An International Comparison of a Web-Based Personalized Feedback Intervention for Alcohol use During the Transition out of High School in the United States and Sweden.

Young adult drinkers engage in a range of drinking patterns from abstaining to heavy drinking in both the United States and Sweden. Heavy drinking during young adulthood in both countries is associated with a variety of negative consequences. Personalized feedback interventions have been identified as effective prevention strategies to prevent or reduce heavy drinking in the United States. This study examined transitions in drinking profiles and compared the efficacy of a personalized feedback intervention for 3965 young adults in the United States (1,735) and Sweden (2230) during their transition out of high school. Using goodness-of-fit criteria, results indicated that three drinking profiles exist among young adults transitioning out of high school: very low drinkers/abstainers, moderate to heavy drinkers, and very heavy drinkers. Latent Markov models revealed a moderating effect of country on personalized feedback intervention such that intervention condition participants in the United States were more likely to belong to the light drinker/abstainer or moderate to heavy profile relative to the very heavy drinking profile at 6-month follow-up. There was no significant effect of personalized feedback intervention in Sweden. Future research could investigate the impact of when personalized feedback interventions are administered and could examine if personalized feedback interventions should be more intentionally culturally adapted in order to be more effective.

Daily Automated Telephone Assessment and Intervention Improved 1-Month Outcome in Paroled Offenders.

This randomized trial evaluates whether automated telephony could be used to perform daily assessments in paroled offenders (N = 108) during their first 30 days after leaving prison. All subjects were called daily and answered assessment questions. Based on the content of their daily assessments, subjects in the intervention group received immediate feedback and a recommendation by automated telephony, and their probation officers also received a daily report by email. The outcome variables were analyzed using linear mixed models. The intervention group showed greater improvement than the control group in the summary scores (M = 9.6, 95% confidence interval [CI] = [0.5, 18.7], p = .038), in mental symptoms (M = 4.6, CI = [0.2, 9.0], p = .042), in alcohol drinking (M = 0.8, CI = [0.1, 1.4], p = .031), in drug use (M = 1.0, CI = [0.5, 1.6], p = .000), and in most stressful daily event (M = 1.9, CI = [1.1, 2.7], p = .000). In conclusion, automated telephony may be used to follow up and to give interventions, resulting in reduced stress and drug use, in paroled offenders.

From Substance Use Disorders in Life to Autopsy Findings: A Combined Case-Record and Medico-Legal Study.

Objectives: Several studies have shown mortality and suicide risk in substance use disorders, and autopsy findings with respect to the used substances. However, there seems to be a gap in the knowledge about substances misused in life and at death at the within-person level. Methods: All consecutive, autopsied patients during 1993 to 1997, who had been in contact with the Addiction Centre in Malmö from 1968, were investigated (365 subjects). Drug misuse in the long-term course noted in case records was related to autopsy findings. Self-inflicted death (suicide/undetermined suicide/accidental overdose) was compared with natural death. Results: Benzodiazepine misuse was associated with a high risk of autopsy findings of the substance in suicide and death of undetermined intent. It was also associated among non-misusers, but less so. An alcohol level above 1‰ was found more often in self-inflicted death. Prescription opioids at autopsy were mainly found in self-inflicted death among non-misusers. Heroin misuse was related to overdose. Central nervous system stimulants (CNS-S) and cannabis were rarely found in self-inflicted death among previous misusers. The overlap between depression in life and antidepressants at death was low. Conclusions: Benzodiazepines and alcohol seem to disinhibit suicidal tendencies. Suicide risk among users of cannabis and CNS-S may be related to other risk factors than acute use. Implications for suicide prevention are discussed.

Trajectories of positive alcohol expectancies and drinking: An examination of young adults in the US and Sweden.

