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National Collaborating Centre for Mental Health (UK). Alcohol-Use Disorders: Diagnosis, Assessment and Management of Harmful Drinking and Alcohol Dependence. Leicester (UK): British Psychological Society; 2011. (NICE Clinical Guidelines, No. 115.)

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Alcohol-Use Disorders: Diagnosis, Assessment and Management of Harmful Drinking and Alcohol Dependence.

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6PSYCHOLOGICAL AND PSYCHOSOCIAL INTERVENTIONS

6.1. INTRODUCTION

This chapter is concerned with structured psychological interventions used to help people who experience alcohol dependence or harmful alcohol use. These approaches have been the focus of much research and debate over the years.

Psychological interventions for people experiencing alcohol misuse or dependence have traditionally made use of the interaction between the service user and a therapist, worker, helper or counsellor (the latter terminologies may vary depending on services and settings). In addition, more recently, there has been some growth and expansion in the use of self-help-based interventions that involve the use of DVDs, books, computer programmes or self-help manuals.

Psychological approaches vary depending on the theoretical models underpinning them. Broadly, psychological interventions can be classified into behavioural, cognitive, psychodynamic, humanistic, systemic, motivational, disease, and social and environmental. The emphasis of each therapy is different, depending on the theoretical underpinning of the approach. Behavioural approaches, for example, are based on the premise that excessive drinking is a learned habit and therefore influenced by principles of behaviour. The latter can hence be used to teach the individual a different behavioural pattern that will reduce the harm emerging from excessive drinking. Cognitive approaches, on the other hand, emphasise the role of thinking and cognition either prior to engaging in drinking behaviour or to prevent or avoid lapse or relapse. Social approaches focus the work on the social environment, for example families or wider social networks. In some instances, a combination of approaches is used and described under the term of ‘multimodal’ treatment, guided by the rationale that a combination of approaches is more powerful than each individual component. Each category of intervention is discussed in more detail later in this chapter within subsections describing the studies reviewed that are relevant to each type of approach.

Whilst the rationale and theoretical frameworks for treatments have been clearly articulated in the various research studies, the evidence for the superiority of one form of treatment over another in the field of alcohol has been difficult to find (Miller & Wilbourne, 2002). This has led to the general view in the field that whilst psychological interventions are better than no intervention, no single approach is superior to another. In this chapter, where available, the evidence for each psychological intervention is assessed in relation to three comparators: (i) is the intervention superior to treatment as usual or a control condition? (ii) is the intervention superior to other interventions? and (iii) is the intervention superior to other variants of the same type of approach (for example, behavioural cue exposure [BCE] versus behavioural self-control training [BSCT])?

The review of this literature is of significant importance, given the potential wide use of psychological interventions in NHS and non-statutory services as well as the need to provide an evidence base to inform and guide the implementation and use of these approaches. It is important to note that previous influential reviews of alcohol treatment (for example, ‘Mesa Grande’, Miller & Wilbourne, 2002) have combined findings from a large number of trials that included a wide range of populations (for example, opportunistic versus help-seeking, mild versus severe dependence). In the current review, only studies that involved treatment-seeking populations experiencing harmful drinking or alcohol dependence were included and therefore the number of trials meeting these criteria was reduced to make them relevant to the population addressed in this guideline.

Finally, psychological treatments can also be used to help people experiencing harmful alcohol use or dependence to address coexisting problems such as anxiety and depression. These approaches are not covered within this review and the reader is referred to the separate NICE guidelines that address psychological interventions for specific mental health problems. Healthcare professionals should note that, although the presence of alcohol misuse may impact, for example, on the duration of a formal psychological treatment, there is no evidence supporting the view that psychological treatments for common mental health disorders are ineffective for people who misuse alcohol. A number of NICE mental health guidelines have specifically considered the interaction between common mental health problems and drug and alcohol use. For example, NICE guidelines, such as for anxiety (NICE, 2004) or obsessive-compulsive disorder (NICE, 2006a), provide advice on assessment and the impact that drug and alcohol misuse may have on the effectiveness or duration of treatment. There is also some evidence to suggest that the active treatment of comorbid mental health problems may improve drug and alcohol substance misuse outcomes (Charney et al., 2001; Hesse, 2004; Watkins et al., 2006). This may be particularly important for service users who have achieved abstinence (note that symptoms of depression and anxiety may remit following successful treatment of the alcohol problem), but whose alcohol use is at risk of returning or escalating due to inadequately treated anxiety or depression.

6.1.1. Current practice

Services for people who are alcohol dependent and harmful drinkers are commonly delivered by statutory and non-statutory providers. The field is undergoing rapid change across different areas of the country due to the impact of the commissioning process. Traditionally, services have been provided by teams where the detoxification and counselling aspects of treatment have been fairly clearly separated. Within the NHS, teams tend to consist of different disciplines including nurses, counsellors, medical practitioners and, less often, other professions such as psychologists and occupational therapists. Teams are commonly under-resourced with practitioners having high caseloads and limited access to supervision. Most practice involves an eclectic approach that combines strategies from various psychological approaches. A more recent development involves contracts between commissioners and providers that may determine, for example the number of sessions to be delivered, yet this is rarely informed by the evidence and tends to be driven by pragmatic or resource issues (Drummond et al., 2005).

Whilst the research literature to date has concentrated mostly on the comparison of well-defined treatment interventions commonly incorporated into treatment manuals, this stands in contrast to what is normally delivered in routine practice. Despite the research on psychological treatments, current UK practice is not underpinned by a strong evidence base and there is wide variation in the uptake and implementation of psychological approaches to treatment across services (Drummond et al., 2005).

A number of factors may contribute to the low implementation of evidence-based psychological interventions. First, there is a lack of availability of reviews of the current evidence in a clear and practical format that can be accessible to practitioners, managers and commissioners. This has led to a weak dissemination of the evidence base concerning psychological interventions for alcohol misuse within routine service provision. Second, there is the varied composition of the workforce with a range of training experiences, not all of which include training in the delivery of psychological interventions. Furthermore, as noted by Tober and colleagues (2005), training programmes for the management of substance misuse vary widely in content with no consensus on methods to provide and evaluate such training or to maintain its effects. Supervision of psychological interventions is equally varied and not always available. Finally, there is a tendency in the field to eclecticism fuelled by the perception that all approaches are either equally valid or equally ineffective.

6.2. THERAPIST FACTORS

Several therapist factors that could potentially affect treatment have been considered, including demographics, professional background, training, use of supervision and competence. Two related aspects are dealt with below, namely the therapeutic alliance and therapist competence.

6.2.1. The therapeutic alliance

There are various definitions of the therapeutic alliance, but in general terms it is viewed as a constructive relationship between therapist and client, characterised by a positive and mutually respectful stance in which both parties work on the joint enterprise of change. Bordin (1979) conceptualised the alliance as having three elements: agreement on the relevance of the tasks (or techniques) employed in therapy; agreement about the goals or outcomes the therapy aims to achieve; and the quality of the bond between therapist and patient.

There has been considerable debate about the importance of the alliance as a factor in promoting change, with some commentators arguing that technique is inappropriately privileged over the alliance, a position reflected in many humanistic models where the therapeutic relationship itself is seen as integral to the change process, with technique relegated to a secondary role (for example, Rogers, 1951). The failure of some comparative trials to demonstrate differences in outcome between active psychological therapies (for example, Elkin, 1994; Miller & Wilbourne, 2002) is often cited in support of this argument and is usually referred to as ‘the dodo-bird hypothesis’ (Luborsky et al., 1975). However, apart from the fact that dodo-bird findings may not be as ubiquitous as is sometimes claimed, this does not logically imply that therapy technique is irrelevant to outcome. Identifying and interpreting equivalence of benefit across therapies remains a live debate (for example, Ahn & Wampold, 2001; Stiles et al., 2006) but should also include a consideration of cost effectiveness as well as clinical efficacy (NICE, 2008a).

Meta-analytic reviews report consistent evidence of a positive association of the alliance with better outcomes with a correlation of around 0.25 (for example, Horvath & Symonds, 1991; Martin et al., 2000), a finding that applies across a heterogeneous group of trials (in terms of variables such as type of therapy, nature of the disorder, client presentation, type of measures applied and the stage of therapy at which measures are applied). However, it is the consistency rather than the size of this correlation that is most striking because a correlation of 0.25 would suggest it could account for only 6% of the variance in the outcome. Specific studies of the role of the alliance in drug and alcohol treatment programmes have been conducted. Luborsky and colleagues (1985), Connors and colleagues (1997) and Ilgen and colleagues, (2006) reported a relationship between treatment outcomes, but others (for example, Ojehagen et al., 1997) have not. Ojehagen and colleagues (1997) suggest that this discrepancy between the various studies may have arisen from methodological differences between the studies; in contrast to Luborsky and colleagues (1985), Connors and colleagues (1997) and Ilgen and colleagues (2006), in Ojehagen and colleagues' (1997) study ratings of the alliance were made by an independent rater from video tapes as opposed to ratings made by the therapist early in treatment. This is consistent with other studies; for example, Feeley and colleagues (1999) reported that alliance quality was related to early symptom change. Therefore, it seems reasonable to debate the extent to which a good alliance is necessary for a positive outcome of an intervention, but it is unlikely to be sufficient to account for the majority of the variance in outcome.

6.2.2. Therapist competence

Studies of the relationship between therapist competence and outcome suggest that all therapists have variable outcomes, although some therapists produce consistently better outcomes (for example, Okiishi et al., 2003). There is evidence that more competent therapists produce better outcomes (Barber et al., 1996 and 2006; Kuyken & Tsivrikos, 2009). This is also the case for psychological interventions in the alcohol field; the Project MATCH Research Group (1998) reported therapist differences that impact on outcome. A number of studies have also sought to examine more precisely therapist competence and its relation to outcomes; that is, what is it that therapists do to achieve good outcomes? A number of studies are briefly reviewed here.

This section draws on a more extensive review of the area by Roth and Pilling (2011), which focused on CBT because this area had the most extensive research. In an early study, Shaw and colleagues (1999) examined competence in the treatment of 36 patients treated by eight therapists offering CBT as part of the National Institute of Mental Health trial of depression (Elkin et al., 1989). Ratings of competence were made on the Cognitive Therapy Scale (CTS). Although the simple correlation of the CTS with outcome suggested that it contributed little to outcome variance, regression analyses indicated a more specific set of associations; specifically, when controlling for pre-therapy depression scores, adherence and the alliance, the overall CTS score accounted for 15% of the variance in outcome. However, a subset of items on the CTS accounted for most of this association.

Some understanding of what may account for this association emerges from three studies by DeRubeis's research group (Feeley et al., 1999; Brotman et al., 2009). All of the studies made use of the Collaborative Study Psychotherapy Rating Scale (CSPRS: Hollon et al., 1988), subscales of which contained items specific to CBT. On the basis of factor analysis, the CBT items were separated into two subscales labelled ‘cognitive therapy – concrete’ and ‘cognitive therapy – abstract’. Concrete techniques can be thought of as pragmatic aspects of therapy (such as establishing the session agenda, setting homework tasks or helping clients identify and modify negative automatic thoughts). Both DeRubeis and Feeley (1990) and Feeley and colleagues (1999) found some evidence for a significant association between the use of ‘concrete’ CBT techniques and better outcomes. The benefits of high levels of competence over and above levels required for basic practice has been studied in most detail in the literature on CBT for depression. In general, high severity and comorbidity, especially with Axis II pathology, have been associated with poorer outcomes in therapies, but the detrimental impact of these factors is lessened for highly competent therapists. DeRubeis and colleagues (2005) found that the most competent therapists had good outcomes even for patients with the most severe levels of depression. Kuyken and Tsivrikos (2009) found that therapists who are more competent have better patient outcomes regardless of the degree of patient comorbidity. In patients with neurotic disorders (Kingdon et al., 1996) and personality disorders (Davidson et al., 2004), higher levels of competence were associated with greater improvements in depressive symptoms. Although competence in psychological therapies is hard to measure in routine practice, degrees of formal training (Brosan et al., 2007) and experience in that modality (James et al., 2001) are associated with competence and are independently associated with better outcomes (Burns & Nolen-Hoeksema, 1992). All therapists should have levels of training and experience that are adequate to ensure a basic level of competence in the therapy they are practicing, and the highest possible levels of training and experience are desirable for those therapists treating patients with severe, enduring or complex presentations. In routine practice in services providing psychological therapies for depression, therapists should receive regular supervision and monitoring of outcomes. Roth and colleagues (2010) reviewed the training programmes associated with clinical trials as part of a programme exploring therapist competence (Roth & Pilling, 2008). They showed that clinical trials are associated with high levels of training, supervision and monitoring–factors that are not always found in routine practice. This is partly due to the inadequate description of training programmes in the trial reports. However, there is an increasing emphasis on describing the process of training in clinical trials, the report by Tober and colleagues (2005) being a notable recent publication describing the training programme for UKATT.

Trepka and colleagues (2004) examined the impact of competence by analysing outcomes in Cahill and colleagues' (2003) study. Six clinical psychologists (with between 1 and 6 years' post-qualification experience) treated 30 clients with depression using CBT, with ratings of competence made on the CTS. In a completer sample (N = 21) better outcomes were associated with overall competence on the CTS (r = 0.47); in the full sample this association was only found with the ‘specific CBT skills’ subscale of the CTS. Using a stringent measure of recovery (a Beck Depression Inventory score no more than one SD from the non-distressed mean), nine of the ten completer patients treated by the more competent therapists recovered, compared with four of the 11 clients treated by the less competent therapists. These results remained even when analysis controlled for levels of the therapeutic alliance.

Miller and colleagues (1993) looked at therapist behaviours in a brief (two-session) ‘motivational check-up’; they identified one therapist behaviour (a confrontational approach) that was associated with increased alcohol intake. Agreeing and monitoring homework is one of the set of ‘concrete’ CBT skills identified above. All forms of CBT place an emphasis on the role of homework because it provides a powerful opportunity for clients to test their expectations. A small number of studies have explored whether compliance with homework is related to better outcomes, although rather fewer have examined the therapist behaviours associated with better client ‘compliance’ with homework itself. Kazantzis and colleagues (2000) report a meta-analysis of 27 trials of cognitive and/or behavioural interventions that contained data relevant to the link between homework assignment, compliance and outcome. In 19 trials, clients were being treated for depression or anxiety; the remainder were seen for a range of other problems. Of these, 11 reported on the effects of assigning homework in therapy and 16 on the impact of compliance. The type of homework varied, as did the way in which compliance was monitored, although this was usually by therapist report. Overall there was a significant, although modest, association between outcome and assigning homework tasks (r = 0.36), and between outcome and homework compliance (r = 0.22). While Kazantzis and colleagues (2000) indicate that homework has greater impact for clients with depression than anxiety disorders, the number of trials on which this comparison is made is small and any conclusions must therefore be tentative.

Bryant and colleagues (1999) examined factors leading to homework compliance in 26 clients with depression receiving CBT from four therapists. As in other studies, greater compliance with homework was associated with better outcome. In terms of therapist behaviours, it was not so much therapists' CBT-specific skills (such as skilfully assigning homework or providing a rationale for homework) that were associated with compliance, but ratings of their general therapeutic skills and particularly whether they explicitly reviewed the homework assigned in the previous session. There was also some evidence that compliance was increased if therapists checked how the client felt about the task being set and identified potential difficulties in carrying it out.

6.3. MATCHING EFFECTS/SEVERITY

One of the main challenges in providing services for alcohol treatment is to increase the effectiveness of the interventions offered. The concept of tailoring treatments to particular types of clients to increase effectiveness has been appealing to researchers both in terms of its logical plausibility and as a possible explanation for the reason why no one intervention has universal effectiveness. However, despite this, there is limited evidence to date that matching people with alcohol misuse or dependence to treatment approaches demonstrates effectiveness.

In 1989 the NIAAA began the largest national multisite RCT of alcoholism treatment matching, entitled Matching Alcoholism Treatments to Client Heterogeneity (Project MATCH). This study outlined matching hypotheses that were investigated across both ‘outpatient’ and ‘aftercare’ settings following inpatient or day hospital treatment. Clients were randomly allocated to one of three manual-guided treatment approaches individually offered, namely cognitive behavioural coping-skills therapy, MET or TSF therapy (Project MATCH Research Group, 1997). However, tests of the primary matching hypotheses over the 4- to 15-month follow-up period revealed few matching effects. Of the variables considered, psychiatric severity was considered an attribute worthy of further consideration because this alone appeared to influence drinking at 1-year follow-up. A UK trial later explored client treatment-matching in the treatment of alcohol misuse comparing MET with SBNT (UKATT Research Team, 2007), the findings of which strongly supported those of Project MATCH in that none of the five matching hypotheses was supported at either follow-up point on any outcome measure.

Despite the limited findings from these major trials, other studies have detected more positive conclusions that have highlighted methodological considerations associated with matching. Several studies have acknowledged the usefulness of matching treatment approaches for individuals who are experiencing severe psychiatric comorbidity. In a trial comparing people with alcohol dependence with a range of psychiatric impairments, more structured coping-skills training yielded lower relapse rates at 6-month follow-up (Kadden et al., 1989). Studies that looked specifically at matching in the context of psychiatric disturbance have acknowledged that the severity of the psychiatric presentation has a negative impact upon the relapse rates (Brown et al., 2002), although matching appears to have assisted in retaining individuals in treatment (McLellan et al., 1997). Although in some cases no significant differences have been detected between overall relapse rates when matching treatments at 2 years' follow-up, relapse to alcohol was found to have occurred more slowly where high psychiatric co-morbidity is matched with more structured coping-skills training (Cooney et al., 1991).

The importance of service user choice in relation to self-matching treatments has been associated with more positive outcomes in two studies (Brown et al., 2002; UKATT Research Group, 2007), whilst other trials have emphasised the negative consequences of ‘mismatching’ including earlier relapse (Cooney et al., 1991), poorer outcomes (Karno & Longabaugh, 2007) and increased need of support services (Conrod et al., 2000).

Treatment providers are now required to consider not only treatment efficacy but also cost effectiveness, and for this reason treatment matching has remained an appealing option (Moyer et al., 2000). However, for the findings of matching trials to be meaningful, one must consider a variety of methodological issues. Many of the recent studies considered have involved small samples, comparing a diverse range of variables both in terms of sample characteristics and treatment process factors (McLellan & Alterman, 1991). It has been suggested that for trials to provide more meaningful findings, there is a need for a clearer focus on matching questions which then focus upon well-specified treatments that have clear goals with specific patient populations. In this way, such designs may be more likely to provide interpretable results as well as a clearer understanding of the processes likely to be responsible for such findings.

Despite the steady development of patient-treatment matching studies in relation to alcohol dependence, the outcomes to date indicate that there is no single treatment that is effective for all clients. There continue to be many obstacles to matching clients to specific treatment programmes in real world settings and for many organisations patient–treatment matching remains impractical. Research would appear to indicate that the nature and severity of co-morbid and complex presentations such as psychiatric disturbance have a negative impact upon treatments for addiction, and this is arguably an area for further research (McLellan et al., 1997). It has been suggested that, given the diversity of presentations and the large number of variables implicated in such research, the development of reliable and generalisable measures will be important for both the effective training and evaluation of treatment-matching efficacy (McLellan & Alterman, 1991).

