https://orcid.org/0000-0002-7092-9056
ABSTRACT
Alcohol misuse is a common, disabling and costly issue worldwide. Internet-delivered cognitive behavior therapy (ICBT) has the potential to reduce the harms of alcohol misuse, particularly for individuals who are unable or unwilling to access face-to-face therapy. A systematic review was conducted using Medline, CINAHL, EMBASE and PsycINFO databases for all relevant articles published from 1980 to January 2019. Randomized controlled trials (RCTs) were included if (i) an ICBT intervention targeting alcohol misuse was delivered; (ii) participants were aged 18 years or older; and (iii) primary outcomes were quantity of drinking. A qualitative analysis was conducted on the content of the ICBT programs. Fourteen studies met inclusion criteria. Most studies included participants from the general population, while studies conducted within clinic settings with diagnosed individuals were rare. The programs were similar in terms of included modules. Small effects were seen in studies on self-guided ICBT, while therapist-guided ICBT rendered small to large effects. The current review indicates that ICBT has a significant effect in reducing alcohol consumption. Larger studies evaluating ICBT compared to active control groups especially within clinic settings are warranted.
Introduction
According to the latest statistics from the World Health Organization, the world average alcohol consumption is 6.4 liters of pure alcohol per year (WHO, Citation2018). Alcohol is the third leading risk factor for burden of disease in the world (Lim et al., Citation2012), causing harm to both the individual drinker and the community. More than 60 somatic diseases (e.g. liver disease, cardiovascular disease, various cancers) have been causally linked to alcohol consumption (Connor, Haber, & Hall, Citation2016). Alcohol also constitutes a major cost to society in the form of treatment costs, crime and law enforcement, and productivity loss (Babor et al., Citation2010).
Despite the existence of effective, evidence-based treatments (including pharmacotherapy, motivational interviewing (MI) and cognitive behavioral therapy (CBT) (Miller & Wilbourne, Citation2002), alcohol misuseFootnote1 is greatly undertreated. Less than 15% of those with an alcohol use disorder are estimated to receive treatment (Cohen, Feinn, Arias, & Kranzler, Citation2007). In an analysis of barriers to treatment, several attitudinal reasons were identified, including stigma and embarrassment, wanting to reduce drinking on one’s own, believing that the issue would resolve itself, and believing that no one could help (Schuler, Puttaiah, Mojtabai, & Crum, Citation2015). Treatment-related barriers among drinkers have also been noted, such as being unaware of available treatment options, treatment costs, and being unable to feasibly access treatment (Saunders, Zygowicz, & D’Angelo, Citation2006).
Internet interventions are considered an attractive treatment option for people with mental health conditions, as they overcome common barriers to treatment. For example, they can enable individuals living in rural or remote areas without feasible travel options to access face-to-face therapy. Also, individuals with busy schedules can access internet interventions on their own without having to make time for, or schedule, treatment. Importantly, individuals concerned about stigma related to accessing face-to-face treatment may prefer internet interventions as a way to privately manage their issues (Andersson, Titov, Dear, Rozental, & Carlbring, Citation2019).
Internet-delivered CBT (ICBT) is a specific form of internet intervention that consists of material based on evidenced-based CBT. The material is usually provided in the form of lessons or modules, introducing clients to CBT strategies. ICBT for alcohol misuse typically incorporates relapse prevention (Larimer, Palmer, & Marlatt, Citation1999), an approach aiming to help clients identify risk situations, develop effective coping strategies and prepare for future slips or relapses, and Community Reinforcement Approach (Smith, Meyers, & Miller, Citation2001), an approach that aims to enhance positive reinforcers for sobriety, for example by helping clients identify new activities that are unrelated to substance use/drinking.
