As a young psychiatrist at Washington University in St. Louis, Helzer joined a distinguished team of researchers at the U.S. Army General Hospital in Fort Gordon, Ga., in an examination of narcotic dependence among returning Vietnam veterans. According to one of his psychiatry colleagues, this work, which demonstrated the importance of prior use and environment in continued dependence, "revolutionized scientific understanding of narcotic and other drug dependence." Helzer was also a leader in the development of multiple editions of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, the diagnostic manual used by mental health clinicians and researchers. He came to UVM as professor and chair of psychiatry in 1989.
In nominating Helzer for University Scholar, one colleague explained that "alcohol use is especially difficult to study across time, because unlike many abused substances, there are no long-lasting metabolites to monitor."
A successful innovation
Helzer's approach to the problem was to borrow an idea from private business. Early in his tenure at UVM, Helzer worked as a consultant to the Vermont Alcohol Research Center, where the idea of using telephone voice-response technology was hatched. The goal of the group, which included former psychiatry faculty member John Searles and Daniel Walter, an information technology professional in psychiatry, was simple: Make it easier for alcohol-dependent research participants to report information about their drinking. Initially, voicemail allowed a repository for this reporting, but it lacked the option to ask and respond to specific questions.
"We thought we'd try what the bank does," said Helzer, referring to the "please press one now"-style of prompts typical of IVR. This low-cost technology, which facilitates collecting of information on the frequency and patterns of substance abuse, requires a dedicated computer to run the system, a script for the system to follow and a programmer to set up the computer.
With those pieces in place, Helzer, Searles and Walter launched a pilot study, recruiting more than 30 male subjects identified as heavy alcohol consumers, and examined the effectiveness of the technology over a two-year period. The resulting compliance - participants made between 90 and 95 percent of the calls expected - made it clear that the technology held promise and might have a future in strengthening interventions.
Helzer's first funding for his IVR research came from the National Institute on Alcohol Abuse and Alcoholism, or NIAAA, and focused on an alcohol-use screening and intervention with primary care and family medicine clinicians. The five-year study enrolled roughly 350 participants, and, in addition to the in-person intervention, included daily reporting in response to a single question regarding daily alcohol consumption.
"The most helpful aspect of this intervention was the visual report of the participants' daily feedback," says Helzer. "We could show them, day-by-day, how much they were drinking compared to the goal they had set for themselves."
From monitoring to treatment
At this point, Helzer had begun collaborating with psychiatry colleague Dr. Magdalena Naylor to examine a more elaborate intervention. Therapeutic IVR (TIVR) was designed to keep chronic pain patients on track after receiving cognitive behavioral therapy, a form of psychotherapy, which involves identifying negative patterns of thinking and reacting and modifying or replacing them with more helpful behavior patterns. They launched another pilot study and eventually received National Institute on Drug Abuse funding for a controlled study.
After the success of the pain study, Helzer thought it would be interesting to incorporate the cognitive behavioral therapy component into his alcohol dependence IVR work. The Office of Patient-Oriented Research at UVM's General Clinical Research Center funded a pilot study of the TIVR for alcohol dependence, which led to the funding he received from the NIAAA to run his current study. The TIVR system is designed to supplement traditional behavioral therapy to prevent relapses. In addition to making daily reports, study participants can use the TIVR to review and/or rehearse coping skills they learned in CBT and get personalized feedback about their progress.
Helzer believes IVR technology holds great promise as a potential treatment method for a host of health problems, having now looked at its merit as an intervention with alcohol-dependent, pain and weight control patients (with Naylor).
"This work relates back to the first 15 years of my research career doing epidemiology," he explains, referring to his tenure at Washington University. "That left me with an interest in interventions that could work in large populations. IVR is easy to set up and inexpensive, so the incremental costs of adding new populations, new clinics, etcetera, is really trivial," he adds.
The next step, according to Helzer, is a recently funded NIAAA grant, which, in collaboration with Dr. Charles Maclean, associate professor of medicine, will pilot-test a stand-alone IVR intervention that would work without the live intervention of a primary care clinician. Helzer does not expect it will be as effective as a live intervention, but if it shows positive effects, the program could have huge public health implications, particularly in rural areas where access to providers is an issue.
Why does the technology work? "There's a long literature that self-monitoring really makes a difference in people's behavior that goes back 50 years," says Helzer. "Just monitoring your own behavior influences good behavior - you're your own best critic."
_____________________________________________________________________ Helzer's University Scholar Lecture, titled "Dr. IVR: Meeting Growing Health Care Needs by Promoting Patient Self-Directed Care," will take place on Wednesday, Nov. 15, at 4 p.m. in Waterman's Memorial Lounge.