Predictors for Abstinence in Socially Stable Women Receiving Treatment for Alcohol Use Disorder

ABSTRACT

There is a knowledge gap about predictors of treatment outcomes in alcohol use disorder (AUD) in socially stable women. This study examined factors that may predict abstinence 12 months after the end of treatment for AUD in socially stable women. Fifty-seven women with AUD participated in 12-month follow-up. Information about sociodemographic, alcohol-related, psychiatric symptoms, psychological functioning, and participants’ treatment goals and ability to change alcohol habits were gathered from structured interviews and self-report instruments. Predictors for abstinence at the 12-month follow up were calculated by univariable and multivariable logistic regression models. Significant predictors for abstinence were having no history of childhood abuse (OR: 8.13; 95%CI: 2.22–29.75; p < .01) and a goal of abstinence at the end of treatment (OR: 15.17; 95%CI: 3.45–66.69; p < .001). Most participants (>60%) achieved their goals of abstinence or low-risk drinking. The results highlight the significance of identifying patients with experiences of childhood abuse, since such experiences may adversely affect the outcome of AUD treatment. Our findings also emphasize the importance of patients’ own goals of abstinence, since it resulted in the most stable outcome. Treatment could, therefore, also focus on motivating individuals to aim for abstinence.

KEYWORDS:

• Alcohol use disorder
• treatment
• 12-months follow up
• childhood abuse
• goal of abstinence
• well-adjusted women

Introduction

The aim of this explorative study was to identify relevant predictors for abstinence in a group of socially stable and well-educated women with high rates of partnership and employment receiving treatment for alcohol use disorder (AUD). Prediction of treatment outcomes may help to identify patients with specific needs and to clarify which areas treatment for AUD should focus on. It may also improve the quality of information provided to the patient during treatment, and result in a more adapted treatment planning (Adamson, Sellman, & Frampton, 2009).

Many different possible predictors have been studied in the area of treatment-related outcomes for AUD. Previous studies have focused on the predictive effects of sociodemographic factors, mental health factors, alcohol-related factors, and childhood abuse factors in abstinence in people with AUD (Adamson et al., 2009; Greenfield et al., 2007; Mann, Aubin, & Witkiewitz, 2017). Sociodemographic conditions that have been shown to predict better alcohol treatment outcomes include higher education and employment, higher socioeconomic status, and religion (Adamson et al., 2009; Durazzo & Meyerhoff, 2017). Conversely, one multicenter study found that having a higher educational level predicted worse outcomes (Haug & Schaub, 2016). Older age and ongoing employment have also been shown to be associated with better treatment retention and completion (Greenfield et al., 2007).

Outcomes in women are more likely to be predicted by social, sociodemographic, and life history characteristics than in men (Green, Polen, Lynch, Dickinson, & Bennett, 2004). Having a higher education level or being employed meant a worse treatment outcome in AUD for women than for men (Blendberg, Àrnadóttir, Tarp, & Bilberg, 2020). Women also appear to be more vulnerable to marital-related issues than men, in that they are more likely to report marital stress as a cause of relapse in drinking alcohol (Walitzer & Dearing, 2006).

The most consistent mental health predictors for drinking-related outcomes have been reported to be psychopathology and neuropsychological functioning (Adamson et al., 2009). Most studies have shown that comorbid psychiatric disorders have a negative impact on treatment outcome in individuals with AUD (Adamson et al., 2009; Greenfield et al., 2007; Walitzer & Dearing, 2006), and that depressive symptoms or a diagnosis of depression are associated with an increased rate of relapse (Durazzo & Meyerhoff, 2017; Walitzer & Dearing, 2006). By contrast, one study found no effect of comorbid depression and anxiety on drinking outcomes (Mellentin, Nielsen, Stenager, & Nielsen, 2015), while another study found that women with comorbid mood and anxiety disorders had significantly lower relapse rates one year after inpatient treatment than non-comorbid women, while there were no significant differences concerning relapse rates among the men (Mann, Hintz, & Jung, 2004).