6.4. SETTING THE CONTEXT FOR 12-STEP FACILITATION AND ALCOHOLICS ANONYMOUS

The 12-step principles were first set out in a publication by AA in the 1950s. AA describes itself as a ‘Fellowship’ and AA groups are widely available in the UK as support networks for people with alcohol dependence. AA is a self-help movement with the 12-step principles at the core. The 12 steps lay out a process that individuals are recommended to follow, based on an assumption that dependence on alcohol is a disease and therefore a goal of lifelong abstinence should be promoted. Membership is entirely voluntary and free of charge, there is a spiritual element to participation and life-long membership is encouraged. Attendance has been associated with successful abstinence from alcohol in a number of studies (see Ferri and colleagues [2006] for a systematic review).

Most 12-step treatment is predicated on the understanding that the treatment would fail without subsequent attendance at 12-step fellowship meetings. However, a common problem in the treatment of alcohol dependence with AA or 12-step groups is that people who misuse alcohol frequently discontinue AA involvement at the end of their designated treatment period and usually do not continue with aftercare treatment (Kaskutas et al., 2005; Kelly et al., 2003; Moos et al., 2001; Tonigan et al., 2003). As a result, manual-guided TSF has been developed as an active standalone or adjunctive intervention which involves: introducing the person who misuses alcohol to the principles of AA and the 12 steps of treatment (for example, Project MATCH Research Group, 1993), providing information on AA facilitates in the geographical area, and engaging with the client in setting goals for attendance and participation in the meetings. The aim of TSF is to maintain abstinence whilst in treatment and to sustain gains made after treatment concludes. This guideline is concerned with the use of TSF as an active intervention in the treatment of alcohol dependence and harmful alcohol use. An evaluation of the classic AA approach is outside the scope of this guideline.

6.5. REVIEW OF PSYCHOLOGICAL THERAPIES

6.5.1. Aim of review

This section aims to review the evidence for psychological interventions without pharmacological interventions for the treatment of alcohol dependence and harmful alcohol use. The literature reviewed in this section is focused on a reduction or cessation of drinking and hence assesses any outcomes pertaining to this. Most of the literature in the field is focused on adults over the age of 18 years. However, for young people under the age of 18 years old, literature assessing the clinical efficacy of psychological therapies for alcohol misuse alone (without comorbid drug misuse) is limited. The psychological evidence below is for an adult population only and a review of the evidence for the treatment of young people is described in Section 6.22.

Psychological interventions were considered for inclusion in the review if they were:

  • Planned treatment
  • For treatment-seeking participants only (of particular importance for the brief interventions because the scope did not cover opportunistic brief interventions – see scope, Appendix 1)
  • Manual-based or, in the absence of a formal manual, the intervention should be well-defined and structured
  • Ethical and safe

The following psychological therapies used in the treatment of alcohol misuse were considered for inclusion in this guideline:

  • Brief interventions (planned only)

    for example, psychoeducational and motivational techniques

  • Self-help based treatments

    brief self-help interventions (including guided self-help/bibliotherapy)

  • TSF
  • Cognitive behavioural-based therapies

    standard cognitive behavioural therapy

    coping skills

    social skills training

    relapse prevention

  • Behavioural therapies

    cue exposure

    BSCT

    contingency management

    aversion therapy

  • MET
  • Social network and environment-based therapies

    social behaviour and network therapy (SBNT)

    the community reinforcement approach

  • Counselling

    couples therapy (including behavioural couples therapy and other variants of couples therapy)

  • Family-based interventions

    functional family therapy

    brief strategic family therapy

    multisystematic therapy

    five-step family interventions

    multidimensional family therapy

    community reinforcement and family training

  • Psychodynamic therapy

    short-term psychodynamic intervention

    supportive expressive psychotherapy.

In addition, physical therapies such as meditation and acupuncture are also covered in this review.

Good quality RCT evidence for the clinical efficacy of some of the psychological therapies listed was not always available. Therefore, the evidence summaries in this chapter describe the psychological therapies for which evidence of sufficient quality (see Chapter 3 for methodological criteria) was available. There are a number of useful studies that add value to the RCT data presented and they are included in this review. For the purpose of this guideline, and to obtain an overview of the available literature, studies that have met other methodological criteria are described in the evidence summaries of the individual therapies.

Full characteristics of included studies, forest plots and GRADE profiles can be found in Appendix 16d, 17c and 18c, respectively, because they were too extensive to place within this chapter.

6.5.2. Review questions

Primary review questions addressed in this chapter:

  1. For people with alcohol dependence or who are harmful drinkers, is psychological treatment x, when compared with y, more clinically and cost effective and does this depend on:
    • presence of comorbidities
    • subtypes (matching effects)
    • therapist-related factors (quality, therapeutic alliance, competence, training and so on).

6.6. OUTCOMES

There were no consistent critical outcomes across studies and outcomes were mainly continuous in nature. This variability in outcomes poses some difficulties in pooling data from different studies. Therefore, continuous outcomes were grouped into three categories:

  • Abstinence, for example,

    percentage/proportion of days abstinent

    abstinent days per week/month

    longest duration abstinent

  • Rates of consumption, for example,

    percentage/proportion of days heavy drinking

    drinking days per month

    days drinking greater than X drinks per week

  • Amount of alcohol consumed, for example,

    DDD

    mean number of drinks per week

    grams of alcohol per drinking day

    number of drinks per drinking episode.

Dichotomous outcomes included:

  • abstinence (number of participants abstinent)
  • lapse (number of participants who have drank at all)
  • relapse (number of participants who have drank more than X number of drinks)
  • attrition (the number of participants leaving the study for any reason).

Studies varied in their definition of these dichotomous terms. For example, the number of drinks defined as constituting a relapse varied.

6.7. MOTIVATIONAL TECHNIQUES

6.7.1. Definition

Motivational enhancement therapy (MET) is the most structured and intensive motivational-based intervention. It is based on the methods and principles of motivational interviewing (Miller et al., 1992). It is patient centred and aims to result in rapid internally-motivated changes by exploring and resolving ambivalence towards behaviour. The treatment strategy of motivational interviewing is not to guide the client through recovery step-by-step, but to use motivational methods and strategies to utilise the patient's resources. A more specific manualised and structured form of motivational interviewing based on the work of Project MATCH is usually utilised (Project MATCH Research Group, 1993).

Brief motivational interventions include the computerised Drinker's Check-Up (DCU), which assesses symptoms of dependence, alcohol-related problems and motivation for change, and ‘feedback, responsibility, advice, menu, empathy, self-efficacy’ (FRAMES; Bien et al., 199332).

6.7.2. Clinical review protocol (motivational techniques)

Information about the databases searched and the inclusion/exclusion criteria used for this section of the guideline can be found in Chapter 3 (further information about the search for health economic evidence can be found in Section 6.21 of this chapter). See Table 32 below for a summary of the clinical review protocol for the review of motivational techniques.

Table 32. Clinical review protocol for the review of motivational techniques.

Table 32

Clinical review protocol for the review of motivational techniques.

6.7.3. Studies considered for review33

The review team conducted a systematic review of RCTs that assessed the beneficial or detrimental effects of motivational techniques in the treatment of alcohol dependence or harmful alcohol use. See Table 33 for a summary of the study characteristics. It should be noted that some trials included in analyses were three- or four-arm trials. To avoid double counting, the number of participants in treatment conditions used in more than one comparison was divided (by half in a three-arm trial and by three in a four-arm trial).

Table 33. Summary of study characteristics for motivational techniques.

Table 33

Summary of study characteristics for motivational techniques.

Eight trials relating to clinical evidence met the eligibility criteria set by the GDG, providing data on 4,209 participants. All eight studies were published in peer-reviewed journals between 1997 and 2007. A number of studies identified in the search were initially excluded because they were not relevant to this guideline. Studies were excluded because they did not meet methodological criteria (see Chapter 3). When studies did meet basic methodological inclusion criteria, the main reason for exclusion was not meeting the drinking quantity/diagnostic criteria; that is, participants were not drinking enough to be categorised as harmful or dependent drinkers, or less than 80% of the sample met criteria for alcohol dependence or harmful alcohol use. Other reasons were that treatment was opportunistic as opposed to planned, the study was not directly relevant to the review questions, or no relevant alcohol-focused outcomes were available. A list of excluded studies can be found in Appendix 16d.

Motivational techniques versus minimal intervention control

Of the eight included trials, three that involved a comparison of motivational techniques versus control met the criteria for inclusion. HESTER2005 assessed the drinker's check-up versus waitlist control; ROSENBLUM2005b investigated MET plus relapse prevention versus information and referral only; and SELLMAN2001 assessed MET versus feedback only. The included studies were conducted between 2001 and 2005. The 5-year follow-up outcomes were obtained from Adamson and Sellman (2008).

Motivational techniques versus other active intervention

Of the eight included trials, six assessed motivational techniques versus another active intervention met criteria for inclusion. DAVIDSON2007 investigated MET versus cognitive behavioural broad spectrum therapy; MATCH1997 assessed MET versus both CBT and TSF; SELLMAN2001 compared MET with non-directive reflective listening (counselling); SHAKESHAFT2002 assessed FRAMES with CBT; SOBELL2002 compared motivational enhancement/personalised feedback with psychoeducational bibliotherapy/drinking guidelines; and, lastly, UKATT2005 investigated MET versus SBNT. The included studies were conducted between 1997 and 2007.

6.7.4. Evidence summary34

The GRADE profiles and associated forest plots for the comparisons can be found in Appendix 18c and Appendix 17c, respectively.

Motivational techniques versus minimal intervention control

One computerised session of MET (drinker's check up) was significantly better than control in reducing average drinks per day at 1-month follow-up (moderate effect size). However, this finding was based on the results of a single study. Furthermore, no significant difference in average drinks per day and DDD was observed between the drinker's check up and control at 2- and 12-month follow-up.

MET (with relapse prevention) (ROSENBLUM2005b) was significantly more effective than control at reducing heavy alcohol use when assessed at 5-month follow-up (moderate effect size). This was further supported by the SELLMAN2001 study, which favoured MET over control in the number of people who drank excessively and frequently (ten or more drinks, six or more times) at 6-month follow-up (large effect size). However, this effect was not observed at long follow-up assessment (5 years). Although no significant difference was observed between groups in reducing the days on which any alcohol was consumed, the analyses showed a trend favouring MET with relapse prevention over control (p = 0.07). No significant difference in attrition rates were observed between MET and control groups across studies.

The quality of this evidence is moderate and further research is likely to have an important impact on confidence in the estimate of the effect. An evidence summary of the results of the meta-analyses can be seen in Table 34.

Table 34. Motivational techniques versus control evidence summary.

Table 34

Motivational techniques versus control evidence summary.

Motivational techniques versus other active intervention

The clinical evidence showed that no significant difference could be found between motivational techniques and other active interventions in maintaining abstinence at up to 15-month follow-up. Furthermore, no difference between groups was observed in reducing the number of participants who had lapsed or reducing heavy drinking at all follow-up points.

Other therapies (namely CBT and TSF) were more effective than motivational techniques in reducing the quantity of alcohol consumed when assessed post-treatment. However, the effect size was small (0.1) and was no longer seen at longer follow-up points of 3 to 15 months.

No significant difference was observed between groups in attrition rates post-treatment or at 3-month follow-up. However, other therapies were more effective at retaining participants at 6-month follow-up (low effect size). Follow-up periods longer than 6 months did not indicate any significant difference between groups.

The quality of this evidence is moderate, therefore further research is likely to have an important impact on confidence in the estimate of the effect. An evidence summary of the results of the meta-analyses can be seen in Table 35.

Table 35. Motivational techniques versus other intervention evidence summary.

Table 35

Motivational techniques versus other intervention evidence summary.

6.8. 12-STEP FACILITATION

6.8.1. Definition

TSF is based on the 12-step or AA concept that alcohol misuse is a spiritual and medical disease (see Section 6.4 for a discussion of AA). As well as a goal of abstinence, this intervention aims to actively encourage commitment to and participation in AA meeting. Participants are asked to keep a journal of AA attendance and participation, and are given AA literature relevant to the ‘step’ of the programme that they have reached. TSF is highly structured and manualised (Nowinski et al., 1992) and involves a weekly session in which the patient is asked about their drinking, AA attendance and participation, given an explanation of the themes of the current sessions, and goals for AA attendance are set.

6.8.2. Clinical review protocol (12-step facilitation)

Information about the databases searched and the inclusion/exclusion criteria used for this section of the guideline can be found in Chapter 3 (further information about the search for health economic evidence can be found in Section 6.21). See Table 36 below for a summary of the clinical review protocol for the review of TSF.

Table 36. Clinical review protocol for the review of 12-step facilitation.

Table 36

Clinical review protocol for the review of 12-step facilitation.

6.8.3. Studies considered for review

The review team conducted a systematic review of RCTs that assessed the beneficial or detrimental effects of TSF in the treatment of alcohol dependence or harmful alcohol use. See Table 37 for a summary of the study characteristics. It should be noted that some trials included in analyses were three- or four-arm trials. To avoid double counting, the number of participants in treatment conditions used in more than one comparison was divided (by half in a three-arm trial, and by three in a four-arm trial).

Table 37. Summary of study characteristics for 12-step facilitation.

Table 37

Summary of study characteristics for 12-step facilitation.

Six trials relating to clinical evidence met the eligibility criteria set by the GDG, providing data on 2,556 participants. All six studies were published in peer-reviewed journals between 1997 and 2009. A number of studies identified in the search were initially excluded because they were not relevant to this guideline. Studies were excluded because they did not meet methodological criteria (see Chapter 3). When studies did meet basic methodological inclusion criteria, the main reason for exclusion was that the studies were assessing the efficacy of 12-step groups (that is, AA) directly (not TSF) and hence were also naturalistic studies. Other reasons included a drug and not alcohol focus, secondary analysis and not being directly relevant to the current guideline. A list of excluded studies can be found in Appendix 16d.

12-step facilitation versus other active intervention

Of the six included trials, five compared TSF with another active intervention. The comparator against TSF was CBT (EASTON2007), couples therapy and psychoeducational intervention (FALSSTEWART2005; FALSSTWEART2006), MET and CBT (MATCH1997), and coping skills (WALITZER2009).

Comparing different formats of 12-step facilitation

Two included studies assessed one form of TSF versus another. TIMKO2007 evaluated intensive TSF versus standard TSF. In the standard TSF condition, people who misuse alcohol were given an AA schedule and encouraged to attend sessions. Counsellors and patients reviewed relapse prevention, but treatment was more focused on psychoeducation. In the intensive TSF condition, standard treatment was provided and counsellors actively arranged AA meeting attendance. Participants were encouraged to keep an AA attendance journal. WALITZER2009 assessed a directive approach to TSF versus a motivational approach to TSF in addition to treatment-as-usual (coping skills).

6.8.4. Evidence summary

The GRADE profiles and associated forest plots for the comparisons can be found in Appendix 18c and Appendix 17c, respectively.

12-step facilitation versus other active interventions

The clinical evidence revealed no significant difference between TSF and other active interventions in maintaining abstinence, reducing heavy drinking episodes when assessed post-treatment and at various follow-up points up to 12 months. TSF was significantly better than other active interventions in reducing the amount of alcohol consumed when assessed at 6-month follow-up. However, the effect size was small (SMD = −0.09) and no significant difference between groups was observed for any other follow-up points.

No significant difference in attrition rates was observed between TSF and other active interventions in attrition post-treatment and up to 6-month follow-up. However, those receiving TSF were more likely to be retained at 9-month follow-up, although his difference was not observed at 12- and 15-month follow-up.

The quality of this evidence is high, therefore further research is unlikely to change confidence in the estimate of the effect. An evidence summary of the results of the meta-analyses can be seen in Table 38.

Table 38. 12-Step Facilitation versus other intervention evidence summary.

Table 38

12-Step Facilitation versus other intervention evidence summary.

Comparing different formats of 12-step facilitation

Directive TSF was more effective at maintaining abstinence than motivational TSF up to 12-month follow-up (RR = −0.41 to −0.81 across follow-up points). However, no difference between groups was observed in reducing heavy drinking episodes.

In addition, intensive TSF was significantly more effective than standard TSF in maintaining abstinence at 12-month follow-up (RR = 0.81).

No significant difference between TSF methods was observed in attrition post-treatment or at various follow-up points up to 12 months.

Additionally, KAHLER2004 was identified as assessing brief advice to facilitate AA involvement versus a motivational enhancement approach to facilitate AA involvement. This study could not be included in analyses because data could not be extracted. However, the study reported that although AA attendance was associated with better drinking outcomes, the more intensive motivational enhancement format of facilitating involvement did not improve involvement in AA and hence did not result in better alcohol outcomes.

The quality of this evidence is moderate, therefore further research is likely to have an important impact on confidence in the estimate of the effect and may change the estimate (see Appendix 18c). An evidence summary of the results of the meta-analyses can be seen in Table 39.

Table 39. Comparing different formats of 12-step facilitation evidence summary.

Table 39

Comparing different formats of 12-step facilitation evidence summary.

6.9. COGNITIVE BEHAVIOURAL THERAPY

6.9.1. Definition

CBT encompasses a range of therapies, in part derived from the cognitive behavioural model of affective disorders in which the patient works collaboratively with a therapist using a shared formulation to achieve specific treatment goals. Such goals may include recognising the impact of behavioural and/or thinking patterns on feeling states and encouraging alternative cognitive and/or behavioural coping skills to reduce the severity of target symptoms and problems. Cognitive behavioural therapies include standard CBT, relapse prevention, coping skills and social skills training.

Standard cognitive behavioural therapy

Standard CBT is a discrete, time-limited, structured psychological intervention, derived from a cognitive model of drug misuse (Beck et al., 1993). There is an emphasis on identifying and modifying irrational thoughts, managing negative mood and intervening after a lapse to prevent a full-blown relapse.

Relapse prevention

A CBT adaptation based on the work of Marlatt and Gordon (1985), this incorporates a range of cognitive and behavioural therapeutic techniques to identify high-risk situations, alter expectancies and increase self-efficacy. This differs from standard CBT in the emphasis on training people who misuse alcohol to develop skills to identify situations or states where they are most vulnerable to alcohol use, to avoid high-risk situations, and to use a range of cognitive and behavioural strategies to cope effectively with these situations (Annis, 1986; Marlatt & Gordon, 1985).

Coping and social skills training

Coping and social skills training is a variety of CBT that is based on social learning theory of addiction and the relationship between drinking behaviour and life problems (Kadden et al., 1992; Marlatt & Gordon, 1985). Treatment is manual-based (Marlatt & Gordon, 1985) and involves increasing the individual's ability to cope with high-risk social situations and interpersonal difficulties.

6.9.2. Clinical review protocol (cognitive behavioural therapies)

Information about the databases searched and the inclusion/exclusion criteria used for this Section of the guideline can be found in Chapter 3 (further information about the search for health economic evidence can be found in Section 6.21). See Table 40 below for a summary of the clinical review protocol for the review of cognitive behavioural therapies.

Table 40. Clinical review protocol for the review of cognitive behavioural therapies.

Table 40

Clinical review protocol for the review of cognitive behavioural therapies.

