Can proactive alcohol e-therapy engage people with problematic alcohol use in effective treatment? Findings from a randomized controlled trial

Background
Problematic alcohol use is linked to numerous mental and physical health issues, violence, accidents, and social consequences. In Denmark, around 470,000 people show signs of problematic alcohol use, but only 25,000 receive treatment annually, and dropout rates are high. First-time entrants typically have an average of 12 years of problematic use, with most being alcohol dependent. An effective treatment for problematic alcohol use is face-to-face psychosocial therapy based on motivational interviewing and cognitive behavioral therapy (face-to-face alcohol therapy). However, this approach requires physical attendance at a clinic, presenting significant barriers related to geographical distance and limited clinic hours. Moreover, the stigmatization surrounding problematic alcohol use and treatment, along with the frequent co-occurrence of anxiety and depression, further complicates engagement in face-to-face treatment. Online alcohol treatment in various forms is increasingly used to address these barriers. One online option is to transition face-to-face alcohol therapy to video conferencing (alcohol e-therapy). This type of online alcohol treatment aims to replicate the effectiveness of face-to-face alcohol therapy while taking advantage of the enhanced privacy, anonymity, and flexibility of the internet. Despite its potential, alcohol e-therapy has received limited research attention

Aim
The overall aim of the thesis was to contribute with knowledge about the potential of proactive alcohol e-therapy to engage people with problematic alcohol use in effective treatment. In 2018, a randomized controlled trial on proactive alcohol e-therapy was initiated by the Danish National Institute of Public Health. Based on that trial, the specific research objectives were as follows: 

To test the hypothesis that proactive alcohol e-therapy is better than face-to-face alcohol therapy in relation to treatment initiation, compliance, and alcohol intake (paper I).

To explore the relationship between proactive alcohol e-therapy and symptoms of anxiety and depression through two subsidiary objectives (paper II): 
1. To explore whether anxiety and depressive symptoms modify the effect of proactive alcohol e-therapy on treatment initiation, compliance, and alcohol intake.
2. To explore the impact of proactive alcohol e-therapy on anxiety and depressive symptoms compared to face-to-face alcohol therapy. 

To explore why individuals with problematic alcohol use initiate and comply with proactive alcohol etherapy (paper III). 

Methods
A two-arm randomized controlled trial assigned 356 participants in equal ratio to proactive alcohol etherapy and face-to-face alcohol therapy (standard care). Participants were recruited online from January 2018 to June 2020. Data for papers I and II were collected through online questionnaires at baseline, 3- and 12-month follow-ups. Dichotomous outcomes were analyzed using logistic regression, while continuous outcomes used non-binomial regression, in both available case and intention-to-treat samples. For paper III, thematic analysis was conducted using ten semi-structured interviews with participants engaged in proactive alcohol e-therapy and observations of 21 therapy sessions. 

Results
Paper I showed that participants in proactive alcohol e-therapy had significantly higher rates of treatment initiation and compliance at both 3- and 12-month follow-up compared to standard care. Only after 3 months, the weekly alcohol intake was significantly lower among participants in the proactive alcohol e-therapy group. Paper II found no evidence that anxiety and depressive symptoms modified the effects of proactive alcohol e-therapy on treatment initiation, compliance, and alcohol intake. Proactive alcohol e-therapy reduced anxiety and depressive symptoms to the same extent as standard care at 3-month follow-up. Paper III revealed that participants were motivated to initiate treatment due to the light framing of alcohol problems and treatment on the project website as it resonated with their self-image. Treatment compliance was supported by the online format’s flexibility, which facilitated easy and discreet integration of treatment into daily life, along with a strong alliance formed with the therapist. 

Conclusion
Proactive e-alcohol therapy, compared to standard care, improved treatment initiation and compliance, and was equally effective in reducing alcohol intake, as well as anxiety and depressive symptoms. The framing of alcohol problems and treatment, combined with the flexibility of an online format and a strong therapeutic relationship, played a crucial role in treatment initiation and compliance. The findings of this thesis suggest that proactive e-alcohol therapy has the potential to engage people with problematic use in effective alcohol treatment.