Review of: Johansson M et al, Addiction 2020 Sep 24. Epub ahead of print.

The COVID-19 pandemic has highlighted the potential value of virtual treatment. This may be particularly useful for individuals with alcohol use disorder (AUD), for whom shame and stigma may limit engagement and/or retention in traditional forms of face-to-face treatment. However, an important question remains: Is virtual care, delivered via modules with which patients can engage on their own time, as effective as face-to-face care for the treatment of AUD? This study evaluated the effectiveness of internet-delivered cognitive behavioral therapy (ICBT) versus face-to-face CBT in adults with AUD using a randomized controlled design.

301 adult patients were recruited from a specialized AUD clinic in Stockholm, Sweden between 2015 and 2018. The mean age was 50 years, and 62% were male. Over two-thirds of the patients had received some college education. Subjects were randomized to either 5 modules of asynchronous therapist-guided ICBT or 5 modules of face-to-face CBT over 3 months. In the ICBT group, the therapist released pre-recorded modules one by one, and all communication between the therapist and patient occurred online asynchronously. Both groups used the same treatment material and therapists. The primary outcome was the number of drinks consumed (by self-report) in the prior week at 6-month follow-up. Secondary outcomes included the number of non-drinking days, number of binge-drinking days, average number of drinks on drinking days, and low-risk consumption in the prior week. Subjects also completed an Alcohol Use Disorders Identification Test (AUDIT) scale and answered questions about treatment satisfaction at 6 months.

In intention-to-treat analyses, the difference in alcohol use between the ICBT and face-to-face arms was non-inferior at 6-month follow-up (ICBT = 12.33 drinks in the prior week; face-to-face = 11.43). However, ICBT was inferior to face-to-face treatment in all secondary outcomes, including the total AUDIT score at 6 months (ICBT = 12.26; face-to-face = 11.57), although this difference may not be clinically meaningful. The face-to-face group rated the working alliance during treatment more highly than the ICBT group, which reported that treatment felt less personal. The ICBT group also indicated that they missed other forms of contact and viewed their treatment as less effective.

Study limitations included a high attrition rate in both groups (33% overall at 3-month follow-up and 43% at 6-month follow-up, without differences between the groups) and recruitment solely from a specialized clinical setting in which most patients were well educated and employed.

CATR’s Take
ICBT for AUD appears to be a promising treatment approach to help motivated patients reduce alcohol use and may help expand treatment to difficult-to-reach populations who have access to smartphones or other devices with video capacity. While there are some measurable—and also intangible—benefits to face-to-face care, ICBT is an important alternative for us to consider in the pandemic context and beyond.