6.9.3. Studies considered for review

The review team conducted a systematic review of RCTs that assessed the beneficial or detrimental effects of cognitive behavioural therapies in the treatment of alcohol dependence or harmful alcohol use. See Table 41 for a summary of the study characteristics. It should be noted that some trials included in analyses were three- or four-arm trials. To avoid double counting, the number of participants in treatment conditions used in more than one comparison was divided (by half in a three-arm trial, and by three in a four-arm trial).

Table 41. Summary of study characteristics for cognitive behavioural therapies.

Table 41

Summary of study characteristics for cognitive behavioural therapies.

Twenty RCT trials relating to clinical evidence met the eligibility criteria set by the GDG, providing data on 3,970 participants. All 20 studies were published in peer-reviewed journals between 1986 and 2009. A number of studies identified in the search were initially excluded because they were not relevant to this guideline. Studies were excluded because they did not meet methodological criteria (see Chapter 3). When studies did meet basic methodological inclusion criteria, the main reasons for exclusion were not having alcohol-focused outcomes that could be used for analysis and not meeting drinking quantity/diagnosis criteria (that is, participants were not drinking enough to be categorised as harmful or dependent drinkers, or less than 80% of the sample met criteria for alcohol dependence or harmful alcohol use). Other reasons were that the study was outside the scope of this guideline, presented secondary analyses, and was drug-focused or did not differentiate between drugs and alcohol, and was focused on aftercare. A list of excluded studies can be found in Appendix 16d.

Cognitive behavioural therapies versus treatment as usual or control35

Three studies compared CBT with treatment as usual or control. BURTSCHEIDT2002 assessed CBT versus coping skills versus treatment as usual (unstructured, nonspecific support and therapy). MONTI1993 investigated cue exposure with coping skills against control (unspecified treatment as usual and daily cravings monitoring). ROSENBLUM2005B assessed relapse prevention with MET versus control (information and referral only).

Cognitive behavioural therapies versus other active intervention

Thirteen studies assessed CBT versus another active intervention. CONNORS2001 was complex in design and investigated alcohol-focused coping skills with or without the addition of life coping skills and with or without the addition of psychoeducational interventions at different intensities. Additionally, the study investigated the difference between low- and high-intensity treatment of these conditions. The results of the 30-month follow-up were obtained from Walitzer and Connors (2007). The other studies included in this analyses were DAVIDSON2007 (broad-spectrum treatment versus MET), EASTON2007 (CBT versus TSF), ERIKSEN1986B and LITT2003 (both assessed coping skills versus group counselling), LAM2009 (coping skills versus BCT with/without parental skills training), MATCH1997 (CBT versus both MET and TSF), MORGENSTERN2007 (coping skills with MET versus MET alone), SANDAHL1998 (relapse prevention versus psychodynamic therapy), SHAKESHAFT2002 (CBT versus FRAMES), SITHARTHAN1997 (CBT versus cue exposure), VEDEL2008 (CBT versus BCT) and WALITZER2009 (coping skills versus TSF).

Comparing different formats of cognitive behavioural therapy

Six studies investigated one form of CBT versus another form of CBT. BURTSCHEIDT2001 investigated CBT versus coping skills; MARQUES2001 assessed group versus individual CBT); CONNORS2001 investigated different intensities of alcohol-focused coping skills; LITT2009 assessed a packaged CBT program versus an individual assessment treatment program, which was cognitive behavioural in nature; MONTI1990 investigated communication skills training (both with and without family therapy) as well as cognitive behavioural mood management training; and ROSENBLUM2005A investigated relapse prevention versus relapse prevention with motivational enhancements.

6.9.4. Evidence summary

The GRADE profiles and associated forest plots for the comparisons can be found in Appendix 18c and Appendix 17c, respectively.

Cognitive behavioural therapies versus treatment as usual or control

Cognitive behavioural therapies were significantly better than control at reducing heavy drinking episodes but no significant difference between groups was observed for a reduction in days any alcohol is used (assessed post-treatment) or the number of participants who have lapsed and relapsed (assessed at 3-month follow-up) when compared with treatment as usual. However, resulting in a moderate effect size, cognitive behavioural therapies were significantly better than treatment as usual in reducing the number of participants who lapsed and relapsed when assessed at 6-month follow-up. No difference between groups was observed in attrition rates post-treatment or at 6-month follow-up.

The quality of this evidence is moderate, therefore further research is likely to have an important impact on confidence in the estimate of the effect and may change the estimate (see Appendix 18c for full GRADE profile).

One study assessing cognitive behavioural therapies versus control could not be added to the meta-analyses. Källmén and colleagues 2003 could not be included because the data was presented in an unusable format. The study reported that the control group (unstructured discussion) drank significantly less alcohol at 18-month follow-up than the group receiving coping skills. An evidence summary of the results of the meta-analyses can be seen in Table 42.

Table 42. Cognitive behavioural therapies versus TAU or control evidence summary.

Table 42

Cognitive behavioural therapies versus TAU or control evidence summary.

Cognitive behavioural therapies versus other active intervention

Meta-analyses results revealed no significant difference between cognitive behavioural therapies and other therapies in maintaining abstinence both post-treatment and up to 15-month follow-up. A single study, however, did favour coping skills over counselling in the number of sober days at 12-month follow-up, and another single study favouring relapse prevention over psychotherapy at 15-month follow-up. However, these single outcomes do not reflect the meta-analyses results described above. In addition, cognitive behavioural therapies were found to be more effective at maintaining abstinence/light days when assessed up to 18-month follow-up (based on data by CONNORS2001). No significant difference was observed between groups in reducing heavy drinking episodes and the amount of alcohol consumed both post-treatment and up to 18-month follow-up. A single study outcome (ERIKSEN1986B) favoured coping skills over counselling in reducing the amount of alcohol consumed, but, again, this single study was not reflective of other analyses with similar variables.

The VEDEL2008 study assessed severity of relapse in their sample. The results indicated that other active intervention (namely CBT) was more effective than couples therapy (namely BCT) in reducing occasions in which participants lapsed (drank over six drinks on one occasion) or relapsed (drank more than six drinks most days of the week), but no significant difference was observed in the number of participants who relapsed on a regular basis (a few times a month). It must be noted that effect sizes were small and the results of a single study cannot be generalised.

No significant difference was observed between CBT and other active therapies in attrition rates.

The quality of this evidence is high, therefore further research is unlikely to change confidence in the estimate of the effect. An evidence summary of the results of the meta-analyses can be seen in Table 43 and Table 44.

Table 43. Cognitive behavioural therapies versus other interventions evidence summary (1).

Table 43

Cognitive behavioural therapies versus other interventions evidence summary (1).

Table 44. Cognitive behavioural therapies versus other interventions evidence summary (2).

Table 44

Cognitive behavioural therapies versus other interventions evidence summary (2).

Comparing different formats of cognitive behavioural therapies

For maintaining abstinence, an individual assessment treatment programme was significantly more effective than a packaged CBT program when assessed post-treatment (moderate effect size, based on a single study). However, for the same comparison, no significant difference was observed between groups in reducing heavy drinking episodes. The addition of motivational enhancement to relapse prevention did not reduce the number of possible drinking days (at 6-month follow-up) and analyses favoured standard relapse prevention (moderate effect size). Furthermore, the addition of family therapy to coping skills did not show any significant benefit. Also, no significant difference in various drinking outcomes was observed between coping skills and other types of cognitive behavioural therapies (for example, cognitive behavioural mood-management training [CBMMT] when assessed at 6-month follow-up. No difference between CBT and coping skills were observed in the number of participants who had lapsed or relapsed at 6-month follow-up. No difference in attrition rates was observed between the various types of CBT.

More intensive coping skills was significantly better than standard coping skills at maintaining abstinent/light drinking at 12-month follow-up (moderate effect size) but this benefit was no longer significant at 18-month follow-up. Individual CBT was significantly more effective than group CBT in reducing the number of heavy drinkers at 15-month follow-up.

The quality of this evidence is moderate, therefore further research is likely to have an important impact on confidence in the estimate of the effect. An evidence summary of the results of the meta-analyses can be seen in Table 45 and Table 46.

Table 45. Comparing different formats of CBT evidence summary.

Table 45

Comparing different formats of CBT evidence summary.

Table 46. Comparing different formats of CBT evidence summary.

Table 46

Comparing different formats of CBT evidence summary.

6.10. BEHAVIOURAL THERAPIES (EXCLUDING CONTINGENCY MANAGEMENT)36

6.10.1. Definition

Behavioural interventions use behavioural theories of conditioning to help achieve abstinence from drinking by creating negative experiences/events in the presence of alcohol, and positive experiences/events in alcohol's absence. Behavioural therapies considered for review included cue exposure, behavioural self-control training, aversion therapy and contingency management. Variants of two therapies (cue exposure and behavioural self-control training) which were based on a similar theoretical understanding of the nature of alcohol misuse, were considered as a single entity for the purposes of the review. Contingency management, although a behavioural intervention, was analysed separately because it is based on the classic reinforcement model and has no alcohol specific formulation (see Section 6.11 for evidence review). Aversion therapy was excluded because it is no longer routinely used in alcohol-misuse treatment in the UK.

Cue exposure

Cue-exposure treatment for alcohol misuse is based on both learning theory and social learning theory models and suggests that environmental cues associated with drinking can elicit conditioned responses, which can in turn lead to a relapse (Niaura et al., 1988). The first case study using cue exposure treatment for excessive alcohol consumption was reported by Hodgson and Rankin (1976). Treatment is designed to reduce cravings for alcohol by repeatedly exposing the service user to alcohol-related cues until they ‘habituate’ to the cues and can hence maintain self-control in a real-life situation where these cues are present.

Behavioural self-control training

Behavioural self-control training is also referred to as ‘behavioural self-management training’ and is based on the techniques described by Miller and Munóz (1976). Patients are taught to set limits for drinking and self-monitor drinking episodes, undergo refusal-skills training and training for coping with behaviours in high-risk relapse situations. Behavioural self-control training is focused on a moderation goal rather than abstinence.

6.10.2. Clinical review protocol (behavioural therapies)

Information about the databases searched and the inclusion/exclusion criteria used for this section of the guideline can be found in Appendix 16d (further information about the search for health economic evidence can be found in Section 6.21). See Table 47, below, for a summary of the clinical review protocol for the review of behavioural therapies.

Table 47. Clinical review protocol for the review of behavioural therapies.

Table 47

Clinical review protocol for the review of behavioural therapies.

6.10.3. Studies considered for review

The review team conducted a systematic review of RCTs that assessed the beneficial or detrimental effects of behavioural therapies in the treatment of alcohol dependence or harmful alcohol use. See Table 48 for a summary of the study characteristics. It should be noted that some trials included in analyses were three- or four-arm trials.

Table 48. Summary of study characteristics for behavioural therapies.

Table 48

Summary of study characteristics for behavioural therapies.

To avoid double counting, the number of participants in treatment conditions used in more than one comparison was divided (by half in a three-arm trial, and by three in a four-arm trial).

Six RCT trials relating to clinical evidence met the eligibility criteria set by the GDG, providing data on 527 participants. All six studies were published in peer-reviewed journals between 1988 and 2006. A number of studies identified in the search were initially excluded because they were not relevant to this guideline. Studies were excluded because they did not meet the methodological criteria (see Chapter 3). When studies did meet basic methodological inclusion criteria, the main reasons for exclusion were not having alcohol-focused outcomes that could be used for analysis, and not meeting drinking quantity/diagnosis criteria, that is, participants were not drinking enough to be categorised as harmful or dependent drinkers or less than 80% of the sample meet criteria for alcohol dependence or harmful alcohol use. A list of excluded studies can be found in Appendix 16d.

Behavioural therapies versus control

Of the six included trials, there were two involving a comparison of behavioural therapies versus control which met criteria for inclusion. ALDEN1988 assessed behavioural self-management training versus waitlist control and MONTI1993 assessed cue exposure with coping skills versus control (treatment as usual and daily cravings monitoring). The included studies were conducted between 1988 and 1993.

Behavioural therapies versus other active interventions

Of the six included trials, four trials that evaluated behavioural therapies versus other active interventions met criteria for inclusion. Behavioural and other active therapies were as follows: ALDEN1988 (behavioural self-management versus developmental counselling); KAVANAGH2006 (cue exposure plus CBT versus emotional cue exposure plus CBT); SITHARTHAN1997 (cue exposure versus CBT); WALITZER2004 (behavioural self management versus BCT with alcohol-focused spousal involvement and alcohol-focused spousal involvement alone). The included studies were conducted between 1988 and 2006.

Comparing different formats of behavioural therapy

Of the six included trials, two trials that assessed one type of behavioural therapy versus another met criteria for inclusion. The behavioural therapies in the HEATHER2000 study were moderation-oriented cue exposure and behavioural self-control training. In the KAVANAGH2006 study, they were cue exposure (plus CBT) and emotional cue exposure (plus CBT). The included studies were conducted between 2000 and 2006.

6.10.4. Evidence summary

The GRADE profiles and associated forest plots for the comparisons can be found in Appendix 18c and Appendix 17c, respectively.

Behavioural therapies versus control/treatment as usual

The review evidence indicated that behavioural therapies were more effective than control in reducing the amount of alcohol consumed (SMD = −0.97, large effect size) and maintaining controlled drinking (SMD = −0.60, medium effect size) when assessed post-treatment. However, it must be noted that this was based on a single study.

No significant difference was observed between behavioural therapies and control in maintaining abstinence when assessed post-treatment. Furthermore, no significant difference could be found between behavioural therapies and control in the number of participants who lapsed or relapsed up to 6-month follow-up. In addition, there was no significant difference between behavioural therapies and control in attrition rates.

The quality of this evidence is moderate, therefore further research is likely to have an important impact on confidence in the estimate of the effect. An evidence summary of the results of the meta-analyses can be seen in Table 49.

Table 49. Behavioural therapy versus TAU or control evidence summary.

Table 49

Behavioural therapy versus TAU or control evidence summary.

Behavioural therapy versus other active intervention

The review evidence indicated that behavioural therapies were not as effective as other interventions (in this case, couples-based therapies) in maintaining abstinent/light drinking days up to 12-month follow-up. In addition, there was no significant difference between behavioural therapies and counselling in maintaining abstinence both post-treatment and up to 24-month follow-up.

No difference was observed between behavioural therapies and other active interventions (for example, CBT) in reducing the amount of alcohol consumed up to 24-month follow-up. However, one study (SITHARTHAN1997) showed a medium effect size favouring cue exposure over CBT in reducing drinks per occasion at 6-month follow-up.

Behavioural therapies were not as effective as other active interventions (namely couples therapies) in reducing heavy drinking days. Medium to high effects favouring couples therapy were found at all assessment points up to 12-month follow-up.

The review results revealed that other therapies (that is, CBT and counselling) had significantly less post-treatment attrition than behavioural therapies. However, no significant difference was observed between treatments at follow-up (3 to 24 months).

The quality of this evidence is moderate, therefore further research is likely to have an important impact on confidence in the estimate of the effect. An evidence summary of the results of the meta-analyses can be seen in Table 50.

Table 50. Behavioural therapy versus other intervention evidence summary.

Table 50

Behavioural therapy versus other intervention evidence summary.

Comparing different formats of behavioural therapy

The clinical evidence indicates that there was no significant difference between cue exposure and BSCT in maintaining abstinence post-treatment or at 6-month follow-up. Furthermore, no significant difference was observed between cue exposure and emotional cue exposure in reducing the amount of alcohol consumed at 6- to 12-month follow-up. In line with this, no significant difference was observed between moderation-oriented cue exposure and behaviour self-control training in reducing alcohol consumption when assessed at 6-month follow-up.

No difference was observed between behavioural therapies in attrition both at post-treatment and 6-month follow-up.

The quality of this evidence is moderate, therefore further research is likely to have an important impact on confidence in the estimate of the effect. An evidence summary of the results of the meta-analyses can be seen in Table 51.

Table 51. Comparing various formats of behavioural therapy evidence summary.

Table 51

Comparing various formats of behavioural therapy evidence summary.

6.11. CONTINGENCY MANAGEMENT

6.11.1. Definition

Contingency management provides a system of reinforcement designed to make continual alcohol use less attractive and abstinence more attractive. There are four main methods of providing incentives:

  • Voucher-based reinforcement: people who misuse alcohol receive vouchers with various monetary values (usually increasing in value after successive periods of abstinence) for providing biological samples (usually urine) that are negative for alcohol. These vouchers are withheld when the biological sample indicates recent alcohol use. Once earned, vouchers are exchanged for goods or services that are compatible with an alcohol-free lifestyle.
  • Prize-based reinforcement: This is more formally referred to as the ‘variable magnitude of reinforcement procedure’ (Prendergast et al., 2006). Participants receive draws, often from a number of slips of paper kept in a fishbowl, for providing a negative biological specimen. Provision of a specimen indicating recent alcohol use results in the withholding of draws. Each draw has a chance of winning a ‘prize’, and the value of which varies. Typically, about half the draws say ‘Good job!’. The other half results in the earning of a prize, which may range in value from £1 to £100 (Prendergast et al., 2006).
  • Cash incentives: people who misuse alcohol receive cash (usually of a relatively low value, for example, £1.50 to £10) for performing the target behaviour, such as submitting a urine sample negative for alcohol or compliance with particular interventions. Cash incentives are withheld when the target behaviour is not performed.
  • Clinic privileges: participants receive clinic privileges for performing the target behaviour, for example providing a negative biological sample. But these privileges are withheld when the target behaviour is not performed. An example of a clinic privilege is a take-home methadone dose (for example, Stitzer et al., 1992). This incentive is appropriate for drug treatment for substances such as heroin but is not applicable to alcohol treatment.

6.11.2. Clinical review protocol (contingency management)

Information about the databases searched and the inclusion/exclusion criteria used for this section of the guideline can be found in Chapter 3 (further information about the search for health economic evidence can be found in Section 6.21). See Table 52 below for a summary of the clinical review protocol for the review of contingency management).

Table 52. Clinical review protocol for the review of contingency management.

Table 52

Clinical review protocol for the review of contingency management.

6.11.3. Studies considered for review

The review team conducted a systematic review of RCTs that assessed the beneficial or detrimental effects of contingency management in the treatment of alcohol dependence or harmful alcohol use. See Table 53 for a summary of the study characteristics.

Table 53. Summary of study characteristics for contingency management.

Table 53

Summary of study characteristics for contingency management.

Three trials relating to clinical evidence met the eligibility criteria set by the GDG, providing data on 355 participants. All three studies were published in peer-reviewed journals between 2000 and 2007. A number of studies identified in the search were initially excluded because they were not relevant to this guideline. Studies were excluded because they did not meet methodological criteria (see Chapter 3). When studies did meet basic methodological inclusion criteria, the main reason for exclusion was that the participants in the study did not meet drinking quantity/diagnosis criteria (that is, participants were not drinking enough to be categorised as harmful or dependent drinkers, or less than 80% of the sample meet criteria for alcohol dependence or harmful alcohol use). Another reason was that the study was drug-focused or did not differentiate between drugs and alcohol. A list of excluded studies can be found in Appendix 16d.

Contingency management versus control

Of the three included trials, there was only one involving a comparison between contingency management and control that met the criteria for inclusion. LITT2007 assessed contingency management with network support versus case management (an active control).

Contingency management versus treatment as usual

Of the three included trials, two trials evaluating contingency management versus treatment as usual (standard care) met criteria for inclusion. Both ALESSI2007 and PETRY2000 assessed contingency management with standard care versus standard care alone. The included studies were conducted between 2000 and 2007.

