Exploring alcohol harm: concluding our series of rapid evidence reviews

The reviews have thrown up some fascinating insights which will help to inform our work going forward and hopefully that of other researchers and funding organisations. Here we summarise some of the interesting findings that have emerged, and how these will help shape our future research and policy work.

In deciding which topics to review, we were not afraid to look at the big issues, or the overlooked ones. In terms of the former, they don’t come much bigger than mental health. Britain has been described as a nation of drinkers, but also one where a quarter of adults experience mental illness during their lifetime.

It is very common for people to experience problems with their alcohol use and their mental health at the same time, and this is frequently described as having a ‘dual diagnosis’. However, the authors of our RER examining this relationship between alcohol and mental health problems argue that the term wrongly implies that there are only two clinical problem areas, when in fact there are usually several, all of which are specific to the individual and manifest in varying and multiple combinations.

It may therefore be more helpful to conceptualise such individuals as having ‘complex needs’, and who require models and strategies that are flexible and founded on a non-judgemental, person-centred approach.

The authors also report how individuals seeking support for their alcohol and mental health problems are often ‘shunted’ between services.

Further, whilst an integrated service model (whereby individuals are treated at the same time by both mental health and substance use service providers in one setting) scores highest in producing positive results in terms of harm reduction, the majority of treatment models in the UK follow an approach where individuals are either treated simultaneously by separate treatment providers, or their alcohol and mental health problems are tackled separately at different times and locations. So something needs to change.

And where better to start than the UK Government’s forthcoming alcohol strategy. To help us better support those with complex needs, the alcohol strategy must place a significant focus on co-occurring alcohol and mental health problems to ensure more people are able to access joined-up help, tailored to their individual needs.

Does the above description of us being a nation of drinkers apply to black and minority ethnic (BME) communities? When compared to the White British population, those from BME backgrounds are regularly reported to have higher rates of abstention from alcohol and other drugs.

However, as the authors of our RER exploring the prevalence of problematic drinking amongst this group highlight, national statistics do not provide a breakdown of alcohol use or misuse by ethnicity, which means it is difficult to assess trends over time.

Moreover, key informant interviews report an increased need for services among minority communities and growing concerns about the levels of hidden alcohol use that are not being addressed.

Adding to this complexity is that BME communities are not a homogeneous group, which inevitably means that engaging with for example, Irish Traveller drinkers, may require an entirely different approach to addressing the needs of migrants, refugees and asylum seekers.

There also appears to be no consensus as to whether specialist or mainstream services are best placed to offer support to BME groups. Either way, the financial crisis facing alcohol treatment services could impact on their ability to offer culturally specific approaches, adding further to difficulties in establishing common strategies for addressing the needs of minority groups.

Unlike some of the other RERs, which examined hundreds of academic studies, our RER looking at the experiences of living with ARBD, found just nine studies.

ARBD is a term used to cover a spectrum of overlapping conditions and disorders, which have been brought about by dependent drinking, resulting in damage to the brain.

The symptoms are very similar to dementia, namely cognitive and memory problems, meaning that ARBD is sometimes misdiagnosed. This is particularly worrying given that, unlike dementia, people with ARBD receiving treatment have a good chance of improvement over time, and sometimes make a full recovery.

The RER found that, despite living with brain damage caused by chronic heavy alcohol use and the associated symptoms, individuals are still capable of expressing their views about their circumstances and their care, but often they feel ignored by staff and generally undervalued within the care setting. In other words, they believe that their needs and experiences are not recognised or can be dismissed as unimportant.

One study, exploring loneliness amongst individuals in long-term care living with Korsakoff’s syndrome, highlighted a real disconnect between the lived experience of ARBD and the staff perception of that experience. In this case, loneliness was overestimated by healthcare professionals in comparison to self-reports from patients – individuals with ARBD were indeed lonely, but not as lonely as perceived by staff.

It is unquestionable that this is a tough group to diagnose and treat but, much like those experiencing co-occurring alcohol and mental health problems described above, the need for a person-centred approach to care, which priorities the views of patients in shaping their own care, is essential.

This inevitably requires a sophisticated skillset in terms of engagement and communication, and staff should be trained in developing these skills, as well as being regularly reminded of the potential for improvement which exists for individuals who have ARBD.

An approach that is gaining traction in public health more generally is the use of digital interventions, the subject of our next RER. Digital interventions offer enormous appeal in delivering health advice and support, particularly because they are easy to access by large numbers of people and can be delivered at a relatively low cost.

Alcohol brief interventions - short, structured conversations which aim to motivate individuals to make changes to their drinking behaviour - have shown success in primary care settings, and has more recently led to health professionals facilitating similar interventions online. Given the stigma still associated with alcohol use, the anonymity of online tools may offer more appeal to some drinkers compared to traditional face-to-face interventions. But are they effective in reducing harm?

The answer it seems, is that they might be, but we aren’t necessarily using the right tools to evaluate them. Technological developments mean that this is a rapidly-evolving field, so much so that results of more traditional approaches, like randomised controlled trials, quickly become out-of-date.

The review’s authors suggest that a ‘living’ systematic review might be the way forward, which provide a high quality, online summary of health research, updated as new research becomes available.

Digital interventions have been targeted not only at the general population but also specific groups that may be particularly vulnerable to alcohol-related harm, including military veterans, homeless people and the prison population.

Our fifth rapid evidence review considered interventions, digital or otherwise, for this latter group. Indeed, it sought to review studies examining interventions that aim to reduce alcohol use for people at any stage of the criminal justice system (CJS), from pre-arrest all the way through to re-settlement and after-care.

The authors report a lack of substantial, robust and consistent evidence relating to reductions in alcohol use from any intervention type, of any intensity, delivered to any group at any stage of the CJS. The largest body of evidence related to brief interventions as described above; however, only a minority of studies reported positive treatment outcomes for such an approach.

Disappointingly, few interventions have followed an individual as they have progressed through the CJS (and their treatment journey), resulting in a ‘cliff edge of support’. The UK Government has previously acknowledged the importance, and current lack of success, of smooth transitions from prison to support in the community.

The final RER similarly highlighted a lack of robust evidence, in this case to determine whether alcohol-focused policies and interventions at the levels of the individual (e.g. brief interventions), relationship (e.g. couples-based treatment), community (e.g. reducing the availability of alcohol) or societal (e.g. increasing prices), can reduce or eliminate occurrences of intimate partner violence. Again, this is disappointing when considering a similar systematic review published five years ago came to much the same conclusion.

Overall, the researchers concluded that we urgently need more research to help develop our understanding of the various factors that link alcohol use to intimate partner violence.

This urgent need for further research is, in fact, a common thread in all of our published RERs. This may not necessarily come as a shock to some readers - researchers calling for more research - and inevitably there’s always more we can learn.

Nevertheless, it’s clear that for each of the topics above, there is still so much we don’t know. It’s for this reason that we have set an ambitious goal of making significant contributions to increasing the knowledge base around alcohol harms through our future research work, one where such research is highly accessible and helps to develop local and national alcohol policy to improve services and practice on the ground.

More details about our plans will be published in the coming months, but in the meantime we have not been standing still on. For example, we are already have plans in place to work with colleagues at the University of South Wales, who have been investigating the prevalence and diagnosis of ARBD for a number of years, to produce targeted ARBD training and awareness raising programmes aimed at the general public; service users and their families/carers; and wider health and care professionals.