Psychosocial factors in heart surgery: presurgical vulnerability and postsurgical recovery.

OBJECTIVE: Distress and low perceived social support were examined as indicators of psychosocial vulnerability in patients about to undergo heart surgery. DESIGN: A total of 550 study patients underwent heart surgeries, including bypass grafting and valve procedures. Psychosocial interviews were conducted about five days before surgery, and biomedical data were obtained from hospital records. MAIN OUTCOME MEASURES: Sociodemographic, personality, religious, and biomedical factors were evaluated as predictors of psychosocial vulnerability, and all five sets of variables were evaluated as contributors to hospital length of stay (LOS). RESULTS: Patients scoring higher on one or more indicator of presurgical psychosocial vulnerability were younger, more likely to be female, less likely to be married, less well educated, lower in dispositional optimism, higher in trait anger, and lower in religiousness. Older age, depression, low support, and low trait anger each showed an independent, prospective association with greater LOS, and several other predictors had prospective relationships with LOS that were statistically mediated by depression or perceived support. CONCLUSION: Evidence that multiple psychosocial factors may influence adaptation to heart surgery has implications for understanding and ameliorating presurgical distress and for improving postsurgical recovery.

FAS and CFL forms of verbal fluency differ in difficulty: a meta-analytic study.

The Controlled Oral Word Association (COWA) Test is a brief and sensitive measure of executive cognitive dysfunction. There are two commonly used forms of the test, one using the letters F, A, and S, and the other using C, F, and L. This study examines the relative difficulty of the two forms using a meta-analytic approach that includes multiple samples of normal individuals. The effects of age, education, gender composition, exclusion criteria, and age of study are also examined. Results indicate that the CFL form of the test is more difficult and that age, education, and the use of strict exclusion criteria influence performance. Performance is more variable for the FAS form, and age and age of study influence performance variability.

Course of depressive symptoms in patients undergoing heart surgery: confirmatory analysis of the factor pattern and latent mean structure of the Center for Epidemiologic Studies Depression Scale.

OBJECTIVE: The purpose of this study was to examine the dimensionality, stability, and course of depressive symptoms over the 12-month period beginning approximately 1 week before heart surgery. METHODS: The Center for Epidemiological Studies Depression Scale (CES-D) was administered to 570 patients before heart surgery and 1, 3.5, 6.5, and 12.5 months later. RESULTS: Confirmatory factor analysis rejected a four-factor model as a result of small variances for two interpersonal items. With their elimination, a three-factor solution (negative affect, low positive affect, somatic/vegetative symptoms) showed good psychometric properties. Except for the somatic/vegetative factor at the 1-month follow up, there was a high degree of stability in the factor pattern over a 12-month period beginning approximately 1 week before heart surgery. Latent mean structure analysis indicated that, apart from elevations in several somatic/vegetative symptoms during the month after surgery, means for all three depressive symptoms declined over time. The recovery of positive affect showed a steeper trajectory toward the end of the follow-up period by comparison with the rates of decline for depressed affect and somatic/vegetative symptoms. CONCLUSIONS: These findings support using 18 CES-D items to measure three depressive symptom dimensions in heart patients and may reflect a normative pattern of adjustment to heart surgery.

Evaluating two brief substance-use interventions for mandated college students.

OBJECTIVE: This study evaluated two brief personal feedback substance-use interventions for students mandated to the Rutgers University Alcohol and Other Drug Assistance Program for Students (ADAPS): (1) a brief motivational interview (BMI) intervention and (2) a written feedback-only (WF) intervention. A key question addressed by this study was whether there is a need for face-to-face feedback in the context of motivational interviewing to affect changes in substance-use behaviors or whether a written personal feedback profile is enough of an intervention to motivate students to change their substance use. METHOD: The sample consisted of 222 students who were mandated to ADAPS, were eligible for the study, and completed the 3-month follow-up assessment. Eligible students completed a baseline assessment from which a personal feedback profile was created. They were then randomly assigned to the BMI or WF condition. Students were followed 3 months later. RESULTS: Students in both interventions reduced their alcohol consumption, prevalence of cigarette and marijuana use, and problems related to alcohol and drug use between baseline and follow-up. There were no differences between the two intervention conditions in terms of any substance-use outcomes. CONCLUSIONS: The results suggest that, under these circumstances and with these students, assessment and WF students changed similarly to those who had an assessment and WF within the context of a BMI. Given the fact that the former is less costly in terms of time and personnel, written profiles may be found to be a cost-effective means of reducing alcohol and drug use and related problems among low- to moderate-risk mandated college students. More research is needed with mandated students to determine the efficacy of feedback interventions and to isolate the effects of interventions from the effects of being caught and being reprimanded to treatment.

