Gerard J. Connors, PhD

Alcohol dependence is commonly associated with severe medical disease1 and is common among hospitalized medical patients. A nationally representative hospital sample found current alcohol use disorders to have a prevalence of 7.4%; most of those with these disorders were alcohol dependent.2 However, depending on the communities served by specific hospitals, prevalence can be much higher among medical inpatients,25 with studies finding problem drinking in as many as 28% of such patients. Although heavy drinking and the psychosocial problems that characterize alcohol dependence cause disease and interfere with disease management, remission is often difficult to achieve. As a result, although inpatient care of such patients probably does not differ from the average,6 this population is at high risk for poor health outcomes. as illustrated by factors such as suboptimal chronic disease management,7 preventable hospitalization,8 and increased mortality.9, 10 Remission involves a major behavior change that has been conceived of as a progression of stages, including precontemplation, contemplation, preparation, action, and maintenance.11 Clinically, this process encompasses an initial lack of awareness of the problem, followed by problem recognition and ambivalence about change, an increasing desire to change and concrete attempts at behavior change, and eventually long‐lasting behavioral improvements. The work described in this article was based on the broad hypothesis that acute illness and other alcohol‐related consequences will accelerate the process of change and that it might be possible to utilize this effect of acute illness to improve treatment outcomes for medically ill, alcohol‐dependent patients. If so, then measures of the change process should be correlated with measures of health status and alcohol consequences, correlations that were estimated in this study. If such measures are correlated and future research supports a causal relationship, then the link between illness and desire to change at the time of hospitalization could be exploited to help motivate changes in drinking and involvement in alcohol dependence treatment following hospital discharge.

METHODS

RESULTS

We identified 117 potential participants, accounting for 6% of total admissions (n = 1964) during the 7‐month recruitment period (late 2004 through mid‐2005). Of this total, 20 (17%) refused or withdrew prior to completing the study questionnaires, 17 (14.5%) were not eligible because of chronic cognitive impairment, 15 (12.8%) were discharged prior to being interviewed, 14 (12%) did not meet current alcohol dependence criteria (4 of whom met abuse criteria), and 1 (<1%) did not speak English. The remaining 50 subjects were included in this analysis. Characteristics of this group are listed in Table 1. They were primarily male, and socioeconomic status (assessed on the basis of education and health insurance) was low relative to the general population.17 Persons listed as having public insurance only were mainly covered by state Medicaid plans with or without Medicare. The less common diagnoses listed as other in Table 1, pertaining to no more than 2 patients, include arrhythmia, upper gastrointestinal bleeding, gout, electrolyte imbalance, hypoglycemia, diabetic ketoacidosis, diarrhea, stroke, and congestive heart failure. Measures of alcohol consumption were consistent with the clinical diagnosis of current alcohol dependence.

Of the components of the change process measured, the Recognition and Ambivalence subscales tended to have high scores. Thirty percent of subjects had the highest possible score on the Recognition scale, and 16% had the highest possible score on the Ambivalence scale. The scores for taking steps to change were more evenly distributed. A description of the study variables is included in Table 2.

The unadjusted correlations of alcohol problem recognition, ambivalence, and taking steps to change drinking with each perceived health status and alcohol‐consequence variable are shown in Table 3. Problem recognition was modestly and inversely associated with overall perception of physical health as measured by the SF‐12 but was not associated with perceived mental health. All the SIP subscales had strong univariate associations with problem recognition (P < .001 for each subscale). Problem recognition was associated with both percent drinking days (r = 0.39, P = .005) and average drinks per drinking day (r = 0.34, P = .0191). Adjustment for age, sex, and ethnicity did not modify the associations of recognition with perceived health and adverse consequences. Additional adjustment for percent drinking days eliminated the significant association with overall physical health from the SF‐12 (35% reduction in the regression coefficient, adjusted P = .100). A similar reduction in the association between problem recognition and overall physical health was observed for average drinks per drinking day (36% reduction in the regression coefficient, adjusted P = .102). All SIP subscales remained strongly associated with problem recognition despite the additional adjustment for alcohol consumption measures (all adjusted P values 0.001).

Ambivalence was associated with overall perception of physical health (P = .003) but not perceived mental health. All SIP subscales were associated with ambivalence (all P < .010). Alcohol consumption measures were not significantly associated with ambivalence (for percent drinking days, r = 0.25, P = .083; for average drinks per drinking day, r = 0.24, P = .106). Adjustment for age, sex, and ethnicity did not alter these findings.