In ICBT, sometimes, a therapist or coach guides the individual through the treatment (G-ICBT) and other times the intervention is self-guided (S-ICBT) (Andersson, Citation2009). Guidance in ICBT varies in terms of intensity. In some cases G-ICBT consists of a therapist who actively highlights treatment content, answers client questions, gives feedback on homework and reinforces module completion. In other cases, guidance only consists of sending out brief motivational texts/emails and reminders (Palmqvist, Carlbring, & Andersson, Citation2007). The literature on G-ICBT versus S-ICBT has not yet been summarized for alcohol misuse. Two systematic reviews on ICBT for anxiety and depression, however, have suggested that G-ICBT is more effective than S-ICBT (Baumeister, Reichler, Munzinger, & Lin, Citation2014; Spek et al., Citation2007), but the optimal form of guidance is still unknown. Baumeister et al. (Citation2014) reported that education of the guide/coach appears to have minimal impact on outcomes while too little research has investigated the optimal dose or importance of synchronicity (e.g. chat versus messages). Recent research has suggested that an adaptive strategy might be a successful way to optimize effects of G-ICBT, such as offering more intensive guidance to patients who display risk of treatment failure at an early stage (Forsell et al., Citation2019).
There are several reviews of internet interventions for alcohol misuse, showing that they are effective in reducing alcohol consumption rendering mostly small effects (Dedert et al., Citation2015; Riper et al., Citation2014, Citation2018; Sundström, Blankers, & Khadjesari, Citation2017). There is also one review on internet interventions for substances other than alcohol that concluded that although results were significantly in favor of these interventions more research was needed on the topic (Boumparis, Karyotaki, Schaub, Cuijpers, & Riper, Citation2017). As of yet there is no review focusing specifically on ICBT for alcohol misuse, as past reviews have combined studies on ICBT and electronic screening and brief intervention (eSBI), two different intervention formats. Brief Intervention (BI) is a form of secondary prevention originally developed to identify people with alcohol problems in non-addiction health care settings and help them reflect on their alcohol consumption (Babor et al., Citation2007). eSBI, the internet version of BI, usually consists of one module where the user enters their alcohol consumption and then receives immediate automated normative feedback along with some brief tips on how to quit or cut down (Donoghue, Patton, Phillips, Deluca, & Drummond, Citation2014). As ICBT is currently being implemented in mental health care settings around the world (Andersson et al., Citation2019; Titov et al., Citation2018), a review focusing specifically on ICBT for alcohol misuse seems timely, as it could help inform policy makers and clinicians about current evidence, thus providing clinical guidelines for implementation.
This review aimed to provide an overview of characteristics, program content and outcomes among published studies on ICBT for alcohol misuse. Specifically, we aimed to answer the following questions:
What were the target populations and methods of recruiting participants?
Which inclusion/exclusion criteria were used?
What were the ICBT programs like (e.g. content of modules, length)?
How many studies included guidance and what was the nature of the guidance?
Which alcohol outcomes were used?
Was ICBT effective in reducing alcohol consumption?
What is the available evidence on ICBT adherence and attrition?
Methods
Literature search strategy
A systematic literature search was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (Moher et al., Citation2015). Relevant articles published from 1990 to January 2019 were retrieved from the following electronic databases: Medline, Cumulative Index to Nursing and Allied Health Literature, PsycInfo, and Embase. A search was conducted (Appendix A details the full search strategy). No grey literature was included.
Study selection
Abstracts were independently assessed for inclusion two independent reviewers (A.W and a research assistant) based on the following eligibility criteria: 1) the study reported results from a randomized controlled trial; 2) the program evaluated constituted a CBT approach to treatment of alcohol misuse; 3) the intervention program was provided online; 4) the evaluation included measurement of the intervention on quantity of drinking; 5) the study focused on alcohol misuse specifically; and 6) participants were ≥18 years and 7) the publication was available in English. Articles were excluded if they were review or case studies. A third author (S.M.) resolved any discrepancies about article inclusion.
