and Moderation Management: outcomes of a randomized clinical trial with non-dependent problem drinkers
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Copy title and link | Comment/query | and Moderation Management: outcomes of a randomized clinical trial with non-dependent problem drinkers.

Hester R.K., Delaney H.D., Campbell W.
Journal of Consulting and Clinical Psychology: 2011, 79(2), p. 215–224.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Hester at

Does it help to add a structured internet-based therapeutic programme to web access to a mutual aid network also geared to moderate drinking? Sustained extra moderation in the form of fewer days drinking was the clearest positive effect; less clear was whether it led to greater reductions in drink-related problems.

Summary In studies, computer and in particular internet-based interventions for problem drinking have proved modestly effective in reducing consumption, but it remains unclear which elements are important to improving effectiveness and who benefits most. This US study addressed these issues by testing whether outcomes were improved by supplementing web-based information and mutual aid with a structured cognitive-behavioural programme built on the same principles, and whether these results differed depending on the severity of the user's drinking.

An ad in a local newspaper aimed to attract phone calls from readers concerned about their drinking. 191 phoned the project of whom 80 met the study's criteria and participated in the study. As initially established over the phone and then (if the caller came) at in-person assessment, the study selected adult drinkers (at least 140g per week or 17–18 UK units) whose scores (at least 8) on the AUDIT screening questionnaire indicated risky drinking, who wanted to moderate their consumption, and who had internet access at home. Among these, the study excluded people whose problems seemed too severe for them to benefit from internet-based intervention, including those previously treated for or diagnosed as suffering from substance use disorders, or who reported symptoms of physical dependence on alcohol now or in the past.

After completing a baseline computerised assessment of their drinking and drink-related problems, the 80 participants were randomly allocated to be introduced by the research assistant to one of the two computer-based intervention packages tested by the study. The first consisted solely of the web site of the mutual aid network Moderation Management, which supports its members in reducing drinking as well as abstinence. Through the site the organisation offers face-to-face and on-line mutual aid meetings, on-line support group discussions via an e-mail mailing list, an on-line discussion forum, on-line drinking limit guidelines, a self-help book, and an on-line calendar on which users can publicly record their drinking. Participants were helped to sign up to the mailing list and it was suggested they access it as least twice a week for the next 12 weeks. Beyond that, whether they used the site and/or went to meetings when they returned home was entirely at their discretion.

The other half of the sample were also introduced in the same way to the Moderation Management site and helped to join its mailing list. The difference was that they were also introduced to the Moderate Drinking web site, which structures the methods recommended by Moderation Management in to a stage-by-stage, interactive cognitive-behavioural therapeutic programme personalised to the site user. It recommends first choosing a goal (abstinence or moderation), building motivation for change, 'doing a 30' (a self-imposed month of abstinence), setting drinking goals/limits, and then self-monitoring drinking. Users are asked to enter their self-monitoring data when they log back onto the site, which the program then uses to generate detailed feedback about their progress. Modules address motivation, identifying and managing triggers to excessive drinking, developing alternatives, problem solving, dealing with lapses and relapses, considering abstinence, and self-monitoring mood. Participants were signed in to the site and it was suggested they use the programme at least once a week for the next nine weeks. Beyond this whether they used the site when they returned home was entirely at their discretion, but over the 12 months of the study they were asked monthly by e-mail how much it had been accessed and how much they felt they had benefited as a result.

The baseline assessment revealed that participants drank on average six days a week and on each of those days about 80g alcohol or 10 UK units. Generally in their 40s and 50s, on average their scores on the AUDIT screening questionnaire indicated highly problematic drinking verging on that considered to warrant assessment for dependence and formal treatment. Assessments were repeated three, six and 12 months after baseline to test whether drinking and drink-related problems subsided and whether these improvements were greater among participants offered the structured Moderate Drinking programme.

Main findings

Nearly all the participants were re-assessed three months after baseline, at which time an earlier report found that across both groups drinking and drink-related problems had subsided, but that the gains were greater among participants offered the structured Moderate Drinking programme as well as the mutual aid site. This difference was due to the combined intervention's greater impact among participants who at baseline did not drink heavily Averaging at least 70g (nearly 9 UK units) alcohol for men or 56g (7 UK units) for women. on each day they drank. Among the heavier 'binge' drinkers, offering the structured Moderate Drinking programme made little or no difference.

The featured report assessed whether this pattern at three months also applied across all the follow-up assessments from three to 12 months, basing its main analyses on the 59 out of 80 participants who completed all assessments. Across both groups, drink-related problems had subsided to well below the average for the population and had continued to improve after three months. Drinking reductions too had been sustained in terms of more than twice as many days without drinking (up from 15% to 33% across the follow-ups), fewer drinks on each of those days (down from 75g or over 9 UK units at baseline to on average 46g), and a lower estimated blood alcohol level on each of those days.

