INTENTION TO CHANGE DRINKING BEHAVIOUR IN GENERAL PRACTICE PATIENTS WITH PROBLEMATIC DRINKING AND COMORBID DEPRESSION OR ANXIETY

JANINA GROTHUES 1 2 GALLUS BISCHOF 1 2 SUSA REINHARDT 1 2 ULFERT HAPKE 0 1 CHRISTIAN MEYER 0 1 ULRICH JOHN 0 1 HANS-JRGEN RUMPF 1 2 0 Ernst-Moritz Arndt University, Department of Epidemiology and Prevention , Greifswald, Federal Republic of Germany 1 Universittsklinikum Schleswig-Holstein , Campus Lbeck, Klinik fr Psychiatrie und Psychotherapie, Ratzeburger Allee 160, 23538 Lbeck, Germany . Tel.: 2 Medical University of Luebeck, Department of Psychiatry and Psychotherapy, Research Group S:TEP (Substance Abuse: Treatment, Epidemiology and Prevention) , Luebeck, Federal Republic of Germany Aims: This paper examines the interaction of intention to change drinking behaviour with comorbid depression and anxiety in pro-actively recruited individuals with a range of drinking problems. Methods: Cross-sectional data of 408 general practice (GP) patients aged 18-64 years, who meet the diagnostic criteria of alcohol dependence or abuse according to DSM-IV, criteria of at-risk drinking or binge drinking, were drawn from a brief intervention study. Of the sample, 89 participants were diagnosed with comorbid anxiety and/or depressive disorders. The Transtheoretical Model (TTM) of behaviour change constructs: stages and processes of change, self-efficacy, and decisional balance were assessed in relation to presence and absence of the respective psychiatric disorders. Results: Analysis including all categories of problematic drinking revealed comorbid anxiety and/or depression to be significantly related to later stages of change. Within subgroups, this was only true for alcohol abuse, not for dependence, at-risk or binge drinking. In addition, comorbidity was related to higher use of processes of change and more pros and cons of drinking, when compared to non-comorbid participants. Comorbid individuals showed higher temptation to drink and lower self-efficacy to abstain from drinking. Separate analyses of readiness to change drinking between the categories anxiety/no comorbidity and depression/no comorbidity both obtained significance, while for anxiety disorders, this was more profound. A multinomial logistic regression analysis revealed that adverse consequences better predicted readiness to change when compared to comorbidity. Discussion: Individuals with problematic drinking and comorbid anxiety or depression may be well accessible for pro-active intervention to reduce drinking. Strategies should focus on the enhancement of coping skills to control temptation and self-efficacy. INTRODUCTION Clinical and epidemiological studies have found a high rate of anxiety and depression in individuals with alcohol problems (Bijl et al., 1998; Grant and Harford, 1995; Kessler et al., 1997; Regier et al., 1990; Schuckitt, 1996; Wittchen et al., 1992, 1996). In terms of motivation to change drinking within clinical populations, higher levels of psychiatric distress may be a predictor for help seeking but have also been related to poorer outcome prognosis (Hasin et al., 2002; Modesto-Lowe and Kranzler, 1999). Little is known about how anxiety or depression may be related to the various motivational mechanisms involved in changing drinking behaviour within the large population of individuals with drinking problems, who do not seek help (Grant, 1997; Rumpf et al., 1999). Gaining further insight may enhance pro-active intervention strategies. The Transtheoretical Model (TTM) (Prochaska and DiClemente, 1984, 1986, 1992, Prochaska et al., 1992) provides an excellent framework for studying such relations. It postulates that behaviour alteration requires individuals to systematically proceed through five motivational stages. During the precontemplation stage of change, individuals are either unconvinced that behaviour change is necessary, or are unwilling to consider change. In the contemplation stage, individuals consider the possibility of change by weighing its costs against its benefits. In the preparation stage, individuals commit to change and undertake initial planning of how to pursue it, while in the action stage, concrete plans are put into practice. During the maintenance stage, individuals consolidate the alterations made and integrate them into their lifestyles. Differential use of cognitive-behavioural processes leads to higher readiness and more consistent change. During the early stages, such mechanisms are of experiential nature, e.g. consciousness raising and social re-evaluation. From the preparation stage onwards, behavioural processes, such as counter-conditioning and stimulus control, become central. Decisional balancing, a weighing of the positive and negative aspects of drinking, can be usefully allied with the cognitive shifts across the stages and the use of experiential and behavioural processes (DiClemente et al., 1985). The TTM suggests, that personal discomfort, namely if the costs of drinking outweigh the benefits, may lead to behaviour change. Previous research suggests, that the more discouraged and frustrated with their alcohol use individuals become, the less ambivalence they experience and the more willing they become to take action to address that problem (Isenhart and Van Krevelen, 1998). Self-efficacy evaluates both the individuals level of temptation to drink when faced with various internal and situational cues, and the persons confidence in his or her own abilities to abstain from drinking in these situations. Previous studies using the TTM have found that mechanisms, which facilitate change and buffer a person from relapse, are the following: higher readiness to change and greater use of the respective experiential and behavioural change processes, higher rating of the negative aspects of drinking while rating the positives lower, lower temptation to drink and higher confidence in ones own abilities to abstain from drinking (Prochaska and DiClemente, 1992; Project MATCH Research Group, 1998). Previously, one study had looked at the association between TTM variables and severity of drinking in the dually diagnosed (Velasquez et al., 1999). The authors found a positive correlation between psychiatric severity as measured on nine subscales of a brief symptom inventory and the maintenance stage of change in an outpatient dual diagnoses sample. Psychiatric severity was positively correlated with the negative aspects of drinking and temptation to drink, particularly in situations that triggered negative effects. In order to gain insights on drinking behavioural change in individuals with depression and anxiety, and who do not seek help, three aspects need to be addressed: First, previous focus on clinical populations implies reactive sampling, which supposedly involves higher motivation to change at baseline than might be found in pro-actively recruited individuals. Second, exploration is needed, on how far prior findings on readiness to change in alcohol-dependent samples apply to at-risk and binge drinking populations. Third, previous findings on TTM and c (...truncated)