Alcohol & Alcoholism Vol. 44, No. 4, pp. 409–415, 2009
Advance Access publication 2 June 2009
Treatment for Alcohol Dependence in Catalonia: Health Outcomes and Stability of Drinking Patterns over
20 Years in 850 Patients
Antoni Gual1,∗, Fabi´ an Bravo1, Anna Lligo˜ na1and Joan Colom2
1Alcohol Unit, Psychiatry Department, Clinical Institute of Neurosciences, Hospital Cl´ ınic, IDIBAPS, Barcelona, Spain and2Program on Substance Abuse,
General Directorate of Public Health, Department of Health, Generalitat de Catalunya, Barcelona, Spain
∗Corresponding author: Alcohol Unit, Psychiatry Department, Clinical Institute of Neurosciences, Hospital Cl´ ınic, IDIBAPS, Villarroel 170, 08036 Barcelona,
Spain. Tel: +34-932279923; Fax: +34-932277300; E-mail: firstname.lastname@example.org
(Received 23 April 2009; in revised form 23 April 2009; accepted 6 May 2009; advance access publication 2 June 2009)
Abstract — Aims: The aim of this study was to evaluate long-term outcomes in alcohol-dependent patients following outpatient
treatment and gender differences in drinking outcome and mortality. Methods: A 20-year longitudinal prospective study was done with
interim analyses at 1, 5 and 10 years. Of the original sample of 850 patients, 767 (90%) were located 20 years later and 393 of these
were interviewed. 273 (32%) patients died during the intervening period and 101 (12%) no longer wished to participate in the study.
Drinking status was assigned based on the 12 months prior to the follow-up interview. Results: At the 20-year follow-up, 277 (32.6%)
of the 393 patients for whom drinking status could be assigned were abstinent (defined never drinking or drinking on less than occasion
per month and never more than four drinks/drinking occasion.), 29 (3.4%) were controlled drinkers and 87 (10.2%) were heavy drinkers.
category from year 10 to year 20. Mortality was higher (39.1%) in those who had been categorized at year 5 as heavy drinkers compared
to those who had been categorized as controlled drinkers or abstinent. Abstinent patients reported fewer alcohol-related problems
and better psychosocial functioning than heavy drinkers. Women achieved higher abstinence rates (47.2% versus 29.0%, P = 0.005)
and had lower mortality (22.4% versus 34.5%, P = 0.03) than men. Conclusions: Over the long-term, abstinence is the most frequent
and stable drinking outcome achieved and is associated with fewer problems and better psychosocial functioning. Controlled drinking
is rarely achieved and sustained. Women appear to do better than men in the long term.
considered from a long-term perspective. Longitudinal cohort
studies have shown that the consequences of alcohol depen-
dence can be observed over long periods, evolve over time
and have an impact on multiple dimensions of quality of life
(Edwards, 1984; Longabaugh et al., 1994). However, relatively
few prospective studies have followed the course of the disease
over long periods and even fewer have assessed the long-term
impact of treatment.
Over the last decades, a limited number of studies have re-
ported treatment outcome in alcohol-dependent patients with
follow-up periods extending beyond 15 years (Hyman, 1976;
O’Connor and Daly, 1985; McCabe, 1986; Nordstr¨ om et al.,
been conducted in English-speaking countries (Hyman, 1976;
O’Connor and Daly, 1985; McCabe, 1986; Moos et al., 2006)
and have followed cohorts in which relatively few women, if
any, were included (McCabe, 1986; Mann et al., 2005), with
the exception of one American study that followed up a sample
of 232 women for 16 years (Moos et al., 2006). The limited
representation of women in such studies explains the lack of
gender-specific data on drinking outcome and our ignorance
of potential gender differences in the long-term course of the
illness following treatment. It is important that future stud-
ies evaluate long-term outcome in more diverse populations in
which different ethnic groups are represented adequately and
in which a sufficient number of women are included.
