Results from sensitivity analyses using prior-year cannabis and smoking measures were similar, and the significance of the measures in predicting prior year hazardous drinking did not change .This study examined the relationship of prior-year hazardous drinking to patterns of alcohol, tobacco and cannabis use, as well as psychiatry diagnoses, in a young adult outpatient psychiatry sample. In this treatment seeking sample, cannabis and tobacco use as well as older age were significant predictors of hazardous drinking. These results highlight the high rates of hazardous drinking in a young adult population seeking mental health treatment, and the need for systematic screening in this group. The levels of prior-year hazardous drinking in our study were approximately twice as high in men and five times higher in women than in individuals of the same age, during the same time frame in the National Health Interview Survey. Our sample also included a substantial proportion of students, we found comparable rates to those seen in college students. These rates are also higher than those seen in a study of hazardous drinking among adults with moderate or greater depression symptoms from the same clinic setting. This sample ranged in age from 18 to 91, with a mean age of 42.2 47.5 % of men and 32.5 % of women reported prior-year hazardous drinking, compared to 53.3 and 51.9 % for men and women in our young adult sample. In addition, younger age was an independent predictor of hazardous drinking in this larger clinic sample. Thus, outdoor cannabis grow the clinical setting, student composition and age of participants may help to explain our findings.
Based on this same previous study in the psychiatry clinic with a mean age of 42.2, the most common primary psychiatric diagnosis assigned to patients following their first visit was major depressive disorder , followed by bipolar disorder , anxiety disorders , depressive disorder not otherwise specified , mood disorder not otherwise specified , adjustment disorders , schizophrenia , and 9.1 % all other diagnoses combined. For most diagnoses, rates were similar to those in the current sample. The exception is anxiety diagnoses, which were identified at a higher rate in the current sample. A potential explanation for the difference is sample selection as well as the way in which diagnoses were identified. The prior study measured only primary diagnoses, while the current young adult study used manual chart review to include all diagnoses assigned by providers. Although rate of AUD assignment was low relative to the rate of prior-year hazardous drinking, especially among men, any self-reported prior-year hazardous drinking was associated with a fourfold higher rate of an AUD diagnosis. These findings highlight the relevance of hazardous drinking screening among young adults seeking mental health treatment as a component of psychiatric evaluation and treatment and an indicator of a possible AUD. It is noteworthy that in our sample AUD diagnoses were twice as prevalent in woman as in men. This is in contrast to many prior epidemiological studies, including the National Epidemiologic Survey on Alcohol and Related Conditions, which found rates of alcohol abuse and dependence to be a little more than double in men compared to women. It is possible that, rather than reflecting actual gender differences in AUD diagnoses, the higher rate of AUD among women in our sample reflects a greater concern from providers regarding problematic drinking in treatment seeking young women than in young men. This pattern has previously been described in a study of the Veterans Health Administration, which found race and gender differences among VA patients with clinically recognized AUDs. That study outlines the importance of validating diagnoses against structured gold-standard clinical assessments to better understand whether providers are over or under-identifying AUDs.
Analyses of the relationship of psychiatric diagnoses to hazardous drinking indicated that, aside from AUDs, no single psychiatric disorder was particularly associated with increased rates of hazardous drinking. The finding of hazardous drinking being associated with lower rates of psychotic disorder diagnosis was not anticipated. There is a large body of data regarding comorbid substance abuse and psychosis. For example, psychosis has been associated with frequent cannabis use in national surveys. Similarly, several studies have described comorbid AUDs in patients with psychosis. It is therefore unexpected that among all diagnoses, hazardous drinking would be negatively associated with psychotic disorder. One possible explanation is that, given that all participants were seeking outpatient mental health treatment, the variability in the sample was more limited than in those seen in other studies. Study findings have important implications for clinical practice. Screening for hazardous drinking should be conducted with all psychiatric patients, regardless of diagnosis. The finding that any marijuana use was associated with 3.3 fold greater odds of prior-year hazardous drinking is also noteworthy. This finding was consistent with previous literature in college students, which found that those who use both marijuana and alcohol are more likely to experience alcohol and other drug problems, including higher mean number of drinks per occasion. Helping clinicians be aware of the frequency of co-occurring marijuana use with hazardous drinking may represent an additional opportunity to improve identification of alcohol and other drug problems. Individuals with AUDs are more likely to seek care in mental health settings than in specialized addiction treatment programs. While effective interventions to reduce co-occurring alcohol problems exist, providers in psychiatry clinics often fail to identify warning signs of problematic drinking and overlook opportunities to intervene. Interventions such as motivational interviewing could be important supplements to mental health treatment. The Screening, Brief Intervention and Referral to Treatment model promoted by the U.S. Substance Abuse and Mental Health Services Administration is another example of a potential supplement to existing mental health care.
