INDIAN PSYCHOSOCIAL FOUNDATION
 
   INDIAN PSYCHOSOCIAL FOUNDATION
         
IJPS >
IJPS April 2011
IJPS October 2011
IJPS April 2012
IJPS October 2012
IJPS April 2013
IJPS October 2013
IJPS Apirl 2014
IJPS October 2014
IJPS Apirl 2015
IJPS Apirl 2016
IJPS October 2016
IJPS Apirl 2017
 
 
 

Review Article

 

THE ROLE OF BRIEF INTERVENTION IN PSYCHIATRY

Roshan Bhad

Senior Resident, Department of psychiatry, All India Institute of Medical Sciences, New Delhi, India.

 

Abstract

The growing body of research suggests that the brief intervention is important psychosocial intervention tool not only for substance use disorders, but also other psychiatric disorders. This overview of role of brief intervention in psychiatry discusses the available evidence base, cost effectiveness and its implication for management psychiatric disorders. The paper presents review of available literature on the role of brief intervention in psychiatry. It also asserts that India presents a suitable and fitting ground for application of this psychosocial intervention and that Indian research in this area should be given priority.

Keywords: Brief intervention, Psychiatry, Psychosocial intervention

Introduction

Psychological interventions are the important part of management of any psychiatric disorder. However, there are only some psychological intervention, which are evidence based and brief intervention (BI) is one of them.1)Brief intervention in simple word is a brief counseling, which aims at changing the specific behavior. Brief interventions typically consist of one to four short counseling sessions with a trained interventionist (e.g., physician, psychologist, social worker, nurse, health worker). Brief intervention (BI) emerged in the 1980s as a strategy to provide early intervention, before or soon after the onset of alcohol-related problems, with the aim of moderating drinking rather than promoting abstinence.2)

What is brief intervention?

Definitions of brief interventions vary. In the recent literature, they have been referred to as "simple advice," "minimal interventions," "brief counseling," or "short-term counseling." Brief interventions should not be referred to as an homogenous entity, but as a family of interventions varying in length, structure, targets of intervention, personnel responsible for their delivery, media of communication and several other ways, including their underpinning theory and intervention philosophy.(3,4) Basic goal of any substance abuse treatment is harm minimization due to substance abuse with ultimate goal of abstinence. The goal in Bi is flexible, ranging from moderation to abstinence and not necessarily abstinence in all the cases. Primary goal of BI is to raise awareness and based on that recommend change in behavior. Goals can differ according to settings, client’s level of consumption, and stage of recovery or readiness to change.(5)

Components of Brief intervention

Six critical elements for effective BI summarized in acronym FRAMES.(6)

a. Feedback- Feedback is given to the individual about personal risk or impairment.

b. Responsibility- Responsibility for change is placed on the participant.

c. Advice- advice to change is given by the provider.

d. Menu- Menu of alternative self self-help or treatment options is offered to the participant.

e. Empathy- Empathic style is used in counseling.

f. Self elf-efficacy or optimistic empowerment is engendered in the participant.

A brief intervention consists of five basic steps that incorporate FRAMES and remain consistent regardless of the number of sessions or the length of the intervention: Introducing the issues, screening, evaluating, and assessing, providing feedback, talking about change and setting goals, talking goals, summarizing and reaching closure. The application could be agency-based intervention; community based intervention or through self helps manuals. Psychiatrist are not needed for the application of Bi as it can be administered by professionals like Primary care physicians, Substance abuse treatment providers, Emergency department staff members, Nurses, Social workers, Health educators, Lawyers, Mental health workers, Teachers, Crisis hotline workers, student counselors, Clergy etc. Practically it can be administer by any professional possessing following essential skills  - an overall attitude of understanding and acceptance, counseling skill such as active listening and and helping to resolve ambivalence helping ambivalence, a focus on intermediate goals and working knowledge on stages of change. (5)

Application of brief intervention in Psychiatry

Brief interventions are useful in management of various psychiatric disorders like substance abuse & behaviors associated with that, chronic medical illness, pain management, HIV risk reduction, sex offenders eating disorder, dual diagnosis cases etc. Although, it has been primarily used in treatment of substance use disorders there is recent interest is application of BI in verity of chronic and debilitating psychiatric disorders.  Among substance use disorders it is evidence-based treatment for management of alcohol use in primary health care setting and for risky and young alcohol users. (5,7–10) Brief interventions have also been used in management of cannabis use disorders and tobacco use disorders successfully. (11–13) Similarly, brief intervention has found useful in psychosocial management of eating disorders, (14,15) self harm behaviors (16) depressive disorder (17) pain disorders including headache (18) and anxiety disorders. (19,20)

