Commentary on Teesson et al. (2010): Getting help to those who need it—improving the delivery of services to people affected by risky drinking

Authors


Timely and reliable data are the base ingredients of effective public health policy and strategies. Teesson et al. [1] update the estimate of alcohol use and mental health disorders in Australia. Notwithstanding the challenges of this work (relatively high non-response rates; limited capacity for symptom identification in surveys [2]; temporal comparisons complicated by changes in approach and variation in participant recruitment) their paper, based on improved methodologies, indicates that Australia has relatively high rates of alcohol use disorders and significant levels of co-existing mental health and other drug use disorders. That more than one in five survey respondents reported life-time experience of alcohol use disorders is of concern in the context of recent reports of increasing alcohol consumption in Australia, with greater prevalence of risky drinking, increases in some adverse outcomes and more people being treated in specialist alcohol treatment services (e.g. [3–6].). We might wonder about the policy context that could contribute to these indicators of increasing alcohol-related harm.

A key issue identified in their report is that, despite the potential need, and despite other reports [6] that more people are being treated for alcohol problems, relatively few affected survey respondents sought treatment. They briefly explore factors that may contribute to this, including the observations that alcohol use disorders are highly stigmatized, that many individuals lack confidence in the available treatment options, and that responses are inadequately funded and poorly coordinated. In combination with other reports [7] that have observed that clinicians either miss or choose not to identify coexisting mental health and alcohol use disorders among their clients, it is apparent that we need to rethink our responses.

The high prevalence of these disorders, which have significant economic and social costs and low treatment engagement, demands an increase in treatment resources, not only in drug specialist services but across mental health services and in primary health care settings—no single service or system will be able to respond to all problems, and it is likely that different individuals will have distinct needs and preferences about where they will seek help. Consistent with this argument, it is interesting to note that Teesson and colleagues find that the most common treatment sought appears to be in the ‘mainstream’ services (such as general practitioners) as opposed to alcohol/drug specialist treatment services. The indications for service diversity clearly demands resources to ensure coordination of care across the various sectors.

However, this is not simply about more resources. We need to consider how we can address the barriers to treatment engagement. As noted by Teesson and colleagues, the alcohol field might learn from mental health. In addition to the recent efforts to raise the profile and acceptability of treatment, mental health services have a longer history of embracing assertive outreach. Alcohol treatment services have, traditionally, been more passive, perhaps because of influential paradigms that emphasized the critical importance of intrinsic motivation to change: poor treatment engagement was interpreted as poor motivation, not a failure to attract clients or offer accessible, meaningful and effective services. Poor treatment engagement is also an outcome of the marginalization of affected individuals, fuelled to some extent by the perception that alcohol use and related problems are volitional, undeserving of care in the context of limited resources. When this has been coupled with the common perception that alcohol problems are experienced uniquely by those afflicted with alcohol dependence, or ‘alcoholism’—‘I'm not an alcoholic so I needn't be concerned’—it is perhaps unsurprising that few of those in need either seek or are engaged in treatment.

We do not simply need more services. We need to re-frame perceptions of what constitutes risky drinking, re-think how we help people understand the personal relevance of risk and explore new and accessible ways of engaging people in reducing this risk. Advances in technology (online advice and interventions; use of telephone applications) provide one potential option. A recent intervention, described by Hallett et al. [8], illustrates the potential reach and impact of such approaches. Also, a large proportion of people affected by alcohol problems attend primary health care services yet, despite evidence of the effectiveness of offering interventions in these contexts, they are not adopted widely. This is probably, at least in part, because primary health care services have not been resourced adequately to implement the interventions and, as mentioned above, the pejorative attitudes about people affected by alcohol problems reduce the inclination to offer assistance.

Alcohol-related problems impact upon the whole community and the costs are unacceptably high. In Australia, and in some other countries, there is emerging evidence that some of these problems are becoming worse. While we have good evidence of cost-effective interventions [9], as noted by Teesson and colleagues, rates of treatment engagement are unacceptably low. In the interests of good public health, they cannot remain so.

Declaration of interests

None.

Acknowledgements

The National Drug Research Institute is funded by the Australian Government Department of Health and Ageing. Thanks for comments from my colleague, A/Professor Tanya Chikritzhs.

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