review contains two major sections. The first section focuses on issues particular to the assessment of substance use and abuse in the context of major mental illness; these include the social and motivational context of assessment, the impact of mental status and acute symptoms, limitations associated with acute and chronic cognitive impairment, and the psychosocial relevance of assessment items. The second section highlights a selected set of substance assessment tools for use with this population; evidence for the reliability, validity, and/or feasibility of these tools is summarized. Each instrument meets the criteria of being: (a). relatively brief; (b). easy to administer and interpret; and (c). useful for treatment planning, motivational feedback, and/or monitoring change.

Assessing sexual risk behaviour with the Timeline Followback (TLFB) approach: continued development and psychometric evaluation with psychiatric outpatients.

This paper describes a series of 4 studies, designed to provide evidence of the feasibility, reliability, and validity of the Timeline Followback (TLFB) method when used to assess sexual risk behaviour with psychiatric outpatients. This population was selected because patients often have difficulty completing assessments of sexual risk behaviours due to deficits in attention, memory, and communication skills. All 4 studies demonstrated the feasibility of the HIV-risk TLFB. Study 1 also demonstrated that it can be completed in 20 min, and scored in less than 10 min. Qualitative data revealed that both patients and assessors found the features of the TLFB helpful. Study 2 provided evidence that the HIV-risk TLFB can be reliably scored by interviewers whereas Study 3 demonstrated that this measure can be completed reliably by patients and that TLFB of sexual behaviour were consistent over time. Study 4 provided initial evidence for the validity of the HIV-risk TLFB but also suggested that the TLFB may yield frequency estimates that are slightly less than those obtained with single-item measures. We conclude that the TLFB is feasible, reliable, and valid, even in a population known to have difficulty with self-report measures.

Treating substance abuse in the context of severe and persistent mental illness: clinicians' perspectives.

Patients with comorbid substance use and major mental disorders are treated frequently in the mental health system. Treatment models relevant for this subset of patients have emerged in recent years, however, few have been validated empirically and so relatively few sites benefit from this treatment development activity. Important additional sources of information about good treatment practices are the clinicians who have adopted the treatment of patients with dual disorders as a specialty. We conducted four focus groups (N = 12) with clinicians who were nominated by their peers as experienced and/or expert in treating persons with comorbid substance use and psychiatric disorders. Discussions followed a four-part outline that included (a) general questions about training and experience with the population, (b) preferred treatment methods, (c) motivational issues, and (d) recommendations to the field. Participants were trained in a variety of mental health disciplines and pursued substance abuse treatment credentials or other educational experiences outside of their primary training programs. Their treatment approaches emphasized psychoeducation, a good therapeutic relationship, and the need to be flexible regarding methods and goals. Abstinence was the preferred goal among most clinicians; even so, they expressed a pragmatic flexibility and other views consistent with the principles of harm reduction. Clinicians tended to respond to patients' ambivalent motivational states by addressing the consequences of behaviors in a nonconfrontive style; they also made use of positive incentives and external support. A number of recommendations were made to improve treatment, including greater institutional and programmatic support for the unique needs of this population.

Methods of changing patterns of substance use among individuals with co-occurring schizophrenia and substance use disorder.

Individuals with a severe mental illness and substance use disorder tend to have medical and social problems and to make slower progress in treatment than those who have either disorder alone. Nevertheless, little attention has been paid to the discovery of effective methods of modifying substance use in the severely mentally ill (SMI). The purpose of this study was to collect qualitative data as a way to help identify techniques that might help to change patterns of substance use in the SMI. The participants were 21 men and women who were psychiatric clinic outpatients and who had a current schizophrenia spectrum diagnosis. A total of 18 participants had a lifetime diagnosis of alcohol abuse or dependence, and 21 lifetime other drug diagnoses were recorded for the sample. These individuals participated in focus group discussions about topics related to substance use and people's experiences with trying to quit. The results showed that participants identified several therapeutic and extratherapeutic factors that helped them to initiate and maintain changes in their substance use, as well as factors that hindered change. The findings are related to knowledge about the effectiveness of substance use disorder treatment techniques in general, and implications of the data are discussed for the conduct of integrated treatment of individuals with severe mental illness and a substance use disorder.

Concurrent validity of clinicians' ratings of substance abuse among psychiatric outpatients.

