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Historically, mentorship has been conceived of as a dyadic relationship between a senior mentor and an early-career investigator. Models involving multiple mentors have gained favor in recent years, but empirical research on multiple-mentor models has been lacking. The current work aims to fill this gap by describing a long-standing health services research mentoring program at the U.S. Department of Veterans Affairs which has adopted a network-based approach to mentoring. As part of a broader project, we surveyed VA HSR&D Career Development Awardees who received an award between 2000 and 2012. In total, 133 awardees participated (84%). Awardees reported on the structure of mentoring relationships with their two most influential mentors. Awardees were mentored by teams consisting of one to five mentors (M = 2.7 mentors). Most often, one mentor served as primary mentor while one or more mentors played a supporting role. In most cases, an awardee's primary mentor was co-located with the awardee, with fewer secondary mentors co-located. More recently funded CDAs had more mentors and were less likely to be co-located with secondary mentors. The VA HSR&D CDA program incorporates current thinking about Developmental Network models of mentorship into a comprehensive program providing a rich mentorship experience for its awardees.

Background Over the past 60 years, the view that “alcoholism” is a disease for which the only acceptable goal of treatment is abstinence has given way to the recognition that alcohol use disorders (AUDs) occur on a continuum of severity, for which a variety of treatment options are appropriate. However, because the available treatments for AUDs are not effective for everyone, more research is needed to develop novel and more efficacious treatments to address the range of AUD severity in diverse populations. Here we offer recommendations for the design and analysis of alcohol treatment trials, with a specific focus on the careful conduct of randomized clinical trials of medications and nonpharmacological interventions for AUDs. Methods This paper provides a narrative review of the quality of published clinical trials and recommendations for the optimal design and analysis of treatment trials for AUDs. Results Despite considerable improvements in the design of alcohol clinical trials over the past 2 decades, many studies of AUD treatments have used faulty design features and statistical methods that are known to produce biased estimates of treatment efficacy. Conclusions The published statistical and methodological literatures provide clear guidance on methods to improve clinical trial design and analysis. Consistent use of state-of-the-art design features and analytic approaches will enhance the internal and external validity of treatment trials for AUDs across the spectrum of severity. The ultimate result of this attention to methodological rigor is that better treatment options will be identified for patients with an AUD.

Oral naltrexone, an opioid antagonist medication, is currently one of only four FDA-approved medications for treating alcohol use disorders (Harris et al., 2010). Although numerous studies and meta-analyses have supported its efficacy, a meta-analysis by Feinn and Kranzler (2005) found that, compared to earlier studies, more recent trials had smaller effects for relapse to heavy drinking and percent drinking days, although the trend for the latter outcome was not quite significant. In addition, multi-center trials (compared to single-site studies) had smaller medication effects on relapse to heavy drinking. Previous reviews of pharmacotherapy trials for depression and schizophrenia have come to similar conclusions (Kemp et al., 2010; Rief et al., 2009). That is, effect sizes in those trials both attenuated over time and were smaller in multi-center studies. Several factors have been pointed to that may account for these findings. The attenuation of effects in more recent pharmacotherapy trials may be attributed to (a) regression to the mean as a function of publication bias for earlier studies (Finney, 2008), (b) confounding of more recent studies with multi-center designs (Feinn and Kranzler, 2005), and (c) increasing placebo group improvement over time (Del Re et al., in submission). Multi-center studies are thought to have smaller effects due to variability in (a) study execution (e.g., varying fidelity to treatment protocol, recruitment procedures) among centers (Feinn and Kranzler, 2005) and (b) other contextual factors across sites (e.g., variation in participant and provider characteristics) which then attenuate the aggregated effect size (ES). The current review extends Feinn and Kranzler’s (2005) meta-analysis by using multivariate meta-analytic methods to examine the efficacy of naltrexone (vs. placebo) in a larger sample of single-site and multi-center studies over a longer time period. The additional studies provide more statistical power to detect the effects of potential moderators, such as time and multi- versus single-center trials. Utilizing multivariate procedures allows for simultaneous modeling of both percent days abstinent (the inverse of percent drinking days) and relapse to heavy drinking outcomes, and thus provides independent estimates for each outcome. This procedure is advantageous as it considers the correlation between the modeled outcome variables, instead of assuming independence as two separate univariate procedures do, thereby reducing the likelihood of Type I error (i.e., erroneously rejecting the null hypothesis). We hypothesize that naltrexone effect sizes continue to decrease after 2003 (the last year examined by Feinn and Kranzler), but eventually plateau (we expect that at no point in time will effect sizes average zero or less) and that multi-center trials continue to yield smaller effect sizes than single-site trials. Further extending the work of Feinn and Kranzler, we planned to examine whether placebo group improvement has been increasing over time, thus accounting for smaller medication effects over time. We also test whether the presence of a placebo run-in period moderates naltrexone effect sizes. Placebo run-in periods eliminate non-compliant participants or participants who exhibit a strong initial placebo response. Thus, studies with a placebo run-in period are expected to have stronger medication effects. Lastly, we examine the interaction between publication year and multi-center (vs. single site), to determine if there are differential effect sizes in multi-center sites versus single site studies on average (grand mean centered intercept) and over time (slope coefficient).