Previous studies have found that other alcohol-related variables, such as dependence severity, treatment history, and alcohol-related self-efficacy, are important predictors of treatment outcomes (Adamson et al., 2009). A more favorable outcome has been found in patients with AUD undergoing a first treatment episode (Haug & Schaub, 2016) and in patients with AUD in which lower-risk drinking levels were achieved during ongoing treatment (Witkiewitz et al., 2017). Predictors at the end of treatment have been found to have a higher predictive value than pretreatment predictors, including both drinking (Flórez et al., 2015; Gueorguieva, Wu, Fucito, & O’Malley, 2015) and motivation measures (Heather & McCambridge, 2013), in treatment outcomes at a one-year follow-up. A positive change in non-consumption outcomes (e.g., craving, temptation, self-efficacy, and alcohol-related consequences) during treatment has also been shown to predict a better 12-month drinking outcome (Kirouac & Witkiewitz, 2019).

Individuals with AUD whose treatment goal is abstinence have better drinking-related outcomes than those who have reduced drinking as a treatment goal (Berger, Brondino, Fisher, Gwyther, & Garbutt, 2016; Mann et al., 2017; Meyer, Wapp, Strik, & Moggi, 2014). Patients with abstinence as a goal at treatment entry have been reported to show more favorable outcomes at the end of treatment (Berger et al., 2016), 12 months after treatment (Adamson, Heather, Morton, & Raistrick, 2010), and up to five years after treatment (Berglund, Rauwolf, Berggren, Balldin, & Fahlke, 2019) than those who had non-abstinence as a goal. Having abstinence as a goal at discharge has been found to have a better predictive value for 12-month outcomes than having abstinence as a goal at admission (Heather & McCambridge, 2013; Meyer et al., 2014).

Less attention has been paid to the role of childhood abuse (emotional, physical, and sexual) as a possible predictor for AUD treatment outcomes. Greenfield et al. found an association between childhood sexual abuse and time to relapse in a mixed inpatient group with AUD. This association disappeared when adjustments were made for other variables, such as sociodemographic factors and comorbid psychiatric disorders (Greenfield et al., 2002). Further, Sugarman et al. found no association between sexual abuse and drinking outcomes in a mixed patient group 12 months after inpatient alcohol treatment, but participants who had been abused exhibited lower levels of functioning compared with non-abused participants (Sugarman, Kaufman, Trucco, Brown, & Greenfield, 2014). By contrast, childhood abuse (sexual, physical and emotional) has been shown to affect drinking-related outcomes in women with AUD, where non-abused women showed better drinking-related outcomes, including a higher proportion of reported abstinence, compared with women who had been abused (Schückher, Sellin, Engström, & Berglund, 2019).

Previous studies that have focused on identifying predictors of AUD treatment outcomes have included groups with a mixed sex, a mix of both alcohol and drug abuse, and/or a mix of both inpatient/outpatient participants. Few studies have focused on socially stable women seeking outpatient treatment for AUD. To address this gap in the literature, the aim of this study was to examine predictors that may affect abstinence at 12-month follow-up in socially stable women receiving treatment for AUD. Given that abstinence from alcohol is the safest option for individuals with AUD, the outcome was abstinence at a 12-month follow-up (Berglund et al., 2019; Mann et al., 2017; Meyer et al., 2014).

Materials and methods

This study is a part of the Kajsa Project, a longitudinal study that started in April 2012 and continued until September 2017. Details of the materials and methods have been published elsewhere (Schückher et al., 2019; Schuckher, Sellin, Fahlke, & Engstrom, 2018). The Kajsa Center, located in central Sweden, offers to county residents a voluntary outpatient treatment for women with AUD who are 25 years and older. It focuses on socially well-adjusted women without excessive social and/or psychiatric burdens.

Participants

The present study included women with a diagnosis of alcohol abuse or dependence according to the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV) (American Psychiatric Association, 1994). Exclusion criteria were ongoing illicit substance abuse or dependence. The project was approved by the Regional Ethical Review Board of Uppsala, Sweden (Dnr 2012/020). All participants provided written informed consent prior to inclusion.

Participants were recruited between April 2012 and June 2015. During this period, 149 participants fulfilled the study inclusion criteria. However, 59 women declined to participate, five women dropped out of treatment before data collection began, six women were not invited due to an administrative error, and four women did not complete the study questionnaires. The group thus consisted of 75 participants, of which 59 (79%) completed the measures at the end of treatment and 57 (76%) at 12-month follow-up. Given that this study focused on results at the 12-month follow-up, the study included 57 participants (alcohol dependence, n = 54; alcohol abuse, n = 3).

