Counselling for Alcohol Problems (CAP), a lay counsellor-delivered brief psychological treatment for harmful drinking in men, in primary care in India: a randomised controlled trial

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·...

The Healthy Activity Program (HAP), a lay counsellor-delivered brief psychological treatment for severe depression, in primary care in India: a randomised controlled trial

“…The findings of this trial, along with the companion trial 18 assessing CAP treatment, represent a substantial step in global mental health for several reasons. First, the interventions are brief, delivered by lay people and provided to primary health-care attenders with almost no exclusion criteria, thus enhancing their generalisability.…”

“…A core feature of PREMIUM is delivery of both treatments by the same lay counsellors in routine primary care settings, thus reproducing the way that they would be used in clinical practice. The results of the trial assessing the CAP treatment for harmful drinking are published separately 18 . The two trials of HAP and CAP were done concurrently in the same primary health centres (PHCs) and over the same period of time, with the same counsellors delivering both treatments according to trial allocations of participants.…”

Impact of a district mental health care plan on suicidality among patients with depression and alcohol use disorder in Nepal

“…HAP is a behavioral activation therapy delivered individually over six to eight weekly sessions and includes psychoeducation, activity structuring and monitoring, problem solving, and activating social networks [35]. CAP is a manualized motivational activation delivered individually over four weekly sessions, consisting of personal appraisal, development cognitive and behavioral skills related to alcohol use, and management of potential relapse [36]. Health facilities in the study received organizational support to provide mental health services in the form of an ensured supply of psychotropic medication and mechanisms for monitoring, capacity building, and resource mobilization.…”

Geographic location as a modifiable cardiac risk factor

“…Disease burden should be considered when determining resource allocation. We can look to lowresource settings, where unmet need in primary health care has been addressed innovatively by training and deploying nonprofessional lay counselors, 11,12 for approaches that could be adapted to local contexts.…”