Increasing access to psychosocial interventions for alcohol use disorders: Home based interventions.

Alcohol use disorders (AUD) are a significant and growing public health problem in India. However, health services for AUD remain largely confined to large institutions and a significant proportion of people with AUD do not having access to help for their alcohol related problems. One way of changing this status quo is making evidence based psychosocial interventions available in communities and closer to people's homes. There is extensive evidence supporting the effectiveness of a range of psychosocial interventions for AUDs. This is further augmented by the growing evidence for the effectiveness of contextually appropriate psychosocial interventions, such as Counselling for Alcohol Problems (CAP) from India, that are designed to increase access to care through delivery by non-specialist health workers. The effective implementation of such interventions integrated into collaborative care models will go a long way in reducing the treatment gap for AUDs in India.

INTRODUCTION

In contemporary India, although the consumption of alcohol varies greatly across the country, after tobacco, it remains the most common substance of abuse1; and hence this article will focus on psychosocial treatment options for alcohol use disorders (AUDs). Although there are relatively high alcohol abstention rates in India, as compared to Western countries, the rates of AUDs amongst those who do drink, are relatively high due to frequent and heavy drinking of spirits2. In fact, like the rest of the world, in India, AUDs are second only to depressive disorders as the leading neuropsychiatric cause of disease burden3. In the post globalisation era, economic growth in India has fuelled the local alcohol industry, resulting in an increase in alcohol availability, alcohol consumption and alcohol related problems. Finally, the epidemiological picture of AUD in India is characterised by high rates of alcohol-attributable mortality and prevalence of AUDs relative to the per capita volume of alcohol consumed4. The official response to the growing public health problem of AUDs in India remains focused predominantly on the visible tip of the iceberg i.e. alcohol dependence (4% of the adult male population) while the bigger public health problem of hazardous drinking and harmful drinking remains neglected2. A testimonial to the limited reach of the current approach is the paradoxical observation that the rates of help-seeking in these centres are the lowest in states with the highest prevalence of alcohol use (5). This effectively means that a focus on institutional delivery of services for AUD results in a large proportion of people with AUD in India not having access to help for their alcohol related problems; a ‘treatment gap’ (proportion of people with an illness, disease, or disorder who need treatment but do not get it)6 of 86%7.

Globally, the ‘treatment gap’ for AUDs is the widest among all mental disorders; the contact coverage of care for AUDs is less than 20% in most countries8. Furthermore, as most patients who are in contact with services do not have their AUD recognized or receive evidence-based interventions, the ‘effective’ coverage gap is likely to be even larger9. Although medications form one component of treatment for some types of AUD, successful long-term recovery is dependent on psychosocial interventions that focus on building motivation to change, and support changing of maladaptive behaviours and expectations about alcohol. However, the vast majority of people with AUDs who live in India do not have access to any structured psychosocial interventions. The two major barriers to making psychosocial interventions accessible in India are the shortage and inequitable distribution of skilled human resources for delivering such interventions10 and concerns regarding the contextual appropriateness and generalisability of interventions developed in ‘Western’ cultural settings.

A range of evidence based psychosocial interventions is available for the treatment of AUDs. They could be broadly summarized as follows. ‘Brief interventions' are evidence based, short, focused psychosocial interventions that are designed to be delivered by non-specialists before or soon after the onset of alcohol related problems and are typically designed to reduce the heavy drinking in high-risk drinkers11. More severe alcohol problems require specialised treatments required to manage alcohol withdrawal, prevention of relapse and rehabilitation. These include medically assisted detoxification using benzodiazepines in inpatient and outpatient settings12, residential or outpatient rehabilitation programmes13, psychosocial interventions (e.g. behaviour therapy, motivational enhancement therapy, Twelve Step Facilitation, family therapy)14, and pharmacotherapy (e.g. Naltrexone, Acamprosate, Disulfiram)1516. Finally the World Health Organization's mhGAP-IG17 recommends the use of Brief Interventions (BI) for harmful drinking and self-help groups like Alcoholics Anonymous (AA) for alcohol dependence. The psychosocial strategies recommended for BI in the mhGAP-IG include behavioural strategies (e.g. not having alcohol at home, not going to pubs or other locations where people use alcohol); family involvement; and Motivational Interviewing (MI) (e.g. discussing pros and cons of drinking, rolling with resistance, promoting independence).