Data extraction and critical appraisal
One of the authors (A.W.) and a research assistant independently extracted the following data from selected articles: author, year, sample size, population, country, intervention type, duration and level of guidance, primary outcome measures, comparator information, and attrition. Cochrane Risk of Bias Tool to assess RCTs (Higgins et al., Citation2011) was used to guide the critical appraisal of included articles. The Cochrane Risk of Bias Tool assesses the quality of articles as good, fair, and poor by measures of bias including: allocation concealment, selective reporting, blinding of participants and research personnel, blinding of outcome assessment, incomplete outcome data and random sequence generation. provides a Prisma Flow Diagram of the study selection process. A.W. and a research assistant assessed risk of bias (see ).
Figure 1. Flow chart.
Data analysis
As studies varied in both comparator groups and outcomes, pooled analysis of primary outcomes was deemed not feasible. However, a forest plot was created for individual studies presenting on drinks consumed preceding week (the most common outcome among the included studies) in order to visually represent effect sizes in these studies. Cohen’s d was used to calculate standard difference in means (SDM) (±SE, 95% confidence intervals) for drinks preceding week using the software package Comprehensive Meta-Analysis, version 3 (Biostat inc). Effect sizes were interpreted as small, >0.2; moderate, >0.5; and large, >0.8. A.W.
Figure 2. Risk of bias.
Qualitative analysis
Modules included in each program were coded in the qualitative data analysis program NVivo 12 by two authors (A.W., C.S.). Repeating content (expressed as being found in two or more studies) were then coded and grouped into categories. The naming of each category was determined by A.W. and C.S. Sub-categories were labelled when applicable. The final coding scheme was reviewed and agreed upon by A.W. and C.S. In some articles, full presentation of the individual modules contained in the program were not included. In two cases, other published studies describing the same program in more detail were consulted (Carroll et al., Citation2008; Linke, McCambridge, Khadjesari, Wallace, & Murray, Citation2008). If no adequately detailed published description was available, the primary authors were emailed and asked to provide a more comprehensive description of the modules included in the program.
Results
Study selection
Of the 4629 studies reviewed, 197 articles were retrieved for full text screen. In total, 14 studies met full inclusion criteria (see ).
Table 1. Characteristics of included studies.
What were the target populations and methods of recruiting participants?
Ten studies targeted individuals in the general population (Blankers, Koeter, & Schippers, Citation2011; Brendryen et al., Citation2014; Cunningham, Citation2012; Cunningham et al., Citation2017; Hester, Lenberg, Campbell, & Delaney, Citation2013; Postel, de Haan, Ter Huurne, Becker, & de Jong, Citation2010; Riper et al., Citation2007; Sinadinovic, Wennberg, Johansson, & Berman, Citation2014; Sundström et al., Citation2016; Wallace et al., Citation2011), two studies targeted clients at substance abuse treatment clinics (Farren, Milnes, Lambe, & Ahern, Citation2015; Kiluk et al., Citation2016), one study targeted veterans (Brief et al., Citation2013) and one study targeted employees in the workplace (Brendryen, Johansen, Duckert, & Nesvag, Citation2017).
Seven studies recruited participants solely online, through email, ads on search engines, social media or alcohol-related websites (Blankers et al., Citation2011; Brendryen et al., Citation2014; Brief et al., Citation2013; Postel et al., Citation2010; Sinadinovic et al., Citation2014; Sundström et al., Citation2016; Wallace et al., Citation2011), one study recruited from newspaper advertisements (Cunningham, Citation2012), and two studies combined online with newspaper advertisement recruitment (Cunningham et al., Citation2017; Riper et al., Citation2007). One study combined online and face-to-face group meetings recruitment (Hester et al., Citation2013). Two studies recruited patients at substance use clinics, one of these recruited inpatients (Farren et al., Citation2015) and one recruited outpatients (Kiluk et al., Citation2016). One study recruited from the intranet of four organizations (hospitals, counties, municipalities and consulting companies) (Brendryen et al., Citation2017).