There were no significant differences in sociodemographic factors, psychiatric symptoms, or alcohol-related variables between participants who did and who did not complete the 12-month follow-up. There were also no significant differences in parental alcohol/substance problems or history of childhood abuse (data not shown). For participants who completed the 12-month follow-up, the mean treatment duration was 11.0 months (SD: 8.2 months; range: 1–36 months).

AUD treatment program

All participants received treatment combining medical, psychological, and social support at the Kajsa Center (Schückher et al., 2019). Each participant decided whether the initial treatment goal was to reduce drinking to a low-risk level (≤108 g of pure alcohol per week) or abstinence. If a participant found it difficult to maintain a low-risk drinking profile, a period of abstinence was recommended. After a period, participants who achieved stable abstinence could choose between maintaining abstinence or trying to consume alcohol at a low-risk level.

Interview instruments

Participants completed the Addiction Severity Index (ASI) and the mini international neuropsychiatric interview (MINI) in interviews that were conducted at the beginning of treatment, the end of treatment, and 12 months after treatment.

The ASI covers information relevant for participants with substance use problems and is considered to have a good reliability and validity (Makela, 2004; McLellan et al., 1992; Nyström, Zingmark, & Jäderland, 2009). For this study, we collected data on the years of education, employment status, marital status, psychiatric symptoms, and parental alcohol/substance problems. To further examine the influence of parental substance use problems, we included an extra question about whether the participant’s parents had experienced problems with prescribed drugs (response: yes or no). We also included a question on the participants’ drinking goal at the start of treatment, end of treatment, and 12-month follow-up (response: abstinence or no abstinence). At the end of treatment and at the 12-month follow-up, we also included a question on whether participants felt they had changed their alcohol habits (response: “no/somewhat” = 0, or “to a large extent” = 1).

For this study, AUD and substance use disorder were assessed using the MINI, which is a diagnostic instrument based on the DSM-IV and has been found to have good psychometric properties (Lecrubier et al., 1997; Sheehan et al., 1997). The onset age of AUD was defined as the age at which participants first fulfilled the DSM-IV criteria for AUD according to both a self-report and hospital records.

Self-reported instruments

Participants completed Childhood Trauma Questionnaire – Short Form (CTQ-SF) (Bernstein & Fink, 2011) at the beginning of treatment. This instrument measures the following five forms of childhood trauma: emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect. The CTQ-SF is considered to have good validity and reliability (Bernstein & Fink, 2011; Gerdner & Allgulander, 2009). The CTQ-SF items are scored on a 5-point Likert scale, whereby higher scores indicate a greater severity for each type of abuse. For each subscale the resulting score also can be used to categorize participants as having a history of abuse or not, as described elsewhere (Schuckher et al., 2018). In this study, participants were defined as having either a history of childhood abuse (emotional, physical, and/or sexual) or as having experienced no abuse.

The Alcohol Habits Inventory – Revised 2 (AVI-R-2) was used to measure alcohol consumption at the beginning of treatment, end of treatment, and 12-month follow-up (Bergman, Wennberg, Hammarberg, & Hubicka, 2018; Wennberg, Bergman, & Berglund, 2014). This instrument measures high alcohol consumption using the same questions as the Alcohol Use Disorders Identification Test (AUDIT) (Babor, Higgins-Biddle, Saunders, & Monteiro, 2001). Weekly alcohol consumption was measured using two questions concerning the frequency and amount of alcohol intake, as described elsewhere (Schückher et al., 2019). Risk drinking is defined as > 108 g of pure alcohol per week for women (Andréasson & Allebeck, 2005). Abstinence was defined as consuming no alcohol at all.