Contingency management versus other active intervention

Of the three included trials, one trial that assessed contingency management versus another active intervention met criteria for inclusion. The treatment conditions in LITT2007 were contingency management with network support versus network support alone.

6.11.4. Evidence summary

The GRADE profiles and associated forest plots for the comparisons can be found in Appendix 18c and Appendix 17c, respectively.

Contingency management versus control

The review evidence indicated that contingency management (with network support) was more effective at maintaining abstinence than control post-treatment (large effect size) and up to 15-month follow-up (medium effect size). However, no significant differences were observed between contingency management with network support and control for follow-up periods greater than 15 months. It should be noted that this analyses was based on the LITT2007 study only.

Contingency management (with network support) was more effective than control (low to medium effect size) at reducing drinking quantity when assessed at 6-, 9- and 21-month follow-up. However, no significant difference was found between treatment conditions post-treatment at 12-, 15-, 18-, 24- and 27-month follow-up.

No significant difference was observed between conditions in attrition post-treatment and at all follow-up points up to 27 months.

The quality of this evidence is moderate, therefore further research is likely to have an important impact on confidence in the estimate of the effect. An evidence summary of the results of the meta-analyses can be seen in Table 54.

Table 54. Contingency management versus control evidence summary.

Table 54

Contingency management versus control evidence summary.

Contingency management versus treatment as usual (standard care)

The clinical review revealed no significant beneficial effect of adding contingency management to standard care in maintaining abstinence when assessed post-treatment. However, the addition of contingency management to standard care was beneficial in reducing the number of participants who relapsed to heavy drinking. Furthermore, the addition of contingency management to standard care was beneficial in reducing attrition rates.

The quality of this evidence is moderate, therefore further research is likely to have an important impact on confidence in the estimate of the effect. An evidence summary of the results of the meta-analyses can be seen in Table 55.

Table 55. Contingency management versus standard care (TAU) evidence summary.

Table 55

Contingency management versus standard care (TAU) evidence summary.

Contingency management versus other active interventions

The addition of contingency management to network support was not beneficial in maintaining abstinence both post-treatment and up to 9-month follow-up. However, network support without contingency management was more effective at maintaining abstinence at 12- to 24-month follow-up.

The quality of this evidence is moderate, therefore further research is likely to have an important impact on confidence in the estimate of the effect. An evidence summary of the results of the meta-analyses can be seen in Table 56.

Table 56. Contingency management versus other intervention evidence summary.

Table 56

Contingency management versus other intervention evidence summary.

6.12. SOCIAL NETWORK AND ENVIRONMENT-BASED THERAPIES

6.12.1. Definition

Social network and environment-based therapies use the individual's social environment as a way to help achieve abstinence or controlled drinking. These therapies include SBNT and the community reinforcement approach.

Social behaviour and network therapy

SBNT comprises a range of cognitive and behavioural strategies to help clients build social networks supportive of change which involve the patient and members of the patient's networks (for example, friends and family) (Copello et al., 2002). The integration of these strategies has the aim of helping the patient to build ‘positive social support for a change in drinking’.

The community reinforcement approach

In the community reinforcement approach (Hunt & Azrin, 1973; Meyers & Miller, 2001; Sisson & Azrin, 1989), emphasis is placed on maintaining abstinence through the development of activities that do not promote alcohol use, for example recreational and social activities, employment and family involvement.

6.12.2. Clinical review protocol (social network and environment-based therapies)

Information about the databases searched and the inclusion/exclusion criteria used for this section of the guideline can be found in Chapter 3 (further information about the search for health economic evidence can be found in Section 6.21). See Table 57 below for a summary of the clinical review protocol for the review of social network and environment-based therapies.

Table 57. Clinical review protocol for the review of social network and environment-based therapies.

Table 57

Clinical review protocol for the review of social network and environment-based therapies.

6.12.3. Studies considered for review

The review team conducted a systematic review of RCTs that assessed the beneficial or detrimental effects of social network and environment-based therapies in the treatment of alcohol dependence or harmful alcohol use. See Table 58 for a summary of the study characteristics. It should be noted that some trials included in analyses were three- or four-arm trials. To avoid double counting, the number of participants in treatment conditions used in more than one comparison was divided (by half in a three-arm trial, and by three in a four-arm trial).

Table 58. Summary of study characteristics for social network and environment-based therapies.

Table 58

Summary of study characteristics for social network and environment-based therapies.

Three trials relating to clinical evidence met the eligibility criteria set by the GDG, providing data on 1,058 participants. All three studies were published in peer-reviewed journals between 1999 and 2007. A number of studies identified in the search were initially excluded because they were not relevant to this guideline. Studies were excluded because they did not meet methodological criteria (see Chapter 3). When studies did meet basic methodological inclusion criteria, the main reason for exclusion was not having alcohol-focused outcomes that could be used for analysis. A list of excluded studies can be found in Appendix 16d.

Social network and environment-based therapies versus control

Of the three included trials, there was only one involving a comparison of social network and environment-based therapies versus control that met the criteria for inclusion. LITT2007 assessed network support (both with and without contingency management) versus a case management active control. In this study, network support involved encouraging the participant to change their social network from one that promotes drinking to one that encourages abstinence as well as encouraging the use of established social support networks such as AA.

Social network and environment-based therapies versus other active intervention

Two of the three included trials that met criteria for inclusion assessed social network and environment-based therapies versus another active intervention. LEIGH1999 investigated a volunteer support condition (a volunteer was part of most treatment sessions and spent a substantial amount of time with the participant whilst in the community) versus an unspecified office-based individual intervention. UKATT2005 investigated SBNT (see Section 6.12.1 for definition) versus MET.

6.12.4. Evidence summary

The GRADE profiles and associated forest plots for the comparisons can be found in Appendix 18c and Appendix 17c, respectively.

Social network and environment-based therapies versus control

The clinical evidence showed that social network and environment-based therapies were significantly better than control at maintaining abstinence (moderate effect size) when assessed post-treatment and at 6-, 9-, 12-, 15- and 24-month follow-up. However, no significant difference was observed at 18-, 21- and 27-month follow-up.

Social network and environment-based therapies were not significantly better than control in reducing drinking post-treatment or at 12-, 15-, 24- and 27-month follow-up. However, a significant benefit (low to moderate effect size) was observed for social network and environment-based therapies over control in reducing the quantity of alcohol consumed when assessed at 6-, 9-, 18- and 21-month follow-up.

No significant difference was observed between treatment conditions in attrition either post-treatment or at all follow-up points. It must be noted that the comparison between social network and environment-based therapies versus control was based on a single study.

The quality of this evidence is moderate, therefore further research is likely to have an important impact on confidence in the estimate of the effect. An evidence summary of the results of the meta-analyses can be seen in Table 59.

Table 59. Social network and environment-based therapies versus control evidence summary.

Table 59

Social network and environment-based therapies versus control evidence summary.

Social network and environment-based therapies versus other active intervention

The clinical evidence did not reveal any significant difference between social network and environment-based therapies and other active interventions in maintaining abstinence, reducing the quantity of alcohol consumed, reducing the number of drinking days and attrition.

The quality of this evidence is moderate therefore further research is likely to have an important impact on confidence in the estimate of the effect. An evidence summary of the results of the meta-analyses can be seen in Table 60.

Table 60. Social network and environment-based therapies versus other intervention evidence summary.

Table 60

Social network and environment-based therapies versus other intervention evidence summary.

6.13. COUPLES THERAPY

6.13.1. Definition

The content and definition of couples therapy can vary and reflect different approaches, for example cognitive behavioural or psychodynamic. Couples-based interventions (including behavioural couples therapy [BCT]) involve the spouse or partner expressing active support for the person who misuses alcohol in reducing alcohol use, including support via the use of behavioural contracts. Couples are helped to improve their relationship through more effective communication skills, and encouraged to increase positive behavioural exchanges through acknowledgement of pleasing behaviours and engagement in shared recreational activities (Fals-Stewart et al., 2005). Standard BCT is manual-based and structured (Fals-Stewart et al., 2004), and combines cognitive-behavioural treatment strategies with methods that address relationship issues arising from alcohol misuse as well as more general relationship problems with the aim of reducing distress.

6.13.2. Clinical review protocol (couples therapy)

Information about the databases searched and the inclusion/exclusion criteria used for this section of the guideline can be found in Chapter 3 (further information about the search for health economic evidence can be found in Section 6.21). See Table 61 below for a summary of the clinical review protocol for the review of couples therapy.

Table 61. Clinical review protocol for the review of couples therapy.

Table 61

Clinical review protocol for the review of couples therapy.

6.13.3. Studies considered for review

The review team conducted a systematic review of RCTs that assessed the beneficial or detrimental effects of couples therapies in the treatment of alcohol dependence or harmful alcohol use. See Table 62 for a summary of the study characteristics. It should be noted that some trials included in analyses were three- or four-arm trials. To avoid double counting, the number of participants in treatment conditions used in more than one comparison was divided (by half in a three-arm trial, and by three in a four-arm trial).

Table 62. Summary of study characteristics for couples therapy.

Table 62

Summary of study characteristics for couples therapy.

Eight trials relating to clinical evidence met the eligibility criteria set by the GDG, providing data on 602 participants. All eight studies were published in peer-reviewed journals between 1988 and 2009. A number of studies identified in the search were initially excluded because they were not relevant to this guideline. Studies were excluded because they did not meet methodological criteria (see Chapter 3). When studies did meet basic methodological inclusion criteria, the main reason for exclusion was not having alcohol-focused outcomes that could be used for analysis. Other reasons were not meeting drinking quantity/diagnosis criteria, that is, participants were not drinking enough to be categorised as harmful or dependent drinkers, or less than 80% of the sample meet criteria for alcohol dependence or harmful alcohol use, the study was outside the scope of this guideline, or the study was drug-focused or did not differentiate between drugs and alcohol. A list of excluded studies can be found in Appendix 16d.

Couples therapy versus other active intervention

Of the eight included RCT trials, seven compared couples therapy with another active intervention met criteria for inclusion. In the FALSSTEWART2005 study, participants received one of two methods of couples therapy (BCT and brief relationship counselling) or individually-based TSF or psychoeducational intervention. All groups also had group counselling as standard. FALSSTEWART2006 assessed BCT (with individual TSF) versus individual TSF or psychoeducational intervention alone. LAM2009 investigated BCT (both with and without parental skills training) versus individually-based coping skills. OFARRELL1992 assessed two methods of couples therapy (interactional couples therapy and behavioural marital therapy) versus counselling. SOBELL2000 compared couples therapy in the form of direct social support with natural social support. VEDEL2008 compared BCT with CBT. WALITZER2004 investigated BCT with and without alcohol-focused spousal involvement with behavioural self-management.

Behavioural couples therapy versus other couples therapy

Three studies assessed BCT versus other methods of couples therapy. Studies that could be included in these analyses compared BCT with the following; brief relationship therapy (FALSSTEWART2005), interactional couples therapy (OFARRELL1992) and alcohol-focused spousal involvement (WALITZER2004).

Intensive behavioural couples therapy versus brief couples therapy

Two studies were included to assess the possible difference in outcome between more intensive and less intensive couples therapy. FALSSTEWART2005 assessed BCT (plus counselling) versus brief relationship therapy plus counselling (brief BCT). ZWEBEN1988 assessed eight sessions of conjoint therapy versus one session of couples advice counselling.

Parental skills and behavioural couples therapy versus behavioural couples therapy alone

This analysis involved a single study (LAM2009), which assessed BCT with and without the addition of parental skills training.

6.13.4. Evidence summary

The GRADE profiles and associated forest plots for the comparisons can be found in Appendix 18c and Appendix 17c, respectively.

Couples therapy versus other active intervention

Not significant difference was observed between couples therapy (all types) and other active interventions in maintaining abstinence at post-treatment and 2-month follow-up assessment. However, over longer periods, couples therapy was significantly more effective than other therapies in maintaining abstinence and/or light drinking (moderate effect size) when assessed up to 12-month follow-up. This difference was not observed in follow-up periods longer than 12 months. An additional randomised study (MCCRADY2009) could not be included in these analyses as no extractable data was provided. The study reported that BCT was more effective than individual coping-skills treatment in maintaining abstinence and reducing heavy drinking days.

Couples therapy was significantly more effective than other active interventions in reducing heavy drinking episodes when assessed up to 12-month follow-up. However, there was no difference between couples therapy and other active interventions post-treatment.

The VEDEL2008 study assessed severity of relapse in their sample. The results indicated that other active intervention (namely CBT) was more effective than couples therapy (namely BCT) in reducing occasions in which participants lapsed (drank over six drinks on one occasion) or relapsed (drank more than six drinks most days of the week), but no significant difference was observed in the number of participants who relapsed on a regular basis (a few times a month). It must be noted that effect sizes were small and from a single study.

No difference in attrition rates was observed between groups post-treatment and at 3-month follow-up. Couples therapy had less attrition than other therapies at 6-month follow-up (large effect size), and other therapies had less attrition than couples therapy at 12-month follow-up (large effect size).

The quality of this evidence is moderate, therefore further research is likely to have an important impact on the confidence in the estimate of the effect. An evidence summary of the results of the meta-analyses can be seen in Table 63.

Table 63. Couples therapy versus other intervention evidence summary.

Table 63

Couples therapy versus other intervention evidence summary.

Behavioural couples therapy versus other couples therapy

No significant difference was observed between BCT and other forms of couples therapy in maintaining abstinence when assessed post-treatment and up to 24-month follow-up. Similarly, no difference between these groups was observed in reducing heavy drinking and attrition rates post-treatment, and up to 12-month follow-up.

The quality of this evidence is moderate, therefore further research is likely to have an important impact on the confidence in the estimate of the effect. An evidence summary of the results of the meta-analyses can be seen in Table 64.

Table 64. Behavioural couples therapy versus other couples therapy evidence summary.

Table 64

Behavioural couples therapy versus other couples therapy evidence summary.

Intensive versus standard couples therapy

At 1-month follow-up, brief couples therapy was more effective than more intensive couples therapy in maintaining abstinence (moderate effect size). However, this difference was not maintained up to 18-month follow-up. Furthermore, no significant benefit of more intensive couples therapy over brief couples therapy in reducing heavy drinking was observed up to 18-month follow-up. Those who received more intensive couples therapy were more likely to be retained for follow-up assessment at 12 months than brief couples therapy (small effect size).

The quality of this evidence is moderate, therefore further research is likely to have an important impact on the confidence in the estimate of the effect. An evidence summary of the results of the meta-analyses can be seen in Table 65.

Table 65. Intensive couples therapy versus brief couples therapy evidence summary.

Table 65

Intensive couples therapy versus brief couples therapy evidence summary.

Parental skills and behavioural couples therapy versus behavioural couples therapy alone

The addition of parental skills training to BCT did not significant improve abstinence rates both post-treatment and up to 12-month follow-up.

The quality of this evidence is moderate, therefore further research is likely to have an important impact on the confidence in the estimate of the effect. An evidence summary of the results of the meta-analyses can be seen in Table 66.

Table 66. Parental skills and behavioural couples therapy versus behavioural couples therapy alone evidence summary.

Table 66

Parental skills and behavioural couples therapy versus behavioural couples therapy alone evidence summary.

6.14. COUNSELLING

6.14.1. Definition

The British Association for Counselling and Psychotherapy defines counselling as ‘a systematic process which gives individuals an opportunity to explore, discover and clarify ways of living more resourcefully, with a greater sense of well-being’ (British Association of Counselling, 1992). This definition, which has been used in other NICE guidelines, was adopted for this review, but in the included studies counselling for alcohol treatment was not often well-defined or manual-based making decisions about inclusion difficult; where there was uncertainty this was resolved in discussion with the GDG.

6.14.2. Clinical review protocol (counselling)

Information about the databases searched and the inclusion/exclusion criteria used for this section of the guideline can be found in Chapter 3 (further information about the search for health economic evidence can be found in Section 6.21). See Table 67, below, for a summary of the clinical review protocol for the review of counselling.

Table 67. Clinical review protocol for the review of counselling.

Table 67

Clinical review protocol for the review of counselling.

6.14.3. Studies considered for review

The review team conducted a systematic review of RCTs that assessed the beneficial or detrimental effects of counselling in the treatment of alcohol dependence or harmful alcohol use. See Table 68 for a summary of the study characteristics. It should be noted that some trials included in analyses were three- or four-arm trials. To avoid double counting, the number of participants in treatment conditions used in more than one comparison was divided (by half in a three-arm trial, and by three in a four-arm trial).

Table 68. Summary of study characteristics for counselling.

Table 68

Summary of study characteristics for counselling.

Five trials relating to clinical evidence met the eligibility criteria set by the GDG, providing data on 630 participants. All five studies were published in peer-reviewed journals between 1986 and 2003. A number of studies identified in the search were initially excluded because they were not relevant to this guideline. Counselling studies were mainly excluded for not being randomised trials. When studies did meet basic methodological inclusion criteria, the main reason for exclusion were that treatment was opportunistic as opposed to planned, the study was not directly relevant to the review questions, or no relevant alcohol-focused outcomes were available. A list of excluded studies can be found in Appendix 16d.

Counselling versus control

Of the five included trials, there was only one involving a comparison of counselling versus control that met criteria for inclusion. SELLMAN2001 assessed counselling (non-directive reflective listening) versus control (no further treatment – feedback only).

Counselling versus other active intervention

All five included trials assessed counselling versus another active intervention and met criteria for inclusion. ERIKSEN1986B assessed counselling (group) versus social skills training (coping skills), JOHN2003 assessed counselling (individual) versus multi-modal standard intervention (see Appendix 16d for more information), LITT2003 assessed counselling (group) versus coping skills, OFARRELL1992 assessed counselling (individual) versus both interactional couples therapy and behavioural marital therapy, and SELLMAN2001 assessed counselling (non-directive reflective listening) versus MET. The included studies were conducted between 1986 and 2003.

6.14.4. Evidence summary

The GRADE profiles and associated forest plots for the comparisons can be found in Appendix 18c and Appendix 17c, respectively.

Counselling versus Control

Based on the SELLMAN2001 study, no significant difference was observed between treatment groups, hence the clinical evidence does not support the benefits of counselling over control in maintaining abstinence or reducing heavy drinking.

The quality of this evidence is moderate, therefore further research is likely to have an important impact on confidence in the estimate of the effect. An evidence summary of the results of the meta-analyses can be seen in Table 69.

Table 69. Counselling versus control evidence summary.

Table 69

Counselling versus control evidence summary.

Counselling versus other active intervention

In maintaining abstinence, no significant difference was observed between counselling and other therapies when assessed up to 6-month follow-up. However, bar the 6-month follow-up, these results are based on a single study (OFARRELL1992) whereas in the analyses assessing couples therapies versus other active therapies, more studies were included in the analyses for this outcome. Other therapies (namely couples therapies and coping skills) showed significant benefits over counselling in maintaining abstinence at longer follow-up periods of up to 18 months.

Overall, no significant difference was observed between counselling and other therapies up to 18-month follow-up in time to first drink (lapse), time to first heavy drink (relapse) and reducing heavy drinking episodes. These analyses were based on data from a single study (LITT2003). However, other therapies (coping skills) were more effective than counselling in reducing amount of alcohol consumed when assessed at 12-month follow-up. Again, this result was based on a single study (ERIKSEN1986B) limiting the ability to generalise the findings.