Therapeutic alliance and treatment adherence in two interventions for bulimia nervosa: a study of process and outcome.

The relationship between therapeutic alliance, therapist adherence to treatment protocol, and outcome was analyzed in a randomized trial of cognitive-behavioral therapy (CBT) and interpersonal psychotherapy for bulimia nervosa. Independent observers rated audiotapes of full-length therapy sessions. Purging frequency was the primary outcome variable. There were no significant therapist or Therapist x Treatment effects on outcome. Although results showed high levels of alliance and adherence across treatments, CBT was associated with greater adherence. Across treatments and time points, better adherence was associated with enhanced alliance. Treatment condition and baseline purging frequency, but not adherence, predicted outcome. Early alliance predicted posttreatment purging frequency. In temporal analyses, prior symptom change assessed early in treatment was significantly related to subsequent adherence at midtreatment.

Impulsivity, negative expectancies, and marijuana use: a test of the acquired preparedness model.

According to the 'acquired preparedness model,' expectancies mediate the relationship between an impulsive personality style and alcohol use. The current study evaluated whether the model can also be applied to marijuana use. Estimated probabilities and subjective evaluations of personally expected marijuana effects, along with impulsivity and frequency of marijuana use, were assessed in 337 college undergraduates. Tests of mediation examining positive and negative marijuana expectancies showed negative expectancies to be a significant mediator for both males and females. That is, participants who were higher on impulsivity had fewer negative expectancies and in turn used more marijuana. This study provides evidence that the acquired preparedness model may help to explain marijuana use.

Binge eating among gastric bypass patients at long-term follow-up.

BACKGROUND: A better understanding of the relationship of eating behavior and attitudes to weight loss following gastric bypass (GBP) will enable the development of interventions to improve outcome. Thus, the present study sought to characterize the postoperative weight, eating behavior, and attitudes toward body shape and weight in a cross-section of GBP patients. A second objective was to examine the relationship of postoperative binge eating to surgery outcome. METHODS: 99 patients who underwent GBP > 2 and < 7 years before the study start date completed the Eating Disorder Examination-Questionnaire (EDE-Q) and the Three-Factor Eating Questionnaire (TFEQ). Subjects self-reported their current body weight, weight change over the past 3 months, and lowest weight since surgery. RESULTS: BMI remained significantly below the preoperative level, but significant weight regain was reported at long-term follow-up. 46% of participants reported recurrent loss of control over eating (objective or subjective bulimic episodes) on the EDE-Q. These patients constituted a distinctive subgroup with a less favorable outcome, including greater weight regain. CONCLUSION: Self-reported loss of control over eating was related to weight regain after GBP and may be an important target for clinical intervention. The relationship of binge eating and related psychopathology to outcome following GBP warrants further investigation.

Prevalence of DSM-IV alcohol diagnoses and symptoms in adolescent community and clinical samples.

OBJECTIVE: Summary prevalence data are critical to determining the utility of DSM-IV criteria for alcohol use disorders among adolescents. This study examined cross-study consistency in the relative prevalence of DSM-IV alcohol symptoms, the ratio of alcohol abuse to dependence diagnoses, the prevalence of the physiological dependence subtype, and the proportion of subthreshold cases of dependence. METHOD: DSM-IV alcohol diagnosis and symptom prevalence data were obtained from five community and four clinical adolescent samples. RESULTS: There was a moderate level of cross-study agreement on the relative prevalence of alcohol symptoms (mean Spearman p = 0.47). The most common symptoms were dependence criteria: tolerance and drinking more or longer than intended. A relatively high degree of variability in the ratio of abuse to dependence diagnoses and the proportion with physiological dependence was observed. All samples included a significant proportion of subthreshold cases of dependence: up to 12% in community and up to 34% in clinical samples. CONCLUSIONS: Alcohol dependence symptoms of tolerance and drinking more or longer than intended have relatively high prevalence among adolescents. These high prevalence symptoms affect the ratio of abuse to dependence diagnoses in some studies, the prevalence of the physiological dependence subtype, and the proportion of subthreshold cases of dependence.

A multi-site study of alcohol subtypes: classification and overlap of unidimensional and multi-dimensional typologies.

