Aims: Home detoxification is a recognized method of treating problem drinkers within their own home environment. The aim of this research is to determine whether a relatively brief psychological intervention adds to its effectiveness. Methods: A pragmatic trial with 91 participants randomly assigned to either the psychological intervention or treatment as usual. Community Psychiatric Nurses were trained to administer the brief psychological intervention involving motivational interviewing, coping skills training and social support. A manual was developed in order to standardize the training and implementation. Results: At the 3 month and 12 month follow-up the psychological intervention resulted in significant positive changes in alcohol consumption, abstinent days, social satisfaction, self-esteem and alcohol-related problems. Further, a cost analysis confirmed that the psychological intervention was a ninth of the cost of inpatient treatment. Conclusions: Adding a psychological intervention to a home detoxification programme was successful and cost-effective. Topic:
• ethanol
• detoxification therapy
• cost effectiveness
• follow-up
• inpatients
• psychiatric nursing
• social support
• self esteem
• community

Issue Section:

DETECTION AND TREATMENT

INTRODUCTION

One of the main reasons for using alternative detoxification treatment programmes, rather than more traditional inpatient treatments, is the inherent high cost of inpatient care. Cooper (1995) estimated that, in the United Kingdom, 12% of mental health beds are utilized for alcohol withdrawal treatment and that 73% of all detoxification admissions are re-admissions. There is thus an obvious need to find alternative, effective and safe alcohol withdrawal treatments that are less costly than admission to hospital care. Outpatient detoxification programmes have been found to be at least half the cost of inpatient treatment (Kraus et al., 1986), while others have reported that outpatient programmes may be up to six times less expensive than the inpatient service (Klansman; Feldman et al., 1975; Bartu and Saunders, 1994). Bartu and Saunders (1994) suggested, following findings from their comparative detoxification study, that a home detoxification programme might be as much as eight times cheaper (depending on the number of visits needed) than a comparable inpatient treatment programme. Cooper (1995) calculated home detoxification treatment to be 26% of the cost of inpatient treatment and suggested that patients detoxified in their own home are more likely to complete the treatment and remain abstinent for longer than patients who are treated in hospital. There is strong evidence to support the safety and effectiveness of both outpatient and home detoxification (Fleeman, 1997). There are also a number of other advantages such as reducing the stigma often attached to inpatient care, encouraging family involvement and support, and reducing the waiting list. Bartu and Saunders (1994) proposed that detoxification in the home is far more realistic in relation to alcohol, as patients are not isolated from drinking cues and drink triggers. The aims of the current study are to develop and test the feasibility of a psychological intervention for use as an adjunct to a home detoxification programme; to assess the impact of this by completing follow-up interviews at 3 months and 12 months post treatment to assess consumption levels, dependence, alcohol-related problems, social satisfaction and health; and to assess the cost effectiveness of this intervention in comparison with other treatment approaches for detoxification. METHODS Design In a pragmatic randomized trial two interventions were compared: treatment as usual (control) involving medication and support, and the psychological intervention, which added a structured psychological approach (manual directed) to the medication. Two main factors were therefore involved: these were treatment (two types) and occasion of assessment (three occasions). Recruitment of participants Participants were recruited by intake assessment medical staff from consecutive referrals to home detoxification services in four participating areas. These four areas had an existing similar home detoxification service in place. The four centres were: Bro Taf Community Addiction Unit, Cardiff; Sandwell Community Alcohol Team, Birmingham; Clwyd Community Addictions Unit; and Gwynedd Community Addictions Unit. Referrals to these home detoxification services came from general practitioners, self-referral, social services and voluntary agencies such as local community alcohol teams. Inclusion/exclusion criteria All referred patients, who met the clinical criteria for home detoxification, were included in the trial. Exclusion criteria were identical to those for existing home detoxification services: previous history of withdrawal fits; epilepsy; very severe physical or psychological disorders; no stable address. Initial screening assessment All patients referred to the community units were assessed by the clinical staff for their suitability for home detoxification, based on the above criteria and were asked whether they would agree to participate in the trial. Informed consent Informed consent was obtained by the researcher prior to initial assessment. Research