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1.  Primary Localization and Tumor Thickness as Prognostic Factors of Survival in Patients with Mucosal Melanoma 
PLoS ONE  2014;9(11):e112535.
Background
Data on survival with mucosal melanoma and on prognostic factors of are scarce. It is still unclear if the disease course allows for mucosal melanoma to be treated as primary cutaneous melanoma or if differences in overall survival patterns require adapted therapeutic approaches. Furthermore, this investigation is the first to present 10-year survival rates for mucosal melanomas of different anatomical localizations.
Methodology
116 cases from Sep 10 1984 until Feb 15 2011 retrieved from the Comprehensive Cancer Center and of the Central Register of the German Dermatologic Society databases in Tübingen were included in our analysis. We recorded anatomical location and tumor thickness, and estimated overall survival at 2, 5 and 10 years and the mean overall survival time. Survival times were analyzed with the Kaplan-Meier method. The log-rank test was used to compare survival times by localizations and by T-stages.
Principal Findings
We found a median overall survival time of 80.9 months, with an overall 2-year survival of 71.7%, 5-year survival of 55.8% and 10-year survival of 38.3%. The 10-year survival rates for patients with T1, T2, T3 or T4 stage tumors were 100.0%, 77.9%, 66.3% and 10.6% respectively. 10-year survival of patients with melanomas of the vulva was 64.5% in comparison to 22.3% of patients with non-vulva mucosal melanomas.
Conclusion
Survival times differed significantly between patients with melanomas of the vulva compared to the rest (p = 0.0006). It also depends on T-stage at the time of diagnosis (p<0.0001).
doi:10.1371/journal.pone.0112535
PMCID: PMC4226547  PMID: 25383553
2.  Mental illness and intensification of diabetes medications: an observational cohort study 
Background
Mental health condition (MHC) comorbidity is associated with lower intensity care in multiple clinical scenarios. However, little is known about the effect of MHC upon clinicians’ decisions about intensifying antiglycemic medications in diabetic patients with poor glycemic control. We examined whether delay in intensification of antiglycemic medications in response to an elevated Hemoglobin A1c (HbA1c) value is longer for patients with MHC than for those without MHC, and whether any such effect varies by specific MHC type.
Methods
In this observational study of diabetic Veterans Health Administration (VA) patients on oral antiglycemics with poor glycemic control (HbA1c ≥8) (N =52,526) identified from national VA databases, we applied Cox regression analysis to examine time to intensification of antiglycemics after an elevated HbA1c value in 2003–2004, by MHC status.
Results
Those with MHC were no less likely to receive intensification: adjusted Hazard Ratio [95% CI] 0.99 [0.96-1.03], 1.13 [1.04-1.23], and 1.12 [1.07-1.18] at 0–14, 15–30 and 31–180 days, respectively. However, patients with substance use disorders were less likely than those without substance use disorders to receive intensification in the first two weeks following a high HbA1c, adjusted Hazard Ratio 0.89 [0.81-0.97], controlling for sex, age, medical comorbidity, other specific MHCs, and index HbA1c value.
Conclusions
For most MHCs, diabetic patients with MHC in the VA health care system do not appear to receive less aggressive antiglycemic management. However, the subgroup with substance use disorders does appear to have excess likelihood of non-intensification; interventions targeting this high risk subgroup merit attention.
Electronic supplementary material
The online version of this article (doi:10.1186/1472-6963-14-458) contains supplementary material, which is available to authorized users.
doi:10.1186/1472-6963-14-458
PMCID: PMC4282515  PMID: 25339147
Psychiatric diagnosis; Diabetes mellitus/therapy; Health care delivery; Hypoglycemic agents/therapeutic use; Veterans; Health services research
3.  Receipt of Cervical Cancer Screening in Female Veterans: Impact of Posttraumatic Stress Disorder and Depression 
Purpose
We evaluated receipt of cervical cancer screening in a national sample of 34,213 women veterans using Veteran Health Administration (VHA) facilities between 2003 and 2007 and diagnosed with either: 1) posttraumatic stress disorder (PTSD); 2) depression; or 3) no psychiatric illness.
Methods
Our study featured a cross sectional design in which logistic regression analyses compared receipt of recommended cervical cancer screening for all three diagnostic groups.
Results
Cervical cancer screening rates varied minimally by diagnostic group: 77% of women with PTSD vs. 75% with depression vs. 75% without psychiatric illness were screened during the study observation period, P < .001. However, primary care use was associated with differential odds of screening in women with vs. without psychiatric illness (PTSD or depression), and findings held after even after adjustment for age, income and physical comorbidities (Wald Chi Square (2): 126.59, P < .0001). Specifically, among low users of primary care services, women PTSD or depression were more likely than those without psychiatric diagnoses to receive screening, but among high users of primary care services, they were less likely to receive screening.