AIMS: The current study examined the usefulness of four prevailing alcohol typologies, assessed in terms of replicability of the multi-dimensional schemas, percentage of the sample classified by each typology, distribution of subtypes by gender and treatment site and construct validity of Type 1/Type 2. In addition, overlap of classification systems was examined to determine whether the four typologies may be narrowed to a smaller set of meaningful, non-redundant subtype schemas. DESIGN: Baseline data from five treatment outcome studies were used to facilitate subtyping according to four alcohol typologies: antisocial (ASP) versus non-ASP, early versus late onset, Type 1/Type 2 and Type A/Type B. SETTING: The studies were conducted at several in-patient and out-patient treatment sites. PARTICIPANTS: The sample included 342 participants (23% female) who met DSM-III-R criteria for alcohol abuse or dependence. MEASUREMENTS: Subjects were assessed on substance use severity, family history, psychopathology, personality and psychosocial functioning. FINDINGS: Type 1/Type 2 and Type A/B typologies were replicated. Type 1/Type 2 had poor construct validity due to symptom cluster overlap between the two subgroups. Only 14% of the subjects met criteria for ASP. The two strongest associations including that between early versus late onset and Type 1/Type 2 and that between ASP versus non-ASP and Type A/Type B, were expected and reflect overlaps in conceptual definitions. In comparison, the relationship between early versus late onset and ASP versus non-ASP and Type A/B was weak. CONCLUSIONS: Clinical utility of the ASP/non-ASP typology is limited in non-Veterans Administration (VA) samples, due to low prevalence. The Type 1/Type 2 subtyping schema was redundant with the age of onset schema, and was the least internally valid of all four typologies. In general, the Type A/B schema was most promising of prevailing typologies studied. It was relatively inclusive, and the A, B groups were distinct from one another. However, dichotomous typologies may not be complex enough to be clinically useful descriptors of alcoholic samples. Aside from ASP and Type B, there appears to be heterogeneity within groups typically considered homogeneous, such as 'early versus late onset' alcoholics.

Risk factors and neuropsychological recovery in clients with alcohol use disorders who were exposed to different treatments.

Risk covariates of neuropsychological ability (NA) at treatment entry and neuropsychological recovery (NR) across 15 months were examined and replicated in 2 samples (Ns = 952 and 774) from Project MATCH, a multisite study of alcoholism treatments. NA at treatment entry was associated with age, education, and other covariates. Statistically significant mean increases in NA over time had small effect sizes, suggesting limited clinical significance of NR in the samples as a whole. However, initial NA and a combination of risk factors in direct and mediated pathways predicted a large proportion of individual differences in NR. Statistically significant but modest differential treatment effects on NR suggest that addiction treatments may need to be modified or developed to facilitate this important aspect of recovery.

An application of item response theory analysis to alcohol, cannabis, and cocaine criteria in DSM-IV.

Item response theory (IRT) is supplanting classical test theory as the basis for measures development. This study demonstrated the utility of IRT for evaluating DSM-IV diagnostic criteria. Data on alcohol, cannabis, and cocaine symptoms from 372 adult clinical participants interviewed with the Composite International Diagnostic Interview--Expanded Substance Abuse Module (CIDI-SAM) were analyzed with Mplus (B. Muthen & L. Muthen, 1998) and MULTILOG (D. Thissen, 1991) software. Tolerance and legal problems criteria were dropped because of poor fit with a unidimensional model. Item response curves, test information curves, and testing of variously constrained models suggested that DSM-IV criteria in the CIDI-SAM discriminate between only impaired and less impaired cases and may not be useful to scale case severity. IRT can be used to study the construct validity of DSM-IV diagnoses and to identify diagnostic criteria with poor performance.

Examining mechanisms of action in 12-Step community outpatient treatment.

Twelve-step theory hypothesizes that changes in specific cognitions and behaviors, including adoption of disease model beliefs and involvement in self-help programs, lead to symptom reduction. We examined the role of self-help affiliation in treatment outcome using causal chain analysis. Baseline, end-treatment and follow-up self-help affiliation and substance use were assessed in 252 drug and alcohol abusers attending a community program. Participants were randomly assigned to one of three cognitive-behavioral or 12-Step oriented individual counseling conditions. Participants also were assigned, based on problem severity, to one of three treatment settings (partial hospitalization; intensive outpatient; standard outpatient) that varied according to intensity of additional 12-Step programming. Repeated-measures ANOVA indicated that self-help affiliation increased overall during treatment, particularly in the 12-Step counseling condition (versus cognitive-behavioral), and the partial hospitalization setting (versus standard outpatient). Multiple regression indicated that self-help affiliation was negatively associated with substance use 6 months post-treatment, and that this was not moderated by condition. Self-help affiliation predicted outcome most strongly in the partial hospitalization setting and not at all in outpatient; however, this effect was accounted for by participants' initial problem severity: high-severity patients had poorer outcomes if they failed to increase self-help affiliation, relative to those who increased affiliation and to low-severity patients regardless of affiliation. Results indicate that, in this community-based program, self-help affiliation increased as a function of exposure to 12-Step oriented treatment programming, and significantly predicted better outcome among patients with high levels of problem severity. Implications for future treatment process and dissemination research are discussed.

