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Problematic alcohol use is common among clients seeking transdiagnostic internet-delivered cognitive behavioral therapy (ICBT) for depression or anxiety but is not often addressed in these treatment programs. The benefits of offering clients a psychoeducational resource focused on alcohol use during ICBT for depression or anxiety are unknown.
This observational study aimed to elucidate the impacts of addressing comorbid alcohol use in ICBT for depression and anxiety.
All patients (N=1333) who started an 8-week transdiagnostic ICBT course for depression and anxiety received access to a resource containing information, worksheets, and strategies for reducing alcohol use, including psychoeducation, reasons for change, identifying risk situations, goal setting, replacing drinking with positive activities, and information on relapse prevention. We assessed clients’ use and perceptions of the resource; client characteristics associated with reviewing the resource; and whether reviewing the resource was associated with decreases in clients’ alcohol use, depression, and anxiety at posttreatment and 3-month follow-up among clients dichotomized into
During the 8-week course, 10.8% (144/1333) of clients reviewed the resource, and those who reviewed the resource provided positive feedback (eg, 127/144, 88.2% of resource reviewers found it worth their time). Furthermore, 18.15% (242/1333) of clients exhibited hazardous drinking, with 14.9% (36/242) of these clients reviewing the resources. Compared with nonreviewers, resource reviewers were typically older (
Overall, ICBT appeared to be associated with a reduction in alcohol consumption scores, but this reduction was not greater among alcohol resource reviewers. Although there was some evidence that the resource was more likely to be used by clients with greater alcohol-related difficulties, the results suggest that further attention should be given to ensuring that those who could benefit from the resource review it to adequately assess the benefits of the resource.
Over the last few decades, internet-delivered cognitive behavioral therapy (ICBT) has been established as an effective treatment option for a variety of mental health concerns [
In transdiagnostic ICBT for depression or anxiety, it is relatively uncommon to address comorbid alcohol use difficulties. This represents a missed opportunity, as previous research suggests that heavy drinking days are common among ICBT clients, with 56.8% (514/905) of clients endorsing drinking ≥6 drinks on 1 occasion during the past year [
In the literature, we identified only 1 study in which participants completing a self-guided ICBT program for depression received a brief intervention related to alcohol use [
This study included an evaluation of data from clients enrolled in an ICBT course offered in a Canadian province (Saskatchewan) over a span of 1 year (January to December 2021). This observational study aimed to add to the sparse literature and explore whether an additional alcohol resource available to clients at any point during transdiagnostic ICBT would be used and positively evaluated by clients. Furthermore, this study sought to explore whether alcohol use improved over time among clients in ICBT and, more specifically, among those who reviewed resources with low-risk or hazardous alcohol consumption.
We aimed to explore the following research questions: (1) What percentage of clients review the alcohol resource? (2) What client characteristics are associated with reviewing the alcohol resource? (3) Is the use of transdiagnostic ICBT generally associated with improvements in alcohol consumption over time? (4) Compared with clients who do not review the alcohol resource, do those who review resources show greater improvements in alcohol consumption, depression, and anxiety over time than those who do not? and (5) How will clients who review the alcohol resource evaluate it?
Given the limited nature of previous research in this area and that this was an exploratory analysis, the only hypothesis was that clients endorsing alcohol use problems at pretreatment would be more likely to review alcohol resources.
This study was an uncontrolled observational trial conducted within the Online Therapy Unit, which is a Saskatchewan government–funded ICBT clinic that accepts clients for treatment on an ongoing basis. This study included data from the Online Therapy Unit’s regular service delivery.
The study was approved by the institutional research ethics board of the University of Regina (approval number 2019-197).
Prospective clients learned about the services of the Online Therapy Unit through a variety of sources (ie, family physicians, other medical professionals, community mental health clinics, web-based searches, word of mouth, media, and posters or cards).
This study included all clients (N=1333) who started ICBT for anxiety and depression at the Online Therapy Unit during 2021, allowing for the analysis of a full year of service delivery.