Aims Although debates over the efficacy of oral naltrexone and acamprosate in treating alcohol use disorders tend to focus on their global efficacy relative to placebo or their efficacy relative to each other, the underlying reality may be more nuanced. This meta-analysis examined when naltrexone and acamprosate are most helpful by testing: (1) the relative efficacy of each medication given its presumed mechanism of action (reducing heavy drinking versus fostering abstinence) and (2) whether different ways of implementing each medication (required abstinence before treatment, detoxification before treatment, goal of treatment, length of treatment, dosage) moderate its effects.

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. Language: en

Aims Regression to the mean (RTM) refers to the tendency for a group of cases that differ from the population mean to move (regress) towards the mean, on average, when re-assessed, if scores at the two points are less than perfectly correlated. This paper considers factors that affect the magnitude of RTM and how RTM may impact findings from primary studies and reviews of substance use disorder (SUD) treatment. Design and methods The paper is guided largely by A Primer on Regression Artifacts by Campbell and Kenny. It reviews potential RTM effects in three areas of SUD treatment research. One is the extent to which within-group improvement in comparative treatment trials, including 'placebo effects', is a function of RTM. The second is the vulnerability of treatment evaluations employing non-equivalent control group designs to RTM and biased estimates of treatment effects when matching, or statistical equating is used to adjust for pre-existing group differences. The final issue is the impact of RTM in syntheses of research findings on SUD treatments. In particular, the tendency for later studies of a particular intervention to have smaller treatment effect sizes relative to earlier studies is considered as an RTM phenomenon. Findings RTM is a pervasive, but often unrecognized phenomenon that can bias findings in SUD treatment studies and in systematic reviews of that research. Conclusion SUD treatment researchers should be aware of RTM, take any available steps to reduce it, and try to diagnose whether it is still affecting research findings.

Aims This study tested the hypothesis that patients with more severe substance use disorders (SUDs) at intake respond better when treated in more structured and intensive settings (i.e. in-patient/residential versus out-patient), whereas patients with less severe SUD problems have similar outcomes regardless of treatment setting. Design, setting and participants Up to 50 new patients were selected randomly from each of a random and representative sample of 50 Department of Veterans Affairs (VA) SUD treatment programs (total n = 1917 patients), and were followed-up an average of 6.7 months later (n = 1277). Measures Patients completed a brief self-report version of the Addiction Severity Index (ASI) at baseline and at follow-up. Findings In mixed-model regression analyses, baseline substance use severity predicted follow-up substance use severity and there were no main effects of treatment setting. However, interaction effects were found, such that more severe patients experienced better alcohol and drug outcomes following in-patient/residential treatment versus out-patient treatment; on the other hand, patients with lower baseline ASI drug severity had better drug outcomes following out-patient treatment than in-patient treatment. Treatment setting was unrelated to alcohol outcomes in patients with less severe ASI alcohol scores. Conclusions Results provide some support to the matching hypothesis that for patients who have higher levels of substance use severity at intake, treatment in in-patient/residential treatment settings is associated with better outcomes than out-patient treatment. More research needs to be conducted before in-patient/residential settings are further reduced as a part of the SUD continuum of care in the United States.