Positive alcohol expectancies and alcohol use tend to increase from adolescence to young adulthood, yet little is known about the associations between these constructs across cultures. The current study adds to the extant literature by examining the growth trajectories of positive alcohol expectancies and drinking behavior among United States (US) and Swedish participants during a critical period where significant change in these outcomes may be expected to occur. A total of 870 (US, N=362; Sweden, N=508) high school seniors completed baseline, 6-month, and 12-month assessments of alcohol expectancies and drinking (i.e., drinks per week). Changes in positive alcohol expectancies and drinking behavior were examined using a parallel process latent growth model. In both samples, higher baseline levels of positive alcohol expectancies were associated with a higher number of drinks consumed per week at baseline. In the US sample, lower baseline levels of positive alcohol expectancies were associated with a greater increase in positive alcohol expectancies at 12-month follow-up, and lower baseline levels of drinks per week were associated with a greater increase in drinks consumed per week at 12-month follow-up. In the Swedish sample, an increase in positive alcohol expectancies over time was associated with an increase in drinks consumed per week over the same period of time. Additional research is needed to examine when and for whom expectancy-based alcohol interventions are most efficacious.

Clinical Prediction of Suicide and Undetermined Death: A Pseudo-Prospective Clinical and Medico-Legal Study of Substance Abusers.

This study examines aspects of prediction of suicide and death of undetermined intent. We investigated all consecutive, autopsied patients between 1993 and 1997 who had been in contact with the Addiction Centre in Malmö from 1968 onwards. The staff was asked, shortly after autopsy but before they knew of the manner of death, if they thought the patient had committed suicide. The case records were blindly evaluated, and toxicological autopsy findings for alcohol in blood samples investigated. The specificity of prediction was 83% and significantly more often correct than the sensitivity, which was only 45% for suicide and for suicide/death of undetermined intent (93% versus 39%). Suicidal communication was more often considered non-serious before death of undetermined intent than before suicide. The former could be predicted by ideation but not by suicide attempt reported in case records, unlike suicide, which was predicted by both. The undetermined group also showed higher levels of alcohol in the blood at autopsy. We concluded that more serious clinical investigation of suicidal feelings, which may be hidden and not taken seriously, and treatment of alcohol use disorders with active follow-up appear urgent in the efforts to prevent suicide.

Daily Assessment of Acute Dynamic Risk in Paroled Offenders: Prediction, Predictive Accuracy and Intervention Effect.

Few studies have assessed acute dynamic risk repeatedly among paroled offenders to investigate the relationship between changes in acute dynamic risk and recidivism in crime. The present study investigates whether one-month changes in ten stress-related acute dynamic risk factors, collected through automated telephony while the participants were still in prison and over 30 consecutive days following parole, predict one-year criminal recidivism, including its predictive accuracy. The study also investigates whether a brief feedback intervention in conjunction with the daily assessments reduces recidivism compared to an assessment-only control group. Changes in five risk factors were found to be associated with increased risk of criminal recidivism after controlling for the results in prison, the initial value after parole, and the intervention. The predictive accuracy is marginally accurate: Summary score (AUC) = .666; Level of stress (AHSS) = .644; Psychiatric symptoms (SCL-8D) = .641; Anxiety symptoms = .673; Severity of most stressful daily event = .690. No differences in one-year recidivism rates were established between the intervention group and the control group. The study shows that daily assessments can usefully be made of dynamic risk factors in paroled offenders.

Effects of parental monitoring on alcohol use in the US and Sweden: A brief report.

OBJECTIVE: Adolescent alcohol use predicts a myriad of negative mental and physical health outcomes including fatality (Midanik, 2004). Research in parental influence on alcohol consumption finds parental monitoring (PM), or knowing where/whom your child is with, is associated with lower levels of alcohol use in adolescents (e.g., Arria et al., 2008). As PM interventions have had only limited success (Koutakis, Stattin, & Kerr, 2008), investigating moderating factors of PM is of importance. Country may serve as one such moderator (Calafat, Garcia, Juan, Becoña, & Fernández-Hermida, 2014). Thus, the purpose of the present report is to assess the relationship between PM and alcohol use in the US and Sweden. METHOD: High school seniors from the US (n=1181, 42.3% Male) and Sweden (n=2171, 44.1% Male) completed assessments of total drinks consumed in a typical week, problematic alcohol use, and perceived PM. RESULTS: Generalized linear mixed modeling (GLM, Cohen, Cohen, West, & Aiken, 2013; Hilbe, 2011) was used to examine whether country moderated the relationship between PM and alcohol use. Results revealed main effects of country and PM and a significant interaction between country and PM in predicting total drinks per week and PM in predicting problematic alcohol use (p<0.001). CONCLUSIONS: While PM is related to lower quantity of alcohol consumed and problematic alcohol use, greater PM appears to be more strongly related to fewer drinks per week and less problematic alcohol use in the US, as compared to Sweden.

