LE-I-CERS TO THE EDITOR

PROSPECTIVE STUDY OF ALCOHOLISM TREATMENT. EIGHT-YEAR FOLLOW-UP

To the Editor: I read with interest the article on alcoholism treatment by Vaillant et al (Am J Med 1983; 75: 455-463). I believe the study is a major contribution in providing systematic fol- low-up on a group of patients, who in most clinical studies would be regarded as poor risks for successful outcome. Dr. Vaillant and his colleagues are to be congratulated on their high follow-up rate as well as on the overall thor- oughness of the study.

I have one objection, however, and it is the title of the article, which suggests that this is a follow-up study re- garding treatment. As is noted in the article, in fact, the hospital provided very little treatment except for detoxi- fication and some counseling over a period of one to nine days. Vaillant et al credit the abstinence that their patients did achieve to attendance at Alcoholics Anonymous. What seems to be ignored, however, is that with this “treatment” approximately 25 percent of the patients were dead at the end of 10 years, and 35 percent still dependent on alcohol. Although all persons in the field would agree that these subjects would have low recovery rates in any treatment program, I believe it is a mistake to describe inpatient hospitalizations as treatment when it includes primarily detoxification and a mistake to describe as a good out- come a therapeutic regimen that has a 25 percent death rate at the end of 10 years.

Perhaps a more appropriate title for this study would be “Prospective Study of Alcoholism Outcomes in Patients with Poor Prognosis Receiving Only Inpatient Detoxifica- tion.”

P. JOSEPH FRAWLEY, M.D. Medical Director Schick Shade1 Hospital Santa Barbara, California 93105

The Reply: I appreciate Dr. Frawley’s letter. From reading it, however, I get the impression that, like most physicians, he does not fully appreciate how serious a disease alcoholism is. The most likely reason is that he is unfamiliar with the rather scanty, long-term follow up literature. He expresses sur- prise at an eight-year death rate of 25 percent. Does he know that 15 percent of the Rand Report patients were dead at four years? I suspect that he might find it helpful to look at the long-term studies summarized on page 124 of my book, The Natural History of Alcoholism [ 11. There he would find that death rates of the magnitude that sur- prises him are the rule and not the exception, even in patients with a good prognosis. He would also find that at

the ten-year mark, only 22 percent of the located, surviving patients who had been hospitalized at the original Shade1 Hospital in the late 1930s continued to enjoy sobriety [2]. Presumably, he would have regarded the original patients of Dr. Shade1 as representing a good prognosis group.

Everyone in the alcoholism field has much to learn from sustained follow-up of the patients with whom they work.

GEORGE E. VAILLANT, M.D. Raymond Sobel Professor of Psychiatry Dartmouth Medical School Hanover, New Hampshire 03756

1. Vaillant GE: The natural history of alcoholism. Cambridge, Mary- land: Harvard University Press, 1983.

2. Voegtlin WL, Broz WR: The conditioned reflex treatment of chronic alcoholism. X: An analysis of 3125 admissions over a period of ten and a half years. Ann Intern Med 1949; 30: 580-597.

DISPARATE CARDIOVASCULAR EFFECTS OF OBESITY AND ARTERIAL HYPERTENSION

To the Editor: I found the study by Messerli et al (Am J Med 1983; 74: 808-8 12) extremely interesting and meticulously con- ducted. I would like to make one further comment on their data.

The documentation of decreased total peripheral re- sistance in obese persons is satisfying, but expected. Obesity entails an increase in the vasculature, which in- creases the cross-sectional area of the circulation (since smaller vessels are arranged in parallel); thus, as predicted by Bernoulli’s questions, decreased pressure would be expected or, more specifically in this case, decreased total peripheral resistance. This alone could account for the lower total peripheral resistance seen when obese hy- pertensive subjects are compared with lean hypertensive subjects, and possibly also when obese hypertensive subjects are compared with lean normotensive subjects. However, when obese hypertensive subjects are com- pared with their own control group-obese normotensive subjects-they exhibit a highly significant (p <O.OOl) in- crease in total peripheral resistance.

Thus, increased total peripheral resistance is a char- acteristic of hypertension in lean as well as in obese persons. I believe this point should have been at least mentioned in the article.

RIF S. EL-MALLAKH, M.S. University of Illinois College of Medicine Department of Basic Sciences One lllini Drive Peoria, Illinois 61605

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