Alcohol dependence is a chronic recurrent disease. If patients suffer from alcohol-related somatic disorders, the treatment takes place in regular (not specialized) hospitals for acute care. Very few patients are treated in a specialized institution and can thus profit from specialized interventions . Whether outpatient or inpatient post-acute treatment is more efficient cannot be answered generally, though the current literature suggests favoring outpatient treatment . There is a consensus that there is a variety of treatment methods and settings and that the ideal treatment has to be defined for each patient group. For some patients, an outpatient treatment can suffice, whereas for other patients a hospital stay is necessary. The AWMF developed guidelines which can help clinicians to decide which post-acute treatment setting is the most appropriate.
In the present study, we tested the hypothesis that patients, who were treated in specialized institutions for alcohol abuse, were treated in the appropriate setting. In order to test the hypothesis, the treatments were classified using the AWMF criteria for post-acute treatment. According to the AWMF, there are several risk factors that, if present, qualify for inpatient treatment: 1) Severe somatic, psychiatric or social disorder, 2) lacking social support, 3) no occupational integration, 4) unstable housing conditions, and 5) repeated relapses during outpatient treatment.
Three out of four investigated inpatients fulfilled at least one of the five inclusion criteria. Applying a more conservative approach than the AWMF required, and thus leaving out the lacking occupational integration, the result remained robust. Again, three out of four inpatients were identified as a population needing a post-acute inpatient setting. Accordingly, for roughly one fourth of the investigated inpatients, the necessity of a treatment in a post-acute hospital could not be identified. Since these patients did not match international criteria for inpatient treatment, the question arises whether these patients are best treated in an outpatient setting. Hence, all the patients who did not meet the criteria for inpatient treatment were investigated with the intention of assessing whether they could just as well have been treated in an outpatient setting.
To investigate this, the AWMF guidelines for outpatient treatment were used. Following the AWMF guidelines, an exclusive outpatient treatment can be recommended if four criteria are met: 1) The social environment offers an adequate support (e.g. stable living conditions), 2) there are no destructive or pathogenic influences in the social environment, 3) the patient is capable of participating in the treatment and is compliant with the treatment plan (by upholding sobriety), and 4) the ambulant treatment setting is explicitly preferred by the patient. In the context of the present investigation, only the first two inclusion criteria could be investigated.
So far, it has not been possible to get a precise estimate of the proportion of patients treated in an inpatient facility, who would have benefitted just as well from an outpatient treatment setting. For now, it is reasonable to assume that, at best, an outpatient setting would have sufficed for one out of four patients. When interpreting the results of this investigation, it is important to bear in mind that the inclusion criteria for inpatient treatment are "either – or" criteria, whereas all four outpatient treatment criteria have to be fulfilled in order to qualify for outpatient treatment. 6.6% of the investigated sample fulfilled at least two out of the four inclusion criteria. Whether those patients would have also met the remaining two criteria cannot be answered at this point. It is thus necessary in future research to develop a questionnaire, which allows the assessment of all four outpatient treatment criteria.
Aside from the above-mentioned methodological limitations, these results serve as evidence that an inpatient treatment was appropriate for at least three out of four patients treated in the investigated specialized institution.
Even though the empirical basis for outpatient treatment is sound, only a limited number of patients hospitalized in a specialized institution for the treatment of alcohol-related disorders can be treated in an outpatient setting. Also, it is noteworthy that 90% of those patients in our study, who fulfilled the two AWMF criteria for outpatient treatment improved during inpatient treatment. Furthermore, logistic regression analyses revealed that the less severe the clinical state of a patient was upon admittance, the higher the odds of improving during the hospital stay. This result thus suggests that inpatient treatment, as performed in a specialized institution, does not increase the dependence of the patients. It could have been assumed that rather long hospital stays increase the dependence of patients, hinder them in developing sustainable coping strategies and may in some cases even lead to mild forms of hospitalism. Why does the interpretation of the findings suggest that the healthier members of the hospital population profit from the hospital stay? The answer is probably multifaceted. Firstly, the degree of control in the hospital is very loose. The hospital is located in a village, the wards and the rooms are not locked, and there is only one hospital employee who is present at night for emergencies. Hence, patients who are not adequately motivated may relapse more easily. Secondly, the requirements for the psychotherapeutic group and single sessions are rather high. Patients have to be able to express themselves, talk about their emotions and needs, and actively participate in the therapeutic assignments. And finally, an important part of the therapeutic program consists of various levels of exposure, such as spending the weekend at home and meeting friends and family. Being able to cope with adverse living conditions and thus avoiding negative emotions as well as cognitive distortions, is an important resource for relapse prevention . Transferred to the problem of which is the appropriate treatment setting, it becomes evident that while an inpatient treatment setting may protect from adverse living conditions, the outpatient setting on the other hand, enables the training of necessary coping strategies which can help prevent relapses.
So far, the obtained results were derived from the population of one institution. Since this hospital is the only specialized institution serving a large geographical region (population size of 1.2 million) there is no evidence suggesting that the investigated sample was severely biased. However, replication studies investigating other hospital populations of specialized institutions such as the Forel-Hospital are needed.
A further potential limitation is the use of the AWMF criteria. Even though these criteria were carefully selected and empirical studies using similar criteria showed a certain degree of validity , studies addressing the issue of the validity regarding these criteria are necessary. Still, even when accounting for the limitations mentioned above, it can be assumed that only a limited proportion of patients treated in a post-acute inpatient setting can benefit from a post-acute outpatient treatment.
Finally, the study design did not permit a direct comparison with other studies investigating the outcome of inpatient and outpatient treatment settings [9–12].