Alcohol treatment that incorporates a stepped-care rationale, in which services are escalated, appears to increase the overall efficacy of the treatment regimen. However, in countries such as Germany and the U.S., medication and individual psychotherapy – either separately or in combination – are rarely used to treat alcohol dependence (AD). A recent study of AD patients who were given a stepped-care approach – first medication, then additional psychotherapy – found that patients who are willing to attend psychotherapy in addition to pharmacotherapy benefit from a reduced or delayed relapse to heavy drinking.
Results will be published in the April 2014 online-only issue of Alcoholism: Clinical & Experimental Research and are currently available at Early View.
"In Germany, usually care is delivered by addiction counselors," said Michael Berner, a professor of psychiatry at the Freiburg University Medical Center as well as chief physician at the Rhine-Jura Hospital for Psychiatry, Psychosomatics and Psychotherapy in Bad Säckingen, Germany. "But this is usually not disorder-specific, evidence-based psychotherapy. It is has only been a few years that formal psychotherapy delivered by physicians or clinical psychologists will be reimbursed. But even now many of the psychotherapists decline therapy for patients with AD because of an assumed poor prognosis. Therefore, this population is generally not offered psychotherapeutic services by regular psychotherapists."
Berner, who is also the corresponding author for the study, added that the situation for AD medication is not much better. "Anti-craving medications, though effective, are rarely used," he said. "Thus, people neither receive one nor the other. And an additional and possibly the biggest problem is public opinion, which does not consider AD a kind of disorder. So if the public is asked where to cut costs, they always choose alcohol-related disorders."
Berner and his colleagues conducted their randomized, multi-center study with the participation of 109 AD patients (86 males, 23 females) who had suffered a heavy relapse either while receiving anti-craving medication or placebo. The patients were randomized into two groups: one group (n=54) was offered medication, medical management, and additional individual, disorder-specific, cognitive- behavioral psychotherapy; while the control group (n=55) was offered medication and medical management only. The main outcome was defined as days until first heavy relapse.
"All therapies were effective," said Berner. "One must not forget that the medical-management group, our control condition, meant that somebody spent time with the patients and did talk to them; you might think of this as a formal yet brief psychosocial intervention to increase motivation and compliance. But altogether those patients who started psychotherapy and continued [for a period of time] had a significant, additional benefit over those in the control group."
Unfortunately, a large number of the patient participants, despite their consent, did not begin the psychotherapy.
"There is a difference between motivation, wanting to do something, and volition, managing to do things," explained Berner. "It is often characteristic of alcoholic patients, that they are motivated to do things like quitting or attending additional services, but do not manage to actually do so in real life. In our study, our patients had to see a new person to start the psychotherapy, which many did not do. Many patients that did not attend psychotherapy preferred continuity over the change in routine. This would perhaps have been different if the same person would have delivered the psychotherapy. And it would have been, and probably should perhaps be, different in the 'real world' where health professionals might work closer together in the same building."
Berner recommended that clinicians offer psychotherapy to their patients, possibly at an earlier stage. "If you get them involved, they might very well profit," he said. "Our results showed that commitment to the treatment offered was the crucial factor, because the patients who opted not to attend the psychotherapy tended to do worse than their compliant counterparts."
That said, Berner noted that stepped-care models are not 'one size fits all.' "Today, we reach only 10 percent of the population in need for therapy," he emphasized. "Therefore, our study highlights that it is important to offer services that work for patients when there is need to do so. Contrary to public opinion, and even what many professionals think, these therapies work. They help patients cope better with their disorder."
Berner called for care to be taken when applying rather rigid stepped-care models in routine care, especially when using psychotherapeutic techniques without having a real commitment from the patient. "The question of whether psychotherapy can be an effective add-on therapy for patients who do not respond sufficiently to pharmacotherapy is still not clearly answered," he said. "All we can say at this point is that this is the case for some of the treated patients, but not for others. It might be worthwhile in future study to focus more on the assumed need by the patients themselves. We are planning to conduct a more
detailed analysis of those patients who did profit from additional psychotherapy in the hope that we may be able to identify a subgroup of patients for whom psychotherapy might be beneficial."