The Brave New World of Behavioral Therapies for Alcohol Use Disorders

June 30, 2014
Kathleen M Carroll, MD

Volume 31, Issue 6

In addition to the approval of novel medications for alcohol use disorders, the past several years have been marked by an emphasis on development, standardization, and dissemination of new behavioral therapies, including computer-based interventions.

The landmark 1990 report, Broadening the Base of Treatment for Alcohol Problems, called for a restructuring of treatment to address all levels of alcohol use problems and to make effective treatments more broadly available.1 In addition to the approval of novel medications such as naltrexone, the past 14 years were marked by an emphasis on development, standardization, and dissemination of new behavioral therapies. For example, Project MATCH2 introduced and made available clinician manuals for the 3 treatments evaluated, including Motivational Enhancement Therapy (a variant of Miller’s Motivational Interviewing), Cognitive-Behavioral Coping Skills (adapted from Monti and colleagues), and a manualized version of Twelve-Step Facilitation. The efficacy of these and other approaches has been established through multiple systematic reviews and meta-analyses; these approaches are included in multiple practice guidelines, including those of the American Psychiatric Association.3

However, because established efficacy does not guarantee effective implementation in clinical practice, research shifted to effective means of training clinicians in these approaches to bridge the research-practice gap. Workshops alone are ineffective in helping clinicians learn to implement behavioral therapies effectively. Rather, effective implementation of behavioral therapies may require exposure through didactic seminars followed by supervisory review and feedback regarding treatment fidelity and skill, as well as ongoing monitoring.

These models have been implemented by some states and large health care systems. However, their relatively high cost in terms of clinician time and high rates of clinician turnover in many treatment settings limits the extent to which these models, however effective, can be used on an outpatient basis.

Thus, what has been particularly exciting is the development of computerized versions of these approaches. Computerized treatments have multiple advantages for broadening the base of treatment for alcohol use disorders, including availability 24 hours a day; greater confidentiality, hence fewer concerns about stigma; lower cost; standardization; and greater ability to reach rural and underserved populations. A clear advantage for psychiatric practice is that computer-based interventions can serve as a clinician extender, offering a means of delivering a high-quality, standardized version of screening, evaluation, and brief treatments, at relatively low cost, thus freeing up the psychiatrists’ time for other critical functions.

Both the quality of these programs and the level of rigor of the studies supporting them vary quite a bit; this is because of their relatively recent development. Approaches that have gone through at least preliminary validation in clinical trials are highlighted in this article. However, psychiatrists must review the programs for quality and appropriateness to the individual patient; moreover, each patient needs to be carefully monitored.

Screening and brief intervention

A particular advantage of computer-based screening and feedback interventions is that individuals can connect to and use them immediately, when their motivation may be highest, rather than wait several days or weeks for an appointment. A number of Web-based applications have been developed; they draw from principles of traditional clinician-delivered screening and brief interventions. Also called eSBIs, these sites usually consist of an assessment of alcohol use and risk, typically using a validated instrument such as the AUDIT (Alcohol Use Disorders Identification Test),4 followed by feedback as to level of risk, with some suggestions or additional resources for reducing drinking. While many eSBIs have been developed, only a few have been evaluated in randomized clinical trials, and of those, the majority come from college populations. The overall effect size for these interventions is small (d = .22), and results of these studies have been mixed, however, underlining the need for careful review before referring a patient to a particular site.5,6

Interventions

Relative to eSBIs, there are fewer intensive, multiple-session interventions that have been developed for computer-based delivery for alcohol use disorders. For non-dependent problem drinkers, online training in moderation management (www.moderatedrinking.com) combined with online moderation management(www.moderationmanagement.org) has been shown to be effective in reducing drinking days.7 A version of CBT4CBT, an 8-session computer-based version of cognitive-behavioral therapy used as treatment of drug use disorders, has been updated for alcohol use disorders; randomized controlled trials to evaluate its efficacy are under way.

As Rounsaville and I8 have noted, “the great promise of computer-assisted therapies may be diminished if their benefits are overstated or if they are broadly released or disseminated before being carefully evaluated using the same methodologic standards that are requirements for evaluating clinician-delivered therapies.” However, provided they are demonstrated to be safe and even moderately effective, they may be tremendously effective for individuals with alcohol use disorders and their families.

The bottom line

Training, monitoring, and feedback are needed to bring most clinicians to competence in empirically validated therapies. Many resources are available through the National Institute on Alcohol Abuse and Alcoholism Web site, including guidance on screening, brief intervention and referral to treatment, treatment manuals, and fact sheets.9

A variety of manuals and training tapes (for contingency management, Twelve-Step Facilitation, Cognitive-Behavioral Coping Skills, and compliance enhancement) as well as fidelity monitoring tools (the Yale Adherence and Competence Scale) can be downloaded at no cost through Yale’s National Institute on Drug Abuse–supported Web site.10www.niaaa.nih.gov/publications/clinical-guides-and-manuals

Technology-based interventions are proliferating, but caveat emptor! Many are of poor quality with weak empirical support: a good source of reviews of the evidence base for available computer-based resources for alcohol and drug use disorders is the Web site for the Center for Technology and Behavioral Health at Dartmouth.11

This article was originally posted on 4/21/2014 and has since been updated.

Disclosures:

Dr Carroll is Albert E Kent Professor of Psychiatry at Yale University School of Medicine Department of Psychiatry in New Haven, Connecticut. The author reports that she is a member of CBT4CBT.com, which makes validated versions of CBT4CBT available to qualified providers. Dr Carroll works with Yale University to manage conflicts of interest issues.

References:

1. Institute of Medicine. Broadening the Base of Treatment for Alcohol Problems. Washington DC: National Academies Press; 1990.

2. Project MATCH. Matching Alcoholism Treatments to Client Heterogeneity. http://www.commed.uchc.edu/match. Accessed May 1, 2014.

3.Practice Guideline for the Treatment of Patients With Substance Use Disorders. 2nd ed. 2006. http://psychiatryonline.org/content.aspx?bookid=28&sectionid=1675010. Accessed May 2, 2014.

4. Babor TF, Higgins-Biddle JC, Saunders JB, Monteiro MG. The Alcohol Use Disorders Identification Test: Guidelines for Use in Primary Care. 2nd ed. World Health Organization, Department of Mental Health and Substance Dependence. 2001. http://whqlibdoc.who.int/hq/2001/who_msd_msb_01.6a.pdf. Accessed May 2, 2014.

5. Carey KB, Scott-Sheldon LA, Elliott JC, et al. Computer-delivered interventions to reduce college student drinking: a meta-analysis. Addiction. 2009;104:1807-1819.

6. Bewick BM, Trusler K, Barkham M, et al. The effectiveness of web-based interventions designed to decrease alcohol consumption-a systematic review. Prev Med. 2008;47:17-26.

7. Hester RK, Delaney HD, Campbell W. ModerateDrinking.com and moderation management: outcomes of a randomized clinical trial with non-dependent problem drinkers. J Consult Clin Psychol. 2011;79:215-224.

8. Carroll KM, Rounsaville BJ. Computer-assisted therapy in psychiatry: be brave-it’s a new world. Curr Psychiatry Rep. 2010;12:426-432.

9. National Institute on Alcohol Abuse and Alcoholism. http://www.niaaa.nih.gov. Accessed May 2, 2014.

10. Yale School of Medicine. Psychotherapy Development Center. http://www.pdc.yale.edu. Accessed May 2, 2014.

11. Center for Technology and Behavioral Health. http://www.c4tbh.org/technology-in-action/program-reviews/substance-use-disorders.html. Accessed May 2, 2014.