The vast majority of individuals with an alcohol use disorder do not receive treatment. However, the vast majority of these individuals also do not perceive any need for treatment. This would help explain why, according to the 2013 National Survey on Drug Use and Health, only approximately 8% of people with an alcohol use disorder received treatment in the past year. Those who do perceive a need for treatment also perceive barriers to treatment access which impedes access to care. This study by Schuler and colleagues published in the journal Psychiatric Services analyzed those individuals who reported barriers to treatment and then attempted to determine if there are identifiably distinct groups based on the barriers to treatment endorsed.
The data for the study was derived from the National Epidemiological Survey on Alcohol and Related Conditions (2001-2002). The study identified 1053 adults with an alcohol use disorder who perceived the need for treatment. The participants included in the study had a history of lifetime alcohol abuse or dependence, or both; and by study design had to be treatment naive.
In the survey, subjects who perceived the need for treatment were asked to identify barriers amongst a list of 26 pre-defined barriers (The list was limited to 15 that were considered significant.). Data associated with the participants, as well as the barriers chosen, was evaluated to determine whether sub-groups could be identified.
In this population sample, two distinct groups were identified. 83% were diagnosed with lifetime history of alcohol dependence and 17% with alcohol abuse. 68% were male and 76% were non-Hispanic-white. Family history of alcoholism was strong with 52% having a father with drinking problems and 20% reporting a mother with alcoholism. Psychiatric co-morbidity was also strong with 56% reporting a mood disorder, 40% an anxiety disorder, and 52% some other type of substance use disorder.
Attitudinal barriers were the most commonly endorsed with the most frequent one being, “I should be strong enough to handle [it] alone” (42%). 33% believed they did not need treatment because the problem would “get better by itself” and 21% believed that their drinking was “not serious enough” to warrant treatment. Stigma-related barriers were not uncommon with 19% stating that they were “too embarrassed to discuss it with anyone.” Structural barriers were also endorsed, but at a much lower frequency with “didn’t know any place to go for help, didn’t have time,” and “didn’t have any way to get there” each being endorsed at less than 10% each.
Two sub-groups were identified characterized as the low-barriers class and the high-barriers class. The low-barriers class primarily consisted of only attitudinal barriers to alcohol treatment and comprised 87% of participants. The other 13% made up the high-barriers class which consisted of a complex set of variables that included willingness to change as well as attitudinal, economic, structural/physical, and stigma barriers.
This study analyzed treatment naïve patients with alcohol use disorder who perceived a need for treatment, but possessed barriers to obtaining that treatment. The vast majority of subjects could be identified as belonging to a “low barriers” class and the remainder in the “high barriers” class. The “low barriers” class possessed primarily just attitudinal barriers, while the “high barriers” group identified attitudinal and various types of other barriers. The high barriers class had a significantly higher rate of maternal alcohol use disorder, lower income, and higher educational level. They were also had a greater likelihood of a life-time mood disorder, anxiety disorder, or another substance use disorder.
Since attitudinal barriers are the primary obstacle to treatment in the low barriers group, and also the most modifiable, this study suggests that tackling the stigma associated with alcohol dependence treatment and employing motivational techniques for behavioral change, may be most beneficial for individuals in this group. Screening, Brief Intervention and Referral to Treatment (SBIRT) modalities are endorsed for this purpose.
Given the presence of a wide variety of barriers in the high barriers group, this study advocates for a multi-modal approach tailored to each patient’s needs which could include SBIRT techniques as well as family interventions, psychiatric treatment of co-morbidities, and financial and social supports.
Innovative and more comprehensive strategies may benefit patients belonging to the high-barrier class and routine screening and motivation for behavioral change may prove useful in the low-barrier class.
Schuler MS, Puttaiah S, Mojtabai R, Crum RM. Perceived barriers to treatment for alcohol problems: A latent class analysis. Psychiatric Services. 2015 Nov 1;66(11):1221-1228. https://doi.org/10.1176/appi.ps.201400160