All clients first completed a web-based screening via the Online Therapy Unit website, after which a telephone screening call was made. Prospective clients were eligible for the Online Therapy Unit’s services and to be a part of this study if they endorsed (1) being aged at least 18 years, (2) experiencing a minimum of mild depression or anxiety symptoms as their primary concern or concerns, (3) residing in Saskatchewan for the duration of treatment, (4) having access to and comfort using a computer and the internet, (5) a willingness to provide emergency medical contact (eg, family physician and psychiatrist), and (6) consenting to and beginning ICBT. Furthermore, prospective clients were excluded from this study if they reported or were assessed as (1) exhibiting unmanaged psychosis or mania, (2) demonstrating high suicide risk, (3) receiving mental health support from another provider more than twice per month, and (4) experiencing severe difficulties with alcohol use (ie, scoring ≥20 on the Alcohol Use Disorder Identification Test [AUDIT]) [
Client flow from screening to 3-month follow-up. ER: emergency room.
All primary and secondary outcome measures were administered at pretreatment, posttreatment (8 weeks after enrollment), and 3-month follow-up. Clients completed treatment satisfaction and resource evaluation questions at posttreatment. Although clients responded to additional questions about their symptoms over the course of the 8-week treatment period, the measures listed below were the focus of this study. Clients also completed questionnaires assessing insomnia, panic, social anxiety, mental health-related disability, treatment experiences, mental health service use, and pandemic-related anxiety but were not used as part of this observational study.
AUDIT [
The DUDIT [
Clients responded to questions regarding their age, gender, relationship status, race and ethnicity, location, education, and employment status during the web-based screening. Furthermore, clients were asked if they had taken psychotropic medications within the past 3 months.
AUDIT-Consumption (AUDIT-C) [
Clients were asked to indicate how many standard drinks of alcohol they had drank in the last 7 days. This question is commonly used in ICBT trials of alcohol misuse [
The Patient Health Questionnaire 9-item (PHQ-9) [
The Generalized Anxiety Disorder 7-item (GAD-7) [
Clients’ treatment engagement was captured based on whether they completed all 5 lessons as well as their total number of website log-ins over the 8-week treatment period. The platform does not track how long clients are logged in because this is a biased estimate impacted by whether clients fail to log out.
Clients were asked yes-or-no questions about whether the course was worth their time and whether they would recommend the course to a friend. On 5-point scales, they were also asked to rate their overall satisfaction with the course (1=
Clients were asked a yes-or-no question about whether they reviewed the alcohol resource. If they reported reviewing the resource, clients were asked to rate their level of effort dedicated to reviewing the resource from 1=
All clients were offered a therapist-assisted well-being course, which is an 8-week transdiagnostic ICBT course for depression and anxiety [
In addition to the 5 core lessons, clients can access additional downloadable resources at any time. The resources addressed a wide range of topics, namely, anger, alcohol use, assertiveness, beliefs, chronic conditions, chronic pain, communication skills, grief, health anxiety, mental skills, motivation, new motherhood, panic, posttraumatic stress disorder, sleep, workplace mental health, and worry. In this trial, therapists informed clients about the availability of resources during their first message to clients and made tailored recommendations based on the clients’ presenting concerns. Clients can also self-select the resources to review. During week 5, therapists asked all clients whether they had questions about any additional resources that they had reviewed.
