Clinical and genetic risk factors for suicide under the influence of alcohol in a Polish sample.

AIMS: Despite the large number of suicides that occur with intoxication, little is known about the unique predictors of suicide after alcohol consumption. The goal of this study was to examine clinical and genetic risk factors for alcohol-related suicide. METHODS: Data on 162 suicide victims were obtained from post-mortem examinations, police and prosecution inquiries, autopsy protocols and available medical records. Four single nucleotide polymorphisms in the central serotonin system and the renin-angiotensin system related genes previously found to be associated with suicide, alcohol dependence or depression were genotyped. RESULTS: The strongest predictor of suicide under the influence of alcohol was alcohol dependence (OR = 4.63). Those who did not drink alcohol before suicide were more likely to have a diagnosis of major depressive disorder in their medical record and more often had the TT genotype of the tryptophan hydroxylase 2 gene. CONCLUSIONS: Suicide under the influence of alcohol is strongly connected with alcohol dependence. The TPH2 gene may play an important role in suicide vulnerability especially in individuals who did not drink alcohol before suicide.

Late-life depression and alcoholism.

The relationship between alcohol use and later-life depression is complex. At-risk and problem drinking elevates the risk of depressive symptoms. The co-occurrence of alcohol use disorders and depression increases the potential for poor mental and physical health outcomes in older adults. Many older adults who are experiencing problems related to alcohol use do not meet alcohol abuse/dependence criteria. Depressive symptoms among older adults often are overlooked or misdiagnosed. The role of at-risk and problem alcohol use in depressive symptoms and vice versa may be underestimated. After a review of the literature, clinical recommendations for addressing late-life alcohol misuse and depression are presented.

Brief physician advice for problem drinking among older adults: an economic analysis of costs and benefits.

OBJECTIVE: Problem alcohol use among elderly persons can have a variety of health-related consequences, complicating management of chronic illnesses and increasing health care utilization and costs. This study evaluates the economic cost and benefits of brief intervention for at-risk drinking older adults. METHOD: A controlled clinical trial with 24-month follow-up tested effectiveness of brief physician advice in reducing alcohol use, health care utilization and other consequences among older (age 65 or older) adult problem drinkers. Of 6,073 patients screened for problem drinking in 24 community-based primary care practices in Wisconsin, 158 patients met inclusion criteria and were randomized into control (n = 71) or intervention (n = 87) groups. Intervention group patients received two 10- to 15-minute physician-delivered counseling sessions including professional advice, education and contracting using scripted workbooks. RESULTS: The intervention group demonstrated significant reductions in alcohol use (p = 0.001) and frequency of excessive drinking (p = 0.03) compared with the control group over 24 months, but no significant differences emerged in economic outcomes, including hospital days, emergency department visits, office visits, medications, lab and x-ray procedures, injuries, legal events or mortality. CONCLUSIONS: Although the clinical benefits of brief alcohol interventions with older adults are clear, the economic results in this age group are less certain. Older adult problem drinkers may require more intensive and costly interventions to achieve economic benefits similar to those seen in younger adult problem drinkers. Methodological issues, such as statistical power, outcome measures, outlier cases and follow-up periods, are identified for future evaluations.

Role of alcohol in late-life suicide.

Suicide is among the leading causes of death in the United States, ranking 10th to 12th annually, depending on the year. Rates of suicide increase markedly among Americans over age 75, especially among white men. After age 85, rates are >5-fold higher in this group than in the general population. The relationship between alcohol use and later-life suicide is complex and currently ill defined. Substance use disorders, particularly alcohol abuse and dependence, are the second most common category of axis I disorders associated with completed suicide among adults aged 65 and older, following only depression. The co-occurrence of alcohol use disorders and depression heightens suicide risk. Most studies that have evaluated the effects of alcohol in geriatric suicide have focused on older adults who met DSM criteria for abuse and/or dependence. However, the majority of older adults who are experiencing problems related to their alcohol use do not meet alcohol abuse/dependence criteria. Therefore, the role of at-risk and problem alcohol use in geriatric suicide may be underestimated. Drinking among elders elevates suicide risk through interactions with other factors that are more prevalent in this age group, such as depressive symptoms, medical illness, negatively perceived health status, and low social support. This article reviews the literature related to alcohol use and suicide among older adults. Clinical and research recommendations for addressing this problem are also presented.

Quality indicators and monitoring of mental health services: what do frontline providers think?

OBJECTIVE: Many health care organizations are giving feedback to mental health care providers about their performance on quality indicators. Mental health care providers may be more likely to respond to this feedback if they believe the indicators are meaningful and within their "sphere of influence." The authors surveyed frontline mental health care providers to elicit their perceptions of widely used indicators for quality monitoring in mental health services. METHOD: The survey was distributed to a stratified, random sample of 1,094 eligible mental health care providers at 52 Department of Veterans Affairs facilities; 684 (63%) returned the survey. The survey elicited perceptions of 21 widely used indicators in five quality domains (access, utilization, satisfaction, process, and outcomes). The data were analyzed with descriptive and multivariate methods. RESULTS: Most mental health care providers (65%) felt that feedback about these widely used indicators would be valuable in efforts to improve care; however, only 38% felt able to influence performance related to these monitors and just 13% were willing to accept incentives/risk for their performance. Providers were most positive about satisfaction monitors and preferentially included satisfaction, access, and process monitors in performance sets to measure overall quality. Despite providers' relatively positive views of monitors, 41% felt that monitoring programs did not assist them in improving care. Providers cited numerous barriers to improving care processes. CONCLUSIONS: Mental health care providers may be more receptive to monitoring efforts if satisfaction, access, and process monitors are emphasized. However, providers' views of monitoring programs appear to be less affected by concerns about specific monitors than by concerns about the accuracy of quality measurement and barriers to changing care processes.