Lastly, no significant difference was observed between counselling and other therapies in attrition rates.

The quality of this evidence is moderate, therefore further research is likely to have an important impact on confidence in the estimate of the effect. An evidence summary of the results of the meta-analyses can be seen in Table 70.

Table 70. Counselling versus other intervention evidence summary.

Table 70

Counselling versus other intervention evidence summary.

6.15. SHORT-TERM PSYCHODYNAMIC THERAPY

6.15.1. Definition

Short-term psychodynamic therapy is a derived from a psychodynamic/psychoanalytic model in which: (a) therapist and patient explore and gain insight into conflicts, and how these are represented in current situations and relationships, including the therapeutic relationship; (b) service users are given an opportunity to explore feelings, and conscious and unconscious conflicts originating in the past, with the technical focus on interpreting and working through conflicts; and (c) therapy is non-directive and service users are not taught specific skills such as thought monitoring, re-evaluation or problem solving. Treatment typically consists of 16 to 30 sessions (Leichsenring et al., 2004), but there are interventions that offer more or less than this range.

6.15.2. Clinical review protocol (short-term psychodynamic therapy)

Information about the databases searched and the inclusion/exclusion criteria used for this section of the guideline can be found in Chapter 3 (further information about the search for health economic evidence can be found in Section 6.21). See Table 71 for a summary of the clinical review protocol for the review of short-term psychodynamic therapy).

Table 71. Clinical review protocol for the review of short-term psychodynamic therapy.

Table 71

Clinical review protocol for the review of short-term psychodynamic therapy.

6.15.3. Studies considered for review

The review team conducted a systematic review of RCTs that assessed the beneficial or detrimental effects of psychodynamic therapies in the treatment of alcohol dependence or harmful alcohol use. See Table 72 for a summary of the study characteristics.

Table 72. Summary of study characteristics for short-term psychodynamic therapy.

Table 72

Summary of study characteristics for short-term psychodynamic therapy.

One trial relating to clinical evidence met the eligibility criteria set by the GDG, providing data on 49 participants. The study was published in a peer-reviewed journal in 1998. A number of studies identified in the search were initially excluded because they were not relevant to this guideline. Studies were further excluded because they did not meet methodological criteria (see Chapter 3). When studies did meet basic methodological inclusion criteria, the main reasons for exclusion were that the study was not directly relevant to the review questions, or no relevant alcohol-focused outcomes were available. A list of excluded studies can be found in Appendix 16d.

Short-term psychodynamic therapy versus other active intervention

The only trial suitable for inclusion was SANDAHL1998, which investigated group-based time-limited group psychotherapy (or a short-term psychodynamic therapy, as described above) versus another active intervention, which in this case was relapse prevention.

6.15.4. Evidence summary

The GRADE profiles and associated forest plots for the comparisons can be found in Appendix 18c and Appendix 17c, respectively.

Short-term psychodynamic therapy versus other active intervention

At 15-month follow-up, short-term psychodynamic therapy was significantly more effective than other therapies (in this case, cognitive behavioural relapse prevention) in maintaining abstinence, although the effect size was moderate. However, no significant difference was observed between short-term psychodynamic therapy and other therapies in reducing the quantity of alcohol consumed, heavy drinking rate or attrition. It must be noted that this analysis was based on a single study.

The quality of this evidence is moderate, therefore further research is likely to have an important impact on the confidence in the estimate of the effect. An evidence summary of the results of the meta-analyses can be seen in Table 73.

Table 73. Short-term psychodynamic therapy versus other intervention evidence summary.

Table 73

Short-term psychodynamic therapy versus other intervention evidence summary.

6.16. MULTI-MODAL TREATMENT

6.16.1. Definition

Multi-modal treatment for alcohol misuse involves a combination of a number of interventions that have been developed and evaluated as stand-alone interventions for alcohol misuse. Components of a multi-modal treatment could include motivational aspects (such as MET), TSF, AA or self-help group participation, group counselling, CBT-based relapse-prevention training and psychoeducational sessions. The intention is that by combining a number of effective interventions the combined treatment will be greater than any one individual treatment.

6.16.2. Clinical review protocol (multi-modal treatment)

Information about the databases searched and the inclusion/exclusion criteria used for this section of the guideline can be found in Chapter 3 (further information about the search for health economic evidence can be found in Section 6.21).

Table 74. Clinical review protocol for the review of multi-modal treatment.

Table 74

Clinical review protocol for the review of multi-modal treatment.

6.16.3. Studies considered for review

The review team conducted a systematic review of RCTs that assessed the beneficial or detrimental effects of multi-modal therapies in the treatment of alcohol dependence or harmful alcohol use. See Table 75 for a summary of the study characteristics.

Table 75. Summary of study characteristics for multi-modal treatment.

Table 75

Summary of study characteristics for multi-modal treatment.

Two trials relating to clinical evidence met the eligibility criteria set by the GDG, providing data on 427 participants. Both studies were published in peer-reviewed journals between 2002 and 2003. A number of studies identified in the search were initially excluded because they were not relevant to this guideline. Studies were excluded because they did not meet methodological criteria (see Chapter 3). When studies did meet basic methodological inclusion criteria, the main reason for exclusion was that no relevant alcohol-focused outcomes were available. A list of excluded studies can be found in Appendix 16d.

Multi-modal treatment versus other active intervention

Both included trials assessed multi-modal treatment versus another active intervention. DAVIS2002 assessed standard multi-modal outpatient treatment versus a psychoeducational intervention. Standard multi-modal treatment included a 3-week orientation period, which consisted of six group therapy sessions, three alcohol education and three leisure education films, three community meetings and a minimum of six AA meetings. After orientation, participants were assigned to a permanent therapist for a mixture of individual and group therapy sessions tailored to the needs of the participant. JOHN2003 assessed multi-modal standard inpatient and outpatient treatment versus individual counselling. Standard treatment was based on the principles of motivational interviewing, relapse prevention and psychoeducational films, with a focus to support the motivation to seek help for substance-misuse problems.

6.16.4. Evidence summary

The GRADE profiles and associated forest plots for the comparisons can be found in Appendix 18c and Appendix 17c, respectively.

Multi-modal versus other active intervention

A small effect was observed favouring other therapies (that is, psychoeducational) over multi-modal treatment in maintaining abstinence when assessed post-treatment. In addition, other therapies (that is, counselling) were significantly better than multi-modal treatment in reducing the number of participants who had lapsed (small effect size). However, this was not the case at 12-month follow-up because no difference between groups was observed. Furthermore, no difference was observed between multi-modal treatment and other therapies in reducing the number of days drinking, the quantity of alcohol consumed and attrition up to 12-month follow-up.

The quality of this evidence is low, therefore further research is very likely to have an important impact on the confidence in the estimate of the effect and is likely to change the estimate. An evidence summary of the results of the meta-analyses can be seen in Table 76.

Table 76. Multimodal intervention versus other intervention evidence summary.

Table 76

Multimodal intervention versus other intervention evidence summary.

6.17. SELF-HELP-BASED TREATMENT

6.17.1. Definition

A self-help intervention is where a healthcare professional (or para-professional) would facilitate the use of the self-help material by introducing, monitoring and reviewing the outcome of such treatment. The intervention is limited in nature–usually no more than three to five sessions, some of which may be delivered by telephone. Self-administered interventions are designed to modify drinking behaviour and make use of a range of books, web pages, CD-ROMs or a self-help manual that is based on an evidence-based intervention and designed specifically for the purpose. An example is guided self-change (Sobell & Sobell, 1993). This treatment is manual-based and uses the principles of CBT and MET. The patient has an initial assessment followed by four treatment sessions and two follow-up telephone calls.

6.17.2. Clinical review protocol (self-help-based treatment)

Information about the databases searched and the inclusion/exclusion criteria used for this section of the guideline can be found in Chapter 3 (further information about the search for health economic evidence can be found in Section 6.21). See Table 77 for a summary of the clinical review protocol for the review of self-help-based treatment.

Table 77. Clinical review protocol for the review of self-help-based treatment.

Table 77

Clinical review protocol for the review of self-help-based treatment.

6.17.3. Studies considered for review

The review team conducted a systematic review of RCTs that assessed the beneficial or detrimental effects of self-help-based treatment in the treatment of alcohol dependence or harmful alcohol use. See Table 78 for a summary of the study characteristics.

Table 78. Summary of study characteristics for self-help-based treatment.

Table 78

Summary of study characteristics for self-help-based treatment.

One trial relating to clinical evidence met the eligibility criteria set by the GDG, providing data on 93 participants. The included study was published in a peer-reviewed journal in 2002. A number of studies identified in the search were initially excluded because they were not relevant to this guideline. Studies were excluded because they did not meet methodological criteria (see Chapter 3). A particular problem for self-help-based treatments is that they usually fall under the grouping of ‘brief interventions’. Therefore, the main reasons for exclusions were the population assessed were hazardous drinkers (outside the scope of this guideline), the population were not treatment seeking, or no relevant alcohol-focused outcomes were available. A list of excluded studies can be found in Appendix 16d.

Guided self-help-based treatment (guided) versus non-guided self-help-based treatment

The single trial included in this analyses involved a comparison of guided self-help-based treatment versus non-guided self-help-based treatment. ANDREASSON2002 assessed guided self change versus self-help manual and advice only (non-guided).

6.17.4. Evidence summary

The GRADE profiles and associated forest plots for the comparisons can be found in Appendix 18c and Appendix 17c, respectively.

Guided self-help-based treatment (guided) versus non-guided self-help-based treatment

Guided self-help was significantly more effective than non-guided self-help in reducing the quantity of drinks consumed per week when assessed at 9-month follow-up. However, no significant difference was observed between groups for the same variable at 23-month follow-up, or for the number of DDD (at 9- and 23-month follow-up) or attrition at 23-month follow-up.

The quality of this evidence is moderate, therefore further research is likely to have an important impact on the confidence in the estimate of the effect. An evidence summary of the results of the meta-analyses can be seen in Table 79.

Table 79. Comparing different formats of self-help-based treatment evidence summary.

Table 79

Comparing different formats of self-help-based treatment evidence summary.

6.18. PSYCHOEDUCATIONAL INTERVENTIONS

6.18.1. Definition

A psychoeducational intervention involves an interaction between an information provider and service user. It has the primary aim of offering information about the condition, as well as providing support and management strategies. Psychoeducational intervention for alcohol misuse involves the use of education videos, literature and lectures that highlight the health and lifestyle risks of excessive alcohol consumption. It is not usually used as a formal method of treatment, but an adjunct to conventional treatment methods. Psychoeducational attention control treatment (PACT) is a form of manual-based psychoeducational therapy developed by Fals-Stewart and Klostermann (2004) and used in some alcohol treatment trials.

6.18.2. Clinical review protocol (psychoeducational interventions)

Information about the databases searched and the inclusion/exclusion criteria used for this section of the guideline can be found in Chapter 3 (further information about the search for health economic evidence can be found in Section 6.21). See Table 80 for a summary of the clinical review protocol for the review of psychoeducational interventions.

Table 80. Clinical review protocol for the review of psychoeducational interventions.

Table 80

Clinical review protocol for the review of psychoeducational interventions.

6.18.3. Studies considered for review

The review team conducted a systematic review of RCTs that assessed the beneficial or detrimental effects of behavioural therapies in the treatment of alcohol dependence or harmful alcohol use. See Table 50 (above, in Section 6.11) for a summary of the study characteristics. It should be noted that some trials included in analyses were three- or four-arm trials. To avoid double counting, the number of participants in treatment conditions used in more than one comparison was divided (by half in a three-arm trial, and by three in a four-arm trial).

Five trials relating to clinical evidence met the eligibility criteria set by the GDG, providing data on 1,312 participants. All five studies were published in peer-reviewed journals between 2001 and 2006. A number of studies identified in the search were initially excluded because they were not relevant to this guideline. Studies were excluded because they did not meet methodological criteria (see Chapter 3). When studies did meet basic methodological inclusion criteria, the main reason for exclusion was not meeting drinking quantity/diagnosis criteria, that is, participants were not drinking enough to be categorised as harmful or dependent or less than 80% of the sample meet criteria for alcohol dependence or harmful alcohol use. A list of excluded studies can be found in Appendix 16d.

Psychoeducational interventions versus other active intervention

All five included trials assessed psychoeducational interventions versus another active intervention. CONNORS2001 was complex in design and investigated a psychoeducational intervention plus alcohol-focused coping skills versus life skills plus alcohol-focused coping skills. Additionally, the study investigated the difference between low- and high-intensity treatment of these conditions. The results of the 30-month follow-up were obtained from Walitzer and Connors (2007). DAVIS2002 assessed a psychoeducational intervention versus standard multi-modal treatment. FALSSTEWART2005 investigated a psychoeducational intervention (used as an attentional control) versus BCT (plus group counselling), brief relationship therapy (plus group counselling) and individually-based TSF (plus group counselling). FALSSTEWART2006 investigated a psychoeducational intervention (as an attentional control) versus BCT (plus individually-based TSF) as well as individually-based TSF alone. SOBELL2002 investigated psychoeducational (bibliotherapy/drinking guidelines) versus motivational enhancement/personalised feedback. See Table 81 for a summary of the study characteristics.

Table 81. Summary of study characteristics for psychoeducational intervention.

Table 81

Summary of study characteristics for psychoeducational intervention.

6.18.4. Evidence summary

The GRADE profiles and associated forest plots for the comparisons can be found in Appendix 18c and Appendix 17c, respectively.

Psychoeducational versus other active intervention

The clinical findings for this comparison are mixed whether in favour of other active intervention over a psychoeducational intervention or finding no clinically significant difference between psychoeducational and other interventions. Other interventions were significantly better than psychoeducational interventions in increasing length of sobriety (post-treatment), and the percentage of abstinent/light drink days at 6- and 12-month follow-up.

No significant difference was observed between a psychoeducational intervention and other active interventions in attrition rates and other drinking-related variables.

The quality of this evidence is moderate, therefore further research is likely to have an important impact on the confidence in the estimate of the effect. An evidence summary of the results of the meta-analyses can be seen in Table 82.

Table 82. Psychoeducational intervention versus other intervention evidence summary.

Table 82

Psychoeducational intervention versus other intervention evidence summary.

6.19. MINDFULNESS MEDITATION

6.19.1. Definition

Mindfulness meditation is rooted in the principles of Buddhism and is characterised by having a non-judgemental approach to experiences that result in the practitioner acting reflectively rather than impulsively on these experiences (Chiesa, 2010). Mindfulness meditation has a goal of developing a non-judgemental attitude and relationship to thoughts, feelings and actions as they are experienced by the practitioner, and not necessarily to change the content of thoughts as in CBT for example (Teasdale et al., 1995).

Mindfulness-based meditation has been suggested as a method of improving physical and mental health (for a review, see Allen et al., 2006). However, the quality of this research is generally poor, not focused on alcohol as the substance of misuse, and few in number.

6.19.2. Clinical review protocol (mindfulness meditation)

In the current review, the role of meditation in maintaining abstinence and drinking reduction was investigated. Its application to other aspects usually associated with alternative therapies in this topic area (such as craving and withdrawal symptoms) was beyond the scope of this guideline and hence was not investigated. Information about the databases searched and the inclusion/exclusion criteria used for this section of the guideline can be found in Chapter 3. See Table 83 for a summary of the clinical review protocol for the review of meditation.

Table 83. Clinical review protocol for the review of meditation.

Table 83

Clinical review protocol for the review of meditation.

6.19.3. Studies considered for review

The review team conducted a systematic search of RCTs and systematic reviews that assessed the beneficial or detrimental effects of meditation in the treatment of alcohol dependence or harmful alcohol use. Following the literature search, there was an insufficient number of studies remaining to perform an unbiased and comprehensive meta-analysis of meditation for the treatment of alcohol misuse. Therefore, the GDG consensus was that a narrative summary of these studies would be conducted and observational studies would be included in the review. See Table 84 for a summary of the study characteristics.

Table 84. Summary of study characteristics for mindfulness meditation.

Table 84

Summary of study characteristics for mindfulness meditation.

Two trials (BOWEN200637; ZGIERSKA2008) providing data on 320 participants were identified by the search. Both studies were published in peer-reviewed journals between 2006 and 2008. To the GDG's knowledge, no other studies that evaluated meditation for a population with alcohol misuse with alcohol-focused outcomes have been published.

6.19.4. Evidence summary

Bowen and colleagues (2006) investigated the effectiveness of mindfulness meditation on substance-use outcomes in an incarcerated population. The study compared mindfulness meditation with treatment as usual (a chemical dependency programme and psychoeducational intervention). The authors reported that mindfulness meditation was significantly more effective than treatment as usual in the amount of alcohol consumed at 3-month follow-up (p <0.005). However, adherence to the therapy was not assessed and therefore the authors were unclear whether participants correctly followed the principles of mindfulness meditation. Furthermore, the level of alcohol dependence in this sample was unclear.

In a feasibility pilot prospective case series study, Zgierska and colleagues (2008) evaluated the efficacy of mindfulness meditation in increasing abstinence and reducing the quantity of alcohol consumed. Alcohol-dependent participants who had recently completed an intensive outpatient treatment programme were recruited. The study found that participants reported significantly fewer heavy drinking days at 4-, 8- and 12-week follow-up (all p <0.005), but not at 16-week follow-up. Furthermore, participants were drinking substantially less when assessed at 4- and 8-week follow-up (p <0.005), but no significant difference was observed at 12- and 16-week follow-up. No significant difference over time was observed in increasing PDA. It must be noted, however, that meditation in this study was not used as an active intervention but as a post-treatment intervention. Furthermore, the sample size was small and the study had no control group.

These studies reported a significant effect of mindfulness meditation on alcohol consumption. Overall, there is limited and poor-quality evidence that does not support the use of mindfulness-based meditation for treating alcohol dependence and harmful alcohol use.

6.20. CLINICAL EVIDENCE SUMMARY

A range of psychological interventions to prevent relapse or promote abstinence in harmful and dependent alcohol misuse were reviewed. The participant populations of the studies included in this review were either harmful drinkers or mildly dependent on alcohol. Evidence for efficacy showed an advantage for BCT both over treatment as usual, active controls and other active interventions. In the cases of the other psychological interventions there was evidence that CBT, SBNT, and behavioural therapies were better than treatment as usual or control. The evidence for the efficacy of the addition of contingency management to standard care was limited and contradictory overall, which was further complicated because contingency management was not a stand-alone intervention and was added to standard care or network support. In the case of TSF and motivational techniques, although there was evidence of equivalence to other interventions, there was no evidence to show that these interventions were, for harmful and dependent alcohol use, more effective than the other interventions. Importantly, there was a lack of evidence for their effectiveness compared with treatment as usual or control. For all of the above interventions the evidence was judged to be of a high or moderate quality on the GRADE profiles.

The duration of treatment and number of sessions across the treatment trials included in the review was also considered. The duration of treatment for motivational techniques was 1 to 6 weeks, TSF was 12 weeks, cognitive behavioural therapies was 2 weeks to 6 months (with most ending at 12 weeks), behavioural therapies was 6 to 12 weeks, social network and environment-based therapies ranged from 8 to 16 weeks, and couples therapies ranged from 4 to 12 weeks. Taking into consideration the intensity of the treatments in these trials, for those with a high-intensity intervention, the duration of treatment was on average 12 weeks.