The alcohol resource was based on content included in an ICBT program for alcohol use called the Alcohol Change Course [
Clients who scored in the clinical range (≥10) on either the PHQ-9 or GAD-7 were offered optional or regular once-weekly therapist support. Clients who scored in the nonclinical range (<10) on both PHQ-9 and GAD-7 were offered optional weekly support. In regular once-weekly therapist support, therapists reviewed symptom measures and sent clients a brief, tailored message once a week. Clients could also be contacted via phone if they had not logged in during the past week, if their PHQ-9 or GAD-7 scores increased by 5 or more points, or if there was an indication of elevated suicide risk. In optional support, therapists would only contact clients if they initiated contact that week, if their PHQ-9 or GAD-7 score increased by 5 or more points, or if there was an indication of elevated suicide risk. Previous research has shown that both approaches are similarly effective, and approximately 25% of clients prefer optional support [
Analyses were conducted using SPSS (version 28.0.0.0; IBM Corp) [
There were no missing data for the clients’ baseline screening variables. Data for the primary and secondary outcome variables were missing mainly because of client dropout (eg, 4/896, 0.4% to 213/687, 23.7% at posttreatment and follow-up, respectively). The missing data were determined to be missing completely at random (MCAR) via Little MCAR test (
To assess whether there was a significant change in clients’ AUDIT-C scores and previous weekly drinks over time, as well as to determine if pretreatment, posttreatment, and follow-up scores differed across clients and between groups (ie, reviewers vs nonreviewers), a series of mixed models were computed using the maximum likelihood estimation method with 3 assessment points (ie, pretreatment, posttreatment, and follow-up). As only 900 clients reported whether they reviewed the alcohol resource, mixed model analyses were performed with this subsample (
Missing data were not imputed because the data were assumed to be MCAR, and linear mixed model analysis can handle missing data [
Treatment engagement and satisfaction were compared between alcohol resource reviewers and nonreviewers through a combination of ANOVA and
Client responses to the Alcohol Resource Evaluation Survey were analyzed using conventional qualitative content analysis [
The coding process consisted of the following steps:
VP reviewed all client responses to questions regarding what clients liked about the alcohol resource, disliked about the resource, and any changes they made to their drinking because of the resource. A codebook was created during the review. The codebook consisted of identified codes, a description of each code, and an example quote for each code. A decision to review all client responses to ensure saturation was made during the creation of the codebook.
AW and TL used the codebook to independently code all client responses. The 2 coders were able to assign more than 1 code to a client response where appropriate (eg, if clients identified making more than 1 change after reviewing the resources).
VP reviewed the responses of AW and TL to identify and resolve instances of disagreement.
The pretreatment client characteristics of the overall sample are presented in
In terms of significant differences between reviewers and QNRs, QNRs were typically younger (
Client characteristics at pretreatment.
Variable | All clients (N=1333) | Reviewers (n=144) | Nonreviewers (n=756) | Questionnaire nonresponders (n=433) | Significance | |||||||||||||||||
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Test | |||||||||||||||||
Age (years), mean (SD; range) | 38.04 (13.78; 18-86) | 43.17 (13.70; 20-77) | 39.46 (14.16; 18-86) | 33.85 (11.95; 18-77) | <.001 | |||||||||||||||||
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<.001 | |||||||||||||||||||||
|
Woman | 1036 (77.72) | 94 (65.3) | 608 (80.4) | 334 (77.1) |
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Man or other | 297 (22.28) | 50 (34.7) | 148 (19.6) | 99 (22.9) |
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<.001 | |||||||||||||||||||||
|
Single or never married | 408 (30.61) | 29 (20.1) | 211 (27.9) | 168 (38.8) |
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Married or common law | 802 (60.17) | 90 (62.5) | 485 (64.2) | 227 (52.4) |
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Separated, divorced, or widowed | 123 (9.22) | 25 (17.4) | 60 (7.9) | 38 (8.8) |
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.22 | |||||||||||||||||||||
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Indigenous | 81 (6.08) | 9 (6.2) | 38 (5) | 34 (7.8) |
