Problem drinking is rarely discussed during medical visits, more so during psychiatric visits

July 14, 2003

"Coercion" is why many people with alcohol and drug problems enter treatment, according to alcohol research. Work problems or criminal activity related to alcohol, for example, have attracted the attention of family members, colleagues, or law enforcement. Generally, however, most individuals with alcohol problems have their first voluntary contact with health professionals in the context of other health or social problems. Yet a study in the July issue of Alcoholism: Clinical & Experimental Research has found that, despite heavy use of medical and mental-health services by problem and dependent drinkers, doctors and mental-health professionals often do not address alcohol consumption during visits.

"We found that the problem and dependent drinkers we interviewed were using medical and mental health services at fairly high rates," said Constance Weisner, a professor in the department of psychiatry at the University of California, San Francisco and first author of the study. "Almost all reported at least one medical visit during the previous year. However, doctors and mental-health professionals were not using the opportunity of the visit to talk to them about their drinking. This is a missed opportunity to address alcohol problems and refer people to counseling and treatment if needed."

"This is a good study," added Keith Humphreys, associate professor of psychiatry at Stanford University School of Medicine, "but the results are disappointing because of what they tell us about how drinking problems are often missed or ignored by health care providers. These and other results indicate that even though we know how to deal with problem drinking within routine health care systems, we haven't figured out how to get those systems to use our screening and treatment methods."

Researchers examined two groups: a general population sample of alcohol-dependent and problem drinkers not entering treatment (n=672) and a treatment sample (n=926) comprised of consecutive admissions to public and private programs in a northern Californian county from 1995 to 1996. Researchers conducted baseline and one-year follow-up interviews with all participants, measured medical and psychiatric visits, and assessed whether or not their drinking was addressed during these visits.

During the one-year after baseline, 65 percent (n=880) of the problem drinkers reported having had a medical visit, yet only 24 percent (n=210) had their drinking addressed during the visit.

"There are two ways to look at these results," said Humphreys. "On the one hand, it is discouraging to see that when problem drinkers go to the doctor, no one asks them about their drinking problem. On the other hand, 24% were asked, which is better than nothing, and probably better than would have been the case 20 years ago."

During this same time period, 33 percent (n=450) had a psychiatric visit, and 65 percent (n=294) of these had their drinking addressed during the visit.

"By their nature," said Weisner, "mental-health visits bring up very personal subjects, and mental-health professionals are more likely to do a full assessment. This may also be more intrinsic in their training. Talking about mental-health problems may more likely include assessing related behavioral issues. Mental-health visits also usually provide a longer time with the patient than do medical visits."

"Even though a visit to the doctor is one of the few places where a professional can say 'go into the next room and take off your clothes,' and the person will listen," added Humphreys, "discussing drinking is still considered 'too personal' a topic for many primary-care doctors. Mental-health settings tend to have a different set of norms in which discussing even very sensitive topics is acceptable to the doctor and the patient, and that includes drinking problems."

Study results also found that, although women and individuals older than 40 were more likely to have medical and psychiatric visits, they were not more likely to have their drinking addressed in either setting.

"This finding suggests that there is something operating other than the chance of being screened being related to the number of visits one has," said Weisner. "There may be some preconceptions by physicians and mental-health providers about which population groups are most at risk for alcohol problems, such as men and young people."

Humphreys agreed. "Physicians are like the rest of us in that they make guesses about people based on generalities," he said. "There are many tall men who don't play basketball, but almost every tall man has had people upon meeting them ask if they play because most of us associate height and being male with playing sports. In the same fashion, physicians know that young to middle-aged men are the group with the highest rate of alcohol problems, so they ask them about it more even though they know some women and older adults also abuse alcohol. Time is a precious commodity for physicians, so they use generalities to increase the likelihood that the screening they do catches the patient's problems."

"We already know from earlier research that individuals with alcohol problems are more likely to use medical and mental-health services than specialty addiction treatment," said Weisner. "[We also know that] brief interventions in such settings are effective. These findings document the fact that screening and interventions are not common or systematic during medical and mental-health visits. We need more comprehensive screening of a broader group of patients." She added that early identification of individuals in non-specialty settings, and provision of interventions or referrals, can also reduce health-care and other costs over time.

"I have some sympathy for primary-care physicians because they are being asked to do so many things," noted Humphreys. "Alcohol experts want them to screen for alcohol problems, cancer experts want them to look for precancerous symptoms, heart experts want them to assess for hypertension, and so on. In reality, most primary-care doctors are under such pressure that they are happy if they can even do primary care during primary care, much less screen for every important disease the patient might have. If as a society we really want thorough screening done, we are going to have to invest more in our primary health-care provision system."
Alcoholism: Clinical & Experimental Research (ACER) is the official journal of the Research Society on Alcoholism and the International Society for Biomedical Research on Alcoholism. The co-author of the ACER paper is Helen Matzger of the Department of Psychiatry at the University of California, San Francisco, and the Alcohol Research Group at the Public Health Institute. The study was funded by the National Institute on Alcohol Abuse and Alcoholism and the Center for Substance Abuse Treatment.

Alcoholism: Clinical & Experimental Research

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