Conclusions
Psychiatric illness (PTSD or depression) had little to no effect on receipt of cervical cancer screening. Our finding that high use of primary care services was not associated with comparable odds of screening in women with vs. without psychiatric illness suggests that providers caring for women with PTSD or depression and high use of primary care services should be especially attentive to their preventive health care needs.
doi:10.1016/j.whi.2013.03.002
PMCID: PMC3704317  PMID: 23660429
cervical cancer screening; PTSD; depression; women; veterans
4.  Alcoholics Anonymous and Reduced Impulsivity: A Novel Mechanism of Change 
Reduced impulsivity is a novel, yet plausible, mechanism of change associated with the salutary effects of Alcoholics Anonymous (AA). Here, we review our work on links between AA attendance and reduced impulsivity using a 16-year prospective study of men and women with alcohol use disorders (AUD) who were initially untreated for their drinking problems. Across the study period, there were significant mean-level decreases in impulsivity, and longer AA duration was associated with reductions in impulsivity. In turn, decreases in impulsivity from baseline to Year 1 were associated with fewer legal problems and better drinking and psychosocial outcomes at Year 1, and better psychosocial functioning at Year 8. Decreases in impulsivity mediated associations between longer AA duration and improvements on several Year 1 outcomes, with the indirect effects conditional on participants’ age. Findings are discussed in terms of their potential implications for research on AA and, more broadly, interventions for individuals with AUD.
doi:10.1080/08897077.2012.691448
PMCID: PMC3558834  PMID: 23327499
Alcoholics Anonymous; Impulsivity; Mechanism of Change
5.  Coping Trajectories in Later Life: A 20-Year Predictive Study 
Aging & mental health  2012;16(3):305-316.
Objectives and Method
Information about aging-related change in coping is limited mainly to results of cross-sectional studies of age differences in coping, and no research has focused on predictors of aging-related change in coping behavior. To extend research in this area, we used longitudinal multilevel modeling to describe older adults’ (n=719; baseline M=61 years) 20-year, intra-individual approach and avoidance coping trajectories, and to determine the influence of two sets of predictors (threat appraisal and stressor characteristics; gender and baseline personal and social resources) on level and rate of change in these trajectories.
Results
Over the 20-year study interval participants declined in use of approach coping and most avoidance coping strategies, but there was significant variation in this trend. In simultaneous predictive models, female gender, more threat appraisal, stressor severity, social resources, and depressive symptoms; and fewer financial resources, were independently associated with higher initial levels of coping responses. Having more social resources, and fewer financial resources, at baseline in late-middle-age predicted faster decline over time in approach coping. Having more baseline depressive symptoms, and fewer baseline financial resources, hastened decline in use of avoidance coping. Independent of other variables in these models, decline over time in approach coping and avoidance coping remained statistically significant.
Conclusion
Overall decline in coping may be a normative pattern of coping change in later life. However, it also is modifiable by older adults’ stressor appraisals, their stressors, and the personal and social resources they possess at entry to later life, in late-middle age.
doi:10.1080/13607863.2011.628975
PMCID: PMC3323682  PMID: 22394319
Coping; Stress; Older adults; Longitudinal trajectories
6.  Alcoholics Anonymous Attendance, Decreases in Impulsivity, and Drinking and Psychosocial Outcomes over 16 Years: Moderated-Mediation from a Developmental Perspective 
Addiction (Abingdon, England)  2011;106(12):2167-2177.
Aims
Examine whether decreases in impulsivity account for links between AA attendance and better drinking and psychosocial outcomes, and whether these mediational “effects” are conditional on age.
Design
A naturalistic study in which individuals were assessed at baseline, and 1, 8, and 16 years later.
Setting
Participants initiated help-seeking through the alcohol intervention system (detoxification programs, information and referral centers).
Participants
Individuals with alcohol use disorders and no prior history of substance abuse treatment at baseline [N=628; 47% women; mean age = 34.7 years (SD=9.4)].
Measurements
Self-reports of impulsivity and drinking pattern at baseline and Year 1, duration of AA (number of weeks) in Year 1, and drinking (alcohol use problems, self-efficacy to resist drinking) and psychosocial outcomes (emotional discharge coping, social support) at baseline and follow-ups.
Findings
Controlling for changes in drinking pattern, decreases in impulsivity were associated with fewer alcohol use problems, better coping, and greater social support and self-efficacy at Year 1, and better coping and greater social support at Year 8. Decreases in impulsivity statistically mediated associations between longer AA duration and improvements on all Year 1 outcomes, and indirect effects were moderated by participant age (significant only for individuals 25 years of age or younger).
Conclusions
Decreased impulsivity appears to mediate reductions in alcohol-related problems over 8 years in people attending Alcoholics Anonymous.
doi:10.1111/j.1360-0443.2011.03522.x
PMCID: PMC3208772  PMID: 21631626
7.  Impulsivity is an Independent Predictor of 15-Year Mortality Risk among Individuals Seeking Help for Alcohol-Related Problems 
Background
Although past research has found impulsivity to be a significant predictor of mortality, no studies have tested this association in samples of individuals with alcohol-related problems or examined moderation of this effect via socio-contextual processes. The current study addressed these issues in a mixed-gender sample of individuals seeking help for alcohol-related problems.