Adding the structured Moderate Drinking programme led to some sustained extra improvements, but not consistently, and the gains were generally not statistically significant. At six and 12 months, drink-related problems had subsided more in the Moderate Drinking group but the differences were no longer statistically significant. More clearly, consistently, and significantly sustained were the extra increases in days without drinking. On average across the follow-ups participants offered the Moderate Drinking programme had gone from abstaining on just one day a week to three, while those just offered the mutual aid web site had only marginally improved from a day to a day and a half; this gap was just as great at 12 months as at three. Less clear cut were any gains in the intensity of drinking on each day. The number of drinks on each drinking day converged after the three-month follow-up until there was little difference between the groups (though still some among the non-binge drinkers). Estimated blood alcohol levels in the Moderate Drinking group were not significantly lower across the follow-ups and the significant extra reductions seen at three months had disappeared by six and 12 months.

The authors' conclusions

The improvements in both groups were clear and consistent and substantial, though without a non-intervention control A group of people, households, organisations, communities or other units who do not participate in the intervention(s) being evaluated. Instead, they receive no intervention or none relevant to the outcomes being assessed, carry on as usual, or receive an alternative intervention (for the latter the term comparison group may be preferable). Outcome measures taken from the controls form the benchmark against which changes in the intervention group(s) are compared to determine whether the intervention had an impact and whether this is statistically significant. Comparability between control and intervention groups is essential. Normally this is best achieved by randomly allocating research participants to the different groups. Alternatives include sequentially selecting participants for one then the other group(s), or deliberately selecting similar set of participants for each group. group it is impossible to say how much of this was due to the interventions and how much to the pre-existing motivation of the participants, to the repeated assessments, or due to the natural resolution of elevated problems over time. It was less clear that adding access to the Moderate Drinking programme further improved outcomes. This supplement did significantly and substantially lead to more days without drinking, and over all the follow-ups (especially among non-binge drinkers) there was also a tendency to less heavy drinking on each drinking day. Drink-related problems subsided more when participants had access to the Moderate Drinking programme, but this effect was confined to those who completed all the follow-up assessments. The fact that binge drinkers – who also had more severe drinking problems overall – did not benefit from the Moderate Drinking programme is consistent with findings that more dependent drinkers do not do well in programmes geared to moderation rather than abstinence.

Findings logo commentary Sustained extra moderation in the form of fewer days drinking was the clearest positive consequence of formalising the mutual aid network's principles in to a structured therapeutic programme. Drink-related problems were the main target of the added intervention. While at some time points and in some analyses it was associated with greater reductions in these problems, this (details below) was at least partly due to the analysis excluding people who did not complete all the assessments. When all or more of these were included, the differences were no longer statistically significant. Positive impacts from the extra intervention were most or only apparent among the less heavy and less dependent drinkers. As the authors suggest, dependent drinkers probably need more than take-it-or-leave-it access to an internet-based programme to make a difference over and above access to a mutual aid network. Across the whole group offered the extra intervention, most did not use it the three or more times the researchers thought would normally be required for an impact. Comments at the end from participants that reminders might have helped them stay on track were later incorporated in to the program as automatic e-mailed reminders. However, the need (noted in the featured report) participants felt to discuss their drinking with the research assistant and the fact that (as noted in the earlier report) many did get face-to-face help from elsewhere, suggests that face-to-face work was what a substantial minority wanted and perhaps needed.

Inconsistent benefits from offering a more intensive intervention accord with the findings of 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. amalgamating results from studies of computer-delivered interventions for problem drinking or smoking. Though interventions offering more sessions or a longer time tended to be more effective, the analysis found this effect was slight and not statistically significant.

In Britain there is no close equivalent to either web site offered to the participants in the featured study. Because they adopt psychological methodologies like motivational interviewing and cognitive-behavioural methodologies, closest are the SMART Recovery web site, which offers volunteer-led mutual aid meetings but geared to abstinence, and the Down Your Drink site, which offer therapeutic programmes ranging from a one-hour brief intervention to several weeks.

In the featured study, the fall in drink-related problems at three months among participants offered the Moderate Drinking programme was sustained to 12 months, but at the later follow-ups those offered just the mutual aid web site 'caught up', leaving no significant extra benefit. However, the problem tally was lower among Moderate Drinking participants when averaged across all the follow-ups, including the three-month point. This difference was no longer apparent when all the participants were included in the analysis on the basis of their predicted scores, not just those who had completed all the assessments. What seems to have happened is that some participants who by three months had virtually eliminated their drink-related problems dropped out of the study. Perhaps because they were not sent monthly e-mail messages, this was especially the case among participants only offered access to the mutual aid web site. It meant that this group disproportionately lost non-problem drinkers at the later follow-ups, creating the possibly misleading impression that drinking problems had subsided more among the group offered access to the structured programme. It also seems that the significant extra improvement in problems at three months was partly due to this analysis excluding people who did not complete all the assessments. The earlier report included all the people reassessed at three months whether or not they completed later assessments. In this larger sample there was no statistically significant difference in the reduction in drink-related problems. However, the all-participants analysis did corroborate the finding that offering the Moderate Drinking programme led to sustained greater increases in days without drinking.

To find other Findings analyses of computer-aided interventions for risky or problem drinking run this search.

Thanks for their comments on this entry in draft to Reid Hester of Behavior Therapy Associates LLP. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 24 July 2011

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