With the advent of brief interventions, treatment for alcohol problems has become more variable in length (duration) and intensity (amount of therapist contact). There is little doubt that, for heavy drinkers not seeking treatment and identified by screening in generalist settings, brief interventions of one or two sessions are all that is necessary in most cases; for those in the treatment-seeking population with more serious problems the optimal intensity of treatment is unknown. Project MATCH (1997a) found that four sessions of MET were generally as effective as eight sessions of CBT or TSF although, as we have seen, certain types of client benefited more from the more intensive treatments. Nevertheless, the Project MATCH findings suggest that, on the whole, less intensive treatment by MET is more cost-effective than more intensive alternatives (Cisler et al., 1998). Against this, in a reanalysis of the MATCH economic data, Holder et al. (2000) reported that, for certain types of client with typically poor prognoses, CBT or TSF was more cost-effective than MET. In the UKATT results, three sessions of MET were significantly cheaper to implement than eight sessions of SBNT and, as has already been stated, no less effective in reducing alcohol problems. Surprisingly perhaps, MET and SBNT did not differ in cost-effectiveness (UKATT Research Team, 2005b). The economic evaluation here was done from a societal perspective, taking into account costs and benefits in the health, social services and criminal justice sectors. However, from the perspective of the individual service provider, MET would be clearly more cost-effective, if only because more clients could be treated within a given time period and waiting lists proportionately reduced. Irrespective of treatment modality, it was found that treatment resulted in savings in costs averted in the one-year follow-up period of roughly five times what treatment cost to implement (UKATT Research Team, 2005b).
An interesting response to the problem of the optimal intensity of treatment is the development of the stepped-care model (Breslin etal., 1997; Sobell & Sobell, 2000) in which clients enter a treatment system at the lowest appropriate level, are followed up and then receive successively more intensive treatment if they have not shown improvement. Humphreys (2004) has suggested that the lowest rung on this ladder might be mutual aid organisations in the community, with obvious advantages for cost savings. Next levels might be brief interventions in generalist settings, brief treatment in specialist settings and more intensive treatment in specialist settings. Despite its interesting possibilities for the provision of effective and cost-effective treatment services, the stepped-care model remains to be properly evaluated.
There has been much attention in the alcohol problems treatment literature to the comparison of outpatient and inpatient services in terms of effectiveness and cost-effectiveness. An early conclusion (Miller, 1986) was that outpatient treatment was no less effective than inpatient treatment but that, since the latter was up to 10 times more expensive, outpatient treatment should generally be preferred. Finney, Haan & Moos (1996) carried out a systematic review of this area and concluded that residential treatment may be indicated for clients who have shown themselves to be unresponsive to treatment in the past, who have meagre financial resources and whose home environments are inimical to recovery.
In terms of cost-effectiveness, while inpatient or residential programmes lasting more than four weeks do not produce better outcomes than very brief hospitalisation, partial hospitalisation programmes are equal to or superior in effectiveness to inpatient programmes. Clients with relative greater social resources, in terms of employment and relationships, were better suited to outpatient treatment.
Certainly, there is little evidence for the cost-effectiveness of expensive, profit-making treatment programmes found under the headings of 'the Minnesota Model' or 'milieu therapy' (see Table 15.1). People with alcohol problems have a right, of course, to spend their own money how they wish but there is no justification for the expenditure of public funds on these residential facilities.
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