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Other | 94 (7) | 9 (6.2) | 49 (6.5) | 36 (8.3) |
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White | 1158 (86.87) | 126 (87.5) | 669 (88.5) | 363 (83.8) |
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.15 | |||||||||||||||||||||
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Large city (>100,000) | 778 (58.36) | 89 (61.8) | 437 (57.8) | 252 (58.2) |
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Small to medium city | 190 (14.25) | 13 (9) | 104 (13.8) | 73 (16.8) |
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Small rural location (<7000) | 365 (27.38) | 42 (29.2) | 215 (28.4) | 108 (24.9) |
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<.001 | |||||||||||||||||||||
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High school or less | 275 (20.63) | 20 (13.9) | 143 (18.9) | 112 (25.9) |
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More than high school or less than university | 589 (44.19) | 69 (47.9) | 317 (41.9) | 203 (46.9) |
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University education | 469 (35.18) | 55 (38.2) | 296 (39.2) | 118 (27.2) |
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.04 | |||||||||||||||||||||
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Employed part time or full time | 699 (52.44) | 75 (52.1) | 380 (50.3) | 244 (56.4) |
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Unemployed or disability | 250 (18.75) | 27 (18.8) | 135 (17.8) | 88 (20.3) |
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Homemaker, student, or retired | 384 (28.81) | 42 (29.2) | 241 (31.9) | 101 (23.3) |
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Psychotropic medication in the past 3 months | 732 (54.91) | 77 (53.5) | 405 (53.6) | 250 (57.7) | .36 | |||||||||||||||
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AUDITa ≥6 for women and ≥8 for men or other | 242 (18.15) | 36 (25) | 96 (12.7) | 110 (25.4) | <.001 | |||||||||||||||
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PHQ-9b ≥10 | 955 (71.64) | 102 (70.8) | 506 (66.9) | 347 (80.1) | <.001 | |||||||||||||||
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GAD-7c ≥10 | 949 (71.19) | 104 (72.2) | 512 (67.7) | 333 (76.9) | .003 | |||||||||||||||
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Drinks per week | 2.89 (6.78) | 6.35 (15.63) | 2.23 (4.42) | 2.87 (4.69) | <.001 | |||||||||||||||
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AUDIT | 3.39 (3.76) | 4.75 (4.17) | 2.72 (3.07) | 4.11 (4.11) | <.001 | |||||||||||||||
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PHQ-9 | 13.50 (5.74) | 13.34 (5.61) | 12.65 (5.69) | 15.03 (5.58) | <.001 | |||||||||||||||
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GAD-7 | 12.64 (5.09) | 12.51 (5.00) | 12.10 (5.06) | 13.61 (5.04) | <.001 |
aAUDIT: Alcohol Use Disorders Identification Test.
bPHQ-9: Patient Health Questionnaire 9-item.
cGAD-7: Generalized Anxiety Disorder 7-item.
Clients’ mean AUDIT-C scores were 2.33 (SD 2.09) at pretreatment, 2.22 (SD 1.94) at posttreatment, and 2.11 (SD 1.94) at 3-month follow-up. The mixed model analysis predicting clients’ AUDIT-C scores revealed a significant decrease in AUDIT-C scores over time (β=−.03, SE 0.01;
On average, clients consumed 2.89 (SD 6.78) weekly drinks at pretreatment, 2.44 (SD 4.18) weekly drinks at posttreatment, and 2.77 (SD 5.29) weekly drinks at 3-month follow-up. The mixed model analysis predicting clients’ previous weekly drinking showed that there was no significant
In sum, the results of the primary analyses show that regardless of their pretreatment alcohol use difficulties, there was a significant decrease in clients’ AUDIT-C scores over time and no change in clients’ previous weekly drinks over time. Furthermore, reviewing the alcohol resources did not influence changes over time in clients’ AUDIT-C scores or previous weekly drinks.
Clients’ mean PHQ-9 scores were 13.50 (SD 5.75) at pretreatment, 6.85 (SD 5.36) at posttreatment, and 5.90 (SD 4.97) at 3-month follow-up. Furthermore, their mean GAD-7 scores were 12.64 (SD 5.09) at pretreatment, 6.16 (SD 4.98) at posttreatment, and 5.36 (SD 4.83) at 3-month follow-up. Mixed model analyses revealed significant
Moreover, the mixed model analysis dichotomizing clients into low-risk and hazardous drinking subgroups showed a statistically significant decrease in depression over time among clients in both the low-risk (β=−1.35, SE 0.05;
Similarly, the mixed model analysis dichotomizing clients into low-risk and hazardous drinking subgroups revealed a significant decrease in anxiety over time for clients in both the low-risk (β=−1.20, SE 0.04;
Treatment engagement was also examined by resource reviewers and nonreviewers (n=900;
Treatment engagement and satisfaction.