OBJECTIVE: Given the prevalence of substance abuse among persons with psychiatric disorders, substance use assessment should be an integral component of mental health evaluations. This study examined the validity of a set of two 5-point rating scales developed for use by mental health clinicians in rating individual clients' levels of alcohol and other drug use. METHODS: A sample of 116 psychiatric outpatients who were participating in a study of psychosocial functioning and substance use was assessed by researchers using an extensive battery of instruments that included the Addiction Severity Index and the Timeline Follow-Back interview. Each client's primary therapist completed the 5-point rating scales to indicate the client's levels of alcohol and drug use. RESULTS: Clients were grouped according to their ratings on the 5-point scales. Significant differences between the groups were found on self-reported patterns of current alcohol and drug use and substance use history. CONCLUSIONS: Outpatient therapists provided ratings of clients' alcohol and drug use that corresponded well with substance use data obtained from an extensive research battery. The study results support use of clinician rating scales as a screening tool for identifying problematic alcohol and other drug use among psychiatric outpatients.

Implementing dual diagnosis services for clients with severe mental illness.

After 20 years of development and research, dual diagnosis services for clients with severe mental illness are emerging as an evidence-based practice. Effective dual diagnosis programs combine mental health and substance abuse interventions that are tailored for the complex needs of clients with comorbid disorders. The authors describe the critical components of effective programs, which include a comprehensive, long-term, staged approach to recovery; assertive outreach; motivational interventions; provision of help to clients in acquiring skills and supports to manage both illnesses and to pursue functional goals; and cultural sensitivity and competence. Many state mental health systems are implementing dual diagnosis services, but high-quality services are rare. The authors provide an overview of the numerous barriers to implementation and describe implementation strategies to overcome the barriers. Current approaches to implementing dual diagnosis programs involve organizational and financing changes at the policy level, clarity of program mission with structural changes to support dual diagnosis services, training and supervision for clinicians, and dissemination of accurate information to consumers and families to support understanding, demand, and advocacy.

Understanding binge drinking: introduction to the special issue.

Widespread interest in binge drinking, demonstrated by scientists, public policymakers, and educators, served as the impetus for assembling this special issue. The contents represent state-of-the-science conceptualizations and empirical work on the topic of binge drinking. This issue begins with 2 invited articles and contains a selection of empirical articles that reflect experimental and correlational designs, longitudinal studies of the course and correlates of binge drinking, and controlled-intervention trials. These articles address the construct validity of binge drinking as well as its utility as a high-risk marker in both theory-testing and intervention contexts. This introductory article discusses several advantages and disadvantages of continued use of the term binge drinking and suggests alternatives for use in research and applied contexts.

Temporal stability of alcohol screening measures in a psychiatric setting.

The authors evaluated the test-retest reliability of two common screening instruments administered in a psychiatric setting. The Michigan Alcoholism Screening Test (MAST; M. L. Selzer, 1971) and the CAGE (D. Mayfield, G. McLeod, & P. Hall, 1974) were administered twice, separated by a 1-week interval, to 71 people receiving outpatient psychiatric services and 64 people in the community with no reported history of psychiatric care. The MAST (r = .95) and the CAGE (r = .80) demonstrated adequate test-retest reliability and showed little evidence of variation with respect to degree or direction when administered in a psychiatric setting. Compared to a nonclinical sample, reliability estimates obtained in a psychiatric setting were only slightly lower and more variable. In the psychiatric sample, younger men who had a history of alcohol use disorder were found to be the least reliable. Overall, data suggest that people with severe and persistent mental disorders can offer reliable information about their alcohol-related problems.

Differential utility of three indexes of risky drinking for predicting alcohol problems in college students.

This study evaluated the relationship between alcohol-related problems and 3 indexes of risky drinking in college student drinkers: number of drinks consumed per week, frequency of binge drinking, and estimated blood alcohol levels (BALs). Use of 2 independent samples (N1 = 204, N2 = 181) allowed a cross-validation of obtained associations. Results indicated that neither binge drinking frequency nor BAL were more highly related to alcohol-related problems than was weekly drinking. Furthermore, BAL did not provide unique explanatory power in accounting for alcohol-related problems; mixed results were obtained regarding the relationship of binge drinking estimates with problems.

Heavy drinking contexts and indices of problem drinking among college students.