Which inclusion/exclusion criteria were used?
All studies included participants ≥18 yearsFootnote2, and three studies had an upper age limit of 65 (Blankers et al., Citation2011; Brief et al., Citation2013; Riper et al., Citation2007). Four studies stated regular internet access as an inclusion criterion (Blankers et al., Citation2011; Hester et al., Citation2013; Riper et al., Citation2007; Wallace et al., Citation2011). The Alcohol Use Disorder Identification Test (AUDIT; Saunders, Aasland, Babor, Delafuente, & Grant, Citation1993) was the most common instrument to assess eligibility for inclusion, with cutoff for inclusion being 8≥ for both sexes in three of these studies (Blankers et al., Citation2011; Cunningham et al., Citation2017; Hester et al., Citation2013), and a slightly lower score (≥6 or ≥5) for women in the other three studies (Brief et al., Citation2013; Sinadinovic et al., Citation2014; Sundström et al., Citation2016). Two studies used the AUDIT-C (an abbreviated version of AUDIT consisting of only the first three consumption-focused items of the scale), to assess eligibility, with inclusion cut-offs being ≥8 in one study (Cunningham, Citation2012) and 5≥ in another (Wallace et al., Citation2011). None of the studies using AUDIT had an upper cut-off, except for one, which excluded those with scores >25 (indicating symptoms of heavy alcohol dependence) (Brief et al., Citation2013). Another screening instrument to assess eligibility, Fast Alcohol Screening Test (FAST), also an abbreviated version of AUDIT (Hodgson, Alwyn, John, Thom, & Smith, Citation2002), was used in two studies (Brendryen et al., Citation2014, Citation2017). Two studies only included those fulfilling diagnostic criteria for alcohol use disorder (Farren et al., Citation2015; Kiluk et al., Citation2016). Three studies used self-reported alcohol consumption as an inclusion criterion in addition to AUDIT (Blankers et al., Citation2011; Brief et al., Citation2013; Hester et al., Citation2013). Two studies used only self-reported alcohol consumption as an inclusion criterion (Postel et al., Citation2010; Riper et al., Citation2007).
Cutoffs for alcohol consumption signifying problem drinking were not consistent across studies. For example, in two of the three studies conducted in the Netherlands more than 14 drinks per week for women and more than 21 drinks per week for men were used to define problem drinking (Postel et al., Citation2010; Riper et al., Citation2007) while in the third study more than 14 drinks per week were used for both sexes (Blankers et al., Citation2011). In one of the two studies conducted in the United States, women were included based on having consumed more than 3 drinks on any day or more than 7 drinks per week, while men were included based on having consumed more than 5 drinks on any day or more than 14 drinks per week (Brief et al., Citation2013). In the other, women were included based on having consumed more than 3 drinks on any day, while men were included based on having consumed more than 5 drinks on any day (Hester et al., Citation2013).
The most common exclusion criterion was having another mental health condition, such as severe depression, bipolar disorder, schizophrenia or persistent suicidal ideation (Blankers et al., Citation2011; Farren et al., Citation2015; Hester et al., Citation2013; Kiluk et al., Citation2016; Postel et al., Citation2010). Further, some studies excluded individuals with previous (Blankers et al., Citation2011; Postel et al., Citation2010) or concurrent (Riper et al., Citation2007) substance abuse treatment or previous treatment for other psychiatric problem (Postel et al., Citation2010). Two studies excluded those with cognitive impairment (Farren et al., Citation2015; Hester et al., Citation2013) and three studies excluded those with low reading level (Hester et al., Citation2013; Kiluk et al., Citation2016; Wallace et al., Citation2011).
What were the ICBT programs like?
In this section, we investigated the modules included in the programs and how the programs were delivered. Eleven different ICBT programs were included in the analysis. Two programs were used in two studies each (Brendryen et al., Citation2014, Citation2017; Cunningham, Citation2012; Cunningham et al., Citation2017).