One way to increase access to such evidence based psychosocial interventions for AUD in low resource settings is through home based care. There are several powerful arguments for home based care, especially in low resource settings. Hospitals in low resource settings do not have the capacity to deal with the increasing numbers of people in need of their services. Hence, most of the burden of care falls on the patients' families and their wider communities. In such circumstances, home based care allows for continuity of care, provides support for affected families, improves the quality of life of patients and their family caregivers, and relieves the burden on the health sector. The following sections describes how community based or home based care can be implemented effectively to increase access to care in low resource settings.

Identification of alcohol use disorders

The first critical step towards effective treatment of AUDs includes using appropriate strategies to identify patients with alcohol problems. One way of doing this is through the use of structured tools as they generally perform better than quantity-frequency questions, clinical impressions, or laboratory data that clinicians commonly use to detect alcohol problems in their patients18. Two commonly used screening tools include the CAGE questionnaire19 and the Alcohol Use Disorders Identification Tool (AUDIT)20. They serve two different purposes; the CAGE questions (Cut Down, Annoyed, Guilty and Eye Opener) are better suitable to identify patients with alcohol dependence while the AUDIT is more sensitive for hazardous and harmful drinkers. It is feasible to use AUDIT in settings where time allows for more in-depth interviewing, while the much shorter CAGE is more suitable in busy clinical settings.

Psychosocial treatments for AUD

Psychosocial treatments remain the foundation of the treatment for AUDs and can be used in a range of settings either as stand-alone treatments or in combination with pharmacological intervention. They can be delivered by a range of health workers, can be brief or intensive and specialized, and are suitable for home based delivery. Briefly, some of the psychosocial interventions that can be delivered in home based settings include the following.

Brief Interventions (BI), ranging from 5 minutes of brief advice to 15-30 minutes of brief counselling, aim to help drinkers understand that their alcohol use is putting them at risk and encourages them to reduce or stop alcohol use21. BIs are targeted at hazardous or risky alcohol use and are not intended to treat people with those with alcohol dependence.

Motivational Interviewing (MI) is used to help drinkers to explore and resolve their ambivalence about their alcohol use and move them collaboratively towards making positive behavioral and psychological changes22. Cognitive behavioral interventions use a theoretical model which focuses on identifying and modifying irrational thoughts, managing negative mood and intervening after a lapse to prevent a full-blown relapse23. Relapse prevention is a set of strategies to help maintain treatment gains by developing skills to identify, avoid, and effectively cope with situations which put that patient at a risk of relapsing24. Finally, there is a considerable evidence-base that pharmacological treatment with anti-craving agents can be enhanced by combining with psychosocial interventions2526.

Considering the range of psychosocial interventions available, choosing an appropriate one to deliver appears an onerous task. However, two large trials, one in the USA (Project MATCH) and the other in the UK (UK Alcohol Treatment Trial), respectively demonstrated that four sessions of Motivational Enhancement Therapy (MET) was as effective as 12 sessions of either Cognitive Behaviour Therapy (CBT) or Twelve Step Facilitation (TSF), and three sessions of MET, were as effective as eight sessions of social behavior and network therapy (SBNT). These findings suggest that access to any evidence based treatment itself leads to a reduction in drinking and that such access may be as important as type of treatment received. Hence, the focus, especially in low resource settings with large treatment gaps, should be on increasing access to evidence based psychosocial interventions for AUDs. However, one of the biggest supply side barriers to achieving this goal is the shortage and inequitable distribution of highly trained health professionals to deliver such interventions.

The other critical issue that limits the use of psychosocial interventions in countries like India is the contextual appropriateness of the existing interventions, as they have been developed and tested in developed countries from Europe and North America, and Australia. Very few trials have tested psychosocial interventions in Low and Middle Income Countries (LMIC). These include a BI for risky drinking in university students in Brazil27, BI based on MI in a mix of hazardous, harmful and dependent drinkers in India28, MET delivered by nurses to hazardous drinkers in Thailand29 and Cognitive Behaviour Therapy (CBT) delivered by lay counsellors to hazardous or binge drinkers in Kenya30. A more recent and contextually relevant example from India is the Counselling for Alcohol Problems (CAP) intervention developed and tested in India. The CAP intervention is arguably the first contextually appropriate intervention for harmful drinking developed using a systematic treatment development process and rigorously tested in Indian settings3132. It merits further discussion as it overcomes two major barriers to access by being contextualised to Indian cultural settings and being suitable for delivery by non specialist health workers, a more easily available and accessible resource in India.