that interim analyses are required in long-term follow-up stud-
ies, together with the evaluation of multiple endpoints in addi-
tion to drinking outcome per se (Duckitt et al., 1985; Edwards
et al., 1988), notably with respect to social outcomes. In con-
trast, no consensus has been reached on other aspects of the
design of such studies, for example with respect to the defi-
nition of treatment success, to the minimum time required to
establish stable remission (6 months, 1 year or 3 years) and
to how patients who no longer wish to participate should be
handled in the data analysis (Vaillant, 1988; Mann et al., 2005;
Moos and Moos, 2005). Differences in the criteria used to as-
For all these reasons, we have performed a prospective study
of long-term outcome in a large sample of patients treated for
ferent challenges. The goals of the study were firstly to assess
long-term outcome in terms of drinking behaviour, morbidity,
alcohol-related socio-legal problems and psychosocial func-
tioning, and secondly to evaluate potential gender differences
in drinking outcome and mortality.
Sample and procedure
This longitudinal, prospective study was initiated in 1987 in
eight Addiction Centres in Catalonia (Spain). The study origi-
nallyincluded 850 patientswhohave nowbeen followedupfor
20 years. The study centres were chosen to cover the sociode-
mographic and territorial diversity of Catalonia. In accordance
patients were recruited in the metropolitan area of Barcelona
and one-third in the rest of Catalonia. The sample size was
planned to correspond to all patients entering treatment during
C ?The Author 2009. Published by Oxford University Press on behalf of the Medical Council on Alcohol. All rights reserved
by guest on November 24, 2015
410 Gual et al.
Table 1. Definition of drinking status
None or <5 drinks/drinking occasion
<5 drinks/drinking occasion
≥5 drinks/drinking occasion
Never or <1 drinking occasion per month
≥1 drinking occasion per month but <7 days per week
aOne drink = 10 g of pure alcohol.
bLast 12 months: never, <1 occasion/month, ≥1 occasion/month, ≥1 occasion/week, daily.
1 year, based on the number of patients who had been treated
for the first time in each of the participating centres in the year
preceding the start of the study. The study included all patients
aged between 18 and 55 years who fulfilled DSM-III crite-
ria for alcohol dependence (American Psychiatric Association,
1980) and who had accepted to enter a treatment programme.
Patients were expected to have a stable home with at least one
other family member.
All patients in the study entered a similar treatment pro-
gramme lasting approximately 2 years. The overall aim of the
programme was to achieve abstinence and set three specific
goals. These were to build awareness of alcohol dependence
as an illness, to acquire new lifestyle habits facilitating absti-
nence and to improve quality of life. The treatment programme
began with acute detoxification of the patient, including med-
ication when needed, followed by a rehabilitation programme
involving medication, medical management and group therapy
led by a clinical psychologist. All treatments were delivered by
health professionals in the facilities of the eight participating
The study cohort was evaluated at inclusion and after 1, 5
(Gual et al., 1999a), 10 (Gual et al., 2004) and 20 years using
a protocol that included information on drinking behaviour,
morbidity, mortality, alcohol-related problems, psychosocial
stress and global functioning (Axes IV and V; DSM-III-R).
At each time-point, data were collected during interviews with
psychiatrists or clinical psychologists from the study centres.
The assessment protocol was designed to allow interviews in
three different settings: study centre, patients’ home and by
telephone. Wherever possible, the patient and family member
were interviewed. In the case of discrepancy between the pa-
tient and the family member, data reporting a worse outcome
were taken into account. All patients lost to follow-up at each
evaluation time-point were systematically searched for at the
Civil Records Office of Mortality at the Health Department.
Drinking patterns. Drinking behaviour was evaluated at the
5-, 10- and 20-year horizons by scoring the quantity and fre-
quency of alcohol consumption according to the information
on the patient as a main source of information, has been used
in previous long-term studies (Mann et al., 2005) since self-
reports are widely accepted as a main source of data on alco-
hol consumption (Babor et al., 2000; Del Boca and Darkes,
2003). No biological markers were used. At each evaluation
point, patients were asked about their alcohol consumption
during the previous 12 months concerning the frequency of
drinking (never, <1 occasion/month, ≥1 occasion/month, ≥1
occasion/week, daily), and amounts drunk per drinking day ex-
pressed in standard drinks (one standard drink = 10 g of pure
tients were assigned to one of three drinking status categories
(abstinent, controlled drinking or heavy drinking) on the basis
have maintained these consumption patterns continually over
the last 12 months in order to meet the criteria. Where con-
sumption patterns had changed during this period, the patient
was assigned to the worst drinking status category.