Methods
Using Cox proportional hazard models, variables measured at baseline and Year 1 of a 16-year prospective study were used to predict the probability of death from Years 1 to 16 (i.e., 15-year mortality risk). There were 628 participants at baseline (47.1% women); 515 and 405 participated in the follow-up assessments at Years 1 and 16, respectively. Among Year 1 participants, 93 individuals were known to have died between Years 1 to 16.
Results
After controlling for age, gender, and marital status, higher impulsivity at baseline was associated with an increased risk of mortality from Years 1 to 16; however, this association was accounted for by the severity of alcohol use at baseline. In contrast, higher impulsivity at Year 1 was associated with an increased risk of mortality from Years 1 to 16, and remained significant when accounting for the severity of alcohol use, as well as physical health problems, emotional discharge coping, and interpersonal stress and support at Year 1. In addition, the association between Year 1 impulsivity and 15-year mortality risk was moderated by interpersonal support at Year 1, such that individuals high on impulsivity had a lower mortality risk when peer/friend support was high than when it was low.
Conclusions
The findings highlight impulsivity as a robust and independent predictor of mortality, and suggest the need to consider interactions between personality traits and socio-contextual processes in the prediction of health-related outcomes for individuals with alcohol use disorders.
doi:10.1111/j.1530-0277.2011.01560.x
PMCID: PMC3167944  PMID: 21631544
Impulsivity; Mortality; Alcohol Use Disorders; Socio-Contextual Processes
8.  Addressing substance abuse and violence in substance use disorder treatment and batterer intervention programs 
Background
Substance use disorders and perpetration of intimate partner violence (IPV) are interrelated, major public health problems.
Methods
We surveyed directors of a sample of substance use disorder treatment programs (SUDPs; N=241) and batterer intervention programs (BIPs; N=235) in California (70% response rate) to examine the extent to which SUDPs address IPV, and BIPs address substance abuse.
Results
Generally, SUDPs were not addressing co-occurring IPV perpetration in a formal and comprehensive way. Few had a policy requiring assessment of potential clients, or monitoring of admitted clients, for violence perpetration; almost one-quarter did not admit potential clients who had perpetrated IPV, and only 20% had a component or track to address violence. About one-third suspended or terminated clients engaging in violence. The most common barriers to SUDPs providing IPV services were that violence prevention was not part of the program’s mission, staff lacked training in violence, and the lack of reimbursement mechanisms for such services. In contrast, BIPs tended to address substance abuse in a more formal and comprehensive way; e.g., one-half had a policy requiring potential clients to be assessed, two-thirds required monitoring of substance abuse among admitted clients, and almost one-half had a component or track to address substance abuse. SUDPs had clients with fewer resources (marriage, employment, income, housing), and more severe problems (both alcohol and drug use disorders, dual substance use and other mental health disorders, HIV + status). We found little evidence that services are centralized for individuals with both substance abuse and violence problems, even though most SUDP and BIP directors agreed that help for both problems should be obtained simultaneously in separate programs.
Conclusions
SUDPs may have difficulty addressing violence because they have a clientele with relatively few resources and more complex psychological and medical needs. However, policy change can modify barriers to treatment integration and service linkage, such as reimbursement restrictions and lack of staff training.
doi:10.1186/1747-597X-7-37
PMCID: PMC3489609  PMID: 22958624
Substance use disorder; Substance abuse treatment policy; Batterer intervention; Intimate partner violence; Treatment integration; Service centralization
9.  Alcohol Screening Scores and the Risk of New-Onset Gastrointestinal Illness or Related Hospitalization 
ABSTRACT
BACKGROUND
Excessive alcohol use is associated with a variety of negative health outcomes, including liver disease, upper gastrointestinal bleeding, and pancreatitis.
OBJECTIVE
To determine the 2-year risk of gastrointestinal-related hospitalization and new-onset gastrointestinal illness based on alcohol screening scores.
DESIGN
Retrospective cohort study.
PARTICIPANTS
Male (N = 215, 924) and female (N = 9,168) outpatients who returned mailed questionnaires and were followed for 24 months.
MEASUREMENTS
Alcohol Use Disorder Identification Test—Consumption Questionnaire (AUDIT-C), a validated three-item alcohol screening questionnaire (0–12 points).