Taking steps to change drinking behavior was not significantly associated with overall perceptions of physical and mental health. The physical (P = .002), interpersonal (P = .006), and intrapersonal (P = .034) SIP subscales were associated with taking steps to change. Alcohol consumption measures were not significantly associated with taking steps (percent drinking days, r = 0.19, P = .196; average drinks per drinking day, r = 0.24, P = .105). Adjustment for age, sex, and ethnicity, had minimal impact on the associations between taking steps and the physical, interpersonal, and intrapersonal SIP subscales.

DISCUSSION

This study evaluated the association of recognition of problem drinking, ambivalence about change, and taking steps to change with measures of perceived health status and alcohol‐related consequences. The results suggest that most medically hospitalized patients with clinically recognized alcohol dependence are highly cognizant of their drinking problem and wonder about the consequences of their drinking, and many feel they either have taken or will take steps to change their drinking behavior. Overall physical health perceptions during hospitalization were correlated with problem recognition (possibly mediated by heavy drinking) and ambivalence, but not with taking steps to change. Conversely, specific alcohol‐related physical and other consequences were often correlated with each process of change.

The SOCRATES results for this group were similar to those found in a large group of alcohol‐dependent persons participating in a large treatment trial.18 Relative to the distribution of SOCRATES scores in that group, 42% of this hospital sample would be above the median for recognition, 66% for ambivalence, and 44% for taking steps to change.19 This finding, coupled with the correlations of problem recognition and ambivalence (but not taking steps to change) with perceived physical health, suggests that medical hospitalization presents a unique opportunity for fostering change by moving ambivalent patients toward initiating change. However, additional research is needed to establish that these change processes during hospitalization predict participation after hospitalization in available treatment programs or other objective indicators of positive behavioral change.

Several limitations should be considered in interpreting our results. The participants represent clinically recognized and subsequently confirmed alcohol‐dependent patients. Results might differ for those initially detected by systematic screening, for example, by using a heavy‐drinking‐day item, as recommended by the NIH,20 or biomarkers.21 It is possible that such patients would have fewer apparent alcohol‐related consequences and may thus be less contemplative of change. In addition, our sample was recruited from a single hospital, and was primarily male and socioeconomically disadvantaged. Results may not generalize to other groups. Although we did not find any evidence that age, sex, and ethnicity altered the relationships examined in this work, the study was not adequately powered for firm conclusions about this. Finally, although the study demonstrated an association of perceived health status with readiness to change drinking, a causal relationship may not exist. Theoretically, poorer health would increase recognition, ambivalence, and intent to change, but close measurement of these variables over time would be required to establish this.

In conclusion, clinically recognized alcohol‐dependent patients with acute medical illness typically are highly cognizant of their drinking problems and often wish to change at the time of hospitalization. This is linked to perceptions of physical health and a variety of alcohol‐related consequences. The association of recognition, ambivalence, and intention to change at the time of hospitalization with postdischarge treatment participation and outcomes should be evaluated further. If these factors do predict such outcomes, intervention studies aimed at enhancing the process of change during hospitalization will be warranted.

Alcohol dependence is commonly associated with severe medical disease1 and is common among hospitalized medical patients. A nationally representative hospital sample found current alcohol use disorders to have a prevalence of 7.4%; most of those with these disorders were alcohol dependent.2 However, depending on the communities served by specific hospitals, prevalence can be much higher among medical inpatients,25 with studies finding problem drinking in as many as 28% of such patients. Although heavy drinking and the psychosocial problems that characterize alcohol dependence cause disease and interfere with disease management, remission is often difficult to achieve. As a result, although inpatient care of such patients probably does not differ from the average,6 this population is at high risk for poor health outcomes. as illustrated by factors such as suboptimal chronic disease management,7 preventable hospitalization,8 and increased mortality.9, 10 Remission involves a major behavior change that has been conceived of as a progression of stages, including precontemplation, contemplation, preparation, action, and maintenance.11 Clinically, this process encompasses an initial lack of awareness of the problem, followed by problem recognition and ambivalence about change, an increasing desire to change and concrete attempts at behavior change, and eventually long‐lasting behavioral improvements. The work described in this article was based on the broad hypothesis that acute illness and other alcohol‐related consequences will accelerate the process of change and that it might be possible to utilize this effect of acute illness to improve treatment outcomes for medically ill, alcohol‐dependent patients. If so, then measures of the change process should be correlated with measures of health status and alcohol consequences, correlations that were estimated in this study. If such measures are correlated and future research supports a causal relationship, then the link between illness and desire to change at the time of hospitalization could be exploited to help motivate changes in drinking and involvement in alcohol dependence treatment following hospital discharge.