Variable | Reviewers and nonreviewers (n=900) | Reviewers (n=144) | Nonreviewers (n=756) | Significance | |||||||
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Test | |||||||
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Accessed lesson 5, n (%) | 799 (88.8) | 133 (92.4) | 666 (88.1) | .14 | ||||||
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Number of website log-ins, mean (SD) | 26.55 (27.78) | 26.58 (15.44) | 26.54 (29.56) | .99 | ||||||
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Course was worth the time | 846 (96) | 140 (97.2) | 724 (95.8) | .41 | ||||||
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Would recommend course to friend | 867 (96.3) | 140 (97.2) | 727 (96.2) | .54 | ||||||
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Satisfied or very satisfied overall | 744 (82.7) | 124 (86.1) | 620 (82) | .23 |
A total of 144 clients responded to the Alcohol Resource Evaluation Survey. Clients indicated dedicating a moderate amount of effort into the resource (mean 3.79, SD 1.92), moderately agreed that they had learned something new by reviewing the resource (mean 4.31, SD 2.00), found the resource moderately helpful (mean 4.74, SD 1.78), and rated the resource as very understandable (mean 6.15, SD 1.11). Most clients who reviewed the resources indicated that it was worth their time (127/144, 88.2%).
Of the 144 responses, 122 (84.7%) were codable as “likes” (see
Client responses to the Alcohol Resource Evaluation Survey.
Responses | Example | Client ID | Values, n (%) | ||||||
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Informative |
“Learning things I didn’t know.” |
35687 |
62 (43.1) | |||||
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Not a like |
“I do not drink. Therefore doesn’t pertain to me.” |
35755 |
23 (16) | |||||
|
Insight into one’s drinking |
“Helped me to gain more perspective about my drinking and helped me make the commitment to stop drinking completely” |
34424 |
21 (14.6) | |||||
|
Presentation of information |
“Very clear and concise” |
36081 |
18 (12.5) | |||||
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Information on the relationship between alcohol use and symptoms of anxiety or depression |
“It confirmed for me the effects alcohol can have on depression and mood.” |
35688 |
12 (8.3) | |||||
|
Resource allowed them to help or understand others |
“I used the resource to help me with family members who are alcohol users” |
35722 |
10 (6.9) | |||||
|
Resource acted as a refresher |
“it refreshed some knowledge I had” |
36292 |
8 (5.6) | |||||
|
Worksheet activity |
“The question prompts were helpful to think about.” |
36027 |
7 (4.9) | |||||
|
Information on the negative effects of drinking |
“That there are negative consequences beyond just drinking too much.” |
35829 |
6 (4.2) | |||||
|
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|
Nothing |
“There was not anything I didn’t like.” |
34368 |
109 (75.7) | |||||
|
Not relevant to client experience |
“It did not apply to me; I drink a couple beers a year.” |
34054 |
12 (8.3) | |||||
|
Format or structure issues |
“I wish the PDF was fillable” |
35890 |
7 (4.9) | |||||
|
Insight into one’s drinking |
“I honestly don’t remember anything I didn’t like except maybe how it forced me to think more actively about my drinking/alcohol consumption patterns.” |
36643 |
5 (3.5) | |||||
|
No new information |
“No new information, but not the fault of the resource...” |
36715 |
4 (2.8) | |||||
|
Resource did not focus on other substances or addictions |
“You should expand this to include cannabis use too” “I would like to see other addiction issues discussed–particularly regarding technology” |
34853 34429 |
3 (2.1) | |||||
|
Generic negative comment |
“I just did not find it helpful.” |
35629 |
2 (1.4) | |||||
|