RESULTS
Two-year risk of hospitalization with a gastrointestinal disorder was increased in men with AUDIT-C scores of 5–8 and 9–12 (OR 1.54, 95% CI = 1.27–1.86; and OR 3.27; 95% CI = 2.62–4.09 respectively), and women with AUDIT-C scores of 9–12 (OR 6.84, 95% CI = 1.85 – 25.37). Men with AUDIT-C scores of 5–8 and 9–12 had increased risk of new-onset liver disease (OR 1.49, 95% CI = 1.30–1.71; and OR 2.82, 95% CI = 2.38–3.34 respectively), and new-onset of upper gastrointestinal bleeding (OR 1.28, 95% CI = 1.05–1.57; and OR 2.14, 95% CI = 1.54-2.97 respectively). Two-year risk of new-onset pancreatitis in men with AUDIT -C scores 9–12 was also increased (OR 2.14; 95% CI = 1.54–2.97).
CONCLUSIONS
Excessive alcohol use as determined by AUDIT-C is associated with 2-year increased risk of gastrointestinal-related hospitalization in men and women and new-onset liver disease, upper gastrointestinal bleeding, and pancreatitis in men. These results provide risk information that clinicians can use in evidence-based conversations with patients about their alcohol consumption.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-011-1688-7) contains supplementary material, which is available to authorized users.
doi:10.1007/s11606-011-1688-7
PMCID: PMC3138581  PMID: 21455813
alcohol; AUDIT; gastrointestinal; hospitalization; new-onset; women
10.  Painful Medical Conditions and Alcohol Use: A Prospective Study Among Older Adults 
Pain medicine (Malden, Mass.)  2011;12(7):1049-1059.
Objective
To determine associations between older adults’ baseline painful medical conditions and their 10-year drinking behavior, and whether personal and life context characteristics moderate these associations.
Method
At baseline, then 1, 4, and 10 years later, late-middle-aged community residents (M=61 years; n=1,291) were surveyed regarding their painful medical conditions, use of alcohol, and personal and life context characteristics. Latent growth modeling was used to determine concurrent and prospective relationships between painful medical conditions and 10-year drinking behavior, and moderating effects of personal and life context characteristics on these relationships.
Results
At baseline, individuals reporting more numerous painful medical conditions consumed alcohol less frequently, but had more frequent drinking problems, than did individuals with fewer such conditions. Being female and having more interpersonal social resources strengthened the association between painful medical conditions and less ethanol consumed. For men more so than women, more numerous painful medical conditions were associated with more frequent drinking problems. Baseline painful medical conditions alone had no prospective effect on 10-year change in drinking behavior, but being older and having more interpersonal social resources made it more likely that baseline painful medical conditions would predict decline over time in frequency of alcohol consumption and drinking problems.
Conclusions
Late-middle-aged individuals who have more numerous painful medical conditions reduce alcohol consumption but nonetheless remain at risk for more frequent drinking problems. Gender, age, and interpersonal social resources moderate the influence of painful medical conditions on late-life alcohol use. These results imply that older individuals with pain are at little immediate or long-term risk for increased alcohol consumption, but clinicians should remain alert to drinking problems among their older pain patients, especially men.
doi:10.1111/j.1526-4637.2011.01156.x
PMCID: PMC3146463  PMID: 21668742
pain; alcohol; drinking problems; older adults
11.  Dually diagnosed patients’ responses to substance use disorder treatment 
Few studies have investigated whether dually diagnosed patients with co-occurring substance use and psychiatric disorders (DD) respond as well to substance use disorder (SUD) treatments as patients with SUD do. Here we assessed whether male veteran DD and SUD patients with alcohol dependence diagnoses differed in the process and outcomes of residential SUD treatment. The main findings showed that (a) DD patients did not perceive SUD programs as positively as patients with SUD did and had worse proximal outcomes at discharge from treatment; (b) DD patients did as well as SUD patients on 1- and 5-year substance use outcomes but had worse psychiatric outcomes; and (c) patients who perceived treatment more positively and had better outcomes at discharge had better longer term outcomes. Thus, residential SUD programs are relatively effective in reducing DD patients’ substance use problems; however, they are less successful in engaging DD patients in treatment and addressing their psychiatric problems.
doi:10.1016/j.jsat.2009.03.012
PMCID: PMC3292216  PMID: 19540699
Dual diagnosis; Substance use disorder treatment; Alcoholism
12.  Personal, Family, and Social Functioning among Older Couples Concordant and Discordant for High-Risk Alcohol Consumption 
Addiction (Abingdon, England)  2010;106(2):324-334.
Aims
This study compares the personal, family, and social functioning of older husbands and wives concordant or discordant for high-risk alcohol consumption and identifies predictors of changes in concordance and high-risk consumption.
Design, Participants, Measurements
Three groups of couples were identified at baseline and followed 10 years later: (1) concordant couples in which husbands and wives engaged in low-risk alcohol consumption (N = 54), (2) concordant couples in which husbands and wives engaged in high-risk alcohol consumption (N = 38), and (3) discordant couples in which one partner engaged in high-risk alcohol consumption and the other partner did not (N = 75). At each follow-up, husbands and wives completed an inventory that assessed their personal, family, and social functioning.
