Short summary

Blended Treatment for Alcohol Use Disorder (BLEND-A) is a pragmatic, cluster randomized controlled trial to assess the clinical effectiveness and cost-effectiveness of a blended treatment intervention that aims to reduce problematic alcohol use. Blended treatment is a treatment format where online and face-to-face interventions are integrated into one treatment protocol. The BLEND-A study will evaluate and implement a blended treatment program in routine alcohol addiction treatment. The trial is led by Unit of Clinical Alcohol Research, University of Southern Denmark (UCAR) in collaboration with partners at the Centre for Telepsychiatry in the Region of Southern Denmark (CTP), and Sundhed.dk.

Rationale

Unguided internet based self-help interventions addressing excessive drinking and alcohol use disorders in non-treatment seeking populations may lead to significant mean differences in alcohol consumed between those receiving the interventions versus controls at up to 3 months (Riper et al., 2014, Dedert et al., 2015, Donoghue et al., 2014). It is also widely assumed that self-help programs may serve as an eye-opener to heavy drinkers, and encourage treatment seeking. Self-help programs are considered to be a useful way to get in contact with drinkers, who avoid seeking traditional treatment due to fear of stigma, due to lack of knowledge of existing treatment options, or due to ambivalence about whether or not treatment is needed. However, although unguided self-help programs are flexible and easy to access and use, non-compliance is a major challenge (Riper et al., 2014). Hence, unguided internet-based self-help interventions may primarily offer the opportunity to drinkers to assess the drinking severity, and thereby function as a discrete and easily available information tool that offers feedback to the drinker on his/her consumption, rather than as a treatment strategy per se. 

Blended treatment interventions may, on the contrary, function not only as an eye-opener to the individual, but also as an important and effective treatment strategy. Several systematic reviews on the use of internet-based treatment in common mental health disorders have found that offering personal support and guidance during online treatment increases clinical outcomes and is associated with higher levels of treatment completion (Andersson and Cuijpers, 2009, Richards and Richardson, 2012). This is also demonstrated in pilot studies in the addictions (Sundstrom et al., 2016, Sundstrom et al., 2017). Qualitative studies on the experiences of patients with online therapy in mental health in general also shows that personal feedback and support are perceived as positive among patients, to optimally use the program, benefit from the program and to keep them motivated (Darvell et al., 2015, Wilhelmsen et al., 2013). 

The blended treatment approach combines individual face-to-face therapy sessions with online content delivered through an internet-based treatment platform. The face-to-face part of treatment ensures that the patient benefits from a supportive therapeutic relationship, that is likely to increase motivation to adhere to and complete treatment (Vaart et al., 2014). The online part of treatment provides flexibility giving patients access to treatment modules at the time and place of their choice. Also, the possibility of working on their own between sessions could improve patients' active participation in the treatment, increasing self-reliance and self-management competencies, which subsequently may contribute to better long term results. Through the internet-based platform therapists can give continuous feedback to the patient and help the patient to stay on track with treatment. By extending the reach of the therapy into the daily life of patients, the number of face-to-face sessions required could be reduced, resulting in a decrease of costs (Smit et al., 2011).

The improved access to treatment due to the flexibility that the online part of treatment offers, may also prevent premature dropout of treatment, which is obviously an advantage: If treatment is too short, the effect of treatment may be less prominent. It has, however, also been suggested that face-to-face treatment can be too long. If the treatment pathway and thereby the interaction with the therapist lasts too long, the patient may develop a sort of new kind of dependency (that of the therapist) (Nielsen, 2003), and the therapy may turn into a less structured and more private kind of conversations. Blending face-to-face sessions with internet based modules may be a way of not only preventing early dropout of treatment due to easy access but also preventing the patient in becoming dependent of the therapist due to empowerment of the patient. Additionally, blended treatment may help preventing 'therapist drift': As the internet modules and exercises not only provide a clear working structure to the patient but also to the therapist, the therapist is nudged to incorporate the full therapy protocol in the sessions, thus improving the compliance on the therapist side with the therapy protocol (Waller and Turner, 2016).

Mental health care institutions are increasingly introducing blended treatment in their mental health and behavioral health care services and the evidence-base for clinical and cost-effectiveness of this form of therapy is developing in a number of psychiatric disorders (Wentzel et al., 2016, van der Vaart et al., 2014, Kooistra et al., 2014, Romijn et al., 2015, Kemmeren et al., 2016, Kleiboer et al., 2016, Rogers et al., 2017, Erbe et al., 2017). However, studies on the development and implementation of blended treatment in the addictions are scarce. 

PURPOSE

The BLEND-A Study will a) improve effectiveness and compliance of out-patient alcohol treatment in Denmark by evaluating a therapist-supported online intervention for alcohol use disorder blended with face-to-face consultations;  b) lower the burden of Alcohol Use Disorder by offering a flexible, blended treatment intervention in routine practice; c) advance the current state of the art and knowledge in Danish alcohol treatment institutions by validating blended treatment in routine alcohol treatment delivery with appropriately tailored implementation strategies; and d) assess the cost effectiveness of blended treatment for Alcohol Use Disorder.

Description of the cohort

Adults seeking public alcohol use disorder treatment in 18 Danish municipalities.

Data and biological material

Register data.

Qualitative data.

Questionnaire data:

- Alcohol Use Disorders Identification Test (AUDIT).

- Alcohol Dependence Scale (ADS).

- Short Inventory of Problems Revised (SIP-2R).

- EuroQol-5 Domain 5 Levels (EQ-5D-5L).

- System Usability Scale (SUS).

Collaborating researchers and departments

Department of Clinical Research, Unit of Clinical Alcohol Research

• Associate Professor Anette Søgaard Nielsen, PhD
• Assistant Professor Randi Bilberg, PhD

Centre for Telepsychiatry, Mental Health Services in the Region of Southern Denmark

• Head of Department Marie Paldam Folker
• Consultant Anders Bay-Smidt
• Postdoc Kristine Tarp, PhD

Sundhed.dk

• Head of Innovation Jakob Uffelmann

Alcohol treatment clinics in the following Danish municipalities:

• Bornholm
• Esbjerg
• Glostrup
• Haderslev 
• Helsingør
• Holbæk
• Kolding
• København
• Nyborg
• Næstved
• Odense
• Roskilde
• Rudersdal
• Silkeborg
• Slagelse
• Svendborg
• Tønder
• Vejle