Rumination as a predictor of relapse in alcohol abuse

Gabriele Caselli1,2, Claudio Ferretti3, Mauro Leoni4,5, Daniela Rebecchi3, Francesco Rovetto6 & Marcantonio Spada7,8

1 Studi Cognitivi, Scuola di Psicoterapia Cognitiva, Modena, Italy2 Roehampton University, London, United Kingdom

3 Dipartimento Salute Mentale, Azienda USL, Modena, Italy4 Fondazione Sospiro, Cremona, Italy

5 Università degli Studi di Parma, Parma, Italy6 Università degli Studi di Pavia, Pavia, Italy

7 London South Bank University, London, UK8 North East London NHS Foundation Trust, London, UK

39th EABCT Annual CongressDubrovnik, September 2009

Introduction

• Returning to using alcohol after treatment is still a common occurrence in patients presenting with alcohol problems

• Amongst the risk factors that may contribute to a return to alcohol use, rumination represents a relatively new construct that has been noted to be associated with alcohol use disorders

Rumination

• Rumination has been conceptualized as a coping strategy for controlling negative affect that is characterised by – Heightened self-focused attention involving persistent,

recyclic and generic internal self-questioning regarding the causes, consequences and symptoms of one’s negative affect

“Why do I react always in the same way?”“Why do I feel always so down?”

Consequences of Rumination

• Dysphoric consequences– Relate to how rumination exacerbates negative

mood and increases negative thinking

• Non-Dysphoric consequences– Relate to impaired cognitive functioning not

directly associated with dysphoric phenomenological experience

Two pathways through which rumination could predict alcohol use

Depression

Rumination

Alcohol use

Dysphoric consequences

Non-Dysphoric consequences

Indirect Effect

Direct Effect

Evidence Supporting Direct Effect Hypothesis

• Individuals high on private self-consciousness may use alcohol to reduce self-focused attention (Hull, 1981)

• Rumination predicts alcohol use to cope with distress in a prospective study of community-based adults (Nolen-Hoeksema and Harrel, 2002)

• Ruminative thinking predicts level of alcohol use and category membership as a problem drinker (versus social drinker) independently of depression (Caselli et al., 2008).

Aims

• Does rumination, as assessed prior to entering a brief cognitive-behavioural treatment programme for alcohol abuse, have implications relapse at 3, 6 and 12 month follow-up?

• Is this independent of baseline levels of alcohol use and depression?

Method• Participants

– 80 outpatients (25 females) seeking treatment for alcohol abuse at the Public Centre for Addiction and Mental Health, Modena, Italy (47.2 years; SD: 9.4; range: 24-64; mean duration of alcohol problem 16.6 years)

• Materials– Depression (BDI), Rumination (RRS), Alcohol Use (QFS)

• Procedure– At baseline a battery of instruments were administered to measure background,

level of alcohol use, depression and rumination.– Participants were assessed prior to commencing a brief course of cognitive

behaviour therapy for alcohol abuse that did not consider ruminative thinking as content

– Level of alcohol use was measured at 3, 6 and 12 months follow-up in a face-to-face meeting or by telephone by the same researcher as at baseline

ResultsDescriptive Statistics

X SD Rangeof Scores

2. 3. 4. 5.

1. BDI - Depression (Baseline) 15.5 8.7 1-37 .43** .32** .30** .32**

2. RRS - Rumination (Baseline) 48.5 12.6 23-85 - .41** .49** .49**

3. QFS - Alcohol Use (3 Months) 18.6 26.6 0-120 - - .70** .71**

4. QFS - Alcohol Use (6 Months) 26.0 28.6 0-105 - - - .84**

5. QFS - Alcohol Use (12 Months) 24.3 25.5 0-98 - - - -

The number of patients that were using alcohol at 3, 6 and 12 months follow-up were 35 (43.8%), 46 (57.5%) and 48 (60%) respectively

Note: n=80. *p<.05; **p<.01.