Morbidity and mortality
At each time-point, data were collected in the presence of
chronic illnesses and use of medication during the previous
3 years. Visits to emergency units and hospital admissions dur-
ing the previous 12 months were also registered. If the family
member reported that the patient had died, the cause of death
was sought, and the date of death was verified from the Civil
Records Office at the Health Department.
We assessed accidents (home, work, traffic), unemployment,
long-term disability, and financial and legal problems over the
previous 12 months. Unemployment was estimated excluding
those retired or with permanent disability. Patients were con-
sidered to have financial problems if they were marginalized or
reported insufficient income to cover basic needs.
Psychosocial stress and social functioning
Psychosocial stress was assessed with DSM-III-R Axis IV cri-
teria (American Psychiatric Association, 1987) with a score
ranging from 1 (absence of stress) to 6 (maximum stress).
Social functioning was assessed with the GAF scale (DSM-
III-R Axis V) with scores ranging from 0 to 100. Both assess-
ments referred to the situation of the patient at the time of the
Percentages in each follow-up status, drinking category and
mortality were calculated with respect to the initial sample of
850 subjects at each time-point analysis. Potential differences
assessed using the two-tailed χ2test. Potential between-group
differences for ordinal and quantitative variables were evalu-
ated using the Kruskal–Wallis test and ANOVA, respectively.
Multiple comparison tests using Bonferroni’s correction were
used for both qualitative and quantitative data (Dawson and
Trapp, 2001). A probability level of <0.05 was taken to be sta-
tistically significant. Data were analysed using SPSS statistical
software version 14.0 (SPSS, Inc, Chicago, IL, USA).
by guest on November 24, 2015
Treatment for Alcohol Dependence in Catalonia 411
Table 2. Baseline sociodemographic and clinical features of the sample
N = 850
685 (81)/165 (19)
39 ± 9
7.2 ± 1.4
9.6 ± 7
Male/female (n, %)
Age (years ± SD)
Married (n, %)
Single (n, %)
Primary school (n, %)
High school (n, %)
Employed (n, %)
Unemployed (n, %)
DSM-III-R criteria (mean ± SD)a(range 0–9)
Years of dependence(years ± SD)
Use of other drugs (n, %)
Psychiatric comorbidity (n, %)
aEach criterion was scored as 0 = not present; 1 = present.
Table 3. Follow-up status at 5, 10 and 20 years
(n = 850)
(n = 850)
(n = 850)
Abstinent (n, %)
Controlled drinker (n, %)
Heavy drinker (n, %)
Refused to answer (n, %)
Lost to follow-up (n, %)
Death (n, %)
Of the 1113 subjects who consulted a participating centre for
ria, 850 (76.3%) agreed to participate in the study and provided
written informed consent. Sociodemographic and clinical fea-
tures of the initial cohort are shown in Table 2. The drinking
behaviour of the cohort before they entered treatment, notably
with respect to alcohol consumption patterns, the type of alco-
in a publication describing the 5-year follow-up data from this
study (Gual et al., 1999a). Initial detoxification was undergone
by 660 patients (77.7% of the sample) and during the first
12 months of follow-up, patients attended 6.7 (±4.3) clinical
At 1 year, 46.2% of the sample (n = 393) reported continuous
abstinence during the first 12 months.
Twenty years after inclusion, it was possible to locate 767
(90%) patients of the original cohort, the remaining 83 patients
being lost to follow-up. According to family members, 15 of
these individuals had disappeared or were living in the street.
Of the patients with known outcome, 273 (32%) had died. It
was possible to interview 393 (46%) patients after 20 years.