What modules were included in the programs?
The qualitative analysis resulted in five main categories of modules (see ).
Table 2. Categories of modules identified in the programs. “X” indicates presence of the subcategory.
1) Alcohol Information. In this category, modules providing: a) information and education about alcohol and its effects; and b) personalized feedback were included.
2) Preparing for Change. In this category, modules with motivational exercises were included. Modules were: a) information about the “stages of change”; b) decisional balance exercise; and c) goal setting.
3) Skills Training. In this category, modules providing varying forms of skills training to handle stressful or alcohol-related situations were included. Modules included: a) analysis of risk situations and triggers; b) self-control skills; c) coping skills to deal with craving, emotions and thoughts; d) refusal skills training; e) problem solving skills; f) social skills (engaging significant others, building new social networks, reaching out to health care) and; g) relapse prevention.
4) Wellbeing. In this category, modules providing information and tips on improving health-related issues were included. Modules included were: a) relaxation and mindfulness; b) exercise and nutrition and; c) sleep.
5) Program Components. We also identified a category of program components separate from the modules where subcategories included: a) drinking diary; b) online discussion forum; c) automated text or email prompts and; d) blood-alcohol concentration (BAC) calculator.
The most commonly included modules were goal setting, analysis of risk situations and triggers, coping skills to deal with craving, emotions and thoughts and relapse prevention. See for a description of the module categories identified in the programs.
How were the programs delivered?
In more than half of the programs, modules were gradually made accessible to the participant based on therapist judgement of client readiness, time elapsed, or activity of the user (Blankers et al., Citation2011; Brendryen et al., Citation2014, Citation2017; Brief et al., Citation2013; Farren et al., Citation2015; Kiluk et al., Citation2016; Postel et al., Citation2010; Sundström et al., Citation2016). Time over which all of the modules were made accessible varied considerably, including 4 weeks (Farren et al., Citation2015), 8 weeks (Brief et al., Citation2013; Kiluk et al., Citation2016), 10 weeks (Sundström et al., Citation2016), 3 months (Blankers et al., Citation2011; Postel et al., Citation2010) and 6 months (Brendryen et al., Citation2014). In other programs, all modules were simultaneously made accessible to the user (Blankers et al., Citation2011; Cunningham, Citation2012; Cunningham et al., Citation2017; Hester et al., Citation2013; Sinadinovic et al., Citation2014; Wallace et al., Citation2011) sometimes with specified recommendations as to how long users were supposed to work with the program. All programs were available anywhere online, except for two that were only available on computers at substance use clinics (Farren et al., Citation2015; Kiluk et al., Citation2016).
How many studies included guidance and what was the nature of guidance?
Four studies included at least one guided arm (G-ICBT) (Blankers et al., Citation2011; Kiluk et al., Citation2016; Postel et al., Citation2010; Sundström et al., Citation2016). Two studies directly compared S-ICBT to G-ICBT (Blankers et al., Citation2011; Sundström et al., Citation2016) with one of these also including a waitlist control group (Blankers et al., Citation2011). One study compared G-ICBT to treatment as usual (weekly group or individual psychotherapy) (Kiluk et al., Citation2016) and one study compared G-ICBT to a waitlist control group (Postel et al., Citation2010). The education level and profession of therapists varied, and included those with a bachelor’s degree in psychology (Blankers et al., Citation2011; Sundström et al., Citation2016), social workers (Postel et al., Citation2010), or clinical psychologists with a doctoral degree (Kiluk et al., Citation2016). Therapists contacted users either asynchronously, through messages on the platform used (Postel et al., Citation2010; Sundström et al., Citation2016) or synchronously, using text-based online chat sessions lasting 40 minutes each (Blankers et al., Citation2011; Sundström et al., Citation2016). In arms with asynchronous online guidance, therapists responded within 2–3 days. In one study, guidance was not provided online, but was in the form of a weekly 10 minute in-person “brief clinical monitoring” session with a doctoral-level psychologist at a substance use clinic (Kiluk et al., Citation2016).
