Pilot study of Assertive Community Treatment in alcohol dependence

Excessive drinking is increasingly common in the UK and leads to a heavy use of health, social and criminal justice services with considerable costs. It was recently estimated that alcohol misuse costs the UK economy #20bn per annum. About 23% of the adult population in England drinks at a level likely to cause harm, and 4% are dependent on alcohol. Only a minority of the people experiencing alcohol dependence enters treatment each year. Many have severe and complicated problems and have difficulties in making best use of the limited treatment services that are currently available. Many drop out of treatment before they have improved, only to return to a cycle of heavy drinking and unplanned use of hospital and GP and other services.

There is a need for better and more effective treatments for people with alcohol dependence, and there is some evidence that treatments that involve assertive outreach and longer term treatment follow-up are better than standard treatment, which tends to be relatively short term and relies on the patients? motivation to engage with it. There is much stronger evidence that Assertive Community Treatment (ACT), which involves extended and assertive contact with often unmotivated patients, is effective in treating people with severe mental illness (e.g. schizophrenia) improving mental health, contact with treatment and client satisfaction, and reducing admissions to hospital.

In this pilot study we plan to adapt the ACT methods successfully used in severe mental illness to find out if it is more helpful than typically available treatment for people with alcohol dependence. This preliminary work will help us to design and carry out a more extensive study to assess the effectiveness of ACT in alcohol dependence across several centres in England. Further, although ACT will be more expensive to deliver than standard treatment, it will be important to find out if it is more cost effective, i.e. if the greater costs of treatment are offset by greater savings to the wider health service. If so, this could potentially have major implications for the NHS and the way treatment is delivered to this population.

BACKGROUND: Alcohol dependence causes significant harm to individuals, their families and communities, contributing to morbidity, mortality and health and wider societal costs. Assertive Community Treatment (ACT) is effective in reducing the impact of severe mental illness on symptomatology, hospital bed use and quality of life, and treatment engagement but evidence for ACT for severe alcohol dependence is lacking.

AIMS: This pilot study aims to develop and refine ACT for use in alcohol dependence, including optimal delivery and target population; to conduct a preliminary randomised controlled trial (RCT) to establish the effect size of ACT versus standard treatment and establish potential recruitment across 6 sites, to advise a definitive RCT.

DESIGN: The development phase will be primarily a qualitative study with alcohol service users and clinicians to develop ACT and standard treatment manuals. The pilot RCT is a parallel group design and 1 year follow up to assess efficacy of ACT versus standard care for alcohol dependence.

SETTING AND PARTICIPANTS: Interventions will take place in community based alcohol services in London. The optimal target group will be determined by the development work but participants are likely to include a DSM IV diagnosis of alcohol dependence, referred to a specialist alcohol service, are over the age of 18, have and have had 1 or more previous episodes of unsuccessful alcohol treatment.

MEASURES: Primary: Alcohol consumption using Time Line Follow Back method: percentage of days abstinence and mean drinks per drinking day. Secondary: Severity of Alcohol Dependence Questionnaire (SADQ), Alcohol Problems Questionnaire (APQ), psychiatric symptoms (SF12), quality of life (EQ5D), motivation (RTCQ), therapeutic relationship (STAR), service use questionnaire (SUQ), number of inpatient admissions and measures of social network involvement (IPA ? Important People and Activities Inventory). Qualitative investigation of patient and clinician views and satisfaction with treatment will be used to refine the intervention manuals.

FINDINGS: The study findings will inform the development of a definitive multicentre RCT of ACT versus standard treatment if indicated. Ultimately if the intervention is effective and cost effective this could lead to a conceptual shift in treatment interventions for alcohol dependence. Outputs and aggregate data from the research will be shared and disseminated via peer reviewed publications and conferences.