In addition, the GDG felt that both motivational techniques and TSF were best seen as components of any effective psychosocial intervention delivered in alcohol services, with the assessment and enhancing of motivation forming a key element of the assessment process. It should also be noted that facilitation of uptake of community support (for example, AA) is seen as a key element of care coordination and case management (see Chapter 5) and that the individual psychological interventions form a required component part of any pharmacological intervention. In developing the recommendations, this was also borne in mind.

There was very limited evidence of low-to-moderate quality to support the efficacy of counselling, short-term psychodynamic therapy, multi-modal treatment, self-help-based treatment, psychoeducational interventions and mindfulness meditation.

6.21. HEALTH ECONOMIC EVIDENCE

6.21.1. Review overview

The literature search identified six studies that assessed the cost effectiveness of psychological interventions for the treatment of alcohol dependence or harmful alcohol use (Alwyn et al., 2004; Fals-Stewart et al., 2005; Holder et al., 2000; Mortimer & Segal 2005; Slattery et al., 2003; UKATT Research Team, 2005). Full references, characteristics and results of all studies included in the economic review are presented in the form of evidence tables in Appendix 19.

The study by Alwyn and colleagues (2004) considered the cost effectiveness of adding a psychological intervention to a conventional home detoxification programme for the treatment of ‘problem drinkers’. The home detoxification programme comprised five home visits of 30 minutes duration delivered by CPNs. The study population consisted of 91 heavy drinkers in the UK who fulfilled inclusion criteria for home detoxification. A number of outcome measures were assessed in the study including: number of DDD; total number of days abstinent; total number of alcohol units consumed; abstinence or moderate drinking; and severity of dependence. The NNT to produce one extra non-drinker was also calculated. An NHS perspective was used for the economic analysis. Resource-use data included inpatient days, outpatient care (including CPN visits) and medications. Because clinical outcomes were left disaggregated and no summary outcome measure was used in the economic analysis, a cost-consequences analysis was used.

The authors made no formal attempt to compare the total costs of a psychological intervention in addition to home detoxification with home detoxification alone. Instead the authors calculated total costs per person of inpatient treatment (£2,186 to £3,901), outpatient treatment (£581 to £768) and home detoxification plus psychological intervention (£231). Therefore, the extra cost of a psychological intervention programme was substantially lower than the cost of inpatient treatment and outpatient visits. In terms of clinical outcomes, significantly better results were observed in people treated with home detoxification plus a psychological intervention. The authors concluded that, due to the low NNT to obtain an extra non-drinker, it is likely that the implementation of a psychological intervention would lead to cost savings to the NHS. Although the results of this study are highly relevant to the UK context, there are a number of methodological limitations. Firstly, no attempt was made to combine costs and effectiveness with an array of effectiveness measures used in the study. The measures of effectiveness used are of limited usefulness to policy makers when assessing the comparative cost effectiveness of healthcare interventions. The clinical-effectiveness study compared psychological intervention and home detoxification with home detoxification alone. However, in the cost-analysis, home detoxification was compared with other detoxification programmes, such as inpatient and outpatient programmes. Therefore, the study did not directly assess the cost-effectiveness of adding psychological intervention to home detoxification.

The study by Fals-Stewart and colleagues (2005) considered the cost-effectiveness of brief relationship therapy (BRT) compared with standard BCT (S-BCT), individual-based treatment (IBT) and PACT for alcohol-dependent males and their non-substance-misusing female partners. BRT, IBT and PACT consisted of 18 therapy sessions over 12 weeks whilst S-BCT consisted of 24 sessions over 12 weeks with participants randomised to one of the four groups and followed up for 12 months. A societal perspective was taken for the analysis with costs including those associated with the four treatment programmes and costs of participants' and their partners' travel time. The primary measure of effectiveness for the economic analysis was the change in percentage days of heavy drinking from baseline to 12 months. Rather than calculating ICERs, the authors calculated mean change in PDHD over 12 months divided by mean cost of treatment delivery (in US$100 units), with higher ratios indicating greater cost effectiveness. Overall, BRT had the highest mean ratio (4.61) of the four treatment programmes considered, suggesting this was the most cost-effective treatment. The findings of this study have limited applicability to this guideline as it is based within the US health system, outcomes were not expressed as QALYs and a societal perspective was taken for the cost analysis (both outside the NICE reference case). Furthermore, no formal attempt at an incremental analysis, in terms of differences in costs and outcomes, was attempted by the authors.

The study by Holder and colleagues (2000) compared the healthcare costs of three treatment modalities (12-session CBT, 4-session MET and 12-session TSF) over 3 years' follow-up. The study participants were a sample (65%) of individuals with alcohol dependency symptoms taken from the US Project MATCH study (Project MATCH Research Group, 1998). The perspective of the cost analysis was from US healthcare providers. Resource-use data included the three treatments and any subsequent inpatient or outpatient care over 3 years. The authors calculated mean monthly costs for the three treatments rather than total costs over 3 years and no incremental or statistical analyses were presented. Overall, mean monthly costs were US$186 for CBT, US$176 for MET and US$225 for TSF, suggesting that MET had the largest potential healthcare savings over 3 years. The major limitations of this analysis were the lack of descriptive detail on the resource use and costs considered whilst no incremental analysis was presented. The findings have limited applicability to this guideline as it was based on the US healthcare system and no formal attempt was made by the authors to combine cost and clinical-outcomes data, which were collected in the study and reported elsewhere (Project MATCH Research Group, 1998).

The study by Mortimer and Segal (2005) conducted separate, mutually exclusive, model-based economic analyses of interventions for ‘problem drinking’ and alcohol dependence. A lifetime horizon was used for all of the analyses considered. The first analysis compared three brief motivational interventions with different levels of intensity (simple was 5 minutes, brief was 20 minutes and extended was four sessions of 120 to 150 minutes) with no active treatment in a population of heavy drinkers within the Australian healthcare setting. The outcome measure used in the analysis was QALYs calculated from disability weights derived from a single published source (Stouthard et al., 1997). Clinical effectiveness data were taken from published studies evaluating interventions that were targeting heavy drinkers at lower severity levels. These data were used to estimate how patients would progress between specific drinking states (problem, moderate or dependent) within the model. The authors did not specify the resource use and cost components included in the model, although a health service perspective was adopted for the analysis. The results of the analysis suggested that brief motivational interventions were cost effective compared with no active treatment. The ICERs ranged from under AUS$82 (£61) per QALY for the simple intervention to under AUS$282 (£179) per QALY for the extended intervention.

The second analysis compared psychotherapies for mild to moderate alcohol dependence. The comparators were moderation-oriented cue exposure (MOCE) versus BSCT and MET or non-directive reflective listening versus no further counselling after initial assessment, also within the Australian healthcare setting. Again, the outcome measure used in the analysis was the QALY calculated from disability weights derived from a single published source (Stouthard et al., 1997). Clinical effectiveness data were taken from published studies evaluating interventions for mild to severe dependence. These data were used to estimate how patients would progress between specific drinking states (problem, moderate or dependent) within the model. No resource use and cost components were specified within the article. The results of the analysis suggested that MOCE was cost effective in comparison with BSCT, resulting in an ICER of AUS$2,145 (£1,589) per QALY. Non-directive reflective listening was dominated by no further counselling after initial assessment, resulting in higher costs but lower QALYs. However, the results of the analysis suggested that MET was cost effective compared with no further counselling after initial assessment, resulting in an ICER of AUS$3366 (£2,493) per QALY.

There are several limitations of the results of the study by Mortimer and Segal (2005) that reduce their applicability to any UK-based recommendations. In the second analysis of interventions for mild to moderate alcohol dependence, a common baseline comparator was not used in the analyses of MOCE, MET and non-directive reflective listening, limiting their comparability in terms of cost effectiveness. Ideally, indirect comparisons of the three interventions would have provided additional information about their relative effectiveness. Little explanation was given in the article as to how the clinical effectiveness data, which were taken from various sources, were used to inform the health states used in the economic models. The article did not specify the resource use and costs that were included in the analyses although a health perspective was used. The analyses all used QALYs as the primary outcome measure, which allows for comparison across interventions, although again there was insufficient description of the utility weights that were applied to the health states within the model.

The study by Slattery and colleagues (2003) developed an economic model to assess the cost effectiveness of four psychological interventions in comparison with standard care within the Scottish health service: coping/social skills training; BSCT; MET and marital/family therapy. The populations examined were 45-year-old men and women with a diagnosis of alcohol dependence. The outcome measures used in the economic model were the number of people who have abstained and number of deaths averted. The clinical effectiveness data were based on a methodologically diverse selection of trials which were not described within the study. Most studies included a treatment arm in which the intervention was thought likely to have little or no effect and this was used as the comparator arm when available. Resource use involved in the delivery of psychological interventions was estimated from expert clinical opinion and included the number and duration of sessions, staff and educational materials. Unit costs were taken from Scottish health service estimates. Other healthcare costs included in the model were those associated with alcohol-related disease endpoints such as stroke, cancer, cirrhosis and alcohol-related psychoses. Costs were applied according to inpatient length of stay taken from Scottish medical records.

For each intervention, the costs of psychological treatment and any disease endpoints for a hypothetical cohort of 1000 patients were compared with standard care over a 20-year time horizon, to determine any net healthcare cost savings. All four therapies demonstrated net savings ranging from £274,008 (coping/social skills training) to £80,452 (BSCT) in comparison with standard care. All four interventions resulted in lower costs per additional abstinent person and lower costs per death averted in comparison with standard care. Whilst the results of the study, based on a hypothetical cohort of patients within the Scottish health service, may be applicable to a UK setting, there are several problematic methodological issues with the study. First, the sources of the effectiveness data used in the model were not explicitly described by the authors, who suggested that the data were taken from a methodologically diverse selection of trials, thus suggesting a high level of heterogeneity. Second, no attempt was made to translate intermediate clinical endpoints such as abstinence rates into QALYs, which are useful to decision makers when assessing the comparative cost effectiveness of healthcare interventions.

The UKATT study (2005) evaluated the cost effectiveness of MET versus SBNT amongst a population comprising people who would normally seek treatment for alcohol misuse at UK treatment sites. The outcome measure used in the economic analysis was the QALY, which was estimated by using the EQ-5D questionnaire completed by patients at baseline, 3 and 12 months. The primary measures of clinical effectiveness were changes in alcohol consumption, alcohol dependence and alcohol-related problems over the 12-month period. A societal perspective was taken for the analysis. Resource-use data that were collected during the study included training and supervision, and materials related to treatment, hospitalisation, outpatient visits, GP and CPN visits, rehabilitation and consultation in alcohol agencies, social service contacts and court attendances. Unit-cost estimates were derived from a variety of UK published sources.

At 12 months, the total mean costs were higher in the MET group, resulting in a mean difference of £206 per patient (95% CI, −£454 to £818) versus SBNT. After adjusting for baseline differences, the MET group achieved slightly higher QALYs than SBNT, resulting in a mean difference of 0.0113 QALYs (95% CI, −0.0532 to 0.0235). Combining costs and QALYs, the MET group had an ICER of £18,230 in comparison with SBNT. CEACs showed that, at a cost-effectiveness threshold of £30,000 per QALY, MET had a 57.6% probability of being more cost effective than SBNT. The results of the study are applicable to a UK setting and the outcome measure used enables comparison across healthcare interventions. However, as the authors note, the analysis had a short time horizon and the longer-term effects of a reduction in drinking were not taken into consideration.

6.21.2. Health economic summary

The systematic search of the health economic literature did not identify evidence on the cost effectiveness of all of the psychological interventions considered in this guideline. Three of the studies identified were UK-based (Alwyn et al., 2004; Slattery et al., 2003; UKATT Research Team, 2005), two were US-based (Fals-Stewart et al., 2005; Holder et al., 2000) and one was Australian (Mortimer & Segal, 2005). The study by Alwyn and colleagues (2004) suggested that adding a psychological intervention to a home detoxification programme may offer the NHS cost savings in ‘problem drinkers’. The study by Slattery and colleagues (2003) showed that four psychological interventions, including coping/social skills training, BSCT, MET and marital/family therapy, offered significant healthcare cost savings compared with standard care for alcohol-dependent patients. The UKATT Research Team (2005) suggested that MET was cost effective in people who misuse alcohol, at current UK thresholds, in comparison with SBNT (but note that it was not identified as a clinically effective intervention in this guideline). Fals-Stewart and colleagues (2005) concluded that brief relationship therapy was significantly more cost effective compared with standard BCT, IBT and psychoeducational control treatment. Holder and colleagues (2000) suggested that MET offered the largest potential healthcare cost savings over 3 years when compared with CBT or TSF. Mortimer and Segal (2005) concluded that brief motivational interventions were cost effective compared with no active treatment among ‘problem drinkers’ whilst MOCE and MET were cost-effective treatments for alcohol dependency, although no common comparators were used in either analysis.

Providing an adequate summary of the health economic evidence presented here is difficult due to the differences across the studies in terms of the interventions and comparators considered, study populations, costs and outcomes considered, and other methodological differences. Overall, the health economic review does not provide evidence of superior cost effectiveness for any particular psychological intervention.

6.21.3. Economic considerations

Of all the psychological interventions included in the systematic effectiveness review and then found suitable for recommendation in the NHS, only a few of these have supporting economic evidence.

A potential solution to this problem would be to undertake economic modelling to determine the most cost-effective psychological intervention. However, certain aspects of the effectiveness evidence made it difficult to do so (that is, there was a lack of common comparators and interventions were usually compared with other active interventions, a ‘no treatment/usual care/placebo’ arm was rarely identified).

Furthermore, the meta-analyses showed that there were small if any differences in effect between active treatments, and only a few of these, for example BCT, showed much evidence of a consistent positive effect, particularly against other therapies.

Therefore, the following costing exercise was undertaken for the possible recommended psychological interventions.

Behavioural couples therapy

The clinical effective studies in the guideline systematic literature review described this intervention being delivered in a variety of ways. The GDG were of the opinion that the number of sessions and duration of these sessions as described by Lam and colleagues (2009) that is, 12 weekly sessions of 60 minutes' duration under the supervision of a competent practitioner, were considered to be reflective of what should be delivered in the UK NHS.

It is very likely that these sessions would be conducted by a clinical psychologist. The unit cost of a clinical psychologist is £75 per hour of patient contact in 2008/09 prices (Curtis, 2009). This cost includes salary, salary on-costs, overheads and capital overheads plus any qualification costs.

Based on these estimates the average cost of a BCT intervention would be £900 per couple.

Cognitive behavioural therapy

No evidence on the cost effectiveness of CBT in this population was identified by the systematic search of the health economic literature.

The clinical evidence in the guideline systematic literature review described CBT interventions being delivered in a variety of sessions and durations either individually or in structured groups under the supervision of a competent practitioner. The clinical evidence was taken in consideration and the GDG agreed that a CBT programme would typically involve weekly sessions of 1 hour's duration over a 12-week period.

These sessions would be conducted by a clinical psychologist. The unit cost of a clinical psychologist is £75 per hour of patient contact in 2008/09 prices (Curtis, 2009). This cost includes salary, salary oncosts, overheads and capital overheads plus any qualification costs.

Based on these estimates the average cost of an individual-based CBT intervention would be £900 per patient.

The GDG were of the opinion that group interventions, although likely to be more cost effective per patient, were unlikely to be delivered successfully in an outpatient setting because of the expected high attrition/low retention rates. They were also of the opinion that group interventions would potentially be more suitable to inpatient/residential settings as the likelihood of patients attending all treatment sessions would be higher. It was unclear from the literature what the optimal number of patients per group would be. Obviously, if the number and duration of sessions as well as the number of staff delivering the service remained the same, the total costs per person would be expected to decrease significantly.

Social network and environment-based therapies

The UKATT Research Team described SBNT as comprising up to eight 50-minute sessions (UKATT2005). This particular intervention can be delivered by a range of mental health professionals. The GDG highlighted that it is likely that the sessions would be supervised by a nurse (or an NHS professional who is trained to deliver this intervention). It was assumed that such workers would be on AfC salary scale 6, which is likely to be comparable with the salary scales of a community nurse. The unit cost of an AfC Band 6 community nurse is £70 per hour of patient contact in 2008/09 prices (Curtis, 2009). This cost includes salary, salary oncosts, overheads and capital overheads plus any qualification costs. Based on these estimates the average cost of such a therapy would be £467 per patient.

Behavioural therapies

The clinical evidence in the guideline systematic literature review described a variety of interventions that were considered to be behavioural therapies. They were delivered in a variety of sessions and durations either individually or in structured groups under the supervision of a competent practitioner. The clinical evidence was taken in consideration and the GDG agreed that behavioural therapies would typically involve weekly sessions of 1 hour's duration over a 12-week period.

Behavioural therapies can also be delivered by a range of mental health professionals. The GDG highlighted the following professionals: a clinical psychologist, a nurse, or an NHS professional who is trained to deliver this intervention. It was assumed that such workers would be on AfC salary scale 6, which would be likely to be comparable with the salary scales of a community nurse. The unit cost of an AfC Band 6 community nurse is £70 per hour of patient contact and the unit cost of a clinical psychologist is £75 per hour of patient contact in 2007/08 prices (Curtis, 2009). These costs include salary, salary oncosts, overheads and capital overheads plus any qualification costs. Based on these estimates the average cost of a behavioural intervention would be £900 per patient if delivered by a clinical psychologist and £840 per patient if delivered by a mental health professional described above.

A summary of the estimated resource use and costs involved in delivering these psychological interventions is presented in Table 85.

Table 85. Summary of resource use and costs associated with psychological interventions.

Table 85

Summary of resource use and costs associated with psychological interventions.

6.22. SPECIAL POPULATIONS – CHILDREN AND YOUNG PEOPLE

6.22.1. Introduction

In the development of the adult treatment sections of this guideline it was accepted that for some people who misuse alcohol (in particular those with harmful use or mild dependence) the reduction in alcohol consumption might be an option. However, given the potential long-term harm experienced by children and young people who are alcohol dependent or harmful drinkers, and the frequent presence of comorbid substance misuse and other psychiatric disorders, it was felt that the appropriate goal for children and young people should be achieving abstinence. However, it was recognised by the GDG that considerable difficulties are faced by some young people in trying to achieve abstinence, particularly if the support they receive from their families, carers and others is limited or non-existent or they experience considerable peer pressure to drink alcohol. Therefore, for some young people the GDG accepted that that an initial reduction in alcohol misuse may be the only achievable short-term objective. Nevertheless, the GDG's view was that, given the considerable problems that young people face, abstinence remained the preferred goal.

A further important difference between the treatment of adults and young people concerns the presence of comorbidities. Although comorbid depressive and anxiety symptoms are common in adults with harmful drinking and alcohol misuse (Weaver et al., 2006), the extent and severity of the comorbidities often found in children is greater (Perepletchikova et al., 2008). Comorbid disorders such as conduct disorder and ADHD significantly complicate the management of alcohol misuse, and concurrent treatment of them is to be considered. This problem is well known (Perepletchikova et al., 2008) and a number of treatments (for example, multisystemic therapy [Henggeler et al., 1999], brief strategic family therapy [Szapocznik et al., 2003] or multidimensional family therapy [Liddle, 1992]) have been developed for conduct disorder explicitly to deal with the complexity of problems faced by children and young people, including drug and alcohol misuse. The latter two interventions have a very explicit focus on substance misuse. At the heart of all these interventions lies the recognition of the considerable complexity of problems presented by young people who misuse alcohol and drugs, and the need often to develop a multisystem, multi-level approach to deliver integrated care.