Effectiveness of brief intervention

At present there is definitive evidence for brief intervention in psychosocial management of substance use disorders, while for rest of the psychiatric disorders there is limited evidence to suggest effectiveness of BI. Numerous studies have reported that brief interventions delivered in primary care, self referred drinkers and substance abuse treatment settings are effective in reducing excessive drinking. The primary meta-analysis(21) included 22 RCTs and evaluated outcomes in over 5800 patients. At 1 year follow up; patients receiving brief intervention had a significant reduction in alcohol consumption compared with controls [mean difference: -38 g week (-1), 95%CI (confidence interval): -54 to -23]. Another met analysis (22) of 18 studies reveled that after approximately 12months of follow-up, students receiving BI showed a significant reduction in alcohol consumption (difference between means=-1.50 drinks per week, 95% CI: -3.24 to -0.29) and alcohol-related problems (difference between means=-0.87, 95% CI: -1.58 to -0.20) compared to controls. In a randomized controlled trial, 40 young cannabis users were given two-session brief intervention and compared with the 3-month delayed-treatment control condition. The intervention resulted in significantly greater reductions in measures like changes in days of cannabis use, mean quantity of cannabis used weekly etc. (23)  A Cochrane review of 74 trials concluded that standard, print-based self-help materials increase quit rates compared to no intervention, but the effect is likely to be small.(24) A randomized control trial studying cost effectiveness of brief physician advice (brief intervention) concluded that it is associated with sustained reductions in alcohol use, health care utilization, motor vehicle events, and associated costs. The cost benefit analysis suggested that for every $10,000 invested in early BI, there is a $43,000 saving in future heath care cost.  While, the cost benefit ratio was 5.6 at 12 month & 4.3 at 4 year for alcohol, there was 80% reduction in absenteeism rate. (25)

Indian perspective

Brief intervention (BI) is advantage for developing country like India, where there is the dearth of manpower resources and treatment centers to address mental health problem in huge population. However, use of brief intervention is under utilized and the research in this area of effectiveness of brief intervention is limited. Varma & Malhotra found that general physicians could make reliable assessment of alcohol related problems in patients in early substance use period. It was demonstrated that screening is possible at primary health center (PHC) level and a prevalence of 10% abuse of alcohol was obtained using screening instruments. (26) Similarly, a case control study from India to test efficacy of BI on mild to moderate alcohol abusers showed significant reduction in consumption of alcohol and improvement in quality of life. A WHO collaborative study on “Identification and Management of Substance use Disorder in Primary Care Setting” conducted in year 2002 also supported the efficacy of BI amongst alcohol and cannabis users.(27) At present there are hardly any studies from India on role of Brief intervention (BI) in psychosocial management of other psychiatric disorders.

Future direction

Major drawback of the studies on BI is poor quality control. In future there is need to conduct studies which mention description of adherence to BI guidelines, specification of training procedure, competency criteria and active ingredients of intervention should also be specified. Moreover, there is need to research on optimal responders characteristics in terms of severity, gender, motivation and other variables like education, age, social support, locus of control, co morbidity etc.

Conclusion

Brief intervention (BI) is a low cost intervention that can be applied to a large population suffering from or at risk of various psychiatric disorders. It is the evidence based psychosocial treatment for substance use disorders. For which effectiveness is established and has been found consistent across cultures and different setting, Outcome significantly better than no treatment & often comparable to those more extensive therapies. With a shift towards early intervention BI offers a suitable & encouraging effective option to be implemented as a part of routine care. Considering its huge potential as a psychosocial intervention, there is need to escalate use of BI as an intervention for psychosocial management of psychiatric disorders. And to achieve this goal it is imperative to fill research gap in the area of brief intervention (BI) in India.

References

1.        The Australian Psychological Society Ltd. Evidence-Based-Psychological-Interventions in the Treatment of Mental Disorders: A Literature Review. 3rd ed. Australia; 2010.

2.        Nilsen P, Kaner E, Babor T. Brief intervention, three decades on. An overview of research findings and strategies for more widespread implementation.  Nord Stud on Alcohol and Drugs. 2009; 25(6): 453-467.

3.        Nilsen P. Brief alcohol intervention-where to from here? Challenges remain for research and practice: Facing Implementation Challenges. Addiction. 2010 Jan 27;105(6):954–9.

4.        Heather N. Interpreting the evidence on brief interventions for excessive drinkers: the need for caution. Alcohol Alcohol Oxf Oxfs. 1995 May;30(3):287–96.

5.        Nilsen P. Brief alcohol intervention-where to from here? Challenges remain for research and practice: Facing Implementation Challenges. Addiction. 2010 Jan 27;105(6):954–9.

6.        Miller, W. R., Sanchez , V. C. Brief Intervention for Alcohol Problems - Alcohol Alert No. 43-1999 [Internet]. 1993 [cited 2014 Aug 26]. Available from: http://pubs.niaaa.nih.gov/publications/aa43.htm

7.        Harris SK, Louis-Jacques J, Knight JR. Screening and brief intervention for alcohol and other abuse. Adolesc Med State Art Rev. 2014 Apr;25(1):126–56.

