Implementing digital interventions for problematic alcohol use in the psychiatric context : visions and reality

The relationship between alcohol use disorder (AUD) and other mental health disorders is complex, with genetic, environmental, and causal factors at play. Comorbid AUD and psychiatric disorders lead to elevated risks of suicide, more severe disease courses, and impaired daily functioning. Screening all patients for alcohol and substance use is crucial, as recurrence rates are higher in individuals with both AUD and mental health disorders. Alcohol use disorders have significant consequences globally, with many individuals in need of help but not receiving it due to various barriers. Implementing digital interventions can improve accessibility, scalability, and reduce stigma associated with seeking help. Research has shown that guided digital interventions are effective in reducing alcohol consumption and improving mental health.

The overall aim of this thesis was to investigate staff perceptions of identifying and treating patients in psychiatry with problematic alcohol or substance use, exploring perceptions of whether digital interventions could be a viable alternative, and exemplifying staff perspectives on how digital interventions are currently being effectively implemented in addiction healthcare.

Study I aimed to map staff knowledge and application of national guidelines for managing alcohol and substance use in psychiatric outpatient clinics. Surveys revealed that clinic directors had guidelines for screening and interventions, but staff reported lower rates of implementation. There was a discrepancy between alcohol and illicit substance screening and intervention provision. Staff did not consistently screen or offer interventions, indicating a need for increased awareness and implementation of guidelines. Despite awareness of the importance of identifying substance abuse, there was a lack of integration of brief interventions in psychiatric treatment.

Study II qualitatively examined open-ended text responses in the online survey in Study I, on challenges and solutions in treating patients with substance use disorders in Swedish outpatient psychiatry clinics. Key themes identified were the necessity for clearer guidelines, enhanced education and collaboration among clinics, and the need for more resources like staff and time. Staff expressed concerns about guideline adherence and its impact on patient care, underscoring the importance of ongoing training and support to improve clinical skills. Time constraints and limited resources were highlighted as barriers to evidence-based treatments, pointing to the need for additional research to allocate resources effectively for screening and treating substance use disorders in psychiatry.

In Study III, the aim was to examine healthcare staff's experiences when treating patients with substance use disorder in psychiatric outpatient settings. Interviews with clinical managers and healthcare professionals revealed three main themes: “Bridging the organizational gap”, “Having beliefs about the patients you encounter”, and “Striving to achieve a therapeutic alliance”. The findings showed struggles in delivering proper care due to collaboration issues and biases, with the staff´s efforts to overcome obstacles leading to improved personalized treatment and collaboration for patients.

Study IV aimed to explore healthcare staff attitudes towards referring patients with substance use disorders to digital interventions in a psychiatric setting in Stockholm, Sweden. Through interviews with clinic managers and nursing staff, themes of encountering obstacles, seeking solutions, and progressing towards the future were uncovered. Staff expressed concerns about resource constraints and adjusting to new technologies but also saw the benefits of integrating digital interventions with traditional care. The Technology Acceptance Model was used to explain how user perceptions of technology influence their willingness to use it. The model underscores the importance of addressing staff apprehensions and offering assistance in incorporating digital interventions in psychiatric care to improve patient results.

Study V aimed to identify and describe addiction healthcare staff's views on the advantages of referring patients to digital interventions for alcohol misuse and ways to enhance these interventions. This qualitative study included 16 participants from the Stockholm Centre for Dependency Disorders, revealing themes such as enhanced access to care, personalized treatment, and improved collaboration between healthcare facilities. Results indicated that digital interventions could enhance patient results and resource efficiency, emphasizing the importance of implementing a clear workflow and working with the in-house e-Support Unit for successful integration. Normalization Process Theory could be used for supporting and assessing continued and expanded implementation.

In summary, digital interventions offer advantages like increased accessibility, anonymity, cost-effectiveness, and scalability, making them a valuable tool in addressing alcohol use disorders in psychiatry care. In Sweden, eHealth and digitization aim to provide personalized digital support for patients to control their health and well-being, with the goal of becoming a leader in eHealth by 2025. In this thesis, clinic directors described that they have guidelines for screening for alcohol use disorder and substance use disorder, but that adherence is low. Training staff in addictive disorders could improve collaboration between clinics and patient care in psychiatry. Integrating digital treatment for alcohol use disorder and substance use disorder in psychiatric clinics could make healthcare more accessible. However, implementing digital interventions for patients with alcohol use disorders and substance use disorders faces challenges. Addressing staff resistance, through training in addictive disorders as well as in knowledge of digital interventions, is necessary for success. Structured routines are crucial for effective collaboration between healthcare clinics or units within the clinics. The Normalization Process Theory (NPT) can simplify the implementation of digital interventions by providing structure and guidance, leading to easier adoption and improved patient access.

List of scientific papers

I. Sundström, C., Petersén, E., Sinadinovic, K. et al. Identification and management of alcohol use and illicit substance use in outpatient psychiatric clinics in Sweden: a national survey of clinic directors and staff. Addict Sci Clin Pract. 14, 10 (2019).
https://doi.org/10.1186/s13722-019-0140-x

II. Petersén, E., Berman, A.H. Screening and treating problematic substance use among patients in psychiatry – obstacles and solutions. BMC Res Notes. 16, 113 (2023).
https://doi.org/10.1186/s13104-023-06389-w

III. Petersén, E., Thurang, A. & Berman, A.H. Staff experiences of encountering and treating outpatients with substance use disorder in the psychiatric context: a qualitative study. Addict Sci Clin Pract. 16, 29 (2021).
https://doi.org/10.1186/s13722-021-00235-9

IV. Petersén, E., Augustsson, H. & Berman, A.H. Problematic substance use among patients in a Swedish outpatient psychiatry setting: staff and manager perceptions of digital options for increased intervention access. Addict Sci Clin Pract. 18, 65 (2023).
https://doi.org/10.1186/s13722-023-00421-x

V. Petersén, E., Augustsson, H., Johansson, M., Sundström, C. & Berman, A.H. Digital interventions as a part of routine addiction care in Sweden: A qualitative exploration of a new path to optimizing resources. [Manuscript]