No abstract

SummaryBackgroundAlthough structured psychological treatments are recommended as first-line interventions for harmful drinking, only a small fraction of people globally receive these treatments because of poor access in routine primary care. We assessed the effectiveness and cost-effectiveness of Counselling for Alcohol Problems (CAP), a brief psychological treatment delivered by lay counsellors to patients with harmful drinking attending routine primary health-care settings.MethodsIn this randomised controlled trial, we recruited male harmful drinkers defined by an Alcohol Use Disorders Identification Test (AUDIT) score of 12–19 who were aged 18–65 years from ten primary health centres in Goa, India. We excluded patients who needed emergency medical treatment or inpatient admission, who were unable to communicate clearly, and who were intoxicated at the time of screening. Participants were randomly allocated (1:1) by trained health assistants based at the primary health centres to enhanced usual care (EUC) alone or EUC combined with CAP, in randomly sized blocks of four to six, stratified by primary health centre, and allocation was concealed with use of sequential numbered opaque envelopes. Physicians providing EUC and those assessing outcomes were masked. Primary outcomes were remission (AUDIT score of <8) and mean daily alcohol consumed in the past 14 days, at 3 months. Secondary outcomes were the effect of drinking, disability score, days unable to work, suicide attempts, intimate partner violence, and resource use and costs of illness. Analyses were on an intention-to-treat basis. We used logistic regression analysis for remission and zero-inflated negative binomial regression analysis for alcohol consumption. We assessed serious adverse events in the per-protocol population. This trial is registered with the ISCRTN registry, number ISRCTN76465238.FindingsBetween Oct 28, 2013, and July 29, 2015, we enrolled and randomly allocated 377 participants (188 [50%] to the EUC plus CAP group and 190 [50%] to the EUC alone group [one of whom was subsequently excluded because of a protocol violation]), of whom 336 (89%) completed the 3 month primary outcome assessment (164 [87%] in the EUC plus CAP group and 172 [91%] in the EUC alone group). The proportion with remission (59 [36%] of 164 in the EUC plus CAP group vs 44 [26%] of 172 in the EUC alone group; adjusted prevalence ratio 1·50 [95% CI 1·09–2·07]; p=0·01) and the proportion abstinent in the past 14 days (68 [42%] vs 31 [18%]; adjusted odds ratio 3·00 [1·76–5·13]; p<0·0001) were significantly higher in the EUC plus CAP group than in the EUC alone group, but we noted no effect on mean daily alcohol consumed in the past 14 days among those who reported drinking in this period (37·0 g [SD 44·2] vs 31·0 g [27·8]; count ratio 1·08 [0·79–1·49]; p=0·62). We noted an effect on the percentage of days abstinent in the past 14 days (adjusted mean difference [AMD] 16·0% [8·1–24·1]; p<0·0001), but no effect on the percentage of days of heavy drinking (AMD −0·4% [–5·7 to 4·...

Substance use patterns are notorious for their ability to change over time. Both licit and illicit substance use cause serious public health problems and evidence for the same is now available in our country. National level prevalence has been calculated for many substances of abuse, but regional variations are quite evident. Rapid assessment surveys have facilitated the understanding of changing patterns of use. Substance use among women and children are increasing causes of concern. Preliminary neurobiological research has focused on identifying individuals at high risk for alcohol dependence. Clinical research in the area has focused primarily on alcohol and substance related comorbidity. There is disappointingly little research on pharmacological and psychosocial interventions. Course and outcome studies emphasize the need for better follow-up in this group. While lack of a comprehensive policy has been repeatedly highlighted and various suggestions made to address the range of problems caused by substance use, much remains to be done on the ground to prevent and address these problems. It is anticipated that substance related research publications in the Indian Journal of Psychiatry will increase following the journal having acquired an ‘indexed’ status.

BackgroundCounselling for Alcohol Problems (CAP), a brief intervention delivered by lay counsellors, enhanced remission and abstinence over 3 months among male primary care attendees with harmful drinking in a setting in India. We evaluated the sustainability of the effects after treatment termination, the cost-effectiveness of CAP over 12 months, and the effects of the hypothesized mediator ‘readiness to change’ on clinical outcomes.Methods and findingsMale primary care attendees aged 18–65 years screening with harmful drinking on the Alcohol Use Disorders Identification Test (AUDIT) were randomised to either CAP plus enhanced usual care (EUC) (n = 188) or EUC alone (n = 189), of whom 89% completed assessments at 3 months, and 84% at 12 months. Primary outcomes were remission and mean standard ethanol consumed in the past 14 days, and the proposed mediating variable was readiness to change at 3 months. CAP participants maintained the gains they showed at the end of treatment through the 12-month follow-up, with the proportion with remission (AUDIT score < 8: 54.3% versus 31.9%; adjusted prevalence ratio [aPR] 1.71 [95% CI 1.32, 2.22]; p < 0.001) and abstinence in the past 14 days (45.1% versus 26.4%; adjusted odds ratio 1.92 [95% CI 1.19, 3.10]; p = 0.008) being significantly higher in the CAP plus EUC arm than in the EUC alone arm. CAP participants also fared better on secondary outcomes including recovery (AUDIT score < 8 at 3 and 12 months: 27.4% versus 15.1%; aPR 1.90 [95% CI 1.21, 3.00]; p = 0.006) and percent of days abstinent (mean percent [SD] 71.0% [38.2] versus 55.0% [39.8]; adjusted mean difference 16.1 [95% CI 7.1, 25.0]; p = 0.001). The intervention effect for remission was higher at 12 months than at 3 months (aPR 1.50 [95% CI 1.09, 2.07]). There was no evidence of an intervention effect on Patient Health Questionnaire 9 score, suicidal behaviour, percentage of days of heavy drinking, Short Inventory of Problems score, WHO Disability Assessment Schedule 2.0 score, days unable to work, or perpetration of intimate partner violence. Economic analyses indicated that CAP plus EUC was dominant over EUC alone, with lower costs and better outcomes; uncertainty analysis showed a 99% chance of CAP being cost-effective per remission achieved from a health system perspective, using a willingness to pay threshold equivalent to 1 month’s wages for an unskilled manual worker in Goa. Readiness to change level at 3 months mediated the effect of CAP on mean standard ethanol consumption at 12 months (indirect effect −6.014 [95% CI −13.99, −0.046]). Serious adverse events were infrequent, and prevalence was similar by arm. The methodological limitations of this trial are the susceptibility of self-reported drinking to social desirability bias, the modest participation rates of eligible patients, and the examination of mediation effects of only 1 mediator and in only half of our sample.ConclusionsCAP’s superiority over EUC at the end of treatment was largely stable over time and was mediated by readiness to change. CAP...