Aims To examine the effectiveness of contingency management (CM) techniques in treating substance use disorders (i.e. illicit drugs, alcohol, tobacco). Design Meta-analysis was used to determine the average effect size and potential moderators in 47 comparisons of the effectiveness of CM from studies based on a treatment–control group design and published between 1970 and 2002. Findings The mean effect size (ES) of CM was positive, with a magnitude of d = 0.42 using a fixed effects model. The magnitude of the ES declined over time, following treatment. CM was more effective in treating opiate use (d = 0.65) and cocaine use (d = 0.66), compared with tobacco (d = 0.31) or multiple drugs (d = 0.42). Larger effect sizes were associated with higher researcher involvement, earlier studies and shorter treatment duration. Conclusions Study findings suggest that CM is among the more effective approaches to promoting abstinence during the treatment of substance use disorders. CM improves the ability of clients to remain abstinent, thereby allowing them to take fuller advantage of other clinical treatment components.

This study examines the association between approach coping and better functioning outcomes and the reciprocal relationships between coping and posttraumatic stress disorder (PTSD) symptoms in patients diagnosed with PTSD. Posttraumatic stress disorder patients receiving services in five VA health care systems were randomly selected and surveyed at baseline and followed 10 months later. Analyses of longitudinal data using structural equation modeling techniques showed that more approach coping predicted better family and social functioning. Cognitive avoidance coping predicted more PTSD symptoms, and more PTSD symptoms predicted more approach coping and more behavioral avoidance coping. Approach coping may enable patients with chronic PTSD to establish and maintain better relationships with family and friends, despite continuing PTSD.

Aims To describe the eligibility criteria (i.e. study participant inclusion and exclusion rules) employed in alcohol treatment outcome research and to identify predictors of their use. Design The eligibility criteria of 683 alcohol treatment outcome studies conducted between 1970 and 1998 were coded reliably into 14 general categories. Predictors of the use of eligibility criteria were then examined. Findings Patients were most often ruled ineligible for research studies because of their level of alcohol problems (39.1% of studies), comorbid psychiatric problems (37.8%), past or concurrent utilization of alcohol treatment (31.8%), co-occurring medical conditions (31.6%), and because they were deemed non-compliant and unmotivated (31.5%). The number of eligibility criteria employed in studies increased from the 1970s through the 1990s, and was positively associated with funding from the US National Institute of Alcohol Abuse and Alcoholism (NIAAA) and from the private sector, lack of an inpatient/residential treatment condition, presence of a pharmacotherapy, and use of a randomized, multiple-condition design. Principal investigators with doctoral degrees used more eligibility criteria than those with lower degrees. Conclusion Participant eligibility criteria are extensively employed in alcohol treatment outcome research, and vary significantly across historical periods, funders and research designs. Researchers should report the details of subject eligibility criteria and excluded patients more fully, and, evaluate how eligibility criteria affect the cost, feasibility, and generalizability of treatment outcome research.

BACKGROUND:: The present study investigated whether or not the effect of treatment setting (inpatient or outpatient) on 6-mo follow-up substance use varied for suicidal and nonsuicidal patients. In particular, the study tested the hypothesis that treatment setting would have no differing effect for nonsuicidal participants, but for suicidal participants, inpatient setting would be more closely associated with positive outcomes than the outpatient setting. METHODS:: A national sample of patients presenting for treatment of substance use disorders in the Veterans Administration healthcare system was selected to participate in the study. A total of 1289 participants provided complete data on psychiatric and substance-related problems at baseline and 6-mo follow-up. RESULTS:: At baseline, 4% (n = 53) of the sample reported having made a suicide attempt within the past 30 days. Those who reported a suicide attempt were no more likely to have been treated in an inpatient setting than in an outpatient setting. A significant interaction between baseline suicide attempt and treatment setting was found, such that nonsuicidal patients reported similar patterns of substance use when treated in inpatient or outpatient settings, but suicidal patients were significantly more likely to have better substance-related outcomes at 6-mo follow-up if they were treated in inpatient compared with outpatient settings. CONCLUSIONS:: Suicidal patients displayed substantial improvement after substance use disorders treatment and seem particularly responsive to treatment in inpatient settings.