The remaining 101 (12%) patients refused to be interviewed at
this stage of the study (see Table 3).
during the follow-up period is presented in Table 3. After 20
years of follow-up, 32.6% of the original cohort was abstinent,
10.2% were still classified as heavy drinkers and 3.4% fulfilled
N = 426
N = 69
N = 254
N = 351
N = 57
N = 178
N = 101
N = 264
N = 257
N = 24
N = 79
N = 490
Heavy Drinkers N = 850
Fig. 1. Stability of drinking patterns over 20 years. ‘Other’ means dead, not
contacted and refused to answer. At each time point,patients were notincluded
if their drinking status had not been established at previous evaluations. Thus,
no arrows go from the category ‘other’ at 5 years to the evaluation of drinking
status at 10 years, and the same between 10 and 20. Instead, in Table 5, we
include those patients who were not followed at any intermediate evaluation
but were traced at the 20-year follow-up.
the criteria for controlled drinking. Abstinence remained the
50.1% at year 5, 41.9% at year 10 and 32.6% at year 20. Heavy
drinking fell from 29.8% to 22.2% and 10.2% over the same
periods of time. The number of controlled drinkers remained
low throughout the study. Abstinence appears to be the most
stable drinking pattern (see Fig. 1). Of abstainers, 64% at year
5 remain abstinent at 10 years, and 57% of abstinent patients
at year 10 remain in the same drinking category at 20 years.
The figures are much lower for heavy drinkers (39% and 22%,
23% of those who comply criteria at year 5 remain controlled
drinkers at year 10, and just 10% of them remain in the same
category 10 years later.
Gender differences in the drinking behaviour status and
follow-up differed markedly between genders (χ2= 10.6, df =
2, P = 0.05). Of the 93 women interviewed at this time-point,
78 (83.9%) were abstinent, 12 (12.9%) were heavy drinkers
and only 3 (3.2%) were controlled drinkers. In contrast, for the
300 men, 199 (66.3%) were abstinent, 75 (25%) were heavy
ences were also observed in mortality rates (χ2= 8.4, df = 1,
P = 0.03), with 236 men (34.5% of the original cohort) having
died over the 20-year period compared with only 37 women
(22.4% of the original cohort).
Drinking status and mortality
Drinking outcome at 5 years predicted mortality at the 10-
and 20-year follow-up points (see Table 4). At the 10-year
follow-up, heavy drinkers showed higher mortality rates than
by guest on November 24, 2015
412 Gual et al.
Table 4. Drinking behaviour at year 5 and mortality at 10 and 20 years
year 5 (n)
5 (m ± SD)
43.6 ± 11.0
41.3 ± 9.6
43.1 ± 8.8
10 (n, %)
20 (n, %)
Multiple comparison tests were performed using Bonferroni’s correction.
aSignificantly different from abstinent and controlled drinkers (P < 0.01).
controlled drinkers and abstainers (15.0%, 7.5%, 5.3%; χ2=
18.3, df = 2, P < 0.01).
The figures were very similar 10 years later, at the 20-
year follow-up, where mortality in the heavy drinking group
still doubles that of controlled drinkers and abstainers (39.1%,
21.7%, 19.7%; χ2= 31.6, df = 2, P < 0.01). No age differ-
ences between the three drinking categories were found at the
5-year follow-up (F = 1.21, df = 2, P = 0.297).
Drinking status and morbidity
observed in the proportion of patients with chronic illnesses,
rate of hospitalization or visits to emergency units between the
three drinking categories. However, when individual morbidi-
significantly higher in the heavy drinker category (χ2= 7.7,
df = 2, P = 0.02) compared to abstainers.
Drinking status and sociolegal problems
The number of subjects reporting social or legal problems over
group,ahigher proportionofsubjectsreportedaccidents (χ2=
6.1, df = 2, P = 0.04), financial difficulties (χ2= 10.5, df =
2, P = 0.05) and legal problems (χ2= 22.4, df = 2, P < 0.01)
compared with abstainers.