assessment Either the research staff or the participating Community Psychiatric Nurses (CPNs) administered the research assessment. This assessment was carried out 2–5 days prior to treatment. The assessment battery took ∼75 min to complete and was administered on a one-to-one basis in patients' homes or treatment centres, at their own convenience. Some of the questionnaires were interviewer led and others were self-completed. In order to avoid data contamination, the presence of a significant other was discouraged. Randomization On completion of the initial research assessment participants were randomly allocated to one of the two treatment conditions, using a random number table. This was implemented by the project administrator who had no knowledge of, or access to any individual patient information. Assessment measures The following measures were chosen in order to reflect the research aims and objectives. (i) Form 90 family of instruments (Miller, 1996); this measure records information on days abstinent, drinks per drinking day (in units, 1 unit = 8 g ethanol), total consumption during the previous 3 months (in units) and other drug use. (ii) Severity of Alcohol Dependence Questionnaire (SADQ) (Stockwell et al., 1979); used to assess the severity of the alcohol dependence syndrome. (iii) Alcohol Problems Questionnaire (APQ) (Drummond, 1990); in order to quantify information on alcohol related problems. (iv) Social Satisfaction Scale (Tober, 2000); to assess levels of dissatisfaction with specific aspects of living. (v) Self Esteem questionnaire (Rosenberg, 1965); a measure commonly used to assess self esteem. Treatments Participants in both groups were detoxified using appropriate medication for detoxification which was consistent for all participants. This was dispensed on a daily basis with the dose gradually being reduced over a period of 5–8 days. Participants' GPs took medical responsibility for the prescribing of the detoxification medication. Control: treatment as usual (five home visits over a 5–8 day period) Treatment as usual involved five home visits of 30 min duration by the CPN for administration of the appropriate dose of medication for detoxification. The other aspect of these sessions included developing rapport and providing simple advice, especially regarding withdrawal symptoms and physical discomfort. The psychological intervention (five home visits over a 5–8 day period) As well as the administration of the appropriate dose of medication for detoxification, the psychological component was a relatively brief intervention consisting of three main approaches within one 30 min session on each of five home visits. Sessions were scheduled as follows. Session 1: motivation. The first session focused on motivation and building rapport with the client. Motivation to change was briefly considered by exploring the benefits of change. Reasons for stopping or reducing drinking were discussed with the aim of gently motivating change. This was carried out with empathy, and confrontation was avoided. Sessions 2 and 3: coping skills. The emphasis in these sessions was upon developing a simple cognitive coping strategy that involved accepting discomfort and bringing to mind reasons to change. These sessions focused on the desensitization of alcohol cues or triggers that may lead to relapse, drink refusal skills and dealing with thoughts about alcohol. The client was encouraged to learn and develop appropriate and relevant coping skills. To help clients with this, a three step coping strategy technique was developed, which they were encouraged to practise regularly, especially when experiencing craving. Sessions 4 and 5: social support. Therapists were encouraged to be as creative as possible in helping the client to access effective support provided by partners, friends or other family members. Positive social support for abstinence (or sensible drinking in a few cases) was the main focus of these sessions. Increasing social activities could involve local groups, or taking up hobbies or activities that encourage social interaction, which may enable the development of new social networks. The integrity by which the two forms of treatment were implemented by the therapists was addressed by (i) supervision and training of the therapists: this involved the initial training plus one further visit to the participating centres by the research team in order to resolve any problems or difficulties experienced. (ii) Monitoring through ongoing telephone contact with therapists: the research team maintained regular telephone contact with the participating centres, and CPNs involved were provided with a mobile 'helpline' number. (iii) All therapists were supplied with a treatment manual (available from the first author). Therapists The control treatment was conducted by CPNs; each CPN carried out both the control and psychological treatments with the exception of one agency. In this agency the psychological treatment was conducted by one of the research psychologists. Therapists all had at least 2 years experience in the alcohol field. All the CPNs were trained in the mental health field and were ‘F’ grade or above. Follow-up Follow-up interviews with participants were carried out at 3 months and 12 months post treatment.