SBIRT is a public health-based approach to early intervention for at-risk individuals identified in primary care and other health settings. Implementing these interventions in general psychiatric treatment for young adults, as well as identifying and referring AUDs to specialty addiction treatment when indicated, could help reduce hazardous drinking and improve overall patient care.This study had several limitations. While computerized self-report measures are valid, under-reporting of alcohol and cannabis use by patients would make our prevalence rates conservative. In addition, the clinic that served as the study site routinely referred patients primarily seeking care for alcohol and drug problems to specialty care treatment programs, which may also lead to lower prevalence rates of hazardous drinking in our population compared to some other psychiatric service settings. Similarly, our study used provider-assigned diagnoses and did not systematically assess AUDs using structured interviews, resulting in potential under- and/ or over-estimate of AUD rates and hindering our ability to determine the sensitivity and specificity of prior-year hazardous drinking as a predictor of AUDs. In addition, the lack of distinction between active AUD or substance use disorder diagnoses and those in remission limits the correlation of hazardous drinking in our study to any lifetime AUD or substance use disorder diagnoses. However, the low number of clinician-assigned AUDs in the context of hazardous drinking remains noteworthy. Lastly, using a lower cutoff for hazardous drinking for women than for men , would increase sensitivity of “at risk” drinking in this group, and is often used in population-based and clinical studies. The use of a higher cutoff in this study may make our estimates of hazardous drinking among women conservative.Alcohol and drug use patterns among psychiatric outpatients have been under investigated in contrast to substance abuse and dependence . Yet there is significant potential for sub-diagnostic alcohol and drug use to exacerbate psychiatric problems. For example, even moderate alcohol use may have a negative impact on antidepressant response and increase the risk of side effects. Although treatments for substance problems are most successful at early stages, most people do not seek treatment until their condition is severe. Instead, many individuals with alcohol or drug problems, especially women, first seek psychiatric services . In these settings, cannabis grow equipment providers often fail to recognize drug use or heavy drinking . As a result, potential substance use problems go untreated. To better identify alcohol and drug use, computerized screening may be a useful innovation. Self-administered systems could increase patient comfort and self-report validity for sensitive questions on quantity and frequency of alcohol and drug use, compared with face-to-face interviews . However, little is known about the feasibility of self-administered screening systems. To address these issues, we report on the implementation of routine electronic assessment in a psychiatric outpatient clinic. Using the electronic patient records generated by consecutive admissions, we investigated the prevalence of alcohol and drug use, including gender differences, to inform potential interventions.Study participants were men and women seeking outpatient services at the Langley Porter Psychiatric Institute of the University of California, San Francisco , who completed an electronic intake survey. The outpatient program includes both adult and geriatric clinics. Patients are mainly referred by their insurance carrier or are self-referred. There are no formal services for patients primarily seeking chemical dependency treatment or who have co-occurring alcohol or drug dependence in addition to a mental disorder. Demographic questions included date of birth, gender, ethnicity, education, employment, and marital status. For each substance participants were asked if they had ever used that substance during their lifetime . Participants who responded yes were asked about their most recent use.
Questions covered usual quantity , frequency of use in the prior 30 days, and number of days when five or more drinks were consumed on an occasion . All patients had scheduled appointments for initial evaluation at the Langley Porter Psychiatric Institute Adult Psychiatry Clinic at UCSF. Patients arrived one hour early to fill out paperwork, including demographic data and billing forms, and to complete the Electronic Health Inventory as part of clinical intake procedures. Individuals were screened by telephone before intake. Patients with serious alcohol or drug problems were referred to programs elsewhere in the community. The EHI is a self-administered computerized questionnaire developed by clinical and information technology staff in cooperation with researchers in the UCSF Department of Psychiatry. Patients completed the instrument on private computers in the clinic intake area. Although not reported here, the inventory also covers medical history, pain, depression, and functional measures. This inventory is designed with the Ultimate Survey Web-based program , which has a simple user interface with primarily multiple-choice questions and a branching structure. Participants indicating risk of prior-year alcohol problems based on usual quantity , frequency , or heavy drinking were directed to complete the Short Michigan Alcoholism Screening Test , a valid and reliable 13-item self-administered scale to detect lifetime alcohol problems . The clinic’s front desk staff provided patients with a log-in number to protect security and assisted them with logging in or navigation if needed. Patients unable or unwilling to use the computer were given a paper version to be completed with their provider. For example, patients arriving late and patients from the geriatric clinic were more likely to be offered the paper version. The computerized system was presented to patients as a standard component of clinical intake. Once the inventory was completed, front desk staff printed out an EHI report for use in evaluating the patient. The study team obtained permission from the UCSF Committee on Human Subjects to examine de-identified records of patients who had an initial clinic visit between September 30, 2005, and October 31, 2006. This approval included exemption from informed consent procedures. Using t tests and chi square tests, we compared demographic characteristics of participants completing the EHI with characteristics of other clinic patients. Among those completing the EHI, we compared gender differences on alcohol and drug measures. Analyses were conducted with SPSS.Because of our interest in the potential impact of substance use on psychiatric services, we conducted this study to examine patterns of alcohol and drug use in an outpatient psychiatry clinic, which were based on an electronically self-administered instrument. Results showed that alcohol and drug use, especially heavy episodic drinking and use of cannabis, were prevalent. With the exception of heavy episodic drinking, women’s rates of use were similar to men’s on most measures. These findings have implications for the development of appropriate substance use interventions, which are integral to effective psychiatric services .