Drinking status and psychosocial functioning. Data on psy-
chosocial functioning are presented in Table 5. At the 20-year
follow-up point, significantly more psychosocial distress (Axis
IV of the DSM-III-R) was observed in the heavy drinker group
(χ2= 20.8, df = 2, P < 0.01). Data obtained with the GAF
scale (Axis V of the DSM-III-R) also revealed a worse social
functioning in the heavy drinker group compared to the absti-
nent and controlled drinker groups (F = 32.7, df = 2, P <
Refusals to answer
Patients who refused to answer at the end of follow-up were
compared with the rest of the cohort in terms of baseline and
age, gender, marital status, employment status, age at drinking
onset, length of dependence or dependence symptoms. As for
treatment compliance, a higher percentage of these patients
had abandoned treatment by the 1-year point in comparison
with the rest of the cohort (63.4% versus 52.2%, respectively,
χ2= 4.47, df = 2, P = 0.034), although no differences were
found in the duration of delivered treatment or the number
of appointments during the first year. Those who refused to
answer at year 20 were not more likely to be heavy drinkers at
any of the previous assessments (34.4% versus 33.7% at year
5; 30.2% versus 29.5% at year 10).
Twenty years after the treatment for alcohol dependence was
initiated, we were able to locate 767 (90%) of the original co-
hort of 850 patients, the remaining 83 being lost to follow-up.
The overall rate of final ascertainment was thus high, with an
attrition rate of 0.5% of subjects per year. Such an attrition
rate is low compared to previous long-term studies (O’Connor
and Daly, 1985; Nordstr¨ om et al., 2004) and below the thresh-
old of 1% per year that has been proposed as the acceptable
limit to ensure the validity of data collected from this type of
Table 5. Morbidity, sociolegal problems, psychosocial stress, global functioning and alcohol consumption in patients contacted at 20 years (includes some
patients not seen at intermediate years)
Abstinent (n = 277)Controlled drinker (n = 29)Heavy drinker (n = 87)
Chronic illness (%)
Digestive system (%)
Cardiovascular system (%)
Respiratory system (%)
Nervous system (%)
Emergency department visits (%)
Job loss (%)
Long-term incapacity (%)
Financial problems (%)
Legal problems (%)
Axis IV and V DSM III-R
Psychosocial stress (mean ± SD, 95% CI)
GAF scale (mean ± SD, 95% CI)
Multiple comparison tests were performed using Bonferroni’s correction.
aSignificantly different from abstinent (P < 0.05).
bSignificantly different from abstinent and controlled drinkers (P < 0.05).
2.8 ± 1.6 2.6 − 3.0
74.7 ± 15.9 72.8 − 76.7
2.8 ± 1.8 2.1 − 3.5
71.5 ± 16.8 64.7 − 78.3
3.7 ± 1.7b3.4 − 4.1
57.4 ± 21.0b52.8 − 61.9
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Treatment for Alcohol Dependence in Catalonia 413
longitudinal study (Vaillant and Milofsky, 1984). Of the 767
identified patients, we managed to interview 393. Of the re-
mainder, 273 had died and 101 no longer wished to participate.
The latter patients who refused to be interviewed at the 20-year
time horizon were excluded from the analysis of drinking sta-
tus. In contrast to other authors (Mann et al., 2005), we did not
consider refusals to be exclusively a surrogate marker of treat-
ment failure or relapse. In fact, being in stable remission for a
or other alcohol-independent factors such as a changed family
situation or professional constraints could be valid reasons for
patients no longer wishing to participate in the study. Data on
refusals are scarce, but there is some evidence that this group
also includes patients with good outcomes when intermediate
evaluations are taken into account (Mackenzie et al., 1987).
Our data seem to confirm this previous evidence; patients who
refused were not different from the rest of the cohort in terms
of baseline variables or intermediate drinking outcomes. How-
ever, we did observe that a higher number of these patients
abandoned treatment, which may result in lower commitment
with the follow-up assessments.