Aim:To assess the impact of COVID-19-related lockdown in India on alcohol-dependent persons. Method: We examined the change in the incidence of severe alcohol withdrawal syndrome presenting to hospitals in the city of Bangalore. Results: A changepoint analysis of the time series data (between 01.01.20 to 11.04.20) showed an increase in the average number of cases from 4 to 8 per day (likelihood ratio test: χ 2 = 72, df = 2, P < 0.001). Conclusion: An unintended consequence of the lockdown was serious illness in some patients with alcohol use disorders.

Tobacco use is a major cause of preventable death and disease in India. Unfortunately, very few people in India quit tobacco use. Lack of awareness of harm, ingrained cultural attitudes, and lack of support for cessation maintains tobacco use in the community. The significant addictive property of nicotine makes quitting difficult and relapse common. Health professionals have received little training, and very few thus carry out proper assessments and interventions among tobacco users. Evidence from the developed countries suggests that brief interventions delivered by diverse health professionals are effective in tobacco cessation. Combining pharmacologic approaches with behavioral counseling produces better results than a single strategy. In India, early experiences with tobacco cessation occurred in the context of primary community education for cancer control. More recently, tobacco cessation clinics have been set up to develop models of intervention, and train health professionals in service delivery. These need to be expanded at the primary, secondary, and tertiary care levels, and cost-effective community tobacco cessation models need to be developed. Tobacco cessation forms one of the critical activities under the National Tobacco Control Program. Tobacco cessation needs to be urgently expanded by training health professionals in providing routine clinical interventions, increasing availability and subsidy on pharmacotherapy, developing wide-reaching strategies, such as quitlines and cost-effective strategies, such as group interventions.

BackgroundDespite harmful drinking causing a significant burden on global health, there is a large treatment gap, especially in low‐ and middle‐income countries. A major barrier to care is the lack of adequately skilled human resources to deliver contextually appropriate treatments. This paper describes the systematic process used to develop Counselling for Alcohol Problems (CAP), a brief psychological treatment (PT) for delivery by lay counselors in routine primary care settings to men with harmful drinking in India.MethodsCAP was developed using a methodology involving 3 sequential steps: (i) identifying potential treatment strategies; (ii) developing a theoretical framework for the treatment; and (iii) evaluating the acceptability and feasibility of the treatment.ResultsCAP is a 3‐phase treatment delivered over 1 to 4 sessions based on a motivational interviewing (MI) stance and involves the following strategies: assessment and personalized feedback, family engagement, drink refusal skills, skills to address drinking urges, problem‐solving skills and handling difficult emotions, and relapse prevention and management. Data from a case series were used to inform several adaptations to enhance the acceptability of CAP to the recipients and feasibility of delivery by lay counselors of the treatment, for example expansion of the target group to include alcohol‐dependent patients and the extension of the delivery settings to include home‐based delivery. There was preliminary evidence of the effectiveness of CAP.ConclusionsCAP is an acceptable brief PT for harmful drinking delivered by lay counselors in primary care whose effectiveness is currently being tested in a randomized controlled trial based in primary care in Goa, India.

Purpose of review To understand the effect of COVID-19 pandemic and lockdown on persons with alcohol use disorders. Recent findings From a total of 455 titles on COVID-19 and alcohol, 227 abstracts were screened, and 95 articles were reviewed (on November 25 th , 2020). The immediate effect was an increase in alcohol related emergencies including alcohol withdrawal, related suicides, and methanol toxicity. Although there are mixed findings with respect to changes in the quantity of drinking, there are reports of binge/heavy drinking during the lockdown as well as relapse postlockdown. Psychological, social, biological, economic and policy-related factors appear to influence the changes in drinking. Although preliminary data suggest no change in alcohol use among persons with comorbid mental illness, findings in this population are presently limited. Among patients with alcohol related liver disease, outcomes appear worse and caution is warranted with the use of medications. Alcohol also appears to increases the risk of COVID-19 infection and complicates its course. Although some nations banned alcohol sales completely during lockdown, others declared it as an essential commodity, resulting in different problems across countries. Alcohol use has added to the burden of the problem particularly among vulnerable groups like the adolescents, elderly, patients with cancer, as well as health professionals. Services for patients with alcohol use disorders have been affected. Summary The COVID-19 pandemic has had considerable impact on alcohol use, with an increase in alcohol related emergencies, changes in alcohol use patterns, increased risk of contracting COVID-19, effect on alcohol policies and sales, and an effect on vulnerable groups. It is essential to understand and respond to the current situation, intervene early, and prevent further repercussions of the pandemic. Video abstract link: https://drive.google.com/file/d/1IJWtIs6e554PryKWhdma4VB--mjSZq1C/view?usp=sharing .