Findings
Compared to the low-risk concordant group, husbands and wives in the high-risk concordant group were more likely to rely on tension-reduction coping, reported more friend approval of drinking, and were less involved in religious activities; however, they did not differ in the quality of the spousal relationship. The frequency of alcohol consumption declined among husbands in discordant couples, but not among husbands in concordant couples. Predictors of high-risk drinking included tension-reduction coping, friend approval of drinking, and, for husbands, their wives’ level of drinking.
Conclusions
High-risk and discordant alcohol consumption do not seem to be linked to decrements in family functioning among older couples in long-term stable marriages. The predictors of heavy alcohol consumption among older husbands and wives identify points of intervention that may help to reduce their high-risk drinking.
doi:10.1111/j.1360-0443.2010.03115.x
PMCID: PMC3017234  PMID: 20883458
alcohol consumption; husband-wife concordance; older couples
13.  Risk of future trauma based on alcohol screening scores: A two-year prospective cohort study among US veterans 
Background
Severe alcohol misuse as measured by the Alcohol Use Disorders Identification Test–Consumption (AUDIT-C) is associated with increased risk of future fractures and trauma-related hospitalizations. This study examined the association between AUDIT-C scores and two-year risk of any type of trauma among US Veterans Health Administration (VHA) patients and assessed whether risk varied by age or gender.
Methods
Outpatients (215, 924 male and 9168 female) who returned mailed AUDIT-C questionnaires were followed for 24 months in the medical record for any International Statistical Classification of Diseases and Related Health Problems (ICD-9) code related to trauma. The two-year prevalence of trauma was examined as a function of AUDIT-C scores, with low-level drinking (AUDIT-C 1–4) as the reference group. Men and women were examined separately, and age-stratified analyses were performed.
Results
Having an AUDIT-C score of 9–12 (indicating severe alcohol misuse) was associated with increased risk for trauma. Mean (SD) ages for men and women were 68.2 (11.5) and 57.2 (15.8), respectively. Age-stratified analyses showed that, for men ≤50 years, those with AUDIT-C scores ≥9 had an increased risk for trauma compared with those with AUDIT-C scores in the 1–4 range (adjusted prevalence, 25.7% versus 20.8%, respectively; OR = 1.24; 95% confidence interval [CI], 1.03–1.50). For men ≥65 years with average comorbidity and education, those with AUDIT-C scores of 5–8 (adjusted prevalence, 7.9% versus 7.4%; OR = 1.16; 95% CI, 1.02–1.31) and 9–12 (adjusted prevalence 11.1% versus 7.4%; OR = 1.68; 95% CI, 1.30–2.17) were at significantly increased risk for trauma compared with men ≥65 years in the reference group. Higher AUDIT-C scores were not associated with increased risk of trauma among women.
Conclusions
Men with severe alcohol misuse (AUDIT-C 9–12) demonstrate an increased risk of trauma. Men ≥65 showed an increased risk for trauma at all levels of alcohol misuse (AUDIT-C 5–8 and 9–12). These findings may be used as part of an evidence-based brief intervention for alcohol use disorders. More research is needed to understand the relationship between AUDIT-C scores and risk of trauma in women.
doi:10.1186/1940-0640-7-6
PMCID: PMC3414833  PMID: 22966411
Alcohol; Trauma; Fracture; AUDIT-C; Age; Gender; Screening; Women
14.  Building the first step: a review of low-intensity interventions for stepped care 
Within the last 30 years, a substantial number of interventions for alcohol use disorders (AUDs) have received empirical support. Nevertheless, fewer than 25% of individuals with alcohol-related problems access these interventions. If several intensive psychosocial treatments are relatively effective, but most individuals in need do not access them, it seems logical to place a priority on developing more engaging interventions. Accordingly, after briefly describing findings about barriers to help-seeking, we focus on identifying an array of innovative and effective low-intensity intervention strategies, including telephone, computer-based, and Internet-based interventions, that surmount these barriers and are suitable for use within a stepped-care model. We conclude that these interventions attract individuals who would otherwise not seek help, that they can benefit individuals who misuse alcohol and those with more severe AUDs, and that they can facilitate subsequent help-seeking when needed. We note that these types of low-intensity interventions are flexible and can be tailored to address many of the perceived barriers that hinder individuals with alcohol misuse or AUDs from obtaining timely help. We also describe key areas of further research, such as identifying the mechanisms that underlie stepped-care interventions and finding out how to structure these interventions to best initiate a program of stepped care.
doi:10.1186/1940-0640-7-26
PMCID: PMC3554471  PMID: 23227807
Alcohol use disorders; Stepped care; Help seeking; Intervention
15.  Associations Between AUDIT-C and Mortality Vary by Age and Sex 
Population Health Management  2010;13(5):263-268.