Which alcohol outcomes were used?
Almost all studies used standard drinks consumed as a primary outcome, either during the preceding week or during a typical week in the past one or three months (Blankers et al., Citation2011; Brendryen et al., Citation2014, Citation2017; Brief et al., Citation2013; Cunningham, Citation2012; Cunningham et al., Citation2017; Farren et al., Citation2015; Postel et al., Citation2010; Riper et al., Citation2007; Sundström et al., Citation2016; Wallace et al., Citation2011). Other alcohol consumption outcome measures included highest number of drinks on one occasion (Cunningham, Citation2012; Cunningham et al., Citation2017), number of heavy drinking days (Brief et al., Citation2013; Kiluk et al., Citation2016), drinks per drinking day (Hester et al., Citation2013) and abstinence, measured as either percent of days abstinent or as longest continuous abstinence (Farren et al., Citation2015; Hester et al., Citation2013; Kiluk et al., Citation2016). One study used AUDIT-C as a primary outcome measure (Sinadinovic et al., Citation2014).
Was ICBT effective in reducing alcohol consumption?
The outcome measurement periods (i.e. the time between randomization and first follow-up measurements) were between one and six months, with the most common being 3 months.
S-ICBT
Two studies compared S-ICBT to a waitlist control group (Blankers et al., Citation2011; Brief et al., Citation2013). Both of these found an intervention effect, one of them with an effect size of 0.36 (Blankers et al., Citation2011). Four studies compared S-ICBT to alcohol information (brochure or e-booklet) (Brendryen et al., Citation2014, Citation2017; Riper et al., Citation2007; Wallace et al., Citation2011). Of these, two found an intervention effect, one with an effect size of 0.20 (Brendryen et al., Citation2014) and one with an effect size of 0.40 (Riper et al., Citation2007). One study compared S-ICBT to a placebo (computerized cognitive stimulation) and found no intervention effect (Farren et al., Citation2015). Three studies compared S-ICBT to an eSBI. Of these, one found an intervention effect on highest number of drinks per occasion (Cunningham, Citation2012), while the other two found no effect (Cunningham et al., Citation2017; Sinadinovic et al., Citation2014). One study compared S-ICBT to SMART Recovery group meetings, either online or in person, and found no significant differences (Hester et al., Citation2013).
G-ICBT
Two studies compared G-ICBT to a waitlist control group. Both found an intervention effect on drinks per week at post-treatment with an effect size of 0.59 in one study (Blankers et al., Citation2011) and 1.21 in the other (Postel et al., Citation2010). One study comparing G-ICBT to treatment as usual found no difference (Kiluk et al., Citation2016). Two studies compared G-ICBT to S-ICBT; in one study, an effect size of 0.77 was found at 10-weeks post-treatment (Sundström et al., Citation2016) and in the other study an effect size of 0.38 was found at 6-month follow-up (Blankers et al., Citation2011), both in favour of G-ICBT.
illustrates effect sizes in the six studies reporting number of drinks consumed preceding week.
Figure 3. Forest plot with 95% confidence interval.
What is the available evidence on ICBT adherence and attrition?