Individual differences in latent neuropsychological abilities at addictions treatment entry.

The latent structure of neuropsychological abilities and risk factors for impairment were examined in 197 persons entering addictions treatment. Confirmatory factor analysis yielded 4 factors: Executive, Memory, Verbal, and Processing Speed. The measurement model was consistent with evidence that neuropsychological test performance is factorially complex and supported by multiple brain regions. Path analyses showed that risk factors explained 34%-57% of the true variance in abilities. Age, education, and medical status had the most generalized and robust associations with abilities. Drug use disorder diagnoses, childhood behavior problems, familial alcoholism, and psychopathology were also significantly related to specific latent abilities. Knowledge of neuropsychological impairment may be clinically useful, and selected risk factors may help treatment providers decide which clients should receive formal neuropsychological assessment.

Motivational subtypes and continuous measures of readiness for change: concurrent and predictive validity.

This study compared the concurrent and predictive validity of motivational subtypes versus a continuous measure of readiness for change as measured by the University of Rhode Island Change Assessment Scale (URICA; E. A. McConnaughy, J. O. Prochaska, & W. F. Velicer, 1983) in 252 individuals participating in a substance abuse treatment study (38% female; mean age = 36). Hierachical cluster analysis identified a 2-cluster solution. Consistent with previous research, both the motivational subtypes and the continuous readiness measure exhibited good concurrent validity with both baseline characteristics and change process variables. Neither readiness-for-change measure predicted end treatment outcomes. Measures of readiness for change based on the URICA exhibit limited clinical utility, because they are not able to predict future behavior.

Development of the OCDS--revised: a measure of alcohol and drug urges with outpatient substance abuse clients.

Urges to use substances is an important construct in understanding the maintenance of substance use as well as relapse. There is a need to evaluate single instruments measuring global urges to use substances (including alcohol). The Obsessive Compulsive Drinking Scale (OCDS; R. F. Anton, D. H. Moak, & P. Latham, 1995) was revised and tested as a single measure of urges to use substances. Participants were 252 adults entering outpatient substance abuse treatment. Results suggest that the revised scale (OCDS-R) primarily assesses 1 global factor for urges to use substances. In addition, strong support was found for the reliability and concurrent validity of the OCDS-R, although results for its predictive validity were mixed. The OCDS-R is a brief, psychometrically sound self-report instrument that has applicability within clinical and research settings.

Reasons for alcohol use in young adulthood: validation of a three-dimensional measure.

OBJECTIVE: To evaluate the reliability and validity of a measure of reasons for use, which is based on a cognitive mediational view of alcohol use as a means for affect regulation. METHOD: Data for this study were obtained from the Rutgers Health and Human Development Project. Self-reports of young men and women aged 25 to 31 years (N = 1,176; 598 women) were used to obtain measures of reasons for use, coping use, sex-enhancing use, use intensity and use problems. Regression analyses and structural equation modeling were used to assess a hypothesized model of relationships between these variables. RESULTS: Factor analysis of 33 reasons for use yielded three hypothesized dimensions: social reasons, disinhibition reasons and suppression reasons. Although moderately correlated with each other, they exhibited distinct relationships with other use variables. Increases in social reasons were related to decelerating increases in use intensity, but increases in disinhibition and suppression reasons were associated with accelerating increases in use intensity Social reasons did not relate to use problems, whereas suppression reasons were strongly related to use problems even when controlling for use intensity. CONCLUSIONS: Suppression reasons not only motivate reactive coping use in response to the appraisal of stressful situations, they are also likely to instigate "prophylactic" or proactive coping use in anticipation of the possible occurrence of stressors, thereby blunting the emotional impact of encounters that would otherwise have been appraised as stressful and aversive.

Examining mechanisms of action in 12-step treatment: the role of 12-step cognitions.

