Calabria B., Shakeshaft A.P., Havard A.
Addiction: 2011, 106, awaiting print publication.
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Though some studies may have been persuasive, this review of recent attempts to find which therapeutic approaches work best for young risky drinkers was unable to reach firm conclusions due to variability in the studies and methodological inadequacies. Still, the tentative conclusions accord with those in UK guidance.
Aims This review identified published studies evaluating interventions delivered outside educational settings, designed for young people with existing alcohol use problems, or who participate in behaviour which places them at high risk of alcohol-related harm. The studies' methodologies were critiqued and opportunities identified for new interventions.
Methods A systematic search of the peer-reviewed literature interrogated 10 electronic databases for English-language studies published in 2005–09 of "youth" formally diagnosed or screened as drinking in a risky, problematic or dependent manner or referred for treatment. No additional studies were found by searching other collections and clearing-houses, or by hand-searching review paper reference lists. Of the 1697 articles retrieved by the searches, nine were evaluation or intervention trials aimed at testing interventions to reduce alcohol-related harm which met all the review's other criteria, primarily that they focused on alcohol and young people with alcohol problems and were not conducted in an educational setting.
The studies Eight of the nine studies evaluated counselling-based interventions, of which seven were individual counselling. In four studies counselling was based on motivational interviewing, in three on cognitive-behavioural therapy, and four studies featured family therapy and/or a community reinforcement approach [Editor's note: for more on this approach intended to harness the patient's social network see this Findings article]. The remaining study investigated the efficacy of medicating alcohol-dependent adolescents with ondansetron [Editor's note: for more on how this drug is intended to work see this Findings analysis], a serotonin antagonist. The young people involved were aged from 11 to 25 years. Seven studies were randomised controlled trials which allocated patients at random to different interventions, minimising the risk that any differences in outcomes would be due to differences in the patients rather than the interventions. Nevertheless, the methodological quality of the studies was variable. Particular problems include the lack of blinding of outcome assessors, reliance on self-report measures, highly variable consent and follow-up rates, infrequent use of 'intention to treat' analyses, which base findings on all the patients in the study, not just those who could be followed up or completed treatment, and the lack of economic or cost analyses. The range of interventions evaluated is largely limited to individually-focused approaches, almost exclusively (all but one study) conducted in the USA.
Effectiveness of the interventions Due to the generally weak methodological quality of the studies, the impacts they recorded are likely to be biased so were not summarised. A meta-analysis A study which uses recognised procedures to combine quantitative results from several studies of the same or similar interventions to arrive at composite outcome scores. Usually undertaken to allow the intervention's effectiveness to be assessed with greater confidence than on the basis of the studies taken individually. combining the studies' findings based on the most commonly reported outcomes was judged inappropriate, given the variability between studies in the outcomes reported.
Despite their methodological limitations, the identified studies represent the best evidence we have for the effectiveness of interventions for young people with existing alcohol use problems or who participate in behaviour that places them at high risk of harm. The most promising approaches to reduce such harms are cognitive-behavioural therapy, family therapy and community reinforcement. More rigorous evaluations are needed before clear conclusions can be reached about the most effective interventions.
Conclusions There is a great need for more intervention trials for young people at high risk of experiencing alcohol-related harm that are both methodologically rigorous and have a broader community focus, to complement the psychological interventions that currently dominate the relevant literature. Such trials would improve outcomes for high-risk young people themselves and would improve the evidence base, both in their own right and by facilitating future meta-analyses.
commentary The tentatively expressed conclusions of this review accord with those of a review conducted for Britain's National Institute for Health and Clinical Excellence (NICE). In respect of interventions for children and young people who misuse alcohol, it recommended offering individual cognitive-behavioural therapy for those with limited comorbidities and good social support, and multi-component programmes (such as multidimensional family therapy, brief strategic family therapy, functional family therapy or multisystemic therapy) for those with significant comorbidities and/or limited social support. This type of advice – segmenting the potential treatment population in terms of severity and life situation – makes sense. The range of situations young people in trouble with drink find themselves in almost certainly precludes any standardised approach, and therefore any attempt to find 'the best' intervention for young drinkers. Even among the few studies included in the featured review, the sampled young populations included: "the underserved, described as the uninsured, working poor, homeless, runaway and high-risk youth; treatment-seeking individuals; those with comorbid suicidality; those with a primary diagnosis of a psychotic illness and substance abuse; young people and their parents; runaways; the homeless; and incarcerated youth".
Last revised 03 July 2011