Background: The aim of this study was to compare women (n= 230) and men (n= 236) who had alcohol use disorders in terms of social context and coping methods and in terms of changes in these indices associated with participation in professional treatment and Alcoholics Anonymous (AA). Methods: Initially untreated problem drinkers were followed up for 8 years. Results: Women and men did not differ in regard to the type of help received, but women had longer professional treatment. At baseline, women had more stressors and fewer resources from family and relied more on avoidance coping and drinking to cope. During the next 8 years, women, more so than men, increased on approach coping and reduced their use of avoidance coping and drinking to cope. When baseline status was controlled, women had better social resource, coping, and drinking outcomes than men did at 1 year and 8 years. A longer duration of professional treatment during year 1 was associated with improved approach coping among men but not women. A longer duration of AA attendance during year 1 and the full 8 years was associated with more resources from friends, more use of approach coping, and less drinking to cope. In turn, more friends resources and approach coping and less drinking to cope were associated with better drinking outcomes. Decreases in avoidance coping and drinking to cope were more strongly associated with better drinking outcomes among men than among women. Conclusions: It may be important to target men for formal services or self-help to increase their use of approach coping in efforts to maintain abstinence. Women's strategies for improving their social context need further explication to be adapted for transfer to male problem drinkers.

Background: This article provides a historical overview of the assessment of outcome variables in alcohol treatment studies that were first published between 1968 and 1998. The review focuses on changes over time in (1) the number of outcome variables and the number of different types of outcome variables assessed, (2) the likelihood of assessing specific types of outcome variables, (3) the methods used to assess outcome variables, and (4) the status of outcome assessment in more recent studies first published between 1990 and 1998. Methods: Reports of 357 alcohol treatment trials with two or more treatment/control groups were coded with respect to the number and types of outcome variables assessed, sources of outcome data, and methodological aspects of outcome assessment. Results: Although the number of outcome variables assessed in studies, on average, did not increase significantly over time, the number of different types of outcome variables did increase. An expected decrease in the assessment of categorical abstinence was not found, but another categorical variable, global ratings of drinking improvement, did decrease over time. More recent studies were more likely to assess such continuous variables as time abstinent, alcohol consumption, time drinking, dependence symptoms, and drinking-related problems. Physiological markers of drinking/alcohol misuse also were assessed more frequently in later years. Some aspects of outcome assessment methods exhibited improvement over time; validity data were more likely to be provided or cited, and self-reports of drinking behaviors were more likely to be corroborated in studies first published in more recent years. However, the percentages of studies that provided/cited reliability data for outcome measures, indicated that follow-up data collectors were not affiliated with treatment and were unaware of respondents' treatment conditions, and reported that respondents were alcohol-free at follow-up did not rise significantly over time. Conclusions: Although the methods of outcome assessment improved between 1968 and 1998, much room for improvement remains.

Aims The aim of this study was to compare initially untreated women and men problem drinkers on help-utilization and outcomes over 8 years. Design and participants At the time of the 8-year follow-up, individuals (N = 466, 49% female) had self-selected into four groups: no help, Alcoholics Anonymous (AA) only, formal treatment only or formal treatment plus AA. Measurements At baseline and 1, 3 and 8 years later, participants completed measures of drinking and functioning. Findings Women were generally worse off than men on baseline drinking and functioning indices. In keeping with their poorer baseline status, women were more likely to participate in AA, and had longer in-patient stays during the next year. When women's baseline status was controlled, women had better outcomes than did men at 1 and 8 years. Generally, women and men did not differ on the extent to which obtaining help, or a particular type of help, was related to improved outcomes. Regarding drinking outcomes, women benefited more than did men from more AA attendance during years 2–8 of follow-up. Conclusions The results suggest that although alcoholism interventions were designed primarily for men, they are currently delivered in ways that are also useful to women. Problem-drinking women appear to benefit from sustained participation in AA, which emphasizes bonding with supportive peers to maintain abstinence.