Ten studies reported on adherence-related issues, using divergent methods. Six studies reported number of modules completed and in these studies modules were gradually unlocked to the participant over time. Three studies reported the mean number of modules completed. In the G-ICBT arms, between 58 and 77% of modules were completed (Kiluk et al., Citation2016; Postel et al., Citation2010; Sundström et al., Citation2016); in the S-ICBT arm, 21% of modules were completed (Sundström et al., Citation2016). Two additional studies that investigated the same program reported percentage of participants who completed all modules, and in this case, it was found that 8 and 12% of participants respectively, completed all modules (Brendryen et al., Citation2014, Citation2017). In a third study, 34% of participants completed all modules (Brief et al., Citation2013). The other approach that has been used to measure adherence involves reporting number of log-ins. The four studies that reported log-ins all evaluated programs where all modules were made accessible to participants simultaneously, with the exception of one study where it was not reported how modules were released to participants (Riper et al., Citation2007). One study reported that 43% of participants only logged in once and that 13.5% logged in 4 times or more (Cunningham et al., Citation2017); another study reported that 45% of participants logged in (Riper et al., Citation2007). Two studies reported the mean number of participant log-ins, with one study reporting a mean of 2.3 log-ins (Wallace et al., Citation2011) and the other study reporting a mean of 7.2 log-ins (Hester et al., Citation2013).
There were large differences in attrition among the studies. Regarding loss to first follow-up (most commonly conducted at 3 months), only four studies reported low attrition (≤20%)(Cunningham, Citation2012; Cunningham et al., Citation2017; Hester et al., Citation2013; Kiluk et al., Citation2016). Eight studies reported attrition in the range of 30 to 50% of participants (Blankers et al., Citation2011; Brendryen et al., Citation2014, Citation2017; Brief et al., Citation2013; Farren et al., Citation2015; Postel et al., Citation2010; Riper et al., Citation2007; Sundström et al., Citation2016), and two studies, reported attrition at greater than 60% (Sinadinovic et al., Citation2014; Wallace et al., Citation2011). Regarding the two studies that compared G-ICBT and S-ICBT, one of them reported a large differential attrition (G-ICBT = 20%, S-ICBT = 52.5%) (Sundström et al., Citation2016) at the 10-week follow-up, while the other study reported no such differences, either at either follow-up (Blankers et al., Citation2011).
Discussion
The purpose of this review was to provide an overview of published research on ICBT for alcohol misuse in order to facilitate implementation efforts within clinic settings. The review revealed that in the vast majority of studies, participants were recruited online from the general population, with the most common screening instrument used being the AUDIT. The reviewed programs appeared quite similar—combining motivational exercises, such as decisional balance and goal setting, with coping skills training, such as learning refusal skills and how to deal with cravings. About half of the programs released modules gradually, specifying a “treatment length” for the user, while other programs made all modules accessible simultaneously, indicating the program was a tool to be used at the chosen speed of the user.
In terms of efficacy, the review revealed that, in two studies, self-guided ICBT was significantly more effective in reducing alcohol consumption when compared to information about alcohol (Brendryen et al., Citation2014; Riper et al., Citation2007), and in one study self-guided ICBT was more effective than waitlist (Brief et al., Citation2013). However, self-guided ICBT was not more effective than eSBI (Cunningham, Citation2012; Cunningham et al., Citation2017; Sinadinovic et al., Citation2014).
As for therapist-guided ICBT, two studies found it to be superior to a waitlist with medium and large effect sizes respectively (Blankers et al., Citation2011; Postel et al., Citation2010), and two studies found it superior to self-guided ICBT with small to moderate effect sizes (Blankers et al., Citation2011; Sundström et al., Citation2016). No differences were found when guided ICBT was compared to treatment as usual in the form of group or individual psychotherapy (Kiluk et al., Citation2016).
Strengths and limitations
A significant strength of this review was the focus on ICBT programs. Other reviews on internet interventions for alcohol misuse have included studies on both ICBT and eSBI, making it difficult to disentangle effects of these two intervention formats. An additional strength was the qualitative analysis of program content which serves to inform clinics in the development of new ICBT programs.
The current review also has limitations. First, although G-ICBT seemed more effective than S-ICBT, evidence was sparse as we found only two medium-sized RCTs comparing the two, and one comparing G-ICBT to waitlist. Thus, although this review suggests that G-ICBT is more effective than S-ICBT, this should be read with a degree of caution.