Not a dislike |
“I think a weekly sessions with a therapist would be helpful via zoom” |
34368 |
2 (1.4) | |||||
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43 (29.9) | |||||||
|
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Reduced drinking |
“Yes, reduced alcohol consumption” |
34811 |
27 (62.8) | ||||
|
|
Increased awareness of drinking habits |
“It helped me realize sometimes I would grab a drink after a long day when my husband wasn’t home because I was lonely.” |
34781 |
18 (41.9) | ||||
|
|
Replaced drinking with more helpful coping strategies |
“...made healthier choices when I was having a bad day.” |
34238 |
7 (16.3) | ||||
|
No |
“No. I read the resource because I was curious (and like information) not because I think I have a problem with alcohol.” |
36099 |
101 (70.1) |
Most clients did not report disliking any aspect of the resource. Among clients who shared a dislike, the most common concern was that the resource was not relevant to their personal experience (eg, “I didn’t think it really applied, I’ve never really had issues with alcohol use outside a short stint in my late teens, early twenties.” [client ID 36202]). Other clients expressed concerns with the format or structure of the resource (eg, “I wish the PDF was fillable” [client ID 35890]) or felt that the resource did not provide them with any new information (eg, “mostly stuff I already knew” [client ID 34733]). Some clients found it challenging to have increased insight into the frequency of their alcohol consumption or severity of their alcohol concerns (eg, “It reminded me how much I’m binge drinking” [client ID 35312]). A small subgroup of clients thought that the resource should address other addictions or substance use (eg, “You should expand this to include cannabis use too” [client ID 34853]). Two clients responded with generic negative comments that did not fit into the other categories (eg, “I just did not find it helpful” [client ID 35629]). See
In total, 3 types of changes emerged in clients’ responses, namely, reduced drinking (eg, “Yes I have cut down and now only will have a drink at a social function” [client ID 34667]), increased awareness of one’s drinking habits (eg, “It helped me realize sometimes I would grab a drink after a long day when my husband wasn’t home because I was lonely” [client ID 34781]), and replacing drinking with more helpful coping strategies (eg, “made healthier choices when having a bad day” [client ID 34238]).
This observational study investigated whether clients enrolled in an 8-week transdiagnostic ICBT course for depression and anxiety would review, benefit from, and positively evaluate an additional resource for addressing alcohol use. We also aimed to explore the demographic and clinically relevant variables associated with reviewing the alcohol resource. Across all groups, participants showed improvements in alcohol consumption, depression, and anxiety over time. Compared with nonreviewers, clients who accessed the resource were more likely to be older; men; and separated, divorced, or widowed. Furthermore, as expected, reviewers were more likely to consume more weekly drinks, report higher alcohol use difficulties, and have higher levels of hazardous drinking. Ratings and comments from resource reviewers indicated high satisfaction with the resource. The client ratings suggested that the resource was helpful and understandable, and most clients indicated that it was worth their time. Clients’ most liked aspects of the resource were that it was informative and that it assisted them in gaining insight into their drinking behavior. Resource reviewers did not differ from nonreviewers in any indices of overall treatment engagement (ie, course completion and website log-ins) or satisfaction with the ICBT course overall.