In order to avoid over-estimating abstinence rates, we used
ing status. At each time horizon (5, 10 and 20 years), the fre-
quency and quantity of alcohol consumed was reported for
the previous year, and the patient assigned to the most severe
drinking category entered during this period. The ‘controlled
drinking’ category was limited to patients drinking less than
five drinks per session on less than 7 days a week and the ab-
stinence category included also patients drinking less than five
drinks less than once a month. These criteria correspond to the
treatment goals for abstinence used in everyday practice in our
Addiction Network clinics.
Drinking status could be assigned in 393 patients inter-
were abstinent, 3.4% were classified as controlled drinkers and
10.2% as heavy drinkers. Three patients achieved the treat-
ment goal of abstinence for each one that continued to drink.
This distribution of long-term drinking outcome at 20 years
was not observed in the interim analyses at 5 or 10 years,
and can be accounted for principally by a progressive loss
of subjects from the heavy drinking and controlled drinking
groups over time. From the 5th to the 20th year, those groups
experienced a reduction in their size of 65.6% and 58%, re-
spectively. The abstinence group experienced a 35% reduction
during the same period of time. As expected, those reductions
mirror the increase in mortality, lost to follow-up and refusal
to answer categories (see Table 3). Other authors have sug-
gested that the heavy drinkers’ reduction may be attributed to
their excess mortality (Gerdner and Berglund, 1997). How-
ever, further analyses are being conducted to evaluate the im-
pact of mortality, refusals to answer and loss to follow-up on
the dynamics of changes in drinking status distribution over
nence outcomes in front of heavy drinking and specially con-
trolled drinking. Controlled drinking appears as a small and
transitional category where it is difficult to stay. This finding
It is difficult to compare longitudinal studies with clinical
populations, since there are crucial differences in sampling,
setting, outcome measures and length of the evaluation. Never-
theless, our mortality rates (32.1%) were close to those found
by Mann (27% at 16 years). Abstinence rates in Mann’s study
(39.6%) were higher than ours (32.6%) but his criteria were
different, since they allowed up to 60 g of ethanol occasional
consumption and even a relapse shorter than 1 week.
A major finding of the study was that long-term outcome in
women treated for alcohol dependence was better than that in
of women achieved abstinence at 20 years compared with only
mortality (22.4% in women and 34.5% in men). Our data are
quite similar to those presented by Moos et al. (2006) and
Timko et al. (2006) who found higher rates of stable remission
(60% versus 49%) and lower mortality rates (16.6% versus
21.7%) among women. It is interesting to note that gender
differences are very similar even though our sample comes
from a ‘wet culture’ (traditional wine drinking culture) and
Alcohol-related mortality in the Spanish general population is
3-fold higher in men and 60% of those deaths are related to
chronical diseases (Fierro et al., 2008). Higher mortality rates
among men have already been described in clinical samples
in the medium (Feuerlein et al., 1995) and long term (Hurt
et al., 1996). Our data show that excess mortality in alcoholics
was mostly due to those who continued drinking heavily. In
our sample, heavy drinkers at year 5 show a 3-fold increase
in their mortality rate at year 10 compared to abstainers (15%
versus 5%), and at year 20 their mortality still doubles that of
abstainers (39.1% versus 19.7%).
In addition to the drinking behaviour, we also evaluated a
number of other outcome variables pertinent to the quality of
life of our patients over the follow-up period. As previously
reported (Duckitt et al., 1985), we were unable to identify any
long-term association between drinking status and chronic ill-
patients had reported significantly less chronic illnesses (Gual
et al., 1999a). This difference could be explained by the ac-
crual over longer periods of time of new chronic illnesses that
were not related to alcohol but a consequence of ageing of the
sample (the mean age of the sample was 56 years at the end
of the study). In order to throw more light on this unexpected
finding, we intend in a future step to compare the information
available from patient interview with data on the same patient
recorded in the Catalan regional hospital admissions registry.
Such data from the Catalan registry will also be of interest to
at 20 years.
