Alcoholics Anonymous and other 12-step programmes for alcohol dependence

Alcoholics Anonymous and other 12-step programs, while effective, are not the be-all and end-all in psychosocial treatments for alcohol dependence, according to new review of studies.

Evidence about the supremacy of these programs was inconclusive when analyzed in a systematic review, found the Italian research team that looked at eight studies of 3,417 adults being treated for alcoholism.

The studies compared interventions for effectiveness in reducing alcohol intake, achieving abstinence, maintaining abstinence and otherwise improving the quality of life of affected people and their families.

"All interventions without distinction proved to alleviate the severity of dependence," said Marica Ferri, an epidemiologist with the public health agency in Rome. Without a standout treatment, Ferri said, "the active collaboration of patients or clients should perhaps be sought to identify the best intervention for that specific person."

The review appears in the current issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.

Ferri and colleagues compared AA and other twelve-step programs with a number of other interventions. Among these, Motivational Enhancement Therapy seeks to evoke patients' own motivation for change and to design a personal plan for such change. Cognitive-behavioral coping skills training helps people learn how to pace their daily activities and relax and improves negative thinking patterns, so they can identify attainable goals. Relapse Prevention Therapy teaches people who how to anticipate and cope with the problem of relapse.

Twelve-step programs were also compared to one another, based on whether groups were spiritually or non-spiritually based, and whether a professional or lay leader led the group.

No available experimental studies unequivocally demonstrated the superior effectiveness of these 12-step approaches, when compared with other treatments, Ferri says. "AA may help patients to accept treatment and keep patients in treatment more than alternative treatments, though the evidence for this is from one small study that combined AA with other interventions and should not be regarded as conclusive."

Studies had various limitations, Ferri said. For instance, many different interventions were compared in some single studies. This leads to too many hypotheses being tested at the same time, she said, making it hard to accurately identify the specific factors leading to treatment success.

A recent single study by Rudolf H. Moos, Ph.D., senior research scientist with the Department of Veterans Affairs, did find a clear positive correlation between AA and long-term remission. Moos' study, published in the October 2005 issue of Alcoholism: Clinical and Experimental Research, followed 362 individuals for 16 years. This study was not included in the Cochrane review.

Moos said, however, that the benefits of participation in AA may not necessarily accrue to all types of individuals: "It is important to specify the characteristics of individuals who may not need to join AA in order to overcome their alcoholic-related problems."

Ferri suggested that psychosocial interventions, unlike drug treatments, don't always lend themselves to well to numerical comparisons: "Where interventions including social environment, human relations, quality of life, and other types of non-biological outcomes need to be measured, however, qualitative studies are more likely to identify meaningful findings."

Ferri said she hopes to see a well-designed qualitative study to identify the best intervention for individuals with alcohol dependence. One approach, she said, may be through unstructured interviews in which people with alcohol problems and their families could tell their stories to trained interviewers who do not judge or stigmatize, but just collect information.

For now, she said, the need to choose the most appropriate and effective intervention "places even more responsibility on the shoulders of those providing care and assistance to patients and their families."

By Patricia McAdams

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