The Outcome Questionnaire (OQ-45.2) was implemented at the beginning of treatment, end of treatment, and 12-month follow-up. It measures psychological functioning using questions concerning symptomatic distress, interpersonal functioning, and social role performance, and is constructed for repeated measurements throughout a course of treatment and termination. The OQ-45.2 comprises 45 statements that are scored on a 5-point Likert scale, ranging from 0 (never true) to 4 (very often true). Nine statements have a reverse scoring. The total score can range from 0 to 180, whereby a higher score indicates more distress experienced by the participant. Furthermore, a score of 63 or more indicates clinically significant symptoms; scores below 63 indicate symptoms of no clinical significance. The OQ-45.2 total score has been shown to have good psychometric properties, with a Cronbach’s alpha of 0.93 and a three-week test-retest reliability of 0.84 (Lambert et al., 1996). The OQ-45.2 questionnaire has been translated and validated for use in addiction clinics in Sweden (Wennberg, Philips, & de Jong, 2010).

Statistical analysis

For descriptive statistics continuous variables are described using the mean, SD, median, minimum, and maximum, and categorical variables are presented as numbers and percentages. For between-group comparisons, Fisher’s exact test were used for dichotomous variables, and the Mantel–Haenszel chi-squared test for ordered categorical variables. To identify predictors of abstinence at the 12-month follow-up, univariable and multivariable logistic regression models were used. First a univariable logistic regression analysis was performed for each independent variable to predict the outcome. The results of these analyses are presented as the odds ratio (OR) with 95% confidence intervals (CIs) and p-values. Significance level were set at 0.05 in all analyses, except for in univariable logistic regression analysis, where we adjusted the significance level to 0.01 due to the risk of type I errors when making multiple comparisons.

To identify independent predictors for abstinence at the 12-month follow-up, variables with a p-value ≤ 0.10 in the univariable analysis were entered into a forward stepwise regression model (Altman, 1991), first with only variables from the beginning of treatment, and thereafter with variables both from the start and end of treatment. The latter analysis was performed to examine whether factors that change during treatment can predict abstinence. The area under the ROC curve (AUC statistic) was calculated for description of goodness of predictors. An AUC of 0.7–0.8 indicates acceptable, and 0.8–0.9 indicates excellent goodness (Hosmer & Lemeshow, 2000).

Power was estimated by assuming that the dichotomous predictor of childhood abuse is allocated at a 1:1 ratio in the population. Assuming that 20% of the group with childhood abuse and 56% of the group without childhood abuse achieve abstinence at the 12-month follow-up, a total of 56 subjects would be needed to obtain 80% power with a two-sided chi-squared test at a significance level of p ≤ .05.

Results

Background variables

The mean onset age of AUD in this sample was 43.5 years, with a range of 14–70 years. Descriptive data are presented in Tables 1 and 2.

Table 1. Univariable logistic regression analyses using sociodemographic, parental alcohol/substance problems, history of childhood abuse, experiences, psychopathological and psychologic functioning variables predicting abstinence at 12-month followp

	Total sample n = 57	Subgroups	Numbers and percentage of abstinence	OR (95%CI) Abstinence at the 12-month follow-up	p-value
Age at treatment start (years) OR per five years	51.1 (SD: 11.5)	≤50 years >50 years	12 (44.4%) 7 (23.3%)	0.85 (0.66–1.09)	0.19
Cohabitant n (% yes)	31 (54.4%)	Cohabitant Not cohabitant	12 (38.7%) 7 (26.9%)	1.71 (0.56–5.30)	0.35
School education (years)	12.3 (SD: 2.6)	≤ 9 years > 9	3 (50%) 16 (31.4%)	0.92 (0.73–1.15)	0.46
Employment/studying n (% yes)	46 (80.7%)	Employment/studying Other	15 (32.6%) 4 (36.4%)	0.85 (0.21–3.35)	0.81
Maternal alcohol/substance problem n (% yes)	11 (19.3%)	Yes No	4 (36.4%) 15 (32.6%)	1.18 (0.30–4.67)	0.81
Paternal alcohol/substance problem n (% yes)	24 (42.1%)	Yes No	11 (45.8%) 8 (24.2%)	2.64 (0.85–8.19)	0.092
Without childhood abuse n (%yes)	27 (47.4%)	No childhood abuse Childhood abuse	15 (55.6%) 4 (13.3%)	8.13 (2.22–29.75)	0.002
Lifetime depression n (% yes)	38 (66.7%)	Yes No	12 (31.6%) 7 (36.8%)	0.79 (0.25–2.51)	0.69
Lifetime anxiety n (% yes)	47 (82.5%)	Yes No	17 (36.2%) 2 (20.0%)	2.27 (0.43–11.92)	0.33
Lifetime suicide attempt n (% yes)	20 (35.1%)	Yes No	6 (30.0%) 13 (35.1%)	0.79 (0.25–2.55)	0.70
OQ-45 at the beginning of the treatment Symptoms of clinical significance n (% yes)	n = 55 32 (58.2%)	Yes No	11 (34.4%) 8 (34.8%)	0.98 (0.32–3.03)	0.98
OQ-45 at the end of treatment Symptoms of clinical significance n (% yes)	n = 49 22 (44.9%)	Yes No	6 (27.3%) 8 (29.6%)	0.89 (0.26–3.11)	0.86