Effect of strengths model versus assertive community treatment model on participant outcomes and utilization: two-year follow-up.

Community-based treatments for persons with serious mental illnesses have consistently proven to be effective. While most studies evaluate assertive community treatment (ACT) programs collectively, distinct models offer different approaches to improving participant outcomes. This study specifically examined the Strengths model versus more traditional ACT programs. Multivariate analyses tested changes in utilization, symptomatology, and clinical outcomes. Both ACT and Strengths reduced inpatient days while increasing outpatient care. Though all patients improved clinically, Strengths demonstrated a significantly greater advantage with symptomatology reduced by half. Findings support both treatment models, but additional clinical gains may be obtained from the Strengths approach.

Health care utilization by older alcohol-using veterans: effects of a brief intervention to reduce at-risk drinking.

The objective of the study was to estimate the effect of a brief alcohol-reduction intervention on health care use. Male veterans aged 55 years and older drinking more than guideline limits participated in an effective primary care-based randomized clinical trial to reduce drinking. Repeated measures ANCOVA assessed short-term and long-term changes in both inpatient and outpatient utilization. Stage of change (SOC) was assessed in a subsample to test for interaction between SOC and the intervention. Veterans exposed to the intervention used more outpatient medical services in the short term. Long-term effects on inpatient/outpatient use were not observed. SOC did not moderate the effect of the intervention but was associated with differential use of health care services. A cost-effective brief intervention to reduce drinking may spur increased efforts to seek health care. Early detection and management of alcohol-related or other illnesses might be expected to accrue savings in later years.

Aging and schizophrenia: current health services research and recommendations.

Little is known about the functioning and health care use of older patients with schizophrenia. Understanding the use patterns of older patients with schizophrenia, a rapidly growing population, will inform health care planners and policy makers who make decisions about resource allocation and program development. The results are presented from a large-scale study to examine the relationship between age and the use of health services and level of functioning in patients with schizophrenia. Older adults with schizophrenia experienced fewer psychiatric hospitalizations but, once hospitalized, had longer inpatient stays. In contrast, older patients had fewer outpatient psychiatric visits and more medical outpatient visits and medical hospitalizations than younger individuals. The relatively lower use of outpatient psychiatric care by older patients with schizophrenia suggests that there may be barriers to accessing these services. When older patients are hospitalized for psychiatric reasons, their stays are longer. The implications of these findings are discussed.

Brief physician advice for problem drinkers: long-term efficacy and benefit-cost analysis.

BACKGROUND: This report describes the 48-month efficacy and benefit-cost analysis of Project TrEAT (Trial for Early Alcohol Treatment), a randomized controlled trial of brief physician advice for the treatment of problem drinking. METHODS: Four hundred eighty-two men and 292 women, ages 18-65, were randomly assigned to a control (n = 382) or intervention (n = 392) group. The intervention consisted of two physician visits and two nurse follow-up phone calls. Intervention components included a review of normative drinking, patient-specific alcohol effects, a worksheet on drinking cues, drinking diary cards, and a drinking agreement in the form of a prescription. RESULTS: Subjects in the treatment group exhibited significant reductions (p < 0.01) in 7-day alcohol use, number of binge drinking episodes, and frequency of excessive drinking as compared with the control group. The effect occurred within 6 months of the intervention and was maintained over the 48-month follow-up period. The treatment sample also experienced fewer days of hospitalization (p = 0.05) and fewer emergency department visits (p = 0.08). Seven deaths occurred in the control group and three in the treatment group. The benefit-cost analysis suggests a 43,000 dollars reduction in future health care costs for every 10,000 dollars invested in early intervention. The benefit-cost ratio increases when including the societal benefits of fewer motor vehicle events and crimes. CONCLUSIONS: The long-term follow-up of Project TrEAT provides the first direct evidence that brief physician advice is associated with sustained reductions in alcohol use, health care utilization, motor vehicle events, and associated costs. The report suggests that a patient's personal physician can successfully treat alcohol problems and endorses the implementation of alcohol screening and brief intervention in the US health care system.

Use and misuse of alcohol among older women.

Older women may be especially at risk for alcohol problems because they are more likely than men to outlive their spouses and face other losses that may lead to loneliness and depression. Physiologically, women are also at greater risk for alcohol-related health problems as they age. Because of these risks, alcohol use recommendations for older women generally are lower than those set for both older men and younger women. Screening and brief intervention may be especially useful in minimizing alcohol problems in older women. Although brief intervention research with this population is limited, the findings are promising.