Results Binary Logistic Regression Analyses

3 Months 6 Months

12 Months

B SE Wald p Class(%) B SE Wald p Class(%) B SE Wald p Class(%) Step 1 57.5 57.5 60.0 QFS .01 .01 1.15 .28 .00 .01 .05 .83 .00 .01 .25 .62

X2

1.17 .28 .05 .83 .25 .62

Step 2 62.5 62.5 61.2

QFS .00 .01 .15 .70 .01 .01 .61 .44 .00 .01 .00 .96

BDI .06 .03 3.93 .05 .05 .03 2.95 .09 .05 .03 2.77 .10

X2

5.36 .06 3.16 .21 3.17 .21

Step 3 68.8 73.8 73.8

QFS .00 .01 .37 .54 .00 .01 .34 .56 .00 .01 .06 .80 BDI .02 .03 .27 .61 .00 .03 .00 .98 .01 .04 .04 .85

RRS .08 .03 8.75 .00 .08 .03 9.77 .00 .09 .03 10.77 .00 X2

16.3 .00 15.65 .00 17.34 .00Dependent: Category membership (relapsed, abstinent)Predictors: baseline alcohol use, baseline depression, baseline rumination

The third step in all three analyses indicates that baseline rumination was the only significant predictor of drinking status at 3, 6 and 12 months follow-up

ResultsHierarchical Multiple Regression Analyses

3 Months 6 Months 12 Months

β t p β t p β t p Step 1

QFS .28 2.65 .01 .18 1.59 .12 .22 1.97 .05

r2

.08 .03 .05

F Change 7.00 .01 2.52 .12 3.89 .05 Step 2

QFS .21 1.83 .07 .09 .77 .44 .13 1.13 .26 BDI .25 2.26 .03 .27 2.35 .02 .27 2.41 .02 r2

.14 .10 .11

F Change 5.09 .03 5.54 .02 5.80 .02 Step 3

QFS .22 2.08 .04 .11 1.05 .30 .15 1.43 .16

BDI .10 .84 .41 .07 .58 .56 .08 .67 .50

RRS .34 3.09 .00 1.03 4.13 .00 .44 4.02 .00

r2

.21 .26 .27

F Change 9.55 .00 17.04 .00 16.15 .00

Dependent: level of alcohol use at 3, 6 and 12 monthsPredictors: baseline alcohol use, baseline depression, baseline rumination

The third step in all three analyses indicates that baseline depression’s predictive power loses its significance as baseline rumination is inserted in the third step with the

latter remaining the only significant predictor of level of alcohol use at all follow-up points.

Discussion• Results obtained showed that baseline rumination predicted relapse status

and level of alcohol use at 3, 6 and 12 months follow-up independently of baseline level of alcohol use and depression.

• These results are consistent with earlier findings and highlight the role of rumination as a mediator of the relationship between depression and drinking behaviour

• Rumination may play a crucial role, as a residual symptom, in predicting return to alcohol use and level of alcohol use after treatment because – It contributes to the escalation and persistence of negative cognitive-affective states

(like depression) that can trigger maladaptive coping strategies such as alcohol use; and

– It may directly activate alcohol use as an attempt to control the ruminative process and its negative consequences (cognitive-affective self-regulatory paradigms)

Clinical Implications

• Assessment: information could be gathered not only in relation to classic co-occurring psychological disturbance in alcohol abuse (e.g. depression) but also associated recyclical thinking style (e.g. rumination)

• Interventions: the facilitation of skills that promote a direct change in rumination may be crucial to reduce the probability of return to alcohol use after treatment

Limitations• Social desirability, self-report biases, context effects and poor recall may have

contributed to errors in self-report measurements

• The presence of concurrent psychological disorder was not assessed

• Drinking status was only assessed for the 30 days prior to the next follow-up interview therefore some patients may have been using alcohol during the time period which was not assessed

• BDI and RRS were not given beyond pre-treatment assessment, so it is was not possible to monitor their change

• The clinical sample was relatively small in size and some patients had received previous treatment which may have exposed them to the identification and exploration of cognitive constructs

Future Research

• Considering the effect of alcohol use on rumination

• Investigating the role of other important construct such as worry and anxiety

• Exploring the effect of rumination induction on craving experience for alcohol abusers a

Thank you for your attention!

Contact details

Dr. Gabriele Caselli

Cognitive Psychotherapy School Studi Cognitivi, Modena, Italy

Roehampton University, London, UK

casellig@roehampton.ac.uk

gabriele.caselli@gmail.com