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Prospective study of alcolism treatment. Eight year follow up
LE-I-CERS TO THE EDITOR
PROSPECTIVE STUDY OF ALCOHOLISM TREATMENT. EIGHT-YEAR FOLLOW-UP
To the Editor: I read with interest the article on alcoholism treatment by Vaillant et al (Am J Med 1983; 75: 455-463). I believe the study is a major contribution in providing systematic follow-up on a group of patients, who in most clinical studies would be regarded as poor risks for successful outcome. Dr. Vaillant and his colleagues are to be congratulated on their high follow-up rate as well as on the overall thoroughness of the study. I have one objection, however, and it is the title of the article, which suggests that this is a follow-up study regarding treatment. As is noted in the article, in fact, the hospital provided very little treatment except for detoxification and some counseling over a period of one to nine days. Vaillant et al credit the abstinence that their patients did achieve to attendance at Alcoholics Anonymous. What seems to be ignored, however, is that with this “treatment” approximately 25 percent of the patients were dead at the end of 10 years, and 35 percent still dependent on alcohol. Although all persons in the field would agree that these subjects would have low recovery rates in any treatment program, I believe it is a mistake to describe inpatient hospitalizations as treatment when it includes primarily detoxification and a mistake to describe as a good outcome a therapeutic regimen that has a 25 percent death rate at the end of 10 years. Perhaps a more appropriate title for this study would be “Prospective Study of Alcoholism Outcomes in Patients with Poor Prognosis Receiving Only Inpatient Detoxification.” P. JOSEPHFRAWLEY, M.D. Medical Director Schick Shade1 Hospital Santa Barbara, California 93105
The Reply: I appreciate Dr. Frawley’s letter. From reading it, however, I get the impression that, like most physicians, he does not fully appreciate how serious a disease alcoholism is. The most likely reason is that he is unfamiliar with the rather scanty, long-term follow up literature. He expresses surprise at an eight-year death rate of 25 percent. Does he know that 15 percent of the Rand Report patients were dead at four years? I suspect that he might find it helpful to look at the long-term studies summarized on page 124 of my book, The Natural History ofAlcoholism [ 11. There he would find that death rates of the magnitude that surprises him are the rule and not the exception, even in patients with a good prognosis. He would also find that at
the ten-year mark, only 22 percent of the located, surviving patients who had been hospitalized at the original Shade1 Hospital in the late 1930s continued to enjoy sobriety [2]. Presumably, he would have regarded the original patients of Dr. Shade1 as representing a good prognosis group. Everyone in the alcoholism field has much to learn from sustained follow-up of the patients with whom they work. GEORGEE. VAILLANT, M.D. Raymond Sobel Professor of Psychiatry Dartmouth Medical School Hanover, New Hampshire 03756 1. Vaillant GE:The natural history of alcoholism. Cambridge, Mary2.
land: Harvard University Press, 1983. Voegtlin WL, Broz WR: The conditioned reflex treatment of chronic alcoholism. X: An analysis of 3125 admissions over a period of ten and a half years. Ann Intern Med 1949; 30: 580-597.
