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QUESTION: What is the long term impact of brief interventions for harmful alcohol consumption?
10-year follow up of a 9-month randomised controlled trial.
6 general practices, 1 hospital outpatient service and 1 privately run health screening programme in Sydney, Australia.
554 non-dependent `harmful drinkers' taking part in the Australian arm of the WHO brief interventions for alcohol treatment project; 37% women; mean age 40 years. Recruitment criteria included weekly consumption of at least 300g alcohol for men or 180g for women; 2 or more episodes of binge drinking per month, or alcohol related harm in the previous 6 months followed by continued drinking. Exclusion criteria were regular alcohol consumption within 2 hours of waking; history of antidepressant or antipsychotic medication; major psychiatric disorder; hospital admission for an alcohol related disorder; pregnancy; advice from a health professional to stop drinking, and 2 or more changes of address within 6 months.
i) 5 minutes of advice from a therapist plus information leaflet; ii) simple advice and leaflet plus 15 minutes of counselling in problem solving techniques; iii) brief advice and 15 minutes of counselling plus invitation to return for 2 additional sessions within 6 months, or iv) no treatment. 89% of the original cohort was followed to a mean of 9 months. After 10 years, 78% of the original cohort was located and 67% interviewed (5% had died and 7% refused).
Main outcome measures
Drinking behaviour; biological markers of alcohol use; symptoms of diagnosable alcohol disorders; self-reported alcohol-related social, psychological and physical harm, and mortality at 10 years.
At 9-months (n=495), people receiving brief interventions reported lower alcohol consumptionand less unsafe drinking. The intensity of the intervention was not related to the amount of change. At 10 years (n=433), there were no differences between intervention and control groups in median alcohol consumption, mean reduction in consumption from baseline, mortality or ICD-10 diagnoses of harmful alcohol use or alcohol dependence.
Brief interventions may be effective in the short term, but there is no evidence that advice and counselling without follow up reduces alcohol consumption in the long term.
Empirical evidence supporting brief interventions for alcohol use has grown substantially in recent years, especially in non-dependent drinkers. `Brief interventions' are not a single intervention, but a 'family' of interventions. Randomised trials suggest that brief interventions reduce alcohol consumption over a period of up to one year compared to no intervention or well controlled `standard care.' Wutzke et al's 9-month outcome data are consistent with this trend. There is less empirical support for the longer term effectiveness of brief interventions. It is in this context that Wutzke et al's 10-year outcome data contribute to the literature. The study was well designed and executed. Although there are questions about the data analyses, they did not affect the finding of no differences in alcohol use after 10 years.
This long term follow up is significant for researchers and clinicians alike, but by itself has limited application. Even if the differences observed at 9 months were evident at 10 years, we would still be unclear about the processes contributing to outcomes. It seems unlikely that a brief intervention administered 10 years ago could fully explain current alcohol consumption patterns. The critical information is how intervention components are or are not related to biological, psychological, or social and environmental events that occur after the intervention. This is a major gap in existing literature, even when considering outcomes over a period of one year or less.
The clinical implications of this study seem clear. The project's 9-month data reaffirm the value of spending even 5 or 10 minutes advising hazardous or harmful drinkers to reduce their alcohol consumption. The 10-year data reinforce the importance of exploring connections between interventions and behaviour change.
For correspondence: Sonia Wutzke, National Prescribing Service, New South Wales, Australia.
Source of funding:National Health and Medical Council of Australia (information provided by author)
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