Abstract
We sought to determine the sex- and age-specific risk of mortality associated with scores on the 3-item Alcohol Use Disorder Identification Test–Consumption (AUDIT-C) questionnaire using data from a national sample of Veterans Health Administration (VHA) patients. Men (N = 215,924) and women (N = 9168) who completed the AUDIT-C in a patient survey were followed for 24 months. AUDIT-C categories (0, 1–4, 5–8, 9–12) were evaluated as predictors of mortality in logistic regression models, adjusted for age, race, education, marital status, smoking, depression, and comorbidities. For women, AUDIT-C scores of 9–12 were associated with a significantly increased risk of death compared to the AUDIT-C 1-4 group (odds ratio [OR] 7.09; 95% confidence interval [CI] = 2.67, 18.82). For men overall, AUDIT-C scores of 5–8 and 9–12 were associated with increased risk of death compared to the AUDIT-C 1-4 group (OR 1.13, 95% CI = 1.05, 1.21, and OR 1.63, 95% CI = 1.45, 1.84, respectively) but these associations varied by age. These results provide sex- and age-tailored risk information that clinicians can use in evidence-based conversations with patients about the health-related risks of their alcohol consumption. This study adds to the growing literature establishing the AUDIT-C as a scaled marker of alcohol-related risk or “vital sign” that might facilitate the detection and management of alcohol-related risks and problems. (Population Health Management 2010;13:263–268)
doi:10.1089/pop.2009.0060
PMCID: PMC3135896  PMID: 20879907
16.  Predictors of Longitudinal Substance Use and Mental Health Outcomes for Patients in Two Integrated Service Delivery Systems* 
Drug and alcohol dependence  2010;110(1-2):92-100.
Aim
Individuals who have both substance use disorders and mental health problems have poorer treatment outcomes. This study examines the relationship of service utilization and 12-step participation to outcomes at 1 and 5 years for patients treated in one of two integrated service delivery systems: the Department of Veterans Affairs (VA) system and a health maintenance organization (HMO).
Methods
Subsamples from each system were selected using multiple criteria indicating severity of mental health problems at admission to substance use disorder treatment (VA = 401; HMO = 331). Separate and multiple-group structural equation model analyses used baseline characteristics, service use, and 12-step participation as predictors of substance use and mental health outcomes at 1 and 5 years following admission.
Results
Substance use and related problems showed stability across time, however, these relationships were stronger among VA patients. More continuing care substance use outpatient visits were associated with reductions in mental health symptoms in both groups, whereas receipt of outpatient mental health services was associated with more severe psychological symptoms. Participation in 12-step groups had a stronger effect on reducing cocaine use among VA patients, whereas it had a stronger effect on reducing alcohol use among HMO patients. More outpatient psychological services had a stronger effect on reducing alcohol use among HMO patients.
Conclusion
Common findings across these two systems demonstrate the persistence of substance use and related psychological problems, but also show that continuing care services and participation in 12-step groups are associated with better outcomes in both systems.
doi:10.1016/j.drugalcdep.2010.02.013
PMCID: PMC2885543  PMID: 20338696
substance use disorder treatment; mental health services; continuing care; 12-step/self-help groups; longitudinal outcomes
17.  Patterns and Predictors of Late-Life Drinking Trajectories: A 10-Year Longitudinal Study 
This study examines the extent of group-level and intra-individual decline in alcohol consumption among adults as they traverse a 10-year interval spanning late-middle to early-old age. Further, it identifies key baseline predictors of these adults' 10-year drinking trajectories. Community residents (n=1,291; age 55 to 65 at baseline) were assessed at 4 points over a 10-year interval on demographic and health characteristics, coping responses, social context, and alcohol consumption. Descriptive cross-wave statistics, and multilevel regression analyses, indicated that in the sample overall, participants' 10-year patterns of alcohol consumption were relatively stable. However, men's patterns, and those of individuals drinking beyond recommended alcohol consumption guidelines at baseline, were more variable and showed steeper rates of decline, than did those of women and individuals drinking within recommended levels. Contrary to expectation, baseline use of substances to reduce tension and heavier reliance on avoidance coping predicted faster rate of decline in alcohol consumption. Post-hoc prospective mediation analyses suggested that this may have occurred because these and other baseline predictors heighten risk of developing new health problems which, in turn, motivate reduced alcohol consumption.
doi:10.1037/a0018592
PMCID: PMC2891546  PMID: 20565151
older adults; alcohol; drinking trajectories
18.  Late-Life and Life History Predictors of Older Adults of High-Risk Alcohol Consumption and Drinking Problems 
Drug and alcohol dependence  2009;108(1-2):13-20.
Aims
This prospective, longitudinal study focused on late-life and life history predictors of high-risk alcohol consumption and drinking problems during a 20-year interval as adults matured from age 55–65 to age 75–85.
Design, Setting, Participants
A sample of older community residents (N=719) who had consumed alcohol in the past year or shortly before was surveyed at baseline and 10 years and 20 years later.
Measurements
At each contact point, participants completed an inventory that assessed their alcohol consumption, drinking problems, and personal and life context factors. Participants also provided information about their life history of drinking and help-seeking.