The proportion of the women who achieved abstinence is presented for each variable.

p-values and odds ratios (OR) are based on continuous variables for age (calculating the OR per five years), years of education and for the OQ-45.2.

All other variables were dichotomized in the analyses. OR is the ratio for an increase of one unit in each of the predictors.

Table 2. Univariable logistic regression analyses using alcohol-related variables predicting abstinence at the 12-month follow-up

	Total sample n = 57	Subgroups	Number and percentage of abstinence	OR (95%CI)	p-value
Onset age of AUD (years) Mean (SD) OR per five years	43.5 (13.3)	0–24 25–44 ≥ 45	1 (16.7%) 11 (45.8%) 7 (25.9%)	1.00 (0.82–1.24)	0.96
Years of AUD Mean (SD)	7.5 (7.8)	0–5 >5	14 (50.0%) 5 (17.2%)	0.91 (0.82–1.00)	0.053
Dependence criteria according to the DSM-IV at the start of treatment	3 (5.3%) 10 (17.5%) 44 (77.2%)	1–2 criteria 3–4 criteria 5–7 criteria	1 (33.3%) 2 (20.0%) 16 (36.4%)	1.12 (0.76–1.67)	0.56
Months of treatment Mean (SD)	11.0 (8.2)	0–10 >10	10 (29.4%) 9 (39.1%)	1.02 (0.95–1.09)	0.63
Grams of alcohol/week at treatment start Mean (SD)	315.5 (307.0)	≤ 108 >108	2 (15.4%) 17 (38.6%)	3.46 (0.68–17.57)	0.13
Grams of alcohol/week at the end of treatment Mean (SD)	n = 51 116.7 (259.2)	≤ 108 >108	12 (30.8%) 3 (25.0%)	0.75 (0.17–3.27)	0.70
Drinking goal of abstinence at the start of treatment n (yes%)	22 (38.6%)	Abstinence Low-risk drinking	10 (45.5%) 9 (25.7%)	2.41 (0.78–7.46)	0.13
Drinking goal of abstinence at the end of treatment n (yes%)	n = 52 21 (40.4%)	Abstinence Low-risk drinking	13 (61.9%) 3 (9.7%)	15.17 (3.45–66.69)	< 0.001
Change alcohol habits, large change at the end of treatment n (yes%)	n = 52 35 (67.3%)	No or some change Large change	3 (17.6%) 13 (37.1%)	2.76 (0.67–11.44)	0.16

The percentage of abstinence reflects the proportion of participants who achieved abstinence within each subgroup. p-values and odds ratios (OR) are based on dichotomous variables for drinking goal, and the change of alcohol habits. All other variables were used as continuous variables in the analyses. OR is the ratio for an increase of the predictor in one unit.

Outcome at the 12-month follow-up

At the 12-month follow-up, there were no significant differences concerning the abstinence rate between participants having lifetime depression, anxiety, or suicide attempt or not, neither having symptoms of clinical significance or not in OQ-45.2 scores at the beginning and end of treatment (for proportions, see Table 1). A total of 75.4% (n = 43) of participants estimated large improvements in their alcohol habits. A total of 33.3% (n = 19) of participants reported abstinence, 47.4% (n = 27) reported low-risk drinking, and 19.3% (n = 11) reported ongoing risk drinking.

