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BACKGROUND: Physicians in the general medical setting commonly encounter but rarely counsel patients with dependent or harmful drinking behaviors. We tested whether providing physicians with their patients' results on the alcohol module of the Diagnostic Interview Schedule and counseling directives would prompt them to counsel these patients. METHODS: We randomly assigned 83 first-, second-, and third-year medical residents to receive or not to receive diagnostic information and counseling directives on 214 patients who reported at least one symptom of alcohol impairment as defined in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition. Using binary logistic regression, we examined the effect of specific covariables on rates of physician counseling. These variables included physician information status, patient gender, and drinking disorder severity and recency. We also examined the effect of physician prompting on counseling of female patients, patients with inactive disorders, and nondependent but harmful drinkers. We determined counseling by post-visit patient interviews. RESULTS: Physician prompting, dependent drinking, and recent disorder activity were significant correlates of physician counseling (P < .05), while male gender was a marginally significant correlate (P = .08). Informed physicians counseled female patients, harmful but nondependent drinkers, and patients with inactive disorders more often than their uninformed colleagues, although only the last variable achieved statistical significance. CONCLUSIONS: Providing physicians with the results of the Diagnostic Interview Schedule and counseling directives resulted in short-term improvement in their rates of counseling patients with a history of dependent or nondependent but harmful drinking. Further research is necessary to determine long-term gains in rates of physician counseling and improvements in the course of these patients.

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OBJECTIVE: To assess the patient and physician characteristics that influence physicians' detection of problem drinking in their medical patients. SETTING: The outpatient medical clinic at an urban university teaching hospital staffed by interns and residents. DESIGN: Cross-sectional study of a randomly chosen subsample of consecutive patients. MEASUREMENT: Univariate and multivariate analysis with calculated adjusted odds ratios of factors associated with physician detection of drinking problems. A problem was diagnosed according to the patient's results on the alcohol module of the Diagnostic Interview Schedule (DIS). RESULTS: Physicians detected 22% of 189 presumably inactive problems and 49% of 92 current problems, i.e., those that have occurred within the preceding year. Multivariate correlates of detection of active problems included male patient gender, presence of gastrointestinal complications of excessive drinking, number of concurrent medical disorders, and previous medical record reference to alcohol (p less than 0.05). Physician gender and year of training were not associated with detection. CONCLUSION: Our physicians appear to rely on specific patient characteristics as well as the patient's medical record to detect drinking problems in their ambulatory patients. Their reliance upon these factors may hinder their detection of drinking problems in women patients and less seriously impaired individuals.

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OBJECTIVE: To assess the performance of the CAGE (acronym referring to four questions, see below) questionnaire in discriminating between medicine outpatients with and without an alcohol abuse or dependence disorder. DESIGN: A cross-sectional design of a sample of consecutive patients who received both the alcohol module of the diagnostic interview schedule and the CAGE (Cut down, Annoyed, Guilty, Eye-opener) screening questionnaire. SETTING: The outpatient medical practice of an urban university teaching hospital. PATIENTS: All patients 18 years or older who signed a consent form approved by the university's institutional review board. MEASUREMENT: Calculation of the sensitivity, specificity, receiver operating characteristic (ROC) curve, and likelihood ratio for CAGE scores of 0 to 4. RESULTS: Thirty-six percent of the sample group met criteria for a history of alcohol abuse or dependence. A CAGE score of 2 or more was associated with a sensitivity and specificity of 74% and 91%. The calculated area under the ROC curve was 0.89, whereas the likelihood ratios for CAGE scores of 0 to 4 were 0.14, 1.5, 4.5, 13, and 100, respectively. These ratios were associated with posterior probabilities for an abuse or dependence disorder of 7%, 46%, 72%, 88%, and 98%, respectively. CONCLUSION: Clinicians can improve their ability to estimate a patient's risk for an alcohol abuse or dependence disorder using likelihood ratios for CAGE scores.

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Over a one-year period the authors administered the Diagnostic Interview Schedule to 459 randomly selected patients attending an urban general medicine practice. Alcohol abuse and alcohol dependence disorders were diagnosed as current in 12% of the patients, while 19% of the patients met criteria for a past disorder. In addition, 11% and 3%, respectively, reported a history of previous or current heavy consumption. The lifetime prevalence of alcohol consumption disorders is significantly higher in males than females, while current disorders are significantly more common in younger than older individuals. Based upon the number of reported symptoms, patients reporting current disorders appear to have a more serious form of disease than patients reporting a past disorder. We conclude that disorders of alcohol consumption are common in our medical practice. Moreover, our findings suggest that many patients do recover from alcohol consumption disorders (i.e. are currently symptom-free by self-report) and disease severity may be an important factor in this process.

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