Brief interventions for alcohol use disorders have been the focus of considerable research. In this meta-analytic review, we considered studies comparing brief interventions with either control or extended treatment conditions. We calculated the effect sizes for multiple drinking-related outcomes at multiple follow-up points, and took into account the critical distinction between treatment-seeking and non-treatment-seeking samples. Most investigations fell into one of two types: those comparing brief interventions with control conditions in non-treatment-seeking samples (n = 34) and those comparing brief interventions with extended treatment in treatment-seeking samples (n = 20). For studies of the first type, small to medium aggregate effect sizes in favor of brief interventions emerged across different follow-up points. At follow-up after > 3-6 months, the effect for brief interventions compared to control conditions was significantly larger when individuals with more severe alcohol problems were excluded. For studies of the second type, the effect sizes were largely not significantly different from zero. This review summarizes additional positive evidence for brief interventions compared to control conditions typically delivered by health-care professionals to non-treatment-seeking samples. The results concur with previous reviews that found little difference between brief and extended treatment conditions. Because the evidence regarding brief interventions comes from different types of investigation with different samples, generalizations should be restricted to the populations, treatment characteristics and contexts represented in those studies.

Aim. To compare participation in treatment and 1-year substance use, symptom and functioning outcomes between patients with substance use disorders who did versus those who did not have an episode of inpatient care immediately prior to an episode of community residential and outpatient mental health care. Design. Two matched groups of 257 patients each with substance use disorders were assessed at entry to and discharge from a community residential facility (CRF) and at a 1-year follow-up. Findings. Patients in the two treatment groups received a comparable amount of CRF and outpatient mental health care. Nevertheless, patients who had prior inpatient care were more likely to be employed at 1-year follow-up. In addition, when they entered CRF care directly, patients with co-morbid psychiatric disorders were more likely to continue use of alcohol and drugs in the CRF and less likely to complete the program. These patients also experienced more distress and psychiatric symptoms, and were less likely to be employed at the 1-year follow-up. Conclusions. Among patients who seek treatment at Department of Veterans Affairs (VA) facilities, those who have both substance use and psychiatric disorders and enter CRF care directly have somewhat worse outcomes than those who have an immediately prior episode of inpatient care.

Aims. This study assesses the viability of a self-administered version of the Addiction Severity Index for monitoring substance abuse patients' functioning. Design and measurements. Patients completed the ASI interview and a self-administered questionnaire containing ASI composite items an average of 4 days apart. Composite scores from both formats were compared using correlations and mean differences. Participants and setting. Participants were 316 veterans entering substance abuse treatment in a US Department of Veterans Affairs medical center. Findings. Composite scores for alcohol, drug, psychiatric, family, legal and employment problems correlated 0.59-0.87 across formats. Patients endorsed more drug use and psychiatric symptoms by questionnaire than by interview. Medical composite scores correlated only 0.47 across formats. Conclusions. This study and previous research suggest that a self-administered questionnaire can be a feasible alternative to ASI interviews for monitoring substance abuse patients' treatment outcomes.

Recent surveys of the substance abuse patient population have shown a striking increase in the proportion of patients with a comorbid psychiatric disorder. In this study, patients with substance abuse and psychotic, anxiety/depressive, or personality disorders were compared with patients with only substance use disorders on treatment experiences and outcomes. Regardless of dual diagnosis status, patients generally improved on both substance use and social functioning outcomes after substance abuse treatment. At the 1-year follow-up, dually diagnosed patients, and patients with only substance use disorders, had comparable substance use outcomes. However, patients with major psychiatric disorders, specifically psychotic and anxiety/depressive disorders, fared worse on psychological symptoms and employment outcomes than did patients with personality disorders and only substance use disorders. Although there were some group differences on the amount of index treatment received and continuing care, the overall pattern of relationships between treatment variables and outcomes was comparable for the patient groups. In addition, there was no diagnostic group by treatment orientation matching effects, which indicated that the dual diagnosis patient groups improved as much in 12-Step as in cognitive-behavioral substance abuse programs.

This study examined several hypotheses for matching patients to 12-Step and cognitive-behavioral (CB) treatments in a multisite evaluation of VA inpatient substance abuse programs. A total of 804 male patients in five 12-Step programs, and 1069 male patients in five CB programs completed an intake, discharge, and 1-year follow-up questionnaire. The findings did not support the notion that certain patient characteristics would differentially predict better outcomes after 12-Step and CB treatment. This conclusion held when the purest 12-Step and CB programs were used, and when patients who received the full dose of treatment (i.e., treatment completers) were examined separately. Process analyses of the hypothesized mechanisms underlying the patient-treatment matching effects did not yield the expected links among patient characteristics, proximal outcomes, and 1-year outcomes. Our conclusion is that there is no advantage to matching men with substance abuse problems to 12-Step or CB treatments based on the patient attributes measured here.

