Epidemiologic data indicate that about three in ten U.S. adults drink alcohol at levels that elevate their risk for physical, mental, and social problems. Heavy drinking can complicate the management of many illnesses, including diabetes, heart disease, gastrointestinal disorders, and hypertension. Yet, in the primary care setting, drinking and alcohol use disorders often go undetected. Only about one in ten patients with alcohol dependence who visit a primary care physician receive the recommended quality of care.
The National Institute on Alcohol Abuse and Alcoholism (NIAAA) has updated its 2005 Helping Patients Who Drink Too Much: A Clinician's Guide as part of its ongoing effort to encourage primary care practices to incorporate alcohol screening and management of alcohol problems into routine care. The target audience has been expanded from primary care practitioners to include mental health professionals who wish to identify patients with comorbid alcohol problems and provide specialized counseling.
Before beginning a screening program, clinicians are first asked to choose between two methods—a single question about heavy-drinking days and a written self-report instrument, the AUDIT (Alcohol Use Disorders Identification Test)—and to decide how best to incorporate screening into their practice (who will conduct the screening and how the results will be recorded and provided to clinicians).
The guide then uses decision-tree diagrams to walk clinicians through four steps: ask about alcohol use, assess for alcohol use disorders, advise and assist (through a brief intervention), and provide continued follow-up and support. Within each broad step, the diagrams list specific actions and suggest language that clinicians can use to address problem drinking in a nonjudgmental way. For example, when a patient screens positive for at-risk drinking, the clinician is advised to clearly state his or her conclusions—"You're drinking more than is medically safe"—and recommendations—"I strongly recommend that you cut down (or quit), and I'm willing to help." The next step is to gauge the patient's willingness to change by asking a single question. A pocket guide is available with the diagrams of the four steps printed in a reduced format.
An appendix to the 34-page guide provides the ten-item AUDIT in English and Spanish along with scoring information. Several pages of clinician support material discuss prescription of medications for alcohol dependence—three oral medications (naltrexone, acamprosate, and disulfiram) and injectable naltrexone—and how to support patients who take them. Two forms are provided to help the clinician document key information in the patient's record—an extensive form for the initial session of medication management for alcohol dependence and a briefer one for follow-up sessions.
A handout included in the guide allows patients to identify the pattern of their alcohol use and understand their risk. Another patient handout lists practical steps for cutting down. The guide concludes with several pages of questions frequently asked by clinicians who undertake treatment of patients with alcohol use disorders.
NIAAA has set up a Web site with additional materials for users of the guide, including an animated 80-slide PowerPoint show that helps instructors present the content of the guide to students and professionals. Clinicians who want more detailed information can download or order manuals from Project COMBINE, a multisite clinical trial started in 1997 to determine whether treatment for alcohol use disorders can be improved by combining pharmacotherapy and behavioral interventions. Later this year clinicians will be able to visit the site to obtain online training in screening and brief intervention for continuing medical education credit.
Helping Patients Who Drink Too Much: A Clinician's Guide and supporting materials are available on the NIAAA Web site at www.niaaa.nih.gov/publications.
Some newer antipsychotic medications are being prescribed to millions of Americans for depression, dementia, and other psychiatric disorders without strong evidence that such off-label uses are effective, according to a new analysis by the Agency for Healthcare Research and Quality (AHRQ) of the Department of Health and Human Services. The report calls attention to the medications' potential for serious side effects and emphasizes the urgent need for more research into new treatments, especially for the growing population of patients with dementia who experience severe agitation.
The 77-page review, which cites 125 references, was written by AHRQ's Southern California-RAND Evidence-Based Practice Center. The center examined 84 published studies that compared second-generation antipsychotics with placebo and with active treatments. The report summarizes evidence about the use of these medications to treat dementia, depression, obsessive-compulsive disorder, posttraumatic stress disorder (PTSD), Tourette's syndrome, and autism.