DISPARATE CARDIOVASCULAR EFFECTS OF OBESITY AND ARTERIAL HYPERTENSION
To the Editor: I found the study by Messerli et al (Am J Med 1983; 74: 808-8 12) extremely interesting and meticulously conducted. I would like to make one further comment on their data. The documentation of decreased total peripheral resistance in obese persons is satisfying, but expected. Obesity entails an increase in the vasculature, which increases the cross-sectional area of the circulation (since smaller vessels are arranged in parallel); thus, as predicted by Bernoulli’s questions, decreased pressure would be expected or, more specifically in this case, decreased total peripheral resistance. This alone could account for the lower total peripheral resistance seen when obese hypertensive subjects are compared with lean hypertensive subjects, and possibly also when obese hypertensive subjects are compared with lean normotensive subjects. However, when obese hypertensive subjects are compared with their own control group-obese normotensive subjects-they exhibit a highly significant (p
A85
PROSPECTIVE STUDY OF ALCOHOLISM TREATMENT. EIGHT-YEAR FOLLOW-UP
To the Editor: I read with interest the article on alcoholism treatment by Vaillant et al (Am J Med 1983; 75: 455-463). I believe the study is a major contribution in providing systematic follow-up on a group of patients, who in most clinical studies would be regarded as poor risks for successful outcome. Dr. Vaillant and his colleagues are to be congratulated on their high follow-up rate as well as on the overall thoroughness of the study. I have one objection, however, and it is the title of the article, which suggests that this is a follow-up study regarding treatment. As is noted in the article, in fact, the hospital provided very little treatment except for detoxification and some counseling over a period of one to nine days. Vaillant et al credit the abstinence that their patients did achieve to attendance at Alcoholics Anonymous. What seems to be ignored, however, is that with this “treatment” approximately 25 percent of the patients were dead at the end of 10 years, and 35 percent still dependent on alcohol. Although all persons in the field would agree that these subjects would have low recovery rates in any treatment program, I believe it is a mistake to describe inpatient hospitalizations as treatment when it includes primarily detoxification and a mistake to describe as a good outcome a therapeutic regimen that has a 25 percent death rate at the end of 10 years. Perhaps a more appropriate title for this study would be “Prospective Study of Alcoholism Outcomes in Patients with Poor Prognosis Receiving Only Inpatient Detoxification.” P. JOSEPHFRAWLEY, M.D. Medical Director Schick Shade1 Hospital Santa Barbara, California 93105
The Reply: I appreciate Dr. Frawley’s letter. From reading it, however, I get the impression that, like most physicians, he does not fully appreciate how serious a disease alcoholism is. The most likely reason is that he is unfamiliar with the rather scanty, long-term follow up literature. He expresses surprise at an eight-year death rate of 25 percent. Does he know that 15 percent of the Rand Report patients were dead at four years? I suspect that he might find it helpful to look at the long-term studies summarized on page 124 of my book, The Natural History ofAlcoholism [ 11. There he would find that death rates of the magnitude that surprises him are the rule and not the exception, even in patients with a good prognosis. He would also find that at
the ten-year mark, only 22 percent of the located, surviving patients who had been hospitalized at the original Shade1 Hospital in the late 1930s continued to enjoy sobriety [2]. Presumably, he would have regarded the original patients of Dr. Shade1 as representing a good prognosis group. Everyone in the alcoholism field has much to learn from sustained follow-up of the patients with whom they work. GEORGEE. VAILLANT, M.D. Raymond Sobel Professor of Psychiatry Dartmouth Medical School Hanover, New Hampshire 03756 1. Vaillant GE:The natural history of alcoholism. Cambridge, Mary2.
land: Harvard University Press, 1983. Voegtlin WL, Broz WR: The conditioned reflex treatment of chronic alcoholism. X: An analysis of 3125 admissions over a period of ten and a half years. Ann Intern Med 1949; 30: 580-597.
DISPARATE CARDIOVASCULAR EFFECTS OF OBESITY AND ARTERIAL HYPERTENSION
To the Editor: I found the study by Messerli et al (Am J Med 1983; 74: 808-8 12) extremely interesting and meticulously conducted. I would like to make one further comment on their data. The documentation of decreased total peripheral resistance in obese persons is satisfying, but expected. Obesity entails an increase in the vasculature, which increases the cross-sectional area of the circulation (since smaller vessels are arranged in parallel); thus, as predicted by Bernoulli’s questions, decreased pressure would be expected or, more specifically in this case, decreased total peripheral resistance. This alone could account for the lower total peripheral resistance seen when obese hypertensive subjects are compared with lean hypertensive subjects, and possibly also when obese hypertensive subjects are compared with lean normotensive subjects. However, when obese hypertensive subjects are compared with their own control group-obese normotensive subjects-they exhibit a highly significant (p
A85