Alcohol dependence : barriers to treatment and new approaches in primary care

Sammanfattning: Alcohol dependence is highly prevalent worldwide, with an estimated prevalence of 4 % in the Swedish adult population. However, alcohol dependence has one of the largest gaps between the number of individuals affected and the number in treatment, where less than one in five seek treatment. The overarching aim of this thesis was to study possible strategies to reduce this treatment gap. In study I, the aim was to investigate which type of treatment for alcohol problems, and setting, that was preferred in the general population. Also, reasons for not seeking treatment. In a cross-sectional design, 9005 individuals representative of the general population between 16-80 years of age were interviewed. The results showed that a majority of the participants preferred treatment for alcohol problems within the health care system, while only 5 % preferred the social services. Support groups, psychotherapy and residential treatment were the most endorsed types of treatments. Shame was the most common reason given for not seeking treatment. In study II, the aim was to describe how individuals with alcohol dependence perceive treatment for alcohol use disorders and their reasons for seeking and not seeking treatment. 32 participants aged 18-62 with alcohol dependence were recruited via a market research company. Data was collected through focus group interviews and individual interviews. The results showed that shame and stigma were important barriers for seeking treatment. Additional barriers were; the perception that treatment meant accepting a goal of lifetime abstinence, low level of knowledge of health consequences associated with alcohol use and also low level of knowledge about treatment. Psychotherapy was the most preferred form of treatment. In study III, the effects of treatment for alcohol dependence in primary care were investigated. 288 adults with alcohol dependence were randomized to treatment in primary care with the 15-method, a brief treatment adapted for generalist settings, or treatment at a specialized addiction unit. The hypothesis was that treatment in primary care was non-inferior to specialist care. At six month follow up, the results on the primary outcome measure, weekly alcohol consumption, were statistically inconclusive, and could not confirm non-inferiority. However, treatment in specialist care was not superior to primary care. Sub-analysis showed that primary care was non-inferior for low to moderate severity of dependence, while participants with high severity of dependence had better outcome after specialist treatment. In study IV, the long-term effect of treatment for alcohol dependence in primary care was investigated, as well as trajectories for change of alcohol consumption. The study was based on the 12 month follow up of the participants in study III. The results confirmed non-inferiority for the primary outcome measure; weekly alcohol consumption. The results for the secondary outcome measures were consistent with the primary outcome – a reduction from baseline to 12 month follow up with no differences between primary care and specialist care. The only exception was that patients randomized to specialist care were more satisfied with treatment. The analyses of trajectories showed that the main reduction in consumption occurred during the first six months and were maintained at the 12 month follow up. In conclusion, treatment for alcohol dependence was seen as an issue for the health care services. Shame and stigma impose strong barriers to seeking treatment. The knowledge of health consequences associated with alcohol and treatment for alcohol dependence was limited. Common perceptions of treatment often stood in sharp contrast to preferred treatments among non-treatment seekers. Treatment for alcohol dependence in primary care with the 15-method is a promising approach. Five strategies are suggested in order to decrease the current treatment gap: reduce stigma; organize treatment in an attractive way; offer controlled drinking as a treatment goal; improve health literacy regarding alcohol use, health, alcohol dependence and treatment and finally - new ways to increase dissemination of alcohol interventions in primary care.