Protective behavioral strategies and future drinking behaviors: Effect of drinking intentions.

Alcohol use is common among United States and Swedish high school students and is related to negative consequences. Whereas drinking intentions are associated with future drinking behaviors, the use of protective behavioral strategies (PBS) is associated with decreased alcohol-related harm among young adults. The interactive effect of PBS and drinking intentions in predicting alcohol outcomes has not been examined. Further, because most PBS studies have been conducted among U.S. college students, PBS research among other populations is needed. The aims of this study were to evaluate longitudinally (a) the relationships between drinking intentions, PBS and alcohol outcomes, and (b) the moderating roles of drinking intentions and country in these relationships among United States and Swedish high school drinkers. Data were collected at baseline, 6- and 12-month follow-ups on 901 Swedish and 288 U.S. high school drinkers. Drinking intentions were associated with more alcohol use and consequences, and use of certain PBS was related to fewer alcohol-related consequences over time. Additionally, the negative prospective relationship between use of PBS and alcohol use, but not alcohol-related consequences, was moderated by intentions, such that the relationship was stronger among participants endorsing high drinking intentions. Country did not moderate these relationships. These results provide initial support for the generalizability of PBS college research to United States and Swedish high school students and suggest that interventions targeting the use of PBS may be most effective among high school drinkers endorsing high drinking intentions. (PsycINFO Database Record

Non-medical prescription drug use (NMPDU) and poor quality of life in the Swedish general population.

BACKGROUND AND OBJECTIVES: Quality of life has become an increasingly important measurement in the substance use field. The main aim of the present study was to examine the relationships between non-medical use of prescription analgesics and sedatives and poor quality of life in the general population. METHODS: Data were drawn from a Swedish national household survey conducted in 2008-2009. A stratified sample of 58,000 individuals aged 15-64 was randomly selected, with a response rate of 38.3% (n = 22,095). We examined the relationships between non-medical prescription drug use and quality of life in a logistic regression analysis, controlling for other substance use and sociodemographic variables. RESULTS: In the final logistic regression model, both non-medical use of prescription analgesics and sedatives were independently associated with poor quality of life. Non-medical use of prescription sedatives was the strongest correlate of poor quality of life among the substance use variables. DISCUSSION AND CONCLUSIONS: The associations between non-medical prescription drug use and poor quality of life might imply a need to better identify and provide treatment for this group, especially individuals with non-medical prescription sedative use, which seems to be a particularly strong correlate of poor quality of life. SCIENTIFIC SIGNIFICANCE: Using a large, general population sample, the present paper is one of few to examine the relationships between non-medical prescription drug use and quality of life.

Alcohol and drug use in groups of cannabis users: results from a survey on drug use in the Swedish general population.

BACKGROUND AND OBJECTIVES: Although cannabis is well studied in the scientific literature, relatively little is known about the relationship between the frequency of cannabis use and the use of alcohol and other drugs. The aim of this study was to identify differences between frequent and occasional cannabis users with respect to the use of other illicit drugs, hazardous alcohol use, and unauthorized use of prescription drugs. METHODS: Results from a questionnaire on drug use taken by 22,095 individuals in the Swedish general population were analyzed with a logistic regression model. Active cannabis use was defined as having used cannabis in the past 12 months. Use of cannabis two-to-three times per week or more was classified as frequent use. RESULTS: Cannabis users were more likely to report hazardous alcohol use, use of other illicit drugs, and unauthorized use of prescription drugs than were non-users. Within the group of active cannabis users, frequent cannabis use, compared to occasional use, was associated with the use of other illicit drugs and negatively associated with hazardous alcohol use. DISCUSSION AND CONCLUSIONS: The association between cannabis use and hazardous alcohol use, use of other illicit drugs, and unauthorized use of prescription drugs was expected. However, the negative association between frequent cannabis use and hazardous alcohol use among active cannabis users was surprising. This indicates that frequent cannabis users may differ from more occasional users in clinical needs. SCIENTIFIC SIGNIFICANCE: These results show a previously unknown characteristic of the association between frequency of cannabis use and hazardous alcohol use in the general population.