8.        hanjee S. Evidence Based Psychosocial Interventions in Substance Use. Indian J Psychol Med. 2014;36(2):112–8.

9.        O’Donnell A, Anderson P, Newbury-Birch D, Schulte B, Schmidt C, Reimer J, et al. The impact of brief alcohol interventions in primary healthcare: a systematic review of reviews. Alcohol Alcohol. 2014 Feb;49(1):66–78.

10.     Zoorob R, Snell H, Kihlberg C, Senturias Y. Screening and brief intervention for risky alcohol use. Curr Probl Pediatr Adolesc Health Care. 2014 Apr;44(4):82–7.

11.     Sarkar BK, Shahab L, Arora M, Lorencatto F, Reddy KS, West R. A cluster randomized controlled trial of a brief tobacco cessation intervention for low-income communities in India: study protocol. Addict Abingdon Engl. 2014 Mar;109(3):371–8.

12.     Tacke U, Seppä K, Winstock A. [Assessment and treatment of cannabis use disorders in primary health care]. Duodecim Lääketieteellinen Aikakauskirja. 2011;127(7):674–81.

13.     Kumar S, Malhotra A. Brief interventions in substance abuse. Indian J Psychiatry. 2000 Apr;42(2):172–83.

14.     Olmsted MP, Davis R, Garner DM, Eagle M, Rockert W, Irvine MJ. Efficacy of a brief group psychoeducational intervention for bulimia nervosa. Behav Res Ther. 1991;29(1):71–83.

15.     Geller J, Brown KE, Srikameswaran S. The efficacy of a brief motivational intervention for individuals with eating disorders: a randomized control trial. Int J Eat Disord. 2011 Sep;44(6):497–505.

16.     Husain N, Afsar S, Ara J, Fayyaz H, Rahman RU, Tomenson B, et al. Brief psychological intervention after self-harm: randomised controlled trial from Pakistan. Br J Psychiatry J Ment Sci. 2014 Jun;204(6):462–70.

17.     James E, Larzelere MM. Behavioral interventions for office-based care: depressive disorders. FP Essent. 2014 Mar;418:24–7.

18.     ristoffersen ES, Straand J, Vetvik KG, Benth JŠ, Russell MB, Lundqvist C. Brief intervention for medication-overuse headache in primary care. The BIMOH study: a double-blind pragmatic cluster randomised parallel controlled trial. J Neurol Neurosurg Psychiatry. 2014 Aug 11;

19.     Van Beek MHCT, Oude Voshaar RC, Beek AM, van Zijderveld GA, Visser S, Speckens AEM, et al. A brief cognitive-behavioral intervention for treating depression and panic disorder in patients with noncardiac chest pain: a 24-week randomized controlled trial. Depress Anxiety. 2013 Jul;30(7):670–8.

20.     Roy-Byrne P, Veitengruber JP, Bystritsky A, Edlund MJ, Sullivan G, Craske MG, et al. Brief intervention for anxiety in primary care patients. J Am Board Fam Med JABFM. 2009;22(2):175–86.

21.     Kaner EFS, Dickinson HO, Beyer F, Pienaar E, Schlesinger C, Campbell F, et al. The effectiveness of brief alcohol interventions in primary care settings: a systematic review. Drug Alcohol Rev. 2009 May;28(3):301–23.

22.     Fachini A, Aliane PP, Martinez EZ, Furtado EF. Efficacy of brief alcohol screening intervention for college students (BASICS): a meta-analysis of randomized controlled trials. Subst Abuse Treat Prev Policy. 2012;7:40.

23.     Martin G, Copeland J. The adolescent cannabis check-up: randomized trial of a brief intervention for young cannabis users. J Subst Abuse Treat. 2008 Jun;34(4):407–14.

24.     Hartmann-Boyce J, Lancaster T, Stead LF. Print-based self-help interventions for smoking cessation. Cochrane Database Syst Rev. 2014;6:CD001118.

25.     Fleming MF, Mundt MP, French MT, Manwell LB, Stauffacher EA, Barry KL. Brief Physician Advice for Problem Drinkers: Long-Term Efficacy and Benefit-Cost Analysis. Alcohol Clin Exp Res. 2002 Jan 1;26(1):36–43.

26.     Murthy P, Manjunatha N, Subodh BN, Chand PK, Benegal V. Substance use and addiction research in India. Indian J Psychiatry. 2010 Jan;52(Suppl 1):S189–199.

27.     Pal HR, Yadav D, Mehta S, Mohan I. A comparison of brief intervention versus simple advice for alcohol use disorders in a North India community-based sample followed for 3 months. Alcohol Alcohol Oxf Oxfs. 2007 Aug;42(4):328–32.