Internet-based psychological interventions for problematic alcohol use: Patient treatment and support for concerned significant others

Abstract: Alcohol has been a part of human history for thousands of years, for both good and bad. The average person in Sweden today is drinking 9 liters of pure alcohol per year, and it is estimated that 780,000 people in Sweden have such serious problems with alcohol that they would benefit from treatment for their problems. The diagnosis of alcohol problems used in this licentiate fol- lows DSM-5, Alcohol Use Disorder (AUD). In addition to being a common problem in Sweden and many parts of the world, AUD has a huge burden on disease, and approximately 3 million people die every year because of alco- hol, making it the third largest cause of death in the world. Alcohol also has a causal effect on more than 60 different diseases, where increased alcohol consumption counted from the first glass in most cases is more likely to cause the disease. Alcohol also has a high level of comorbidity with other psychiatric disorders, such as depression, bipolar disorder, hypomania, panic syndrome, personality disorders and schizophrenia. Despite the major illness burden that often accompanies AUD, there are estimations that as few as 10-20% of people with problematic alcohol use ever seek treatment. This may be due to various reasons, such as concern that treatment is not effective, a desire to take care of the problem by oneself, denial of having problems, and that it is associated with shame and stigma to have alcohol problems. Internet treat- ment an easier way to seek treatment for those who otherwise would not seek help. The overall aim of the two studies included in this thesis was to investigate the efficacy of two internet-based interventions for alcohol problems; (Study I) high-intensity internet treatment (the so called ePlus treatment) for people with alcohol use disorders (AUDs) and (Study II) internet-based version of Community Reinforcement and Family Training program (iCRAFT) for Con- cerned Significant Others (CSOs) to individuals with AUD. The aim of Study I was to evaluate the high-intensity internet treatment ePlus for people with a diagnosed AUD. This treatment was compared with a low-intensity internet treatment (eChange) and with a waiting list (WL). It was hypothesized that participants in ePlus would reduce their alcohol consump- tion significantly more than participants both in eChange and on the WL. A secondary aim was to evaluate the psychological negative effects of high- and low intensity internet treatment for AUD. Study II aimed to evaluate iCRAFT compared to a WL. It was hypothesized that participants receiving iCRAFT would increase Identified Persons’ (IPs) treatment engagement. An IP is the person with AUD, who is not receiving any treatment for his or hers problem- atic alcohol use at the time the CSO starts the intervention. Secondary aims were to investigate if iCRAFT had increased CSOs’ quality of life and decreased IPs’ alcohol use. Data was collected partly via self-report questionnaires administered over each study’s technical platform, and partly via telephone interviews. Data was collected from 166 participants in Study I and 94 participants from Study II. The primary outcomes in Study I were two measurements of the partici- pants’ alcohol consumption: number of standard drinks per week and number of heavy drinking days (HDD) per week. The primary outcome in Study II was treatment engagement, as expressed in the IP’s initiative to seek treatment. Each group reduced alcohol consumption from screening to post treat- ment within each group, and this reduction was more or less maintained after three months compared to screening. Comparison between ePlus versus WL showed no significant differences at screening for any of the primary outcome variables. A significant reduction of standard drinks as well as HDD for the ePlus group occurred compared to WL at post treatment. Participants in the ePlus condition also displayed greater treatment satisfaction than partici- pants in the eChange condition. The results showed that although twice as many Concerned Significant Others (CSOs) in the iCRAFT condition reported IP treatment engagement, this difference was not statistically significant. Results in Study I indicate that ePlus is both effective in reducing both standard drinks per day and heavy drinking days compared to WL and, compared to eChange, it is also effective in reducing heavy drinking days immediately after treatment. Results in Study II were unexpected, since previous research on CRAFT using a face-to-face approach has shown substantial effects. The lack of statistically significant ef- fect can possibly be due to an underpowered study, but also a need to further develop the program. In summary, the results in Study I indicate that ePlus is effective in reduc- ing both standard glasses per day and the number of high consumption days compared to waiting lists, and compared to eChange, it is also effective to reduce short-term high-consumption days, i.e. immediately after treatment. The results in Study II were unexpected, as earlier research on CRAFT face-to- face has shown significant effects. The lack of statistically significant effects may be due to the fact that there were too few participants in the study, but also a need for further development of the program.