Mortality, attempted suicide, re-hospitalisation and prescription refill for clozapine and other antipsychotics in Sweden-a register-based study.

PURPOSE: The aim of this study was to analyse prescription refill, re-hospitalisation, total mortality, mortality because of suicide and attempted suicide among patients who were taking various types of antipsychotics. METHODS: A population-based cohort study analysed all patients (n=26046) in Sweden who had been treated for schizophrenia from 2006 to 2009 with regard to re-hospitalisation and prescription refill for various types of antipsychotic treatment. A case-control study nested within the cohort analysed all-cause mortality, mortality because of suicide and attempted suicide in relation to antipsychotic use. The study adjusted for history of hospitalisation for psychiatric and medical care, attempted suicide and use of antidepressants. RESULTS: Aripiprazole users were the only ones who showed significantly lower all-cause risks of death, but so few events occurred among users of this relatively new drug that the results should be interpreted with caution. Clozapine users showed lower odds of death by suicide (odds ratio [OR]=0.45 [95%CI 0.20-0.98]) and of attempted suicide (OR=0.44 [0.28-0.70]) than haloperidol users after adjustment for age, sex and year of discharge. Olanzapine users showed approximately the same favourable pattern. Patients who used clozapine were most likely to refill prescriptions and had lower rates of re-hospitalisation. Only one death and 23 cases of agranulocytosis were reported compared with 223 suicides and 831 suicide attempts. An etiologic fraction calculation suggests that the use of clozapine rather than traditional drugs could have prevented 95 suicide attempts during the period. CONCLUSION: Clozapine and olanzapine reduce the risk of suicide, attempted suicide and re-hospitalisation.

The AVI-R2: an inventory for a differentiated diagnosis of alcohol problems.

Often in clinical practice, a diagnosis of alcohol dependence or abuse does not provide enough information to establish an adequate treatment plan. Hence, multidimensional instruments have been constructed better to describe the extent and character of a patient's alcohol problem. The purpose of the current article is to present the AVI-R2, a self-report test that provides a standardized and differentiated description of an ongoing drinking problem. The instrument includes 81 items categorized into 16 primary scales that were further summarized into four secondary scales: alcohol dependence, psychological benefits, relational complications and multiple dependence. The article provides reference values and psychometric properties of the Swedish version of the test. Data were based on 270 alcoholic patients recruited from the Centre for Dependency Disorders in Stockholm. Except for one primary scale (social complications due to drinking), the psychometric properties of the test were satisfactory. Recommendations on when and how the test can be used were also provided.

Case management in aftercare of involuntarily committed patients with substance abuse. A randomized trial.

OBJECTIVE: Case management has since the 1970s been widely used to co-ordinate services for mental health patients. The methodology has expanded to support patients in many different types of conditions. This study is one of very few randomized trials on case management in a European setting. It examined the impact of case management on substance abuse and use of service after discharge from court-ordered institutional care. METHODS: Court-ordered patients with substance abuse ( n = 36) were randomly assigned to either strengths based case management or treatment-as-usual during 6 months in aftercare. Data was collected at intake, at conclusion of intervention and at 6 month's follow-up with a follow-up rate of 94%. RESULTS: Case management interventions were well received by the patients with no drop-out during intervention. Patients with the support of a case manager seemed to sustain abstinence in a higher degree compared with treatment-as-usual but no differences were detected in regard to use of care. A subgroup analysis showed that patients with a continuous drug abuse did have access to care from both social welfare and hospital care systems. CONCLUSIONS: Case management may be useful in order to retain abstinence in aftercare following court-ordered treatment. The social welfare and hospital care systems seem to provide care irrespective of case manager intervention. The study design, interventions and assessments instruments were well received by patients but needs to be replicated with a larger population. CLINICAL IMPLICATIONS: The 100% retention in the case management support group indicates that patients were satisfied with this type of intervention and the methodology seems to be useful in order to retain abstinence.