METHODS

RESULTS

We identified 117 potential participants, accounting for 6% of total admissions (n = 1964) during the 7‐month recruitment period (late 2004 through mid‐2005). Of this total, 20 (17%) refused or withdrew prior to completing the study questionnaires, 17 (14.5%) were not eligible because of chronic cognitive impairment, 15 (12.8%) were discharged prior to being interviewed, 14 (12%) did not meet current alcohol dependence criteria (4 of whom met abuse criteria), and 1 (<1%) did not speak English. The remaining 50 subjects were included in this analysis. Characteristics of this group are listed in Table 1. They were primarily male, and socioeconomic status (assessed on the basis of education and health insurance) was low relative to the general population.17 Persons listed as having public insurance only were mainly covered by state Medicaid plans with or without Medicare. The less common diagnoses listed as other in Table 1, pertaining to no more than 2 patients, include arrhythmia, upper gastrointestinal bleeding, gout, electrolyte imbalance, hypoglycemia, diabetic ketoacidosis, diarrhea, stroke, and congestive heart failure. Measures of alcohol consumption were consistent with the clinical diagnosis of current alcohol dependence.

Of the components of the change process measured, the Recognition and Ambivalence subscales tended to have high scores. Thirty percent of subjects had the highest possible score on the Recognition scale, and 16% had the highest possible score on the Ambivalence scale. The scores for taking steps to change were more evenly distributed. A description of the study variables is included in Table 2.

The unadjusted correlations of alcohol problem recognition, ambivalence, and taking steps to change drinking with each perceived health status and alcohol‐consequence variable are shown in Table 3. Problem recognition was modestly and inversely associated with overall perception of physical health as measured by the SF‐12 but was not associated with perceived mental health. All the SIP subscales had strong univariate associations with problem recognition (P < .001 for each subscale). Problem recognition was associated with both percent drinking days (r = 0.39, P = .005) and average drinks per drinking day (r = 0.34, P = .0191). Adjustment for age, sex, and ethnicity did not modify the associations of recognition with perceived health and adverse consequences. Additional adjustment for percent drinking days eliminated the significant association with overall physical health from the SF‐12 (35% reduction in the regression coefficient, adjusted P = .100). A similar reduction in the association between problem recognition and overall physical health was observed for average drinks per drinking day (36% reduction in the regression coefficient, adjusted P = .102). All SIP subscales remained strongly associated with problem recognition despite the additional adjustment for alcohol consumption measures (all adjusted P values 0.001).

Ambivalence was associated with overall perception of physical health (P = .003) but not perceived mental health. All SIP subscales were associated with ambivalence (all P < .010). Alcohol consumption measures were not significantly associated with ambivalence (for percent drinking days, r = 0.25, P = .083; for average drinks per drinking day, r = 0.24, P = .106). Adjustment for age, sex, and ethnicity did not alter these findings.

Taking steps to change drinking behavior was not significantly associated with overall perceptions of physical and mental health. The physical (P = .002), interpersonal (P = .006), and intrapersonal (P = .034) SIP subscales were associated with taking steps to change. Alcohol consumption measures were not significantly associated with taking steps (percent drinking days, r = 0.19, P = .196; average drinks per drinking day, r = 0.24, P = .105). Adjustment for age, sex, and ethnicity, had minimal impact on the associations between taking steps and the physical, interpersonal, and intrapersonal SIP subscales.

DISCUSSION

This study evaluated the association of recognition of problem drinking, ambivalence about change, and taking steps to change with measures of perceived health status and alcohol‐related consequences. The results suggest that most medically hospitalized patients with clinically recognized alcohol dependence are highly cognizant of their drinking problem and wonder about the consequences of their drinking, and many feel they either have taken or will take steps to change their drinking behavior. Overall physical health perceptions during hospitalization were correlated with problem recognition (possibly mediated by heavy drinking) and ambivalence, but not with taking steps to change. Conversely, specific alcohol‐related physical and other consequences were often correlated with each process of change.

The SOCRATES results for this group were similar to those found in a large group of alcohol‐dependent persons participating in a large treatment trial.18 Relative to the distribution of SOCRATES scores in that group, 42% of this hospital sample would be above the median for recognition, 66% for ambivalence, and 44% for taking steps to change.19 This finding, coupled with the correlations of problem recognition and ambivalence (but not taking steps to change) with perceived physical health, suggests that medical hospitalization presents a unique opportunity for fostering change by moving ambivalent patients toward initiating change. However, additional research is needed to establish that these change processes during hospitalization predict participation after hospitalization in available treatment programs or other objective indicators of positive behavioral change.