Affiliation with Alcoholics Anonymous (AA) and other 12-Step self-help groups is becoming more common at the same time as professional substance abuse treatment services are becoming less available and of shorter duration. As a result of these two trends, patients' outcomes may be increasingly influenced by the degree to which professional treatment programs help patients take maximum advantage of self-help groups. The present study of 3018 treated veterans examined how the theoretical orientation of a substance abuse treatment program affects (1) the proportion of its patients that participate in self-help groups, and, (2) the degree of benefit patients derive from participation in self-help groups. Patients treated in 12-Step and eclectic treatment programs had higher rates of subsequent participation in 12-Step self-help groups than did patients treated in cognitive behavioral programs. Furthermore, the theoretical orientation of treatment moderated the outcome of self-help group participation: As the degree of programs' emphasis on 12-Step approaches increased, the positive relationships of 12-Step group participation to better substance use and psychological outcomes became stronger. Hence, it appears that 12-Step oriented treatment programs enhance the effectiveness of 12-Step self-help groups. Findings are discussed in terms of implications for clinical practice and for future evaluations of the combined effects of treatment and self-help groups.

This study examines the relationship between stressors and resources and the functioning of a sample of 515 men and women who had a drinking problem. At a one-year follow-up, both women and men had improved on three functioning measures: alcohol consumption, days intoxicated, and depression. There were no gender differences at Time 2 on alcohol consumption, but men had more days intoxicated and women had more symptoms of depression. The impact of stressors and resources varied by life domain, functioning criterion, and gender. Although the predictors varied, the amount of variance in depression accounted for was the same for women and men. The most striking gender difference was the stronger impact of friendships for women on all aspects of functioning. This study provides support for reconsideration of the stress vulnerability of women and men.

Previous reviews have concluded that there was no evidence for the superiority of inpatient over outpatient treatment of alcohol abuse, although particular types of patients might be more effectively treated in inpatient settings. In this review, we first consider the conceptual rationales that have been offered to support inpatient and outpatient treatment. Following that, the results of the relevant research on setting effects are presented. Five studies had significant setting effects favoring inpatient treatment, two studies found day hospital to be significantly more effective than inpatient treatment, and seven studies yielded no significant differences on drinking-related outcome variables. In all but one instance in which a significant effect emerged, patients in the 'superior' setting received more intensive treatment and patients were not 'preselected' for their willingness to accept random assignment to treatment in either setting. Studies finding significant setting effects also conducted more treatment contrasts (18.6 vs. 4.9), on average, and had a mean statistical power level of 0.71 (median 0.79) to detect a medium-sized effect, whereas studies with no significant findings had an average power level of 0.55 (median 0.57). When inpatient treatment was found to be more effective, outpatients did not receive a respite in the form of inpatient detoxification and the studies were slightly less likely to have social stability inclusion criteria and to use random assignment to treatment settings. We consider the implications of our findings for future research, especially the need to examine the conceptual rationales put forward by proponents of inpatient and outpatient treatment, i.e. mediators and moderators of setting effects.

We examined the relationships of treatment, patient and research design characteristics to treatment outcome (i.e. abstinence rates) in a sample of 150 treatment conditions drawn from 100 alcohol treatment outcome studies published between 1980 and 1992. Treatment characteristics were related to abstinence rates: more intensive treatments had higher abstinence rates than less intensive treatments, whereas treatments with an expressed goal other than abstinence had lower abstinence rates than treatments with an abstinence goal. When the public vs. private ownership status of the treatment facility was taken into account, the presence of behavioral elements in the treatment condition also was related to higher abstinence rates. Because of inconsistent reporting in primary studies, we assessed the effects of only one patient pre-treatment characteristic; treatment conditions with a higher proportion of socially stable patients had better outcomes. Research design characteristics were also related to abstinence rates. Treatment conditions with shorter follow-ups and treatments drawn from studies that did not use criteria to exclude more impaired subjects had better outcomes. We discuss possible reasons why our findings regarding the effects of treatment intensity and the use of exclusionary criteria differ from those in previous reviews.