The Counselling for Alcohol Problems (CAP) intervention is designed to be delivered in three phases to harmful drinkers (Box 2). The common thread that runs across these phases is the counselling style of the therapist, and that is informed by Motivational Interviewing (MI) and client centred supportive counselling.

Box 2

Community Oriented Non-specialist Treatment of Alcohol Dependence (CONTAD)

CAP is delivered over a maximum of four sessions, one session being a minimum requirement and two sessions being optimal. The sessions should ideally be delivered at a weekly to fortnightly frequency. Each session lasts 30 to 50 minutes and can span one or more ‘phases' of CAP. For example, if a patient entering treatment is not ready for change then the complete first session would be focused on ‘initial phase’, but if a patient enters treatment ready for change then the counsellor could quickly move through the ‘initial phase’ in session 1 and proceed to the ‘middle phase’ in the same session. There is flexibility in where the intervention could be delivered based on the mutual convenience of the patient and the therapist. The intervention could be delivered in the clinic, patient's home, or in any other convenient but safe place (e.g. friend's home). Involving a significant other (SO) in the treatment is optional. It is recommended that the SO should be engaged as far as possible in the first session to get a better understanding of the patient's drinking and its impact, and also to help in developing a change plan. However, subsequent involvement of the SO may be encouraged based on how helpful the involvement was; and the patient and the therapist should decide this collaboratively. Finally, the use of the accompanying information booklet is strongly recommended as it helps the patient engage with the treatment in between sessions. Thus the CAP has an inbuilt flexibility not just in what is delivered (i.e. the strategies used), but also in other aspects like where it is delivered (i.e. clinic, home, or any other alternative place), how it is delivered (i.e. phasic delivery), and who is involved in the treatment process (i.e. SO involved or not).

Figure 1 illustrates these various components of CAP and a proposed mechanism through which they would lead to a change in the drinking outcomes and the eventual bio-psycho-social outcomes. Supportive counselling and MI strategies are used throughout the course of the treatment and help to engage and increase the motivation of the patient. The detailed assessment and personalised feedback along with SO involvement in treatment is postulated to increase the patient's motivation to change by facilitating the patient's recognition of the link between his drinking and the resultant adverse impact on his life. Furthermore, the process of reporting one's own drinking and subsequent personalised feedback leads to reflection on one's own behaviour and may initiate self-monitoring. This in turn may lead to cognitive dissonance where the drinker recognises inconsistencies between current drinking and a personal standard, leading to change in drinking behaviour. Once the patient makes a decision to change his drinking behaviour, the various ‘thinking and behavioural’ skills will increase his capacity to manage drinking triggers which in turn will further increase his motivation to change and help him achieve his drinking goals, as well as help in managing lapse and relapse. The achievement of the patient's drinking goals will then have a positive effect on the various domains of his life and eventually the overall quality of his life.

Figure 1

Modelling of CAP components and pathways to outcomes

Working with family members

A critical component of home based interventions, especially in socio-centric countries like India, is working collaboratively with family members of patients with AUDs. Family members of patients experience a host of adverse impacts on their physical and mental health, and they need support not only to deal with the patient but also help for themselves. Interventions for family members can broadly be categorised into those that focus on: (1) supporting family members to promote the entry and engagement of patients into treatment; (2) the joint involvement of family members and patients in the treatment; and (3) the needs of the family members in their own right.