Several limitations should be considered in interpreting our results. The participants represent clinically recognized and subsequently confirmed alcohol‐dependent patients. Results might differ for those initially detected by systematic screening, for example, by using a heavy‐drinking‐day item, as recommended by the NIH,20 or biomarkers.21 It is possible that such patients would have fewer apparent alcohol‐related consequences and may thus be less contemplative of change. In addition, our sample was recruited from a single hospital, and was primarily male and socioeconomically disadvantaged. Results may not generalize to other groups. Although we did not find any evidence that age, sex, and ethnicity altered the relationships examined in this work, the study was not adequately powered for firm conclusions about this. Finally, although the study demonstrated an association of perceived health status with readiness to change drinking, a causal relationship may not exist. Theoretically, poorer health would increase recognition, ambivalence, and intent to change, but close measurement of these variables over time would be required to establish this.

In conclusion, clinically recognized alcohol‐dependent patients with acute medical illness typically are highly cognizant of their drinking problems and often wish to change at the time of hospitalization. This is linked to perceptions of physical health and a variety of alcohol‐related consequences. The association of recognition, ambivalence, and intention to change at the time of hospitalization with postdischarge treatment participation and outcomes should be evaluated further. If these factors do predict such outcomes, intervention studies aimed at enhancing the process of change during hospitalization will be warranted.

Alcohol dependence is commonly associated with severe medical disease1 and is common among hospitalized medical patients. A nationally representative hospital sample found current alcohol use disorders to have a prevalence of 7.4%; most of those with these disorders were alcohol dependent.2 However, depending on the communities served by specific hospitals, prevalence can be much higher among medical inpatients,25 with studies finding problem drinking in as many as 28% of such patients. Although heavy drinking and the psychosocial problems that characterize alcohol dependence cause disease and interfere with disease management, remission is often difficult to achieve. As a result, although inpatient care of such patients probably does not differ from the average,6 this population is at high risk for poor health outcomes. as illustrated by factors such as suboptimal chronic disease management,7 preventable hospitalization,8 and increased mortality.9, 10 Remission involves a major behavior change that has been conceived of as a progression of stages, including precontemplation, contemplation, preparation, action, and maintenance.11 Clinically, this process encompasses an initial lack of awareness of the problem, followed by problem recognition and ambivalence about change, an increasing desire to change and concrete attempts at behavior change, and eventually long‐lasting behavioral improvements. The work described in this article was based on the broad hypothesis that acute illness and other alcohol‐related consequences will accelerate the process of change and that it might be possible to utilize this effect of acute illness to improve treatment outcomes for medically ill, alcohol‐dependent patients. If so, then measures of the change process should be correlated with measures of health status and alcohol consequences, correlations that were estimated in this study. If such measures are correlated and future research supports a causal relationship, then the link between illness and desire to change at the time of hospitalization could be exploited to help motivate changes in drinking and involvement in alcohol dependence treatment following hospital discharge.

METHODS

RESULTS

We identified 117 potential participants, accounting for 6% of total admissions (n = 1964) during the 7‐month recruitment period (late 2004 through mid‐2005). Of this total, 20 (17%) refused or withdrew prior to completing the study questionnaires, 17 (14.5%) were not eligible because of chronic cognitive impairment, 15 (12.8%) were discharged prior to being interviewed, 14 (12%) did not meet current alcohol dependence criteria (4 of whom met abuse criteria), and 1 (<1%) did not speak English. The remaining 50 subjects were included in this analysis. Characteristics of this group are listed in Table 1. They were primarily male, and socioeconomic status (assessed on the basis of education and health insurance) was low relative to the general population.17 Persons listed as having public insurance only were mainly covered by state Medicaid plans with or without Medicare. The less common diagnoses listed as other in Table 1, pertaining to no more than 2 patients, include arrhythmia, upper gastrointestinal bleeding, gout, electrolyte imbalance, hypoglycemia, diabetic ketoacidosis, diarrhea, stroke, and congestive heart failure. Measures of alcohol consumption were consistent with the clinical diagnosis of current alcohol dependence.

Of the components of the change process measured, the Recognition and Ambivalence subscales tended to have high scores. Thirty percent of subjects had the highest possible score on the Recognition scale, and 16% had the highest possible score on the Ambivalence scale. The scores for taking steps to change were more evenly distributed. A description of the study variables is included in Table 2.