OBJECTIVE: Heavy drinking among college students carries with it the risk of adverse consequences. This study explored the relationship between alcohol-related problems and the social-emotional contexts of drinking in college students. METHOD: Undergraduate volunteers (N = 139; 61% female; 27% minority) completed an assessment of drinking patterns, the short form of the Inventory of Drinking Situations (IDS-42) and an alcohol problems index. RESULTS: Heavy drinkers drank more, relative to light/moderate drinkers, in five of the eight situations assessed by the IDS-42. Several IDS-42 subscales correlated highly with the number of alcohol-related problems. Subjects identified by their extreme scores on the IDS-42 reported more alcohol problems, greater maximum quantities consumed and more frequent intoxication. CONCLUSIONS: The IDS-42 can identify the contexts in which heavy drinking occurs and individuals who are likely to experience alcohol problems.

Effects of alcohol intoxication on self-focused attention.

OBJECTIVE: Self-focused attention has been associated with many cognitive, affective and behavioral consequences. Although Self-Awareness Theory predicts that alcohol intoxication reduces self-focused attention, empirical support for this effect has been inconsistent. The purpose of this study was to provide a critical test of the conditions under which alcohol intoxication will reduce self-focused attention. Consumption of alcohol and exposure to a mirror were independently manipulated to evaluate the effects of alcohol intoxication on self-focused attention both in the presence and the absence of situational cues that maintain self-focus. METHOD: Subjects were 47 male volunteers; 24 consumed alcohol and 23 consumed a placebo beverage. Approximately one-half of each group sat in front of a mirror while completing a sentence completion task, a situational manipulation previously shown to enhance self-focus. RESULTS: Manipulation checks indicated that all subjects believed that they had consumed alcohol, although subjects who actually drank alcohol did feel more intoxicated than those who did not. The pattern of means suggests that both mirror exposure and alcohol intoxication enhanced the frequency of self-focused responses. CONCLUSIONS: The effects of alcohol consumption were contrary to predictions from Self-Awareness Theory, but consistent with findings from previous research on the acute effects of alcohol intoxication on self-disclosure. That is, alcohol intoxication may have prompted subjects to focus on immediate and salient information which, in the absence of distractions, happened to be self-focused.

Effect of a change in drinking pattern on the cognitive function of female social drinkers.

The relationship between social drinking patterns and sober cognitive performance was evaluated, and the effects of a change in alcohol consumption on cognitive function were measured. Sixty female drinkers were randomly assigned either to abstain for 3 weeks or to continue to drink as usual; 25 female abstainers served as a comparison group. Subjects' drinking patterns during the last 6 months were assessed, and a battery of cognitive tests was administered both before and after the 3-week interval. Results indicated that cognitive performance at baseline was not inversely correlated with either the quantity or the frequency of drinking over the last 6 months. Furthermore, the abstinence manipulation did not result in differential improvement on any of the tests between the subjects who abstained and the subjects who continued to drink. Thus, recent drinking practices were not related to cognitive test performance in this sample of female social drinkers.

Drinking motives predict alcohol-related problems in college students.

OBJECTIVE: Drinking motives have frequently been linked to both the quantity of alcohol consumption and the likelihood of negative consequences. For motivational models of drinking to be useful, however, drinking motives must have predictive power independent of other variables typically associated with alcohol-related problems. Thus, this study evaluated the relationship between drinking motives and alcohol-related problems, after first accounting for high-risk alcohol consumption and gender, METHOD: Subjects were 139 male and female (61%) college undergraduates, who completed a battery of self-report questionnaires as part of a course requirement. RESULTS: Using hierarchical regression techniques, we found that the combination of maximum daily quantity and negative reinforcement reasons for drinking accounted for 61% of the variance on a measure of lifetime alcohol-related problems. Contrary to earlier research, neither gender nor positive reinforcement motives were significant predictors in the complete model. Follow-up analyses, conducted separately for negative and positive reinforcement motives, indicated that maximum daily quantity partially mediated the relationships between both types of motives and drinking problems; however, both positive and negative reinforcement motives retained unique predictive power. CONCLUSIONS: Motives operate both indirectly through heavy drinking and directly to account for drinking problems. Results support the utility of motivational models of alcohol use in understanding alcohol-related problems in college students.