Predictors of abstinence at the 12-month follow-up

Tables 1 and 2 provide the ORs for the ability of the variables to predict abstinence at the 12-month follow-up. The significant predictor of abstinence at the start of the treatment was having no history of childhood abuse with an OR: 8.13 (95%CI: 2.22–29.75, p = .002). Only 13.3% (n = 4) of participants with a history of childhood abuse reported abstinence at the 12-month follow-up, compared to 55.6% (n = 15) of participants without a history of childhood abuse. Participants without a history of childhood abuse were also more likely to have abstinence as a goal at the end of treatment compared with women with a history of childhood abuse (58.3%, n = 14 vs 25.0%, n = 7; Fisher’s exact test, p = .023).

The significant predictor of abstinence at the end of treatment was having a goal of abstinence with an OR: 15.17 (95%CI: 3.45– 66.69), p < .001). In participants who had abstinence as a goal at the end of treatment, 61.9% (n = 13) reported abstinence, 33.3% (n = 7) reported low-risk drinking, and 4.8% (n = 1) reported risk drinking at the 12-month follow-up. By contrast, of the participants with low-risk drinking as the goal at the end of treatment, 9.7% (n = 3) reported abstinence, 61.3% (n = 19) reported low-risk drinking, and 29.0% (n = 9) reported risk drinking. There was a significant between-group difference (Mantel–Haenszel chi-squared test χ² = 14.76, df 1, p < .001).

The results from the forward stepwise regression model using variables from the start of treatment (childhood abuse, paternal alcohol or substance use problems, years of AUD) showed that no experience of childhood abuse was the only significant predictor of abstinence at the 12-month follow-up, with an OR = 8.13 (95%CI: 2.22–29.75, p = .002) and AUC = 0.74. A paternal alcohol or substance use problem was entered as a secondary variable into the model, but did not reach the significance level of p < .05 (OR = 3.84 (95%CI: 0.99–14.86, p = .052) and AUC = 0.62).

A second forward stepwise regression model of variables registered both before and at the end of treatment (drinking goal at the end of treatment) showed that the goal of abstinence at the end of treatment was the only independent predictor for abstinence at the 12-month follow-up, with an OR = 15.17 (95%CI: 3.45–66.69, p < .001) and AUC = 0.80.

As the use of disulfiram in combination with other treatment might have had an impact on the maintenance of abstinence, an extra calculation was performed excluding patients using disulfiram. However, the predictors “having no childhood trauma” and “having a goal of abstinence” remained strongly significant in a univarable analysis OR = 7.94 (95%CI: 1.87–33.81, p = .005) respectively OR = 11.67 (95%CI: 2.58–52.85, p = .001).

Discussion

In this explorative study, we investigated predictors for abstinence 12 months after AUD treatment in socially stable and well-educated women with high rates of partnership and employment. The only significant predictors for abstinence at the 12-month follow-up were not having a history of childhood abuse and having a goal of abstinence at the end of treatment. This was confirmed by both the univariable and multivariable stepwise logistic regression models. This study also found that the majority (> 60%) of participants reached their drinking goals, regardless of whether their goal was abstinence or low-risk drinking at the end of treatment. Participants who focused on abstinence as a goal at the end of treatment generally achieved better outcomes at the 12-month follow-up than participants with a goal of low-risk drinking. There were significantly more participants in the low-risk drinking goal group who reported risk drinking at the 12-month follow-up.

Our findings suggest that while a goal of low-risk drinking is a valid treatment option, having a goal of abstinence remains the safest drinking-related outcome, which is in agreement with previous findings (Berglund et al., 2019; Mann et al., 2017). Our study showed that stable abstinence at the 12-month follow-up was predicted by a goal of abstinence only at the end of treatment. This is in line with other studies that recruited mixed outpatients (Heather & McCambridge, 2013; Meyer et al., 2014), while other studies have found that the treatment goal at the beginning of treatment predicted abstinence at follow-up (Adamson et al., 2009; Berger et al., 2016; Berglund et al., 2019). Some studies have raised the importance of motivational changes during treatment and how treatment can affect drinking goals (Cook, Heather, & McCambridge, 2015; Heather & McCambridge, 2013; Meyer et al., 2014). Ultimately, our results indicate that the goal of abstinence at the end of treatment is the strongest predictor for reaching abstinence at the 12-month follow-up. However, regardless of the drinking goal at the end of treatment, the majority of participants reported a large improvement in their alcohol habits at the 12-month follow-up.