Second, ICBT attrition rates were often in the range of 30–50%, which could reduce the generalizability of results of this review. Previous studies have suggested greater attrition in internet interventions of alcohol misuse compared to other psychiatric problems (Postel et al., Citation2011).
Third, measures of alcohol consumption varied from study to study (i.e. drinks preceding week, drinks per week, drinks per drinking day). As too few studies used the same measures, we were not able to calculate a meta-analysis summary score.
Fourth, it is well-known that psychiatric comorbidity is common among people with alcohol problems. However, most studies in this review excluded participants with severe psychiatric comorbidity. Thus, results from the current review are not generalizable to individuals suffering from both alcohol misuse and severe psychiatric comorbidity.
Fifth, a limitation to our qualitative analysis of program content is that we did not have access to the actual content of the programs. We were limited to what was reported in the article (e.g. list of modules).
Conclusions and future directions
ICBT is a promising intervention for reducing alcohol consumption, at least among those without severe psychiatric comorbidity. While G-ICBT appears superior to S-ICBT, incorporating either form of ICBT into a stepped-care model for people with alcohol misuse in healthcare settings could assist in reaching rural populations that currently face difficulties travelling long distances to attend face-to-face treatment, and may also be a less stigmatizing first treatment option than face-to-face treatment. It could also improve opportunities for treatment of individuals who may not be active in the community or workforce.
More studies are needed to confirm the added value of guidance. Future studies could add to the literature by investigating different levels of guidance (for example guidance provided “on demand” compared to once a week guidance or guidance provided as a booster after ICBT) so as to be able to inform the optimal timing, intensity and frequency of guidance.
Second, although programs in this review were similar in terms of content and theoretical underpinnings, little is known about effects of individual modules. Future studies could add to the literature by evaluating effects of individual modules, thereby benefitting the development of new, more effective, programs. Factorial trials provide a suitable design to approach this (Baker et al., Citation2017).
Third, new strategies to evaluate engagement in ICBT for alcohol misuse would benefit to the field (Short et al., Citation2018), for example assessing the quality of homework completed (Kazantzis, Deane, & Ronan, Citation2004). Exploration of new strategies for decreasing attrition would also be useful (Radtke, Ostergaard, Cooke, & Scholz, Citation2017). Although incentives such as vouchers or prizes have been used with some success, this strategy is ethically controversial (Permuth-Wey & Borenstein, Citation2009), and may not render reliable information (Bedendo & Noto, Citation2016).
Fourth, over a third of those with alcohol misuse are estimated to have an affective or anxiety disorder (Grant et al., Citation2004). There is support for integrated psychotherapy for depression and alcohol misuse (Baker, Thornton, Hiles, Hides, & Lubman, Citation2012), and some studies on internet interventions have attempted to blend ICBT for depression and alcohol misuse (Kay-Lambkin, Baker, Lewin, & Carr, Citation2009). Given the multitude of psychiatric comorbidities that commonly occur alongside alcohol misuse, a tailored approach where certain modules are added depending on psychiatric profile of the client would be worthy of future investigation.
Fifth, as it is unlikely that ICBT would be sufficient for managing patients with severe alcohol-related symptomatology, developing a clinical model that involves coordinating ICBT with medical and/or other supports would be a vital next step. Studies conducted within clinic rather than research settings are crucial for the field to gain insight into the potential benefits and pitfalls of providing ICBT for alcohol misuse within clinics.
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We thank Annemieke Kidd for her help in conducting searches related to this review.
Supplemental material
Supplemental data for this article can be accessed here.
Disclosure statement
No potential conflict of interest was reported by the authors.
Additional information
Funding
Notes
1. Alcohol misuse is used as an umbrella term encompassing all categories describing an individual’s problems related to alcohol (risky drinking, hazardous drinking, problem drinking, alcohol misuse, problematic alcohol use, alcohol abuse and alcohol dependence).
2. Sinadinovic et al. Citation2014 included participants from 15 years and up, but as only three participants were under the age of 18, this study was included.
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