The residual association observed between drinking status
and chronic respiratory diseases may be related to the pos-
sibility that heavy drinkers might also smoke more heavily
than abstinents. The interaction between alcohol and tobacco
in clinical samples of alcoholics is not yet clear. In the short
1995; Gulliver et al., 2000; Friend and Pagano, 2005a; Friend
and Pagano, 2005b). In the long term, it would be reasonable
to expect that, as in the general population, alcohol and smok-
ing should reinforce each other. Surprisingly this was not the
case in the 16-year follow-up of Mann (Mann et al., 2005),
by guest on November 24, 2015
414 Gual et al.
and even though 76.8% of our patients were smokers at base-
line, unfortunately the smoking status was not collected in the
We observed an association between alcohol-related prob-
lems and drinking status throughout the follow-up period,
which has also been consistently found in other studies
(Vaillant, 1983; McCabe, 1986; Finney and Moos, 1991). Ac-
cidents, financial difficulties and legal problems were signifi-
cantly higher in the heavy drinker group compared to abstinent
patients. It is worth to mention that at 20 years, the controlled
drinking group performs closer to heavy drinkers than to ab-
stainers in terms of alcohol-related problems.
With respect to psychosocial distress, this was less marked
in abstinent and controlled drinkers than in heavy drinkers at
the end of the follow-up period. Social functioning measured
with the GAF scale was also better in abstinent patients and in
controlled drinkers than that in heavy drinkers. These findings
time horizons (Gual et al., 1999a, 2004).
Strengths and limitations
The context, length and size of our sample represent important
strengths of our study, since it covers a wide Mediterranean
region and provides data that extend our knowledge of long-
term treatment outcomes beyond English-speaking countries,
where treatment modalities and the drinking patterns may be
different. Inclusion of a large proportion of female patients into
the cohort enabled potential gender differences in treatment
outcome to be assessed and revealed that long-term outcome is
in fact better in women.
With respect to the study design, evaluation of drinking
behaviour over the previous year with conservative criteria
minimizes the risk of over-estimating the rate of abstinence,
which was estimated at 32.6%. This methodological feature
limits comparison with long-term abstinence rates determined
of patients who declined to be interviewed after 20 years limits
comparisons that can be made with other studies in which such
patients were considered to be treatment failures.
The study presents a number of limitations. In particular, the
relatively large proportion of subjects (11.8%) who declined
to be interviewed at 20 years introduces a possible source of
bias (see above). Moreover, although psychiatric comorbidity
was not an exclusion criterion, it is possible that patients with
ordination between conventional psychiatric services and the
addiction centres at the time when the study was initiated, re-
sulting in such patients not being seen in the participating cen-
tres. Also, the study excluded at the outset patients who did not
have a stable home and at least one other family member, and
such individuals may have a poorer outcome than the sample
Finally, it is important to point out that the present results
need to be completed with further analyses in order to under-
other outcomes over time. The identification of drinking phe-
notypes, of risk factors for remission and relapse, of changes
in mortality over time and of the evolution of drinking be-
haviour in women represent important challenges for future
Acknowledgements — We thank all the professionals from the eight Addiction Centres of
the Catalan Addiction Network [Unitat d’Alcohologia de la Generalitat, Hospital Cl´ ınic;
Programa DROSS (Centre d’Atenci´ o i Seguiment Garb´ ı-Vent; Centre d’Atenci´ o i Segui-
ment de Sarri` a-Sant Gervasi; Centre d’Atenci´ o i Seguiment de Sants); Centre d’Atenci´ o i
Seguiment de Girona. Fundaci´ o Teresa Ferrer; Centre d’Atenci´ o a les Drogodepend` encies
CAP Tarragon` es; Dispensari d’Alcoholisme i altres Toxicomanies, Hospital Santa Maria
de Lleida] for their continuous support to the project and for their help in keeping track
of patients. We also thank Anna Sanahuja and Cecilia Garcia for their participation in the
follow-up interviews with patients and relatives. Data on mortality were provided by the
Registre de Mortalitat de Catalunya, Barcelona, and the Instituto de Informaci´ on Sanitaria
from the Ministerio de Sanidad, Madrid, Spain. Funding for this study was provided by a
grant from the Department of Health, Government of Catalonia, Spain.
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