Treating alcohol use disorder on the internet

Background: Alcohol use disorders are highly prevalent worldwide, but most of the people with such disorders are never treated. Internet interventions are effective in reducing alcohol consumption and could help overcome some of the reasons for why people do not seek or receive treatment. The aim of this thesis was to study if internet alcohol programs are an effective treatment option for people with alcohol use disorder.

Method: Internet Cognitive Behavioural Therapy (ICBT) alcohol programs were studied in one naturalistic study, one randomized controlled trail, one randomized controlled non-inferiority trail and one qualitative content analysis. Study I investigated user characteristics, intervention use patterns, and variables associated with reductions in alcohol use, among anonymous individuals with hazardous alcohol use who signed up for an ICBT self-help program. Study II was a randomized controlled trial with anonymous users with likely alcohol dependence (n =1169), comparing guided ICBT program and self-help ICBT program with information. Study III was a randomized controlled non-inferiority trail comparing guided ICBT to face-to-face CBT at a specialized clinic among patients diagnosed with alcohol use disorder (n = 301). Study IV investigated the differences between internet treatment and face-to-face as perceived by twelve therapists working with internet-based treatment for alcohol or cannabis use disorders within different programs, interviewed in three focus group interviews.

Results: In Study I, 4165 individuals signed up during two years. Half of the participants were women, the mean age was 42 years, 82 % had high (>15) total score on the Alcohol Use Disorders Identification Test, 74% had symptoms of anxiety and 90% were in the contemplation stage of readiness to change. Scoring higher on baseline readiness, completing the program, and accessing other support predicted low-risk drinking at follow-up after the program. In Study II, no significant differences were found in weekly alcohol consumption between the self-help and the therapist-guided ICBT groups at three months, between the self-help group and the control group at three months or between any of the groups at six months. At three months follow-up a significant difference was identified between the therapist guided and control group in weekly alcohol consumption (difference = -3.84, 95 CI = -6.53 to -1.16, t = 2.81, p = 0.005). The difference in alcohol consumption between the internet and the face-to-face CBT group in Study III was non-inferior according to the prespecified limit of five standard drinks, in the intention-to-treat analysis of data from six months follow-up and in most secondary outcomes at three- and six-months. The analysis in Study IV revealed five themes in the differences between internet-based and face-to-face treatment: communication, anonymity, time, presence and focus. Treatment online in written and asynchronous form creates something qualitatively different from regular face-to-face meetings between patients and therapists.

Conclusions: A publicly available web-based program for problematic alcohol use attracted users with considerable alcohol and health-related problems. A web-based ICBT program with therapist guidance was not found to be more effective than the same program as self-help in reducing alcohol consumption or other alcohol-related outcomes. An ICBT program with therapist guidance might be more effective in the short run than information. Internet CBT was not inferior to face-to-face CBT in reducing alcohol consumption among patients with alcohol use disorder. There are important differences between conducting internet-based and face-to-face treatment. Different aspects of the working alliance seem to be important on the internet compared to face-to-face. Internet alcohol interventions can be an effective treatment alternative for alcohol use disorder.

List of scientific papers

I. Johansson, M., Sinadinovic, K., Hammarberg, A., Sundström, C., Hermansson, U., Andreasson, S., & Berman, A. H. (2017). Web-based self-help for problematic alcohol use: a large naturalistic study. International journal of behavioral medicine. 24 (5), 749-759.
https://doi.org/10.1007/s12529-016-9618-z

II. Johansson, M., Berman, A. H., Sinadinovic, K., Lindner, P., Hermansson, U., & Andreasson, S. Web-Based treatment of alcohol dependence: a randomized controlled trial. [Submitted]

III. Johansson, M., Sinadinovic, K., Gajecki, M., Lindner, P., Berman, A. H., Hermansson, U., & Andreasson, S. Internet-based therapy vs. face-to-face therapy for alcohol use disorder, a randomized controlled non-inferiority trial. [Submitted]

IV. Ekström, V., Johansson, M. (2019). Sort of a nice distance: a qualitative study of the experiences of therapists working with internet-based treatment of problematic substance use. Addiction science & clinical practice. 14(1), 1-11.
https://doi.org/10.1186/s13722-019-0173-1