Childhood abuse has been associated with a younger age of onset of AUD (Schuckher et al., 2018) and to affect drinking-related outcomes in mixed inpatient treatment (Greenfield et al., 2002) and in women with AUD in outpatient treatment (Schückher et al., 2019). In contrast to Sugarman et al., who found no influence of childhood sexual abuse on drinking outcomes in a mixed inpatient study (Sugarman et al., 2014), our results indicate that childhood abuse (emotional, sexual, and/or physical) is a negative predictor of abstinence at the 12-month follow-up.

We also found that participants with a history of childhood abuse were less likely to have abstinence as a drinking goal at the end of treatment. According to a previous review, individuals with a history of childhood abuse have more difficulty with emotional regulation than individuals without (Jaffee, 2017). This may generate dysfunctional coping strategies, such as substance use, as well as difficulties engaging in goal-oriented behavior (Weiss, Tull, Anestis, & Gratz, 2013). This interpretation suggests that abstinence is a bigger step for women with a history of childhood abuse than it is for women who have not experienced abuse.

Our study also investigated if paternal alcohol or substance problems could predict abstinence at the 12-month follow-up. The analysis did not fully reach the significance level at p < .05, even though a high proportion (46%) of the women with fathers having alcohol or substance problems reported abstinence at 12-month follow-up. It is possible that female patients may turn experiences of their father’s alcohol or substance problems into a motivation to aim for abstinence. To our knowledge, there are a lack of studies concerning the impact of paternal substance abuse on offspring’s AUD treatment outcomes. This should be investigated in future studies with a larger sample.

Surprisingly, the psychopathological variables measured in this study (depression and anxiety) did not predict abstinence at the 12-month follow-up, which conflicts with some prior studies (Adamson et al., 2009; Greenfield et al., 2007; Walitzer & Dearing, 2006), and supports others (Mellentin et al., 2015). There was also no difference in psychological functioning at the beginning or end of treatment between those who achieved abstinence at the 12-month follow-up and those who did not, which is in line with previous studies (Crits-Christoph et al., 2015; Strid, Andersson, & Öjehagen, 2018). This could be because our sample included socially well-adjusted women without excessive psychiatric burdens.

Limitations

A limitation in the study is that our findings may not be generalizable to other AUD-populations than well-educated and socially stable women with high rates of partnership and employment. Another limitation in this study is that it partly relied on retrospective self-reports on alcohol consumption and childhood abuse, which comes with the risk of recall biases and subjective reports. However, self-reports of childhood maltreatment are still more likely to be underestimated (Gilbert et al., 2009). The interviews and questionnaires used in this study are well-established instruments in the field and have been found to have good psychometric properties. A possible limitation could be the small sample size at the start of the study, and a drop-out rate of 21% at the end of treatment and 24% at the 12-month follow-up. Dropout rates of this scale are common in clinical studies, and the power analysis showed that our sample size was sufficient.

Conclusion

Our results highlight the importance of identifying traumatic experiences during childhood and the need to address these in AUD treatment in socially stable woman. Previous studies have shown that women who have experienced childhood abuse may have reduced levels of trust and emotional regulation (Jaffee, 2017), thus additional support to deal with a history of abuse may improve treatment results. Given that women who had experienced childhood abuse were also less likely to have abstinence as a treatment goal, with worse outcomes as a result, they could also benefit from additional motivational treatment. This merits further investigation.

Although both groups, with and without a drinking goal of abstinence at the end of treatment, had a high consensus with their goals at the 12-month follow-up, the group who had the goal of abstinence exhibited less risk drinking than those who did not. Individuals who find it more difficult to maintain low-risk drinking may benefit from additional motivation to set abstinence as a goal during treatment.

List of abbreviations

ASI: Addiction Severity Index; AUC: area under the ROC curve; AUD: alcohol use disorder; AUDIT: Alcohol Use Disorder Identification Test; AVI-R-2: Alcohol Habits Inventory –Revised; 2CTQ-SF: Childhood Trauma Questionnaire – short form; DSM-IV: Diagnostic and Statistical Manual of Mental Disorders Fourth Edition; MINI: mini international neuropsychiatric interview; OQ-45.2: outcome questionnaire; OR: odds ratio; SD: standard deviation

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

The authors reported there is no funding associated with the work featured in this article.