Results
Older adults who, at baseline, had more friends who approved of drinking, relied on substances for tension reduction, and had more financial resources were more likely to engage in high-risk alcohol consumption and to incur drinking problems at 10-year and 20-year follow-ups. With respect to life history factors, drinking problems by age 50 were associated with a higher likelihood of late-life high-risk alcohol consumption and drinking problems; having tried to cut down on drinking and participation in Alcoholics Anonymous were associated with a lower likelihood of high-risk consumption and problems.
Conclusion
Specific late-life and life history factors can identify older adults likely to engage in excessive alcohol consumption 10 and 20 years later. Targeted screening that considers current alcohol consumption and life context, and history of drinking problems and help-seeking, could help identify older adults at higher risk for excessive or problematic drinking.
doi:10.1016/j.drugalcdep.2009.11.005
PMCID: PMC2835829  PMID: 19969428
Aging; alcohol consumption; drinking problems; life history; help-seeking
19.  The structure of late-life depressive symptoms across a 20 year span: A taxometric investigation 
Psychology and aging  2010;25(1):142-156.
Past studies of the underlying structure of depressive symptoms have yielded mixed results, with some studies supporting a continuous conceptualization and others supporting a categorical one. However, no study has examined this research question with an exclusively older adult sample, despite the potential uniqueness of late-life depressive symptoms. In the present study, the underlying structure of late-life depressive symptoms was examined among a sample of 1289 individuals across three waves of data collection spanning 20 years. A taxometric methodology was employed using indicators of depression derived from the Research Diagnostic Criteria. Maximum eigenvalue (MAXEIG) analyses and inchworm consistency tests generally supported a categorical conceptualization and identified a group that was primarily characterized by thoughts about death/suicide. However, compared to a categorical depression variable, depressive symptoms treated continuously were generally better predictors of relevant criterion variables. These findings suggest that thoughts of death and suicide may characterize a specific type of late-life depression, yet a continuous conceptualization still typically maximizes the predictive utility of late-life depressive symptoms.
doi:10.1037/a0018514
PMCID: PMC2850820  PMID: 20230135
Depression; Taxometric Method; Older Adults; Suicidal Ideation; Aging
20.  Stress Generation, Avoidance Coping, and Depressive Symptoms: A 10-Year Model 
This study examined (a) the role of avoidance coping in prospectively generating both chronic and acute life stressors and (b) the stress-generating role of avoidance coping as a prospective link to future depressive symptoms. Participants were 1,211 late-middle-aged individuals (500 women and 711 men) assessed 3 times over a 10-year period. As predicted, baseline avoidance coping was prospectively associated with both more chronic and more acute life stressors 4 years later. Furthermore, as predicted, these intervening life stressors linked baseline avoidance coping and depressive symptoms 10 years later, controlling for the influence of initial depressive symptoms. These findings broaden knowledge about the stress-generation process and elucidate a key mechanism through which avoidance coping is linked to depressive symptoms.
doi:10.1037/0022-006X.73.4.658
PMCID: PMC3035563  PMID: 16173853
life stressors; stress generation; coping strategies; avoidance coping; depressive symptoms
21.  Gender Differences in 16-Year Trends in Assault- and Police-Related Problems Due to Drinking 
Addictive behaviors  2009;34(9):744-750.
This study examined the frequency and predictors of physical assault and having trouble with the police due to drinking over 16 years among women and men who, at baseline, were untreated for their alcohol use disorder. Predictors examined were the personal characteristics of impulsivity, self-efficacy, and problem-solving and emotional-discharge coping, as well as outpatient treatment and Alcoholics Anonymous (AA) participation. Women and men were similar on rates of perpetrating assault due to drinking, but men were more likely to have had trouble with the police due to drinking. Respondents who, at baseline, were more impulsive and relied more on emotional discharge coping, and less on problem-solving coping, assaulted others more frequently during the first year of follow-up. Similarly, less problem-solving coping at baseline was related to having had trouble with the police more often at one and 16 years due to drinking. The association between impulsivity and more frequent assault was stronger for women, whereas associations of self-efficacy and problem-solving coping with less frequent assault and police trouble were stronger for men. Participation in AA was also associated with a lower likelihood of having trouble with the police at one year, especially for men. Interventions aimed at decreasing impulsivity and emotional discharge coping, and bolstering self-efficacy and problem-solving coping, during substance abuse treatment, and encouragement to become involved in AA, may be helpful in reducing assaultive and other illegal behaviors.
doi:10.1016/j.addbeh.2009.04.013
PMCID: PMC2735107  PMID: 19446963
addictions; emotional health; law & psychology; personality; violence; women & men
22.  Older Adults’ Alcohol Consumption and Late-Life Drinking Problems: A 20-Year Perspective 
Addiction (Abingdon, England)  2009;104(8):1293-1302.