Some studies cited in the report suggest that second-generation antipsychotics may help patients with mental health conditions for which there are no approved alternatives. Risperidone and quetiapine, for example, have been found to help some patients with obsessive-compulsive disorder when used in conjunction with antidepressants. Risperidone and olanzapine improve sleep problems, depression, and other symptoms of persons with combat-related PTSD when these medications are used to augment therapy with other psychotropic medications.
Overall, however, researchers found that much of the scientific evidence for off-label use of antipsychotics was of insufficient quality because studies were too small or lacked scientific rigor. The report also noted that enrollment criteria for many studies were highly selective, rendering the results "only modestly applicable to the patients seen in typical office-based care."
Efficacy and Comparative Effectiveness of Off-Label Use of Atypical Antipsychotics is the latest analysis from AHRQ's Effective Health Care program. Information on the program, including the full report, can be found at www.effectivehealthcare.ahrq.gov.
CMHS publications on system transformation: The Center for Mental Health Services (CMHS) has released two publications in its Building Bridges Series. The series features reports of dialogue meetings convened by CMHS at which participants discuss their experiences, identify factors that promote and hinder change for people and systems, and offer recommendations. A 44-page report, Mental Health Consumers and Primary Health Care Representatives in Dialogue, discusses the findings of a two-day meeting. Topics discussed include availability, affordability, and quality of services; interactions between general health and mental health; and cross-training in primary care and mental health care. Consumers and Representatives of the Mental Health and Criminal Justice Systems in Dialogue is a 37-page publication that seeks to provide an understanding of consumers' experiences in the criminal justice system. Issues discussed include diversion and community reentry. The reports are available online at www.mentalhealth.samhsa.gov/publications.
CSG's national resource center on criminal justice policy: The Council of State Governments (CSG) has announced the creation of its Justice Center. The center, which is an outgrowth of a smaller initiative within the organization's Eastern Regional Conference, will develop nonpartisan, consensus-driven strategies to address complex public safety problems, particularly those at the intersection of the criminal justice system and other disciplines, such as public health. Strategies will be grounded in research and make efficient use of state and local resources. A group of senior-level state officials who shape criminal justice policy has been assembled to guide the 25-member Justice Center staff until a board of directors has been named. The center will coordinate projects on improving the system's response to people with mental illness, addressing prisoner reentry issues, and promoting justice reinvestment strategies. The Justice Center will have offices in New York City and Bethesda, Maryland. The center's Web site is at www.justicecenter.csg.org.
Kaiser issue brief on aging out of EPSDT: States have considerable flexibility in deciding which services for adults are covered by Medicaid. However, the Medicaid statute established uniform and higher standards for children under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program. For children with disabilities, having continued access to a comprehensive range of services is especially important if they are to remain in the community as adults. The Kaiser Commission on Medicaid and the Uninsured has released a 13-page issue brief that discusses the challenges and implications for young people with disabilities when they become adults and lose their EPSDT benefits. The brief explains how recent changes to the Deficit Reduction Act of 2005 give states an opportunity to increase the availability of home- and community-based services that allow disabled individuals to lead as normal a life as possible in the community as they move into adulthood.
AHRQ-CDC report on genetic tests in depression treatment: There is insufficient evidence to determine whether gene-based tests intended to personalize dosages of serotonin reuptake inhibitors (SSRIs) improve treatment or aid in treatment decisions, according to an evidence report from the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Disease Control and Prevention (CDC). Tests evaluating differences in genes belonging to the cytochrome P450 (CYP450) family that affect the rate at which a person metabolizes an SSRI are largely accurate, researchers have found. However, a comprehensive literature review found no well-designed studies that evaluated clinical outcomes. The likelihood that a person will experience relief from all symptoms of depression after one year of SSRI treatment is approximately 40%, and side effects cause 12% to 15% of patients to stop taking the drug. The report is the first step in the two-step process of CDC's Evaluation of Genomic Applications in Practice and Prevention, a pilot project to evaluate and make recommendations regarding use of gene-based tests. Later this year the project's working group will issue recommendations on the use of CYP450 tests and on research needs. Free copies of the report can be obtained by contacting the AHRQ Publications Clearinghouse at firstname.lastname@example.org or at 800-358-9295.