Intervention with feedback using Outcome Questionnaire 45 (OQ-45) in a Swedish psychiatric outpatient population. A randomized controlled trial.

AIM: The objective of the study was to evaluate the efficacy of the Outcome Questionnaire 45 (OQ-45) with feedback in a Swedish psychiatric outpatient population using a randomized controlled design. METHOD: In all 1720 patients made at least one regular visit to the clinics in the period 12 February 2007 to 10 February 2008 and received information about the study. Of these, 374 patients (22%) agreed to participate. After written consent, 188 patients were randomized to the feedback group and 186 patients to the control group. Those constituted the intention-to-treat (ITT) group. Two hundred and sixty-two patients (70%) completed the OQ-45 questionnaire at least twice, and they were included in the per-protocol analysis. Those who improved less than expected and were at risk for treatment failure were called alerted patients. RESULTS: There was a tendency that patients who received feedback improved more than the controls in OQ-45 total score. In the ITT analysis, the P-value was 0.061 and the effect size g = 0.21. In the per-protocol analysis the P-value was 0.076 and the effect size g = 0.24. In the intervention group, 27% of the patients were alerted because of risk of treatment failure vs. 28% in the control group (reaching level of alertness). The OQ-45 differences between the intervention and control groups did not significantly differ for patients who were alerted/reaching level of alertness and for non-alerted patients (g = 0.17 and g = 0.28, respectively). CONCLUSIONS: The feedback group had a tendency to improve more than the control group, possibly indicating that the method is effective, and the result (basically) supports previous findings.

Respondent-driven sampling in a syringe exchange setting.

AIMS: Respondent-driven sampling is a research technique, new to the Scandinavian setting, used in hard-to-reach populations, such as subjects at risk for HIV, including drug users. This study aimed to evaluate the use of respondent-driven sampling originating from syringe exchange clients, as a method to identify 'hidden' drug users without treatment or social service contact. METHODS: Nine heroin and amphetamine injectors were recruited as 'seeds' and instructed to recruit up to three heavy drug users in a chain-referral process. Recruited clients were interviewed about drug use, social conditions and contacts with treatment, syringe exchange and other authorities. In order to estimate whether the recruitment managed to evolve into groups of 'hidden' drug users, clients included beyond the fourth wave of chain-referral were compared with seeds (wave 0) and clients recruited in waves 1-3. RESULTS: Five seeds were generative, and in total, 66 clients were assessed. Except for one of the 35 variables studied, clients in waves 4-9 did not differ from clients in waves 0-3, and were no less likely to have contacts with authorities. All clients except one were injectors and syringe exchangers, and clients recruited later in the chain-referral even tended to attend the syringe exchange more frequently. CONCLUSIONS: Respondent-driven sampling originating from syringe exchange clients may have difficulty reaching beyond the population of injectors and syringe exchangers. The technique, new to this geographical setting, has potential for future studies, but particular efforts may be necessary to study out-of-treatment heavy drug users unknown to the syringe exchange program.

Risk factors for criminal recidivism - a prospective follow-up study in prisoners with substance abuse.

BACKGROUND: Substance use in general has been shown to predict criminal recidivism. The present study aimed to examine potential predictors of criminal recidivism, including substance-specific substance use patterns, in prisoners with substance use. METHODS: A cohort of prisoners with substance use problems (N = 4,152) were assessed with the Addiction Severity Index (ASI) in the Swedish criminal justice system. Clients were followed for an average of 2.7 years. Criminal recidivism was defined as any return to the criminal justice system. RESULTS: During follow-up, 69 percent (n = 2,862) returned to the criminal justice system. Recidivism was associated with amphetamine and heroin use, with an additive risk for injectors, and with polysubstance use. Also, recidivism was negatively associated with alcohol, other opioids than heroin/methadone and with hallucinogenic drugs, and positively associated with previous psychiatric in-patient treatment, violent behaviour, and with a shorter index sentence. Associations remained when controlling for type of crime. CONCLUSIONS: Even when controlling for type and severity of crime, and for psychiatric problems, risk of criminal relapse was increased by substance use variables, including amphetamine, heroin and polysubstance use, and an additional risk was shown for injection drug users. These findings have implications for the need for substance abuse treatment after release from prison.