This study used a stress and coping model to examine the process of entering treatment among 515 problem drinkers without prior formal treatment for alcohol abuse who were recruited at alcoholism information/referral (I&R) and detoxification centers. Over a 1-year follow-up period, 76% of the individuals in the sample entered some form of treatment, including Alcoholics Anonymous. People were more likely to enter treatment if they perceived their drinking problem as more severe, had more dependence symptoms, experienced more adverse consequences as a result of drinking, had more symptoms of depression, were more self-derogating, experienced more negative life events in the past year, and/or experienced more stressors in various life domains. Facilitative factors also related positively to treatment entry: people who had sought help from non-formal treatment sources before, who recalled being referred to treatment programs by an I&R center, and/or who received detoxification at a center that had treatment services available on-site, also were more likely to enter treatment. For people with greater resources in multiple life domains the positive effects of days intoxicated, dependence symptoms and stressors on help-seeking were intensified. Overall, the findings suggest that perceived severity of drinking problem plays a central role in the treatment entry process and mediates the effects of many other intrapersonal and environmental variables in generating an impetus or readiness to seek treatment.

Few studies of mutual help have been guided by coherent conceptual frameworks. We introduce a stress and coping model that can guide research on self-help groups and contribute to conceptualizing them as normative social groupings. Our model suggests that coping responses, life stressors, and social resources influence the processes by which persons become involved in mutual help organizations and, in turn, are influenced by involvement in mutual help. To provide initial empirical support for the model, we present a longitudinal study of stress and coping and Alcoholics Anonymous (AA) affiliation among 439 problem drinkers. Problem drinkers who relied more on avoidant coping responses, had fewer work and partner resources, and had more partner stressors became more intensely involved in AA. The results also suggest that AA involvement affects members' coping responses and increases their friendship resources.

Aims: This study examined general and substance-specific coping skills and their relationship to treatment climate, continuing care and 1-year post-treatment functioning among dual diagnosis patients (i.e. co-occurrence of substance use and psychiatric disorders). Design: In a prospective multi-site study, dual diagnosis patients participating in substance abuse treatment were assessed at intake, discharge and at a 1-year follow-up. Setting: Patients were recruited from 15 substance abuse treatment programs, which were selected from a larger pool of 174 inpatient treatment programs in the Department of Veterans Affairs Health Care System. Participants: A total of 981 male dual diagnosis patients participated in the study. Measurements: Assessments included general and substance-specific coping skills, treatment climate, continuing outpatient care, abstinence and clinically significant psychiatric symptoms. Findings: Dual diagnosis patients modestly improved on general and substance-specific coping skills over the 1-year follow-up period. Patients who were in programs with a 'dual diagnosis treatment climate' and who participated in more 12-Step self-help groups showed slightly more gains in adaptive coping. Both general and substance-specific coping were associated with abstinence, but only general coping was associated with freedom from significant psychiatric symptoms. Conclusions: Enhancing general and substance-specific coping skills in substance abuse treatment may reduce dual diagnosis patients' post-treatment substance use and improve their psychological functioning.

This article first explains the conceptual framework and plan of a naturalistic, multisite evaluation of Department of Veterans Affairs (VA) substance abuse treatment programs. It then examines the effectiveness of an index episode of inpatient treatment and the effectiveness of continuing outpatient care and participation in self-help groups. The study was conducted among 3018 patients from 15 VA programs that emphasized 12-Step, cognitive-behavioral (CB), or eclectic treatment. Casemix-adjusted 1-year outcomes showed that patients in 12-Step programs were the most likely to be abstinent, free of substance abuse problems, and employed at the 1-year follow-up. Patients who obtained more regular and more intensive outpatient mental health care, and those who participated more in 12-Step self-help groups, were more likely to be abstinent and free of substance use problems at the 1-year follow-up. These findings support the effectiveness of 12-Step treatment and show that patients with substance use disorders who become more involved in outpatient care and self-help groups tend to experience better short-term substance use outcomes. Subsequent papers in this section focus on the proximal outcomes of treatment, patients with psychiatric as well as substance use disorders, patient-treatment matching effects, and the link between program treatment orientation and patients’ involvement in and the influence of 12-Step self-help groups.