6.22.2. Aim of review

This section aims to review the evidence for psychological interventions for the treatment of alcohol dependence and harmful alcohol use in children and young people. However, although there are several published reviews on the efficacy of psychological interventions for adults and for the prevention of adolescent substance misuse, there are only a limited number of trials assessing the clinical efficacy of psychological interventions for alcohol misuse alone (without comorbid drug misuse) for children and young people under the age of 18 years. In addition, the patient populations assessed in these trials more often than not have comorbid substance misuse. Therefore, a GDG consensus-based decision was agreed that the literature search would be for alcohol-specific primary studies as well as published systematic reviews to guide the overall strategy of a narrative synthesis of the evidence.

Psychological therapies were considered for inclusion in the review if they were:

  • alcohol-focused only
  • planned treatment (especially for brief interventions)
  • for treatment-seeking participants only (of particular importance for the brief interventions because the scope did not cover opportunistic brief interventions – see Appendix 1)
  • manual-based or, in the absence of a formal manual, the intervention should be well-defined and structured
  • ethical and safe.

6.22.3. Review questions

The primary review question addressed in this section is:

For children and young people who are alcohol dependent or harmful drinkers, is treatment x when compared with y more clinically- and cost-effective, and does this depend on the presence of comorbidities?

6.22.4. Clinical review protocol

As part of the overall search for effective individual, group and multicomponent psychological and psychosocial interventions for children and young people, the review team conducted a systematic review of published systematic reviews (in part, to take account of the complex comorbidity) of interventions for young people who misuse drugs and alcohol, and also RCTs of interventions for children and young people for alcohol misuse specifically. The literature search identified a number of primary studies investigating the efficacy of psychological interventions for children and young people. However, the participant population in the majority of these studies did not reach inclusion criteria for drinking severity and could not be classified as dependent/harmful. See Table 86 for a summary of the clinical review protocol for the review of psychological interventions for children and young people.

Table 86. Clinical review protocol for the review of psychological interventions for children and young people.

Table 86

Clinical review protocol for the review of psychological interventions for children and young people.

6.22.5. Narrative review

This review of psychological and psychosocial interventions for children and young people should be read in conjunction with the review of brief interventions contained in the NICE public health guidance (NICE, 2010a), and the review of psychological interventions for adults contained within this guideline. A limited number of studies, specifically on alcohol-focused interventions, have been undertaken for children and young people. However, a number of studies have considered the treatment of conduct disorder in the presence of drug or alcohol misuse. In light of this significant comorbidity, in addition to the two guidelines referred to above, the GDG also drew on other recent NICE guidelines, specifically the review of conduct disorders in young people contained within the NICE guideline on antisocial personality disorder (NICE, 2008a) and three other systematic reviews (Perepletchikova et al., 2008; Tripodi et al., 2010; Waldron & Kaminer, 2004). Individual- and group-based therapies and multicomponent interventions used in the treatment of alcohol dependence and harmful alcohol use in children and young people were considered in the review of the evidence.

Individual and group psychological interventions

The public health guidance on the prevention of alcohol-related problems in adults and young people (NICE, 2010a), and also on community interventions for vulnerable young adults (NICE, 2007b), recognise the value of individual and/or group CBT. A number of studies that assess the use of individual- or group-based psychological interventions have been identified and reviewed (Perepletchikova et al., 2008; Tripodi et al., 2010; Waldron & Kaminer, 2004).

In a recent systematic review, Tripodi and colleagues (2010) conducted a metaanalysis of experimental studies (including RCTs) evaluating both individual- and group-based interventions collectively (brief interventions, MET and CBT) as well as family-based interventions with a focus on reducing alcohol misuse. However, of these studies only a limited number of trials evaluated the use of CBT (with an emphasis on relapse prevention) and MET in a sample of children or young people identified with harmful or dependent drinking. The review consisted of 16 studies (14 RCTs, two of which were quasi-experimental) assessing both individual and group treatment, and multicomponent therapies. Ten of these included studies assessing individual/group treatment. However the studies included in the metaanalysis were concerned with individuals who did not meet criteria for harmful drinking or alcohol dependence (n = 1), had a participant population that had a significant comorbid psychiatric disorder (n = 2), and in the majority of cases the focus was not specifically on alcohol misuse, but rather on substance misuse more generally (n = 7). The results of the meta-analyses showed a significantly large effect in drinking reduction for individual interventions (effect size −0.75; 95% CI, −1.10 to −0.40). However, the meta-analyses did not distinguish between different types of individual interventions in pooled analyses; therefore, other reviews that focused on specific interventions were considered.

Brief interventions and motivational interviewing

The NICE guidance on prevention of alcohol-related problems in adults and young people (NICE, 2010a) and on community interventions for vulnerable young adults (NICE, 2007b) both consider the evidence for brief motivational techniques (motivational interviewing and MET). Motivational interviewing and other brief interventions may serve to heighten motivation, increase self-efficacy, and provide personalised feedback and education tailored to specific substances and comorbid problems such as psychiatric disorders. The evidence for this is mainly from the adult literature although there is an emerging, albeit still limited, literature for young people where modifications of motivational interviewing or MET for young people have shown promise for both evaluation and treatment (Colby et al., 1998; Monti et al., 1999). However, a more recent review by Perepletchikova and colleagues (2008) reported uncertain outcomes for MET when used alone for alcohol misuse (this is consistent with the approach to harmful and dependent alcohol misuse identified for adults in this guideline). There is some evidence to suggest that motivational techniques when combined with CBT may be effective, for example in the Cannabis Youth Trial (CYT; Dennis et al., 2004), although this population was predominately diagnosed as dependent on cannabis.

Cognitive behavioural therapy

Waldron and Kaminer (2004), in a review of CBT approaches to substance-use disorders (which is broader than alcohol misuse alone), concluded that individual CBT treatment may be effective in reducing substance misuse as well as other related problems. They also made a number of suggestions about the adaptation of CBT approaches to young people, addressing developmental stages and levels of maturity. This review reported that CBT in group format was as effective as individual therapy. CBT has been applied both in individual and group modalities, in combination with family approaches and MET. Interventions with the young person alone (for example, CBT or CBT plus MET) have been reported as effective (Dennis et al., 2004; Kaminer & Burleson, 1999; Kaminer et al., 1998). However, much of the evidence base is from approaches dealing with comorbidity such as conduct disorders, and anxiety and affective disorders where information on the extent and severity of alcohol misuse specifically is lacking. Perepletchikova and colleagues (2008) in a subsequent review considered five studies looking at the effectiveness of CBT in the reduction of alcohol misuse, three of which were of CBT alone, one evaluated an integrated family- and group-CBT approach and one looked at the efficacy of CBT on the reduction of substance use in those with comorbid conduct disorder. Again it appears that the data is primarily concerned with children and young people who did not have a high severity of alcohol misuse.

Kaminer and colleagues (2002), in one of the few studies that had a more substantial proportion of participants with alcohol dependence, randomised participants to CBT or a psychoeducational intervention. Of 88 included participants, 12.5% (n = 11) had an alcohol-use disorder only and 60% (n = 53) had an alcohol-use disorder as well as marijuana-use disorder. Of these 64 participants with an alcohol-use disorder, 58% met criteria for abuse and 42% for dependence (DSM III-R; APA, 1987). The authors reported reductions across both therapies in alcohol use. At 3 months alcohol use had improved significantly, and up to 9 months showed continued improvement. Substance use also showed a positive trend towards improvement. Kaminer and colleagues (2008) only included participants who met DSM–IV criteria for alcohol dependence, although 81.8% of the sample also used marijuana. However, all participants received CBT and the focus on the study was on aftercare.

Although the primary focus of studies of comorbidity has been on individuals with conduct disorder, a few studies have also examined the problems presented by co-occurring common mental health disorders such as depression and anxiety. One study evaluated the efficacy of an integrated 20-week programme of CBT with case management in a population of substance-misusing young people (aged between 15 and 25 years). Sixty-three per cent of the sample met criteria for alcohol dependence. Treatment resulted in a significant improvement in abstinence rates as well as a reduction in the number or participants meeting diagnostic thresholds for dependence. These positive effects were also observed at 44-week follow-up. This study (like others) evaluates the effectiveness of psychological interventions for young people including participants whom are over the age of 18 years. However, this age-range makes interpretation of datasets such as this difficult.

12-step facilitation

The development of TSF, which grew out of the initial work of AA, has been developed into a treatment intervention for adults (Project MATCH Research Group, 1993 and 1997) but has not been tested as an individual treatment in young people with harmful and dependent drinking. There have been no programmes for young people built around the 12-step model and, as far as the GDG was aware (or was able to identify), no evaluation of the effectiveness of a 12-step model for children and young people. It should be noted that some residential treatment centres for young people have refined the TSF, resulting in the development of residential treatment models (for example, the Minnesota model [Winters et al., 2000]). However, no formal evaluations in alcohol-dependent young people were identified.

6.22.6. Evidence summary

The evidence reviewed using these systematic reviews and primary studies suggests that, although there has been recent progress in the development of individual or group psychological treatment of alcohol dependence and harmful alcohol use in children and young people, no individual treatment has a convincing evidence base for harmful alcohol use or dependence. In some respects this is in line with the adult literature and findings of the guideline meta-analyses where a number of structured treatments (including CBT, behavioural therapies and SBNT) had some benefits for harmful and mildly dependent use, but it was not possible to distinguish between them on the basis of the current available evidence. The issue is further complicated by the fact that many of the trials that evaluate the efficacy of these interventions, and that are representative of this population, involved participants with comorbid drug misuse.

6.22.7. Multicomponent psychological interventions

Components of a multicomponent intervention

The need to involve family members, particularly parents, has been recommended in policy guidance, for example Every Parent Matters (DfES, 2007) and in Supporting and Involving Carers (National Treatment Agency, 2008). Family involvement has been shown to be positively associated with improved outcomes on domains and level of engagement of the young person (Dakof et al., 2001). This involvement is multifold and aims:

  • to obtain (depending on consent of the child and capacity) any necessary consent to treatment
  • to engage the support of the family in the treatment process
  • to obtain more information on the assessment of the child's alcohol use and general functioning
  • to ascertain possible family involvement in parent training, coping skills and problem-solving approaches to parenting, and more formal involvement in specific family programmes.

Common elements identified for review in these programmes include:

  • comprehensive assessment and monitoring
  • a focus on engagement of individuals (and usually their families) in treatment
  • an explicit linking of goals and interventions at all levels of the system
  • a goal-focused approach to treatment of family substance misuse
  • the involvement of the family aimed at improving family communication, problem solving and parenting skills
  • the provision of individual interventions, again often focused on coping skills identified for the child or young person.

The programmes also require staff who are experienced and highly trained clinicians (all were graduates; most had masters or doctoral degrees).

Although there are many approaches to family intervention for substance-misuse treatment, they have common goals: providing education about alcohol and drug misuse; improving motivation and engagement; assisting in achieving and maintaining abstinence; setting consistent boundaries and structure; improving communication; and providing support. Family interventions are the most evaluated modality in the treatment of young people with substance-use disorders. Among the forms of family-based interventions are functional family therapy (Alexander et al., 1990), brief strategic family therapy (Szapocznik et al., 1988), multisystemic therapy (Henggeler et al., 1992) and multidimensional family therapy (Liddle, 1992). An integrated behavioural- and family-therapy model that combines a family systems model and CBT has also been developed (Waldron et al., 2001). These interventions fall broadly under what would be called a systemic approach. They do not focus explicitly on the provision of specified individual interventions, but rather it is for the therapist, in conjunction with their supervisor, to develop the specific therapeutic approach in light of the identified needs of the young person. Some trials, such as the large trial of cannabis misuse and dependence (Dennis et al., 2004), have focused on the provision of a systemic approach (in this case, multi-dimensional family therapy), but have also provided a specified range of psychological interventions such as MET, the development of a family support network including parental education, and the development of conditioning models from children in the community.

Definitions of interventions

Functional family therapy is a psychological intervention that is behavioural in focus. The main elements of the intervention include engagement and motivation of the family in treatment, problem solving and behaviour change through parent training and communication training, and seeking to generalise change from specific behaviours to have an impact on interactions both within the family and with community agencies such as schools (see, for example, Gordon et al., 1995).

Brief strategic family therapy is a psychological intervention that is systemic in focus and is influenced by other approaches such as structural family therapy. The main elements of this intervention include engaging and supporting the family, identifying maladaptive family interactions, and seeking to promote new and more adaptive family interactions (see for example, Szapocznik et al., 1989).

Multisystemic therapy involved using strategies from family therapy and behavioural therapy to intervene directly in systems and processes related to antisocial behaviour (for example, parental discipline, family affective relations, peer associations and school performances) for children or young people (Henggeler et al., 1992).

Effectiveness of multicomponent interventions

The GDG used the NICE antisocial personality disorder guideline (NICE, 2008a) review of family interventions and multisystemic therapies for the treatment of conduct disorder in evaluating the effectiveness of multicomponent interventions for children and adolescents. The primary focus of the review in the antisocial personality disorder guideline was on a reduction in offending behaviour, but all the interventions, in particular brief strategic family therapy and multi-dimensional family therapy, had an explicit focus on substance misuse. The current guideline utilises the definitions from the antisocial personality disorder guideline.

In the antisocial personality disorder guideline, the meta-analysis of 11 trials assessed the effectiveness of family interventions. The results of the meta-analysis showed that family interventions are more effective than control for reducing both behavioural problems (SMD −0.75; −1.19 to −0.30) and offending (RR −0.67; 0.42 to 1.07). Furthermore, 10 trials on multisystemic therapy that met the inclusion criteria for the review were analysed. There was significant heterogeneity for most outcomes; however, there was consistent evidence of a medium effect on reduction in offending outcomes including number of arrests (SMD −0.44; −0.82 to −0.06) and being arrested (RR 0.65; 0.42 to 1.00).

In a recent meta-analysis, Tripodi and colleagues (2010) evaluated six trials of multicomponent and family-based interventions. However, none was focused specifically on alcohol misuse and, in two of the trials, only approximately 50% of the sample met criteria for alcohol dependence and harmful alcohol use. The overall findings were in line with the NICE antisocial personality disorder guideline (NICE, 2008a). The review did, however, report that multicomponent family therapies were effective in reducing drinking in young people (Hedges g = −0.46; 95% CI, −0.66 to −0.26). Perepletchikova and colleagues (2008) reviewed the evidence of family interventions specifically on alcohol use, although some included substance-use disorders. The types of family therapies evaluated included: multisystemic therapy, multidimensional therapy, brief family therapy, functional family therapy and strength-oriented family therapy. The review reported that multi-component therapy again showed some benefits over standard group therapy for substance misuse and criminal activity outcomes.

6.22.8. Evidence summary

The evidence for the use of multicomponent interventions demonstrates clear benefits on offending behaviour and promising results for the reduction of alcohol and drug misuse. As was found with the individual- or group-based interventions, much of the research focuses on children and young people with substance-use disorders and who are more likely have comorbid psychiatric disorders. Although not specifically focused on alcohol, this does not significantly detract from their applicability to this guideline because comorbidity with conduct disorder and polydrug use is a common feature among young people with significant alcohol misuse. The research to date does not, however, favour one particular multicomponent intervention over another for the treatment of alcohol misuse.

6.23. FROM EVIDENCE TO RECOMMENDATIONS

The GDG reviewed the evidence for the clinical and cost effectiveness of various psychological interventions for the treatment of alcohol misuse. The GDG discussed and agreed that the main outcomes of interest related to drinking-focused outcomes. When considering the evidence presented, it should be noted that due to the lack of consistent critical outcomes assessed across studies, the number of studies evaluating the same outcomes within the included reviews was generally low. Outcomes had to be grouped according to more general outcomes that would indicate efficacy of treatment (for example, outcomes relating to abstinence, the amount of alcohol consumed and the frequency or intensity of consumption). The GDG took the view that to be recommended, an active psychological intervention should show evidence of effectiveness against no treatment control/waitlist in the first instance, then against treatment as usual, and preferably should be more effective than other active interventions. However, the evidence evaluating the effectiveness of an intervention against no treatment control/waitlist or standard care was not always available because most studies compared two or more active interventions with each other. The GDG considered this limitation of the evidence as well as individual treatment comparisons and the patient population evaluated in the trials during the process of making recommendations about the relative efficacy of the interventions. The overall quality of the evidence was moderate and any limitations of the data addressed in the GRADE profiles were considered before making recommendations.

As can be seen from the above evidence summary, the strongest evidence for effectiveness in harmful and dependent drinking was for BCT. The GDG therefore agreed that BCT should be considered as an effective stand-alone intervention for individuals with harmful and mildly-dependent alcohol misuse who have a partner and who are willing to engage in treatment. Consideration should also be given to giving BCT in combination with a pharmacological intervention for those individuals who meet the above criteria and have moderate or severe alcohol dependence (see Chapter 7).

The evidence for individual psychological interventions for harmful and mildly dependent use was limited but stronger for cognitive behavioural therapies, social network and environment-based therapies, and behavioural therapies than other individual therapies reviewed, and are therefore recommended. The GDG considered the costings of the various psychological interventions (indications from these costings were that SBNT was less costly than either CBT or behavioural therapy) but came to the conclusion that, given the uncertainty about the relative cost effectiveness of the interventions and the need to have available a range of interventions to meet the complexity of presenting problems, all three interventions should be recommended as stand-alone therapies. One of the three interventions should also used in combination with the drug treatments reviewed in Chapter 7.

As can be seen from the clinical summary, the GDG considered that appropriate elements of TSF and motivational-based interventions should be provided as a component of an assessment and subsequent intervention because the evidence, particularly against treatment as usual or similar controls, was not strong enough to support their use as a stand-alone intervention for harmful and mildly dependent use.

Children and young people

The evidence base is limited for the treatment of alcohol misuse in children and young people. As a consequence, the GDG was required to extrapolate from a number of datasets and sources that did not directly address the treatment of alcohol misuse in children and young people. This included data on adults with alcohol misuse, as well as children and young people with substance misuse, conduct disorder and antisocial personality disorder. The GDG considered this to be a justified approach because there is an urgent need to provide recommendations for the treatment of the increasing problem of alcohol misuse in children and young people. In extrapolating from these datasets the GDG was cautious, recognising that as new evidence emerges the recommendations in this guideline will need revision.

Despite limited evidence a reasonably clear picture emerged about the effectiveness of interventions to promote abstinence and prevent relapse in children and young people. There was some evidence for individual interventions such as CBT and less so for MET. There was stronger evidence for the use of multicomponent interventions such as multisystemic therapy, functional family therapy, brief strategic family theraphy, and multi-dimensional family therapy, but little evidence to determine whether one of the interventions had any advantage over the others. This evidence also mirrored the evidence for effectiveness in adults. The GDG therefore decided that both types of intervention should be made available with CBT reserved for cases where comorbidity is either not present or of little significance; where comorbidity is present, multicomponent interventions should be offered.

