Counseling for Alcohol Problems (CAP), a lay counsellor-delivered brief psychological treatment for harmful drinking in men, in primary care in India: a randomised controlled trial
Research in context
Evidence before this study
The researchers updated WHO’s Mental Health Gap Action Programme systematic review with their own systematic review. They searched the PubMed, PsycINFO, and IndMed databases from Jan 1, 1990, to Jan 1, 2011, for English language publications using the following search terms: “alcohol”, “drinking”, “addiction”, “psychological”, “therapy”, “counselling”, and “treatment”. Brief psychological treatments based on motivational enhancement have been shown to be effective for management of harmful drinking and are recommended as first-line interventions by WHO’s Mental Health Gap Action Programme for delivery in routine health-care settings. However, the existing evidence has low generalisability to many low-income and middle-income countries where both supply side barriers (low availability of mental health professionals) and demand side barriers (low levels of mental health literacy) lead to large treatment gaps.
Added value of this study
This study reports the first findings from any low-income and middle-income country assessing the effectiveness and cost-effectiveness of a brief psychological treatment for harmful alcohol use, delivered by lay counsellors in primary care. The brief (up to four-session) psychological treatment (Counselling for Alcohol Problems), based on motivational enhancement, with additional behavioural and cognitive elements, was better than was enhanced usual care according to all prespecified primary clinical outcomes, except for mean daily alcohol consumed in the past 14 days among those who reported drinking in this period, but no effect occurred on social and functional outcomes. The treatment was readily accepted by this previously untreated population and was highly likely to be cost-effective in this setting.
Implications of all the available evidence
Brief psychological treatments for harmful drinking, based on motivational enhancement, are acceptable, feasible, and cost-effective, even when delivered by non-specialist health workers in routine health-care settings in previously untreated populations. Such treatments should be scaled up as one of the key strategies to address the large and rising global burden of alcohol use disorders.
Summary of the study
Background
Although structured psychological treatments are recommended as first-line interventions for harmful alcohol use, only a small fraction of people globally receive these treatments because of poor access in routine primary care. We assessed the effectiveness and cost-effectiveness of Counselling for Alcohol Problems (CAP), a brief psychological treatment delivered by lay counsellors to patients with harmful drinking attending routine primary health-care settings.
Findings
Between Oct 28, 2013, and July 29, 2015, the researchers enrolled and randomly allocated 377 participants (188 [50%] to the EUC plus CAP group and 190 [50%] to the EUC alone group [one of whom was subsequently excluded because of a protocol violation]), of whom 336 (89%) completed the 3 month primary outcome assessment (164 [87%] in the EUC plus CAP group and 172 [91%] in the EUC alone group).
The proportion with remission (59 [36%] of 164 in the EUC plus CAP group vs 44 [26%] of 172 in the EUC alone group; adjusted prevalence ratio 1·50 [95% CI 1·09–2·07]; p=0·01) and the proportion abstinent in the past 14 days (68 [42%] vs 31 [18%]; adjusted odds ratio 3·00 [1·76–5·13]; p<0·0001) were significantly higher in the EUC plus CAP group than in the EUC alone group, but the researchers noted no effect on mean daily alcohol consumed in the past 14 days among those who reported alcohol use in this period (37·0 g [SD 44·2] vs 31·0 g [27·8]; count ratio 1·08 [0·79–1·49]; p=0·62).
The researchers noted an effect on the percentage of days abstinent in the past 14 days (adjusted mean difference [AMD] 16·0% [8·1–24·1]; p<0·0001), but no effect on the percentage of days of heavy alcohol use (AMD −0·4% [–5·7 to 4·9]; p=0·88), the effect of drinking (Short Inventory of Problems score AMD–0·03 [–1·93 to 1·86]; p=0.97), disability score (WHO Disability Assessment Schedule score AMD 0·62 [–0·62 to 1·87]; p=0·32), days unable to work (no days unable to work adjusted odds ratio 1·02 [0·61–1·69]; p=0.95), suicide attempts (adjusted prevalence ratio 1·8 [–2·4 to 6·0]; p=0·25), and intimate partner violence (adjusted prevalence ratio 3·0 [–10·4 to 4·4]; p=0·57).
The incremental cost per additional remission was $217 (95% CI 50–1073), with an 85% chance of being cost-effective in the study setting.
The researchers noted no significant difference in the number of serious adverse events between the two groups (six [4%] in the EUC plus CAP group vs 13 [8%] in the EUC alone group; p=0·11).
Interpretation
CAP delivered by lay counsellors plus EUC was better than EUC alone was for harmful alcohol users in routine primary health-care settings, and might be cost-effective. CAP could be a key strategy to reduce the treatment gap for alcohol use disorders, one of the leading causes of the global burden among men worldwide.