Sexual force at sexual debut. Swedish adolescents with disabilities at higher risk than adolescents without disabilities.

UNLABELLED: The aims of this study are first to compare the incidence of force on the first occasion of sexual intercourse reported by participants with disabilities to that of students without disabilities; second to determine whether there are significant differences in mental health, substance abuse, and school performance as reported by participants forced into their sexual debut as opposed to those who were not forced, analysed by gender; and finally to identify the significant variables that predict girls reporting force at sexual debut as opposed to girls not reporting force, as well as to identify similar variables within the male group. There were no data on sexual abuse prior to the first occasion of full sexual intercourse. METHOD: This cross-sectional study is based on 2 surveys: Life and Health---Young People 2005 and 2007. All 17/18-year-old adolescents in upper-secondary schools in a county in Sweden were asked the same questions both years. A total of 2,254 students completed the survey in 2005 and 2,641 in 2007. RESULTS: The main finding is that force at sexual debut (intercourse) is more common among adolescents with a disability (4.0%) than those not reporting any disability (1.6%), and is most common among those reporting multiple disabilities (10.4%). This was found both for girls and boys, even if the rates for girls were several times higher. Other findings are that girls and boys reporting force at sexual debut (disability and non-disability groups taken together) reported different profiles. For girls, their country of origin and who they live with are significant. This background data is not significant for boys. Boys report a strong psychosomatic reaction. CONCLUSION: Culture-, functionality-, and gender-sensitive studies of adolescents' reactions to sexual abuse are needed to help determine relevant and effective interventions.

Anabolic androgenic steroids in the general population: user characteristics and associations with substance use.

AIMS: To analyse correlates of anabolic androgenic steroids (AAS) use in the general male population. DESIGN: A national household survey. PARTICIPANTS: Individuals aged 15-64 years in Sweden. MEASUREMENTS: AAS use and potential correlates of AAS use, including demographic data, financial situation, physical training, and substance use. In hierarchical logistic regression analyses, lifetime users of AAS (n = 240) were compared to all nonusers (n = 13,920) and to nonusers who reported that they had been offered AAS (n = 487). RESULTS: AAS use was most strongly associated with a lifetime history of illicit drug use and the misuse of prescription drugs. When controlling for substance use, AAS was associated with physical training and lower education. Illicit drug use and misuse of prescription drugs separated AAS users from nonusers who had been offered AAS. No associations were seen with AUDIT scores for risk alcohol drinking. CONCLUSIONS: In this general population survey in men, lifetime use of AAS appears to share common characteristics with illicit substance use. Both substance use variables and physical training remained associated with AAS use when controlling for one another.

Antidepressant therapy in severe depression may have different effects on ego-dystonic and ego-syntonic suicidal ideation.

The objective of the present study was to investigate whether ego-dystonic and ego-syntonic suicidal ideation occurred at different frequencies during antidepressant therapy. A blind evaluation has been performed on records of 100 suicides with a primary severe depression and 100 matched controls, admitted to the Department of Psychiatry, Lund, Sweden. Ego-dystonic suicidal ideation was more commonly reported during adequate treatment as compared to ego-syntonic ideation (P = .004). Men who committed suicide during adequate antidepressant therapy more often reported ego-dystonic suicidal ideation earlier in their lives compared with those who were not treated (P = .0377). This may indicate that treatment failure for ego-dystonic ideation was a precursor of their suicides. Consequently, ego-dystonic ideation seems to show a poorer response to antidepressant therapy as compared to ego-syntonic ideation, which may be more directly related to depression. Ego-dystonic ideation is proposed to be related to depressive psychosis.