Aims
The aim was to identify changes in patterns of alcohol consumption over a 20-year interval among older women and men, and to examine the associations between guideline-defined excessive drinking and late-life drinking problems.
Design, Participants, and Measures
A community sample of 719 adults between 55 and 65 years of age who consumed alcohol at or prior to baseline participated in a survey of alcohol consumption and drinking problems and was followed 10 years and 20 years later.
Findings
The likelihood of excessive drinking declined over the 20-year interval as adults matured into their 70s and 80s. However, at ages 75–85, 27% of women and 49% of men consumed more than 2 drinks per day or 7 drinks per week. At comparable guideline levels of alcohol consumption, older men were more likely to have drinking problems than were older women. Consumption of more than 2 drinks per day or 7 drinks per week was identified as a potential conservative guideline for identifying excessive drinking associated with an elevated likelihood of drinking problems.
Conclusions
A substantial percentage of older adults who consume alcohol engage in guideline-defined excessive drinking and incur drinking problems. The finding that older men may be more likely than older women to experience problems when they drink beyond guideline levels suggests that alcohol guidelines for men should not be set higher than those for women.
doi:10.1111/j.1360-0443.2009.02604.x
PMCID: PMC2714873  PMID: 19438836
Alcohol; aging; drinking problems; gender differences
23.  Course of Recovery from Alcoholism 
This article represents the proceedings of a symposium at the 2005 Research Society on Alcoholism meeting in Santa Barbara, California, organized and chaired by Kamilla L. Venner. This symposium integrated current empirical research on the course of recovery from alcoholism from multiple perspectives, an aim that is consistent with NIAAA's new focus on the process of recovery. The presentations and presenters were as follows: (1) The Role of Community Services and Informal Support on 7-Year Drinking Outcomes in Treated and Untreated Drinkers, by Helen Matzger; (2) The Sequence of Recovery Events in a Native American Sample, by Kamilla L. Venner; (3) Transformational Change in Recovery, by Alyssa A. Forcehimes; (4) Social Settings and Substance Use: Contextual Factors in Recovery, by Rudolf H. Moos; and (5) A Broader View of Change in Drinking Behavior, by discussant Mark L. Willenbring. A theme connecting the presentations was that treatment is but one discrete aspect to recovery and that sustained recovery is often influenced by an individual interaction with others within a social context. Collectively, presentations underscored the need to think more broadly about factors contributing to the remission of alcohol dependence.
doi:10.1111/j.1530-0277.2006.00121.x
PMCID: PMC2911355  PMID: 16737468
Recovery; Alcohol Dependence; Social Context
24.  Depressive Symptoms, Drinking Problems, and Smoking Cessation in Older Smokers 
Addictive behaviors  2009;34(6-7):548-553.
This study modeled the predictive association between depressive symptoms and smoking cessation in a sample of 442 late-middle-aged smokers; assessments occurred at four time-points across a 10-year period. In addition, the study examined the role of baseline drinking problems in moderating the relationship between depressive symptoms and smoking cessation. Findings supported hypotheses. More depressive symptoms prospectively predicted a lower likelihood of smoking cessation. In addition, the presence of baseline drinking problems strengthened the relationship between depressive symptoms and a lower likelihood of smoking cessation. Understanding the mechanisms underlying depression and cigarette smoking among older adults is applicable to secondary prevention and treatment and suggests additional public health benefits from treating depression in older persons.
doi:10.1016/j.addbeh.2009.03.020
PMCID: PMC2752429  PMID: 19372009
depression; smoking cessation; drinking problems; comorbidity; aging
25.  Justice in Health Care Decision-Making: Patients’ Appraisals of Health Care Providers and Health Plan Representatives 
Social justice research  2005;18(1):63-81.
This study describes the development of two versions of a Health Care Justice Inventory (HCJI). One version focuses on patients’ interactions with their providers (HCJI-P) and the other focuses on patients’ interactions with the representatives of their health plans (HCJI-HP). Each version of the HCJI assesses patients’ appraisals of their interactions (with either their Provider or representatives of their Health Plan) along three common dimensions of procedural justice: Trust, Impartiality, and Participation. Both the Provider and Health Plan scales assess indices that are relatively independent of patients’ demographic characteristics. In addition, patients’ appraisals of their interactions with their provider were only moderately related to their appraisals of their interactions with representatives of their health plan, indicating that the Provider and Health Plan scales tap distinct aspects of patients’ overall experience with the health care system. Overall, procedural justice dimensions were significantly related to patient satisfaction in both the Provider and the Health Plan contexts. As predicted, procedural justice factors were more strongly tied to patient satisfaction in the Provider than in the Health Plan context, and health care decisions based on distributive justice principles of Need (rather than Equity or Equality) were most closely tied to patient satisfaction in both contexts.
PMCID: PMC2878657  PMID: 16021741
procedural justice; distributive justice; patient satisfaction; provider; health plan

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