6.24. RECOMMENDATIONS

6.24.1.1.

For all people who misuse alcohol, carry out a motivational intervention as part of the initial assessment. The intervention should contain the key elements of motivational interviewing including:

  • helping people to recognise problems or potential problems related to their drinking
  • helping to resolve ambivalence and encourage positive change and belief in the ability to change
  • adopting a persuasive and supportive rather than an argumentative and confrontational position.
6.24.1.2.

For all people who misuse alcohol, offer interventions to promote abstinence or moderate drinking as appropriate (see 5.26.1.8–5.26.1.11) and prevent relapse, in community-based settings.

6.24.1.3.

Consider offering interventions to promote abstinence and prevent relapse as part of an intensive structured community-based intervention for people with moderate and severe alcohol dependence who have:

  • very limited social support (for example, they are living alone or have very little contact with family or friends) or
  • complex physical or psychiatric comorbidities or
  • not responded to initial community-based interventions (see 6.24.1.2).
6.24.1.4.

All interventions for people who misuse alcohol should be delivered by appropriately trained and competent staff. Pharmacological interventions should be administered by specialist and competent staff38. Psychological interventions should be based on a relevant evidence-based treatment manual, which should guide the structure and duration of the intervention. Staff should consider using competence frameworks developed from the relevant treatment manuals and for all interventions should:

  • receive regular supervision from individuals competent in both the intervention and supervision
  • routinely use outcome measurements to make sure that the person who misuses alcohol is involved in reviewing the effectiveness of treatment
  • engage in monitoring and evaluation of treatment adherence and practice competence, for example, by using video and audio tapes and external audit and scrutiny if appropriate.
6.24.1.5.

All interventions for people who misuse alcohol should be the subject of routine outcome monitoring. This should be used to inform decisions about continuation of both psychological and pharmacological treatments. If there are signs of deterioration or no indications of improvement, consider stopping the current treatment and review the care plan.

6.24.1.6.

For all people seeking help for alcohol misuse:

  • give information on the value and availability of community support networks and self-help groups (for example, Alcoholics Anonymous or SMART Recovery) and
  • help them to participate in community support networks and self-help groups by encouraging them to go to meetings and arranging support so that they can attend.
6.24.1.7.

For children and young people aged 10–17 years who misuse alcohol offer:

  • individual cognitive behavioural therapy for those with limited comorbidities and good social support
  • multicomponent programmes (such as multidimensional family therapy, brief strategic family therapy, functional family therapy or multisystemic therapy) for those with significant comorbidities and/or limited social support.

Delivering psychological and psychosocial interventions for children and young people

6.24.1.8.

Multidimensional family therapy should usually consist of 12–15 family-focused structured treatment sessions over 12 weeks. There should be a strong emphasis on care coordination and, if necessary, crisis management. As well as family sessions, individual interventions may be provided for both the child or young person and the parents. The intervention should aim to improve:

  • alcohol and drug misuse
  • the child or young person's educational and social behaviour
  • parental well-being and parenting skills
  • relationships with the wider social system.
6.24.1.9.

Brief strategic family therapy should usually consist of fortnightly meetings over 3 months. It should focus on:

  • engaging and supporting the family
  • using the support of the wider social and educational system
  • identifying maladaptive family interactions
  • promoting new and more adaptive family interactions.
6.24.1.10.

Functional family therapy should be conducted over 3 months by health or social care staff. It should focus on improving interactions within the family, including:

  • engaging and motivating the family in treatment (enhancing perception that change is possible, positive reframing and establishing a positive alliance)
  • problem solving and behaviour change through parent training and communication training
  • promoting generalisation of change in specific behaviours to broader contexts, both within the family and the community (such as schools).
6.24.1.11.

Multisystemic therapy should be provided over 3–6 months by a dedicated member of staff with a low caseload (typically between three and six cases). It should:

  • focus specifically on problem-solving approaches with the family
  • use the resources of peer groups, schools and the wider community.

Interventions for harmful drinking and mild alcohol dependence

6.24.1.12.

For harmful drinkers and people with mild alcohol dependence, offer a psychological intervention (such as cognitive behavioural therapies, behavioural therapies or social network and environment-based therapies) focused specifically on alcohol-related cognitions, behaviour, problems and social networks.

6.24.1.13.

For harmful drinkers and people with mild alcohol dependence who have a regular partner who is willing to participate in treatment, offer behavioural couples therapy.

6.24.1.14.

For harmful drinkers and people with mild alcohol dependence who have not responded to psychological interventions alone, or who have specifically requested a pharmacological intervention, consider offering acamprosate39 or oral naltrexone40 in combination with an individual psychological intervention (cognitive behavioural therapies, behavioural therapies or social network and environment-based therapies) or behavioural couples therapy (see Chapter 7 for pharmacological interventions).

Delivering psychological interventions

6.24.1.15.

Cognitive behavioural therapies focused on alcohol-related problems should usually consist of one 60-minute session per week for 12 weeks.

6.24.1.16.

Behavioural therapies focused on alcohol-related problems should usually consist of one 60-minute session per week for 12 weeks.

6.24.1.17.

Social network and environment-based therapies focused on alcohol-related problems should usually consist of eight 50-minute sessions over 12 weeks.

6.24.1.18.

Behavioural couples therapy should be focused on alcohol-related problems and their impact on relationships. It should aim for abstinence, or a level of drinking predetermined and agreed by the therapist and the service user to be reasonable and safe. It should usually consist of one 60-minute session per week for 12 weeks.

6.24.2. Research recommendation

6.24.2.1.

Is contingency management effective in reducing alcohol consumption in people who misuse alcohol compared with standard care?

This question should be answered using a randomised controlled design that reports short-and medium-term outcomes (including cost-effectiveness outcomes) of at least 18 months' duration. Particular attention should be paid to the reproducibility of the treatment model and training and supervision of those providing the intervention to ensure that the results are robust and generalisable. The outcomes chosen should reflect both observer and service user-rated assessments of improvement and the acceptability of the intervention. The study needs to be large enough to determine the presence or absence of clinically important effects, and mediators and moderators of response should be investigated.

Why this is important

Psychological interventions are an important therapeutic option for people with alcohol-related problems. However, even with the most effective current treatment (for example, cognitive behavioural therapies and social network and environment-based therapies), the effects are modest at best and the treatments are not effective for everyone. Contingency management has a considerable and compelling evidence base in the treatment of substance misuse (for example, opioid misuse) but there is only a limited, if promising, evidence base for contingency management in the treatment of alcohol-related problems. The results of this research will have important implications for the provision of psychological treatment for alcohol misuse in the NHS.

6.25. ACUPUNCTURE

Introduction

Acupuncture is a form of Chinese medicine that has been practiced for over 3,000 years (Jordan, 2006). It involves inserting fine needles at selected points on the skin to balance the body's energy (chi), with the aim of treating and preventing disease. Acupuncture was introduced specifically for use in the treatment of substance-related disorders approximately 30 years ago (Kao, 1974; Leung, 1977; Sacks, 1975; Wen, 1973). However, research has predominantly been for drug misuse, for example opioid dependence (Jordan, 2006) and cocaine dependence (Gates et al., 2006; Mills et al., 2005), as well as nicotine dependence (White et al., 2006). Research for the use of acupuncture in alcohol misuse is rather more limited and to date there are only two systematic reviews of acupuncture for alcohol dependence (Cho & Whang, 2009; Kunz et al., 2007). Addiction-specific auricular acupuncture involves inserting five small needles on each ear at points regarded to be specific to chemical dependence (known as ‘shen men’, ‘sympathetic’, ‘kidney’, ‘liver’ and ‘lung’) (Smith & Khan, 1988; Wen, 1979).

6.25.1. Clinical review protocol

In the current review, the role of acupuncture in maintaining abstinence and drinking reduction was investigated. Its application to other aspects usually associated with alternative therapies in this topic area (such as craving and withdrawal symptoms) was beyond the scope of this guideline and hence was not considered. Information about the databases searched and the inclusion/exclusion criteria used for this section of the guideline can be found in Chapter 3. The GDG was of the opinion that a search for RCT studies alone may result in an insufficient number of studies to perform a review, therefore a consensus-based decision was made to also search for systematic reviews. See Table 87 for a summary of the clinical review protocol for the review of acupuncture.

Table 87. Clinical review protocol for the review of acupuncture.

Table 87

Clinical review protocol for the review of acupuncture.

6.25.2. Studies considered for review

The review team conducted a systematic search of RCTs and published systematic reviews that assessed the beneficial or detrimental effects of acupuncture in the treatment of alcohol dependence or harmful alcohol use. Following the literature search, 11 primary studies were identified. Of these, four investigated the effects of acupuncture on withdrawal symptoms and two assessed its use for the management of cravings. These six studies were excluded because the outcomes are outside the scope of this guideline. Therefore, five studies (four RCTs and one observational study) were identified for inclusion in the review. However, the review team could not perform an unbiased and comprehensive meta-analysis because there were inconsistent outcome measures across studies. Therefore, the GDG consensus was that a narrative summary of these studies would be conducted. The studies included for review were Bullock and colleagues (1987) (addiction-specific versus non-specific acupuncture); Bullock and colleagues (1989) (addiction-specific versus non-specific acupuncture); Bullock and colleagues (2002) (addiction-specific acupuncture versus symptom-based acupuncture versus non-specific acupuncture versus standard care); Rampes and colleagues (1997) (addiction-specific versus non-specific acupuncture versus no treatment control); and Worner and colleagues (1992) (addiction specific acupuncture versus sham transdermal stimulations versus standard care control). These studies were conducted between 1987 and 2002, and provided data on 752 participants. See Table 88 for characteristics of these studies. All included studies were RCTs except Bullock and colleagues (1989).

Table 88. Summary of study characteristics for acupuncture.

Table 88

Summary of study characteristics for acupuncture.

6.25.3. Evidence summary

Bullock and colleagues (1987) investigated acupuncture at addiction-specific points versus non-specific points for reducing craving and maintaining abstinence. The authors reported that the treatment group had significantly fewer drinking episodes than the control group (p = 0.007) after the second (28 days) and third (45 days) phase of treatment, but not after the first phase (5 days).

Bullock and colleagues (1989) also investigated acupuncture at addiction-specific points versus non-specific points for craving reduction, maintaining abstinence and drinking reduction in people with chronic alcohol misuse. The study found that there was no significant difference between the treatment group and control group at 1-month follow-up in the number of drinking episodes (consumption of more than three drinks in one period). However, at both 3- and 6-month follow-up, the treatment group reported significantly fewer drinking episodes than the control group (p <0.001). Furthermore, the treatment group was significantly more effective than control at maintaining abstinence and controlled drinking goals when assessed at 1-month (p <0.01), and at 3- and 6-month follow-up (both p <0.05). This study was not randomised, therefore the results must be viewed with caution.

Worner and colleagues (1992) evaluated acupuncture at addiction-specific points versus needleless transdermal stimulation as well as a standard care group that received no acupuncture. This study found no significant difference between groups in the number of participants who relapsed or needed further withdrawal management at 3-month follow-up.

Rampes and colleagues (1997) assessed addiction-specific electro-acupuncture versus non-specific electro-acupuncture and no treatment (control). The main outcome of interest was craving reduction, which is outside the scope of this guideline. However, the authors also reported no significant difference between groups in amount of alcohol consumed at 2- and 6-month follow-up.

Bullock and colleagues (2002) investigated addiction-specific and non-specific acupuncture as well as symptom-based acupuncture and standard care (based on the Minnesota model). The authors found no significant difference in alcohol consumption at 3-, 6- and 12-month follow-up. Overall, the evidence suggests that acupuncture is not effective in drinking reduction and maintaining abstinence.

The results of these studies are conflicting and show both a benefit of addiction-specific acupuncture as well as no difference between addiction-specific acupuncture and other control conditions. Additionally, the treatments across studies are not comparable because the studies used different body parts for acupuncture treatment, different types of control group, had different length of treatment and follow-up, and varied significantly in sample size. Although the quality of these trials are acceptable in the most part, the number of studies are limited and there is not enough evidence to confirm the benefit of acupuncture in maintaining abstinence or reducing the amount of alcohol consumed. Therefore no clinical recommendations are made but the GDG has developed a recommendation for further research.

6.25.4. Research recommendation

6.25.4.1. Is acupuncture effective in reducing alcohol consumption compared with usual care?

This question should be answered using a randomised controlled design that reports short- and medium-term outcomes (including cost-effectiveness outcomes) of at least 12 months' duration. Particular attention should be paid to the reproducibility of the treatment model and training and supervision of those providing the intervention to ensure that the results are robust and generalisable. The outcomes chosen should reflect both observer and service user-rated assessments of improvement and the acceptability of the treatment. The study needs to be large enough to determine the presence or absence of clinically important effects, and mediators and moderators of response should be investigated.

Why this is important

Non-pharmacological treatments are an important therapeutic option for people with alcohol-related problems. There is an evidence base for acupuncture in reducing craving but not alcohol consumption in a number of small trials. The evidence for pharmacological treatments (for example, acamprosate or naltrexone) and psychological treatments (for example, cognitive behavioural therapies and social network and environment-based therapies) is modest at best and the treatments are not effective for everyone. Anecdotal evidence suggests that acupuncture, like psychological treatment, is valued by service users both in alcohol misuse and substance misuse services (although the evidence base for effectiveness is weak). The results of this study will have important implications for increased treatment choice in the NHS for people who misuse alcohol.

6.26. PSYCHOLOGICAL INTERVENTIONS FOR CARERS

6.26.1. Introduction

There is an increasing recognition that alcohol misuse affects the entire family and the communities in which these families live but what constitutes best practice in the area is not well understood (Copello et al., 2006). What is not in doubt is the considerable suffering and hardship experienced by many families where a family member has a significant alcohol misuse problem (Orford et al., 2005).

In developing this guideline the GDG drew on a previous review of psychological interventions for carers that had been undertaken for the NICE guideline on psychosocial interventions for drug misuse (NCCMH, 2008). This was a pragmatic decision because the previous review had drawn on literature covering both drug misuse and alcohol misuse, and searches conducted for this current guideline had failed to find any substantial new evidence for interventions to support family members and carers. The outcome of the NCCMH (2008) review is summarised below in narrative form.

The NCCMH (2008) guideline identified a number of interventions in the drug and alcohol field that had been developed and tested in formal trials. They are listed below.

Five-step intervention

The five-step intervention seeks to help families and carers in their own right, independent of relatives who misuse drugs or alcohol. It focuses on three key areas: stress experienced by relatives; their coping responses; and the social support available to them. Step 1 consists of listening to and reassuring the carer, step 2 involves providing relevant information, step 3 is counselling about coping, step 4 is counselling about social support and step 5 is discussion of the need for other sources of specialist help. This intervention consists of up to five sessions.

Community reinforcement and family training

Community reinforcement and family training is a manualised treatment programme that includes training in domestic violence precautions, motivational strategies, positive reinforcement training for carers and their significant other, and communication training. However, the primary aim of the treatment appears to be encouraging the person who misuses drugs or alcohol to enter treatment. This intervention again consists of up to five sessions.

Self-help support groups

A group of families and carers of people who misuse drugs meets regularly to provide help and support for one another.

Guided self-help

A professional offers a self-help manual (for example, based on the five-step intervention), provides a brief introduction to the main sections of the manual and encourages the families and/or carers of people who misuse drugs to work through it in their own time at home.

6.26.2. Summary of the NCCMH 2008 review

The review identified a total of three RCTs including two trials (Kirby et al., 1999; Meyers et al., 2002) for community reinforcement and family training compared with 12-step self-help groups and one trial (Copello et al., 200941) of the five-step intervention in which five-step interventions of various intensities were compared.

Neither Kirby and colleagues (1999), or Meyers and colleagues (2002) found any significant different between community reinforcement and family training and 12-step self-help groups for reported levels of drug or alcohol use42. However, Kirby and colleagues (1999) found statistically significant changes from baseline for both groups in relation to carer problems and psychological functioning. In contrast, Meyers and colleagues (2002) found no statistically significant differences (after Bonferroni corrections for multiple testing) in changes from baseline at 12-month follow-up. In the case of the five-step intervention Copello and colleagues (2009) on two primary outcomes related to physical and psychological health and coping, found no statistically significant differences between the full intervention and the guided self-help conditions for both physical and psychological health (WMD −0.23; 95% CI, −4.11 to 3.65) and coping (WMD −0.12; 95% CI, −5.42 to 5.19).

6.26.3. Clinical summary

For both community reinforcement and family training and five-step intervention, there were no statistically significant differences found between these more intensive interventions and self-help (that is, 12-step self-help groups and guided self-help). It appears that self-help interventions are as effective as more intensive psychological interventions in reducing stress and improving psychological functioning for families and carers of people who misuse drugs and alcohol.

6.26.4. From evidence to recommendations

In developing the recommendations for this section of the guideline the GDG also took into account the reviews of family members' experience in Chapter 4 of this guideline which confirmed the view that families typically have considerable unmet needs. This meant that despite the limited evidence the GDG felt that the provision of information and the use of a range of self-help interventions (with relatively low cost) should be offered to families. The GDG also felt that where families could not make use of or have not benefitted from the use of the self-help materials that an offer of a structured intervention as set out in the five-step intervention should be made.

6.26.5. Recommendations

6.26.5.1.

When the needs of families and carers of people who misuse alcohol have been identified:

  • offer guided self-help, usually consisting of a single session, with the provision of written materials
  • provide information about, and facilitate contact with, support groups (such as self-help groups specifically focused on addressing the needs of families and carers).
6.26.5.2.

If the families and carers of people who misuse alcohol have not benefited, or are not likely to benefit, from guided self-help and/or support groups and continue to have significant problems, consider offering family meetings. These should:

  • provide information and education about alcohol misuse
  • help to identify sources of stress related to alcohol misuse
  • explore and promote effective coping behaviours
  • usually consist of at least five weekly sessions.

Footnotes

32
33

Here and elsewhere in the guideline, each study considered for review is referred to by a study ID in capital letters (primary author and date of study publication, except where a study is in press or only submitted for publication, then a date is not used).

34

Sensitivity analyses were conducted to assess the effect of combining studies investigating brief motivational techniques with structured MET studies. The findings were found to be robust in sensitivity analysis and the effects found were not determined by the intensity and duration the motivational intervention.

35

Treatment as usual and control were analysed together because treatment as usual was unstructured, unspecified and brief, and similar to what would be classified as control in other studies.

36

See Section 6.11 for a review of contingency management.

37

A secondary analysis of this sample was conducted by Bowen and colleagues (2007).

38

If a drug is used at a dose or for an application that does not have UK marketing authorisation, informed consent should be obtained and documented.

39

Note that the evidence for acamprosate in the treatment of harmful drinkers and people who are mildly alcohol dependent is less robust than that for naltrexone. At the time of publication of the NICE guideline (February 2011), acamprosate did not have UK marketing authorisation for this indication. Informed consent should be obtained and documented.

40

At the time of publication of the NICE guideline (February 2011), oral naltrexone did not have UK marketing authorisation for this indication. Informed consent should be obtained and documented.

41

This trial was identified prior to publication in 2008, but the reference to the published trial is used here.

42

For family members' reports of a person misusing alcohol or drugs and self-report measures.

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