OBJECTIVE: Twelve-step treatment appears to be modestly effective in treating alcohol and cocaine dependence, but little is known about its mechanisms of action. The primary aim of this study was to examine the hypothesized mechanism of action of 12-step cognitions. In addition, the psychometric properties of a measure used to assess 12-step cognitions were tested. METHOD: The psychometric properties of a measure to assess 12-step cognitions were examined in a sample of individuals (N = 370, 61% male) seeking inpatient (n = 118) or outpatient (n = 252) 12-step-oriented community treatment. Additional analyses of data from the inpatient sample examined changes in cognitions from entry to discharge and 12-month follow-up. The univariate and multivariate relationship of cognitions at discharge, and substance use outcomes across the 12-month follow-up were also examined in the inpatient sample. RESULTS: The measure of 12-step cognitions demonstrated good internal consistency. Findings supported some, but not all, of the hypothesized active ingredients of 12-step treatment. Cognitive processes common to many treatment-approaches significantly mediated outcomes, whereas processes unique to the 12-step approach (e.g., spirituality) did not. Overall, some 12-step cognitions at discharge were good predictors of outcome, explaining as much variance in outcome as illness severity factors (e.g., dependence severity). CONCLUSIONS: Results provided greater support for 12-step treatment theory than those reported in prior studies. At the same time, findings suggest that diverse treatment approaches may operate through a common set of active ingredients.

Development and validity of drinking pattern classification: binge, episodic, sporadic, and steady drinkers in treatment for alcohol problems.

This study refines an empirically derived drinking pattern classification system [Addict. Behav. 20 (1995) 23] and assesses its concurrent and predictive validity in a new sample of alcohol-dependent adults in treatment. Drinking data were collected from 195 adults (133 men) at baseline and for 52 weeks postbaseline using the Timeline Follow-back (TLFB) method. Ninety-three percent of the sample were classified into one of four drinking patterns: binge (n=13, 6.5%), episodic (n=41, 21%), sporadic (n=17, 9%), or steady (n=111, 57%). The steady drinking group showed substantial variability in drinking intensity and was divided into steady/high intensity (n=67, 34%) and steady/low intensity (n=44, 23%) subgroups. With age and gender controlled, the five subgroups did not differ on baseline employment or marital status, but differed on a measure of relationship functioning. Binge and steady/high groups reported the most severe alcohol-use histories. Steady/low intensity drinkers had later age of onset of alcohol problems. The five-pattern classification demonstrated predictive validity; steady (heavy and low intensity) drinkers most dramatically reduced the frequency of their drinking at 26 weeks postbaseline, while binge drinkers reduced their drinking intensity. Binge and steady/heavy drinkers were more likely than steady/low and sporadic drinkers to be abstinent at follow up. The final classification into five pattern groups shows promise of clinical utility for treatment-seeking samples.

[Willingness and alternatives to drunk driving among young people from São Paulo city, Brazil]. / Disposição e alternativas ao dirigir alcoolizado entre jovens paulistanos.

UNLABELLED: The new Brazilian Traffic Code considers drinking and driving as a traffic crime. A health behavior model suggests that much of the young people's risky behavior is not planned and that questions measuring the willingness to drink and drive are useful. In face of the importance of drinking and driving as a national health problem, the objective of the present study was to analyze the behavior willingness among youngsters about to receive their driver's licenses. METHODS: The study was carried out at the Sao Paulo Department of Traffic (DETRAN-SP) in 1998. Data were obtained from a sample of 2,166 youths, 18 to 25 years old, who took the written drivers' license examination. Data about, among other things, alcohol consumption, willingness and alternatives to drinking and driving in the following year was examined. RESULTS: In general, individuals displayed willingness to both the risky behavior (drunk driving) and to the safe behavior (alternatives as taking a cab or getting a ride). Regression analyzes were done by dividing the sample in three groups. Several significant differences were found between the groups, suggesting that the attitudes and behaviors went on a direction from safer to riskier from groups 1 to 3. CONCLUSION: Findings suggest that prevention efforts presenting a spectrum of alternatives to drunk driving and the enforcement of drink and driving laws would be two useful addenda to the more severe laws created in the 1998 Traffic Code.

Looking Inside the Black Box of "Attendance at Services": New Measures for Exploring an Old Dimension in Religion and Health Research.

Research in religion and health has spurred new interest in measuring religiousness. Measurement efforts have focused on subjective facets of religiousness such as spirituality and beliefs, and less attention has been paid to congregate aspects, beyond the single item measuring attendance at services. We evaluate some new measures for religious experiences occurring during congregational worship services. Respondents (N=576) were religiously-diverse community-dwelling adults interviewed prior to cardiac surgery. Exploratory factor analysis of the new items with a pool of standard items yielded a readily interpretable solution, involving seven correlated but distinct factors and one index variable, with high levels of internal consistency. We describe religious affiliation and demographic differences in these measures. Attendance at religious services provides multifaceted physical, emotional, social, and spiritual experiences that may promote physical health through multiple pathways.