Effectiveness of a Web-based Intervention for Problem Drinkers and Reasons for Dropout: Randomized Controlled Trial

Abstract

Background: Online self-help interventions for problem drinkers show promising results, but the effectiveness of online therapy with active involvement of a therapist via the Internet only has not been examined.

Objective: The objective of our study was to evaluate an e-therapy program with active therapeutic involvement for problem drinkers, with the hypotheses that e-therapy would (1) reduce weekly alcohol consumption, and (2) improve health status. Reasons for dropout were also systematically investigated.

Method: In an open randomized controlled trial, Dutch-speaking problem drinkers in the general population were randomly assigned (in blocks of 8, according to a computer-generated random list) to the 3-month e-therapy program (n = 78) or the waiting list control group (n = 78). The e-therapy program consisted of a structured 2-part online treatment program in which the participant and the therapist communicated asynchronously, via the Internet only. Participants in the waiting list control group received “no-reply” email messages once every 2 weeks. The primary outcome measures were (1) the difference in the score on weekly alcohol consumption, and (2) the proportion of participants drinking under the problem drinking limit. Intention-to-treat analyses were performed using multiple imputations to deal with loss to follow-up. A dropout questionnaire was sent to anyone who did not complete the 3-month assessment. Reasons for dropout were independently assessed by the first and third author.

Results: Of the 156 individuals who were randomly assigned, 102 (65%) completed assessment at 3 months. In the intention-to-treat analyses, the e-therapy group (n = 78) showed a significantly greater decrease in alcohol consumption than those in the control group (n = 78) at 3 months. The e-therapy group decreased their mean weekly alcohol consumption by 28.8 units compared with 3.1 units in the control group, a difference in means of 25.6 units on a weekly basis (95% confidence interval 15.69-35.80, P < .001). The between-group effect size (pooled SD) was large (d = 1.21). The results also showed that 68% (53/78) of the e-therapy group was drinking less than 15 (females) or 22 (males) units a week, compared with 15% (12/78) in the control group (OR 12.0, number needed to treat 1.9, P < .001). Dropout analysis showed that the main reasons for dropouts (n = 54) were personal reasons unrelated to the e-therapy program, discomfort with the treatment protocol, and satisfaction with the positive results achieved.

Conclusions: E-therapy for problem drinking is an effective intervention that can be delivered to a large population who otherwise do not seek help for their drinking problem. Insight into reasons for dropout can help improve e-therapy programs to decrease the number of dropouts. Additional research is needed to directly compare the effectiveness of the e-therapy program with a face-to-face treatment program.

Trial registration: ISRCTN39104853; http://controlled-trials.com/ISRCTN39104853/ISRCTN39104853 (Archived by WebCite at http://www.webcitation.org/5uX1R5xfW)

Introduction

Problem drinking is a highly prevalent public health issue, with serious consequences in terms of morbidity and mortality [1], and associated economic costs [2] and social problems [3]. However, most problem drinkers will never seek treatment [4]. In the United States, only 16% of people with an alcohol-abuse disorder had received treatment in 2001 [5], and in the Netherlands, only 10% of the problem drinkers received professional help in 2006 [6]. Furthermore, people often seek help only at a late stage; usually after 10 or more years of alcohol abuse or dependence [7]. Therefore, improved access to therapy for problem drinkers is needed [8-10]. The Internet offers a novel opportunity to reach a larger and more diverse segment of the population of problem drinkers [11,12] and improves the availability of alcohol treatment services. Online treatment programs are distinguishable by the intensity of the therapist involvement. Andersson and colleagues [13] distinguished the different forms of Internet interventions in a clear manner: (1) fully self-administered therapy or pure self-help, (2) predominately self-help (ie, therapist assesses and provides initial rationale, and teaches how to use the self-help tool), (3) minimal-contact therapy (ie, active involvement of a therapist, but to a lesser degree than in traditional therapy, eg, using email), and (4) predominantly therapist-administered therapy (ie, regular contact with therapist for a number of sessions, but in conjunction with self-help material). A meta-analysis of 12 randomized controlled trials (RCTs) of Internet-based cognitive behavioral therapy programs for depression and anxiety showed that Internet-based interventions are effective; especially those with therapist involvement [14].

RCTs of Internet interventions for problem drinking are available, and they show promising results [15-23]. However, all of these online alcohol interventions are fully self-help interventions without therapist involvement. The effectiveness of predominantly therapist-administered online therapy for problem drinkers solely via the Internet has not yet been examined in a RCT. It is expected that active therapeutic involvement will lead to greater treatment effects compared with self-help. In addition, we expect to reach another group of people, who prefer intensive personal therapist contact instead of dealing with their problem themselves.

This report describes the main findings from a RCT in which participants were randomly assigned to the 3-month therapist-involved e-therapy program or to the waiting list control group. Because of poor adherence and high dropout rates in e-health interventions [24-26], and a low completion rate (173/527, 33%) in our pilot study [27], we decided to systematically investigate the reasons for dropout as part of our RCT study as well. Insight into those reasons may identify factors that are responsible for dropout, and online treatment programs can consequently be improved to reduce the number of participants ending treatment prematurely. Based on the prior results of our uncontrolled observations, where we found a significant decrease in alcohol consumption and alcohol-related health complaints [27], we tested the hypothesis that e-therapy would (1) reduce weekly alcohol consumption, and (2) improve health status. To our knowledge this is the first RCT that evaluates the effectiveness and reasons for dropout of an e-therapy program for problem drinking with active therapeutic involvement.

Methods

Study design and participants

We undertook an open RCT, with recruitment taking place between October and December 2008. To be included in the trial, participants had to be Dutch-speaking problem drinkers in the general population aged 18 years or more. Problem drinking was defined as drinking currently at least 15 units (of 10 g of ethanol) a week for females and 22 units for males, with a maximum of 67 units a week for females and 99 units for males. This was based on the mean weekly alcohol consumption in the pilot study, added with 1.5 SD. We excluded participants treated for problem drinking in the preceding year and participants with psychiatric treatment in the past 6 months or those currently having a psychiatric disorder.

Participants were recruited through an advertisement on the website’s homepage (http://

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