The unadjusted correlations of alcohol problem recognition, ambivalence, and taking steps to change drinking with each perceived health status and alcohol‐consequence variable are shown in Table 3. Problem recognition was modestly and inversely associated with overall perception of physical health as measured by the SF‐12 but was not associated with perceived mental health. All the SIP subscales had strong univariate associations with problem recognition (P < .001 for each subscale). Problem recognition was associated with both percent drinking days (r = 0.39, P = .005) and average drinks per drinking day (r = 0.34, P = .0191). Adjustment for age, sex, and ethnicity did not modify the associations of recognition with perceived health and adverse consequences. Additional adjustment for percent drinking days eliminated the significant association with overall physical health from the SF‐12 (35% reduction in the regression coefficient, adjusted P = .100). A similar reduction in the association between problem recognition and overall physical health was observed for average drinks per drinking day (36% reduction in the regression coefficient, adjusted P = .102). All SIP subscales remained strongly associated with problem recognition despite the additional adjustment for alcohol consumption measures (all adjusted P values 0.001).

Ambivalence was associated with overall perception of physical health (P = .003) but not perceived mental health. All SIP subscales were associated with ambivalence (all P < .010). Alcohol consumption measures were not significantly associated with ambivalence (for percent drinking days, r = 0.25, P = .083; for average drinks per drinking day, r = 0.24, P = .106). Adjustment for age, sex, and ethnicity did not alter these findings.

Taking steps to change drinking behavior was not significantly associated with overall perceptions of physical and mental health. The physical (P = .002), interpersonal (P = .006), and intrapersonal (P = .034) SIP subscales were associated with taking steps to change. Alcohol consumption measures were not significantly associated with taking steps (percent drinking days, r = 0.19, P = .196; average drinks per drinking day, r = 0.24, P = .105). Adjustment for age, sex, and ethnicity, had minimal impact on the associations between taking steps and the physical, interpersonal, and intrapersonal SIP subscales.

DISCUSSION

This study evaluated the association of recognition of problem drinking, ambivalence about change, and taking steps to change with measures of perceived health status and alcohol‐related consequences. The results suggest that most medically hospitalized patients with clinically recognized alcohol dependence are highly cognizant of their drinking problem and wonder about the consequences of their drinking, and many feel they either have taken or will take steps to change their drinking behavior. Overall physical health perceptions during hospitalization were correlated with problem recognition (possibly mediated by heavy drinking) and ambivalence, but not with taking steps to change. Conversely, specific alcohol‐related physical and other consequences were often correlated with each process of change.

The SOCRATES results for this group were similar to those found in a large group of alcohol‐dependent persons participating in a large treatment trial.18 Relative to the distribution of SOCRATES scores in that group, 42% of this hospital sample would be above the median for recognition, 66% for ambivalence, and 44% for taking steps to change.19 This finding, coupled with the correlations of problem recognition and ambivalence (but not taking steps to change) with perceived physical health, suggests that medical hospitalization presents a unique opportunity for fostering change by moving ambivalent patients toward initiating change. However, additional research is needed to establish that these change processes during hospitalization predict participation after hospitalization in available treatment programs or other objective indicators of positive behavioral change.

Several limitations should be considered in interpreting our results. The participants represent clinically recognized and subsequently confirmed alcohol‐dependent patients. Results might differ for those initially detected by systematic screening, for example, by using a heavy‐drinking‐day item, as recommended by the NIH,20 or biomarkers.21 It is possible that such patients would have fewer apparent alcohol‐related consequences and may thus be less contemplative of change. In addition, our sample was recruited from a single hospital, and was primarily male and socioeconomically disadvantaged. Results may not generalize to other groups. Although we did not find any evidence that age, sex, and ethnicity altered the relationships examined in this work, the study was not adequately powered for firm conclusions about this. Finally, although the study demonstrated an association of perceived health status with readiness to change drinking, a causal relationship may not exist. Theoretically, poorer health would increase recognition, ambivalence, and intent to change, but close measurement of these variables over time would be required to establish this.

In conclusion, clinically recognized alcohol‐dependent patients with acute medical illness typically are highly cognizant of their drinking problems and often wish to change at the time of hospitalization. This is linked to perceptions of physical health and a variety of alcohol‐related consequences. The association of recognition, ambivalence, and intention to change at the time of hospitalization with postdischarge treatment participation and outcomes should be evaluated further. If these factors do predict such outcomes, intervention studies aimed at enhancing the process of change during hospitalization will be warranted.