Examples of home based psychosocial interventions that can be delivered in each of these three categories are as follows: 1) Family members can influence those with alcohol problems to seek or accept help and support their engagement in treatment. The ‘pressures to change’ approach engages the family member in treatment by providing relevant psychoeducation, discussing the family member's response to drinking situations, sets up activities incompatible with drinking, and prepares the family member to confront the person with the drinking problems and facilitates approaching services to seek help33. CRAFT (Community Reinforcement and Family Training) works with family members to reinforce non-alocol misusing behaviour through a positive reinforcement process34. This involves restructuring of social, family and vocational aspects of everyday living of the drinker, and thus selectively encouraging abstinence. To achieve this goal, the family members could play the roles of ‘Disulfiram monitors’, partners in marital counselling, active agents in re-socialisation and reinforcement programs, and ‘detection monitors for relapse’; 2) The joint involvement of family members and the patient in treatment is useful as the quality of family relationships impacts on someone's alcohol misuse and positive family relationships are related to better treatment outcomes. An example of a psychosocial intervention which focuses on the drinker and his/her partner is the alcohol-focused behavioural couples therapy (ABCT). It focuses on strategies that teach family members to support the drinker's efforts to change, reduce protection for drinking-related consequences, develop better skills to cope with negative affect, and communicate around alcohol-related topics; strategies to increasing the couple's positive exchanges and improving their communication and problem-solving skills; and behavioural contracts between partners to support the use of medication35; and 3) Interventions, such as the 5 Step Method, that are aimed directly at supporting family members affected by the alcohol misuse of a relative. The 5 Step Method, involves (1) giving the family member the opportunity to talk about the problem; (2) providing relevant information; (3) exploring how the family member responds to their relative's substance misuse; (4) exploring and enhancing social support; and (5) discussing the possibilities of onward referral for further specialist help (36).

General principles that should underpin home-based psychosocial interventions for AUDs

Psychosocial interventions for people with AUDs should be delivered by adequately trained and competent staff.

Psychosocial interventions that are delivered should be based on a relevant evidence-based treatment manual.

Clinicians delivering psychosocial interventions should receive regular supervision from individuals competent in delivering the relevant intervention and in providing supervision.

For harmful drinking and mild alcohol dependence, offer a psychosocial intervention focused on building motivation to change, alcohol-related cognitions, behaviour, problems and social networks.

For moderate and severe alcohol dependence offer psychosocial interventions to promote abstinence and prevent relapse.

Attempt to engage family members to help the patient and also to support them in their own right.

Providing home based care through collaborative care models

Community-based or home-based delivery of psychosocial interventions effectively and efficiently addresses the challenges associated with the burden of AUDs and involves a strategic shift away from a traditional model of care based on psychiatric institutions or clinics. This paradigm shift will contribute to improved access to care, allows patients to maintain family relationships, friendships, and employment while receiving treatment, and is associated with greater continuity of care, higher user satisfaction, increased adherence to treatment, and reduced stigmatisation. This involves the establishment of a structured collaboration with a range of stakeholders who play critical roles in the community to identify and treat people with AUD.

An example of such a collaborative care model focused on home based care is influenced by the evidence based MANAS model developed for management of common mental disorders in low resource settings37. This model, when adapted for AUDs could be structured as follows [Table 1]: The first step would be the identification of people with AUDs in a range of primary care and community settings by various non specialist health workers. Community based psychosocial interventions could then be delivered by non-specialist health workers for hazardous and harmful drinkers. The non-specialist health workers and psychiatrists could work collaboratively to deliver appropriate biological and psychosocial interventions for uncomplicated alcohol dependence. For complex alcohol dependence and treatment resistant AUDs the psychiatrist would take the lead in providing clinic and/or hospital based care as appropriate. To summarise, in such a collaborative care model the specialist's role is training, supervising and providing support to non-specialist health workers, managing biological treatments, providing leadership to the team, and managing complex cases that require more time and greater expertise.

Table 1

Community based collaborative care model for AUDs

Although such a model can have a potentially multiplier effect on access to care, the success of such an effective collaborative care model focused on home-based psychosocial interventions hinges on the willingness of specialists to do the following38: share healthcare responsibilities with non-specialists, without fear of losing their work, identity and income; reduce the amount of time devoted to individual clinical care and increase the time for training of other personnel; and devote significant time to periodic support and supervision of the non-specialists. An example of such a collaborative care model for treatment of alcohol dependence is Community Oriented Non-specialist Treatment of Alcohol Dependence (CONTAD), a proof of concept project implemented in Goa (Box 2).

Summary and future directions

AUDs are a significant and growing public health problem in India. Despite the availability of a range of interventions, a large proportion of people with AUDs in the country do not have access to evidence based care. The supply side barriers to access to care for AUDs can be overcome through home based care delivered by non specialist health workers. Interventions such as CAP, developed and tested in India, are suitable for home based delivery, designed to be delivered by non specialist health workers, and attuned to the cultural context. Effective use of such interventions will depend on systemic changes in which collaborative care models allow various stakeholders to work synergistically to generate optimal outcomes even within the constraints of a resource limited setting.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Box 1

Counselling for Alcohol Problems