Interestingly, the prevalence of hazardous or harmful drinking based on AUDIT was slightly higher in this trial (242/1333, 18.15%) than in previous ICBT samples (160/1155, 13.85%) [
Findings from this study are consistent with a randomized controlled trial that examined the inclusion of a brief web-based alcohol use intervention in conjunction with a web-based depression intervention [
This study had several limitations that can help guide future research. The study was observational in nature and had no control group; therefore, causal conclusions about the impact of the resource cannot be made. The Alcohol Resource Evaluation Survey was administered at posttreatment, and responses were missing from approximately one-third of the clients. It is possible that some of the clients who did not respond to the Alcohol Resource Evaluation Survey actually reviewed the resource; however, because of their missing self-reports, we did not have information about their perceptions of the resource and whether the resource was helpful in reducing alcohol consumption by these clients. Future studies could include a resource evaluation survey at midtreatment to ensure higher response rates. Clients could also be asked about their alcohol consumption weekly to allow for tracking of changes in alcohol use over the span of the course. Moreover, it would be beneficial to use the Alcohol Timeline Followback [
Only 10.8% (144/1333) of clients in this study reviewed the additional alcohol resource, including only 14.9% (36/242) of those with AUDIT scores indicating hazardous alcohol use. As the ICBT course included 19 additional resources, clients who may have benefited from alcohol may have prioritized other resources. Alternatively, clients who scored above the cutoff for hazardous drinking may not have perceived difficulties with their drinking patterns or they may have been focused on managing their symptoms of depression or anxiety before addressing any concerns related to alcohol. A limitation of the Alcohol Resource Evaluation Survey was that it did not ask clients to provide a reason for why they chose not to review alcohol resources. As such, future studies could include questions to better understand clients’ decisions not to review resources. Including a measure of motivation to change drinking behaviors could also be worthwhile, as this study only assessed need based on hazardous or harmful drinking, and it is not possible to determine how motivated these clients were to use resources or change their drinking behaviors. In the future, the main ICBT course content could include information regarding low-risk drinking guidelines and therapists could direct clients’ attention to the alcohol resource if they fall within the hazardous risk ranges for their drinking. Such methods could assist in increasing the uptake of alcohol resources, thereby facilitating more substantial opportunities for future research to elucidate the impact of reviewing resources in transdiagnostic ICBT. Therapists could recommend the resource at the beginning of the course based on clients’ pretreatment scores on the AUDIT or throughout the course based on clients’ concerns related to alcohol consumption. This study did not examine whether therapists recommend resource-predicted clients to review the resource, which could be an area of future study. It would also be worthwhile to ensure consistent follow-up from therapists regarding the resource after it has been recommended to clients.
Nearly one-fourth (326/1333, 24.46%) of clients reported never drinking alcohol on the pretreatment AUDIT; interestingly, 5.8% (19/326) of these clients reviewed the resource. In addition, almost half of the clients (662/1333, 49.66%) did not consume any drinks in the previous week at pretreatment, and 6.8% (45/662) of them reviewed the resource. This may have because of many reasons (eg, having a family member with alcohol use difficulties or having undisclosed or past problems with alcohol). Nonetheless, as only increases in drinking over time are possible for these groups, nondrinkers reviewing alcohol resources may have confounded the results, particularly for the mixed model analysis predicting changes in clients’ previous weekly drinks. We can also see echoes of further potential confounds within these nondrinkers’ qualitative feedback. For instance, the most common (12/33, 36%) dislike expressed by clients was that the resource was not relevant to their experience. As such, a further direction for research would be to randomly assign clients with alcohol use difficulties to (1) a transdiagnostic ICBT course targeting depression and anxiety or (2) the same transdiagnostic ICBT course plus an additional alcohol resource.
In terms of pretreatment characteristics, it is also important to highlight that most clients in this study identified as a woman and as White. These trends in mental health service use based on gender and ethnicity are not unique to ICBT [
To our knowledge, no previous studies on transdiagnostic ICBT for depression and anxiety have specifically examined the inclusion of a resource addressing alcohol use. As drinking difficulties are a prevalent concern among ICBT clients with depression and anxiety [
Consistent with previous research [
Alcohol Use Disorder Identification Test
Alcohol Use Disorder Identification Test-Consumption
Drug Use Disorder Identification Test
Generalized Anxiety Disorder 7-item
internet-delivered cognitive behavioral therapy
missing completely at random
Patient Health Questionnaire 9-item
questionnaire nonresponder
The authors wish to acknowledge the Patient-Oriented Research Steering Committee, including Matthew Keough and Michael Schaub, for their contributions to developing the alcohol resource, and the Saskatchewan Health Resource Foundation and Saskatchewan Centre for Patient-Oriented Research for funding that supported the development of the resource. The authors would also like to thank the clients, research and clinical staff, students, and web developers associated with the Online Therapy Unit at the University of Regina; the therapists from the Saskatchewan Health Authority; and the Saskatchewan Ministry of Health for funding, which allowed the delivery of internet-delivered cognitive behavioral therapy in Saskatchewan.
None declared.