Delay to first treatment contact for alcohol use disorder
Introduction
Alcohol use disorders (AUD) are common. Prevalence estimates in the United States, the United Kingdom and Australia indicate between one in four and one in six adults in the population will meet criteria for DSM-IV alcohol abuse or dependence over their lifetime (Bunting et al., 2012, Hasin et al., 2007, Teesson et al., 2010). AUD is associated with substantial negative social and health consequences and poses significant public health concern (Whiteford et al., 2013). However, despite the high prevalence and negative impact of AUD, and the existence of effective interventions (Dawson et al., 2012, Jonas et al., 2012), most people with an AUD do not seek treatment (Edlund et al., 2012, Hasin et al., 2007). Moreover those who do, typically delay seeking treatment for many years following the onset of symptoms. Large community studies have reported median delays to first treatment contact of between 6 and 18 years after the onset of problems associated with alcohol (Bruffaerts et al., 2007, Bunting et al., 2012, Kessler et al., 2001, Keyes et al., 2010b, Wang et al., 2005, Wang et al., 2007b). Even if it is argued that a proportion of people with AUD will recover naturally over the course of their lives, these long delays are thought to represent considerable unmet need for care (ten Have et al., 2013, Witkiewitz et al., 2014). Identification of the factors associated with delay to seek treatment is key to understanding how to reduce these delays and lessen this unmet need.
Several large community studies have examined the factors associated with delay to seek treatment for AUD over lifetime. Generally these studies have reported longer delays and lowered odds of ever seeking treatment among those with earlier onset of symptoms (Bruffaerts et al., 2007, Hingson et al., 2006, Kessler et al., 2001, Kessler et al., 1998, Olfson et al., 1998, ten Have et al., 2013, Wang et al., 2005) and shorter delays and higher odds of ever seeking treatment among more recent cohorts (Bruffaerts et al., 2007, Kessler et al., 2001, Kessler et al., 1998, Olfson et al., 1998, Wang et al., 2005) – although three studies have reported no effect of one or both of these variables (Borges et al., 2007, Keyes et al., 2010b, Lee et al., 2007). With the exception of one study (Alvanzo et al., 2014), previous community studies have not reported sex differences in delay to seek treatment. No other predictors of treatment delay have been consistently examined or reported.
These studies are all based on large representative community surveys and are therefore a robust source of information. However, commonly these studies focused on one or two variables or examined only sociodemographic factors, thereby missing the impact of potentially important factors such as comorbidity, symptom type and severity. Both comorbidity and severity have been shown to be associated with a greater likelihood of seeking treatment among those with mental and substance use disorders (Cohen et al., 2007, Edlund et al., 2012, Ilgen et al., 2011, Wang et al., 2007a), and previous studies on treatment seeking for AUD have found particular symptoms or consequences of alcohol use to be associated increased odds of treatment seeking (Dawson et al., 2012, Naughton et al., 2013, Saunders et al., 2006). It is reasonable to expect that that these factors may also be associated with shorter treatment delays among those with an AUD.
The present study sought to address this gap by simultaneously examining the relationship between sex, birth cohort, age of onset, comorbidity, severity and symptom type and delay to first treatment contact for AUD in a large representative community sample in Australia. Australia is a country with high rates of alcohol use and dependence (Teesson et al., 2010). This is the first time data on treatment delay among those with AUD in Australia has been reported.
Section snippets
Sample
The 2007 Australian National Survey of Mental Health and Wellbeing (NSMHWB) is a nationally representative population survey with a sample size of 8841 (Slade et al., 2009). Respondents were selected at random from a stratified, multistage area probability sample of persons aged 16–85 years living in private dwellings and data were weighted according to the inverse probability of being selected. Interviews were conducted in respondent's households using a computer-assisted personal interview
Lifetime probability of treatment contact and treatment delay
Fig. 1 displays Kaplan–Meier failure curves for the cumulative lifetime probability of treatment contact after onset of AUD stratified by alcohol abuse and dependence. Table 1 displays the expected lifetime treatment rates, proportion who made contact within 1 year of onset and median duration of delay among those who eventually made treatment contact. Just over one third of people with an AUD were estimated to eventually make treatment contact with a median treatment delay of 18 years among
Discussion
The present study estimated that one in three people with an AUD in Australia will make treatment contact over lifetime and those who do will delay seeking treatment for a median of 18 years after onset of AUD symptoms. Expected rates of 1 year and lifetime treatment contact are higher among those with alcohol dependence than those with alcohol abuse and shorter median delay. Individuals from more recent cohorts, with later onset, or with comorbid anxiety disorder are more likely to make
Role of funding source
The 2007 National Survey of Mental Health and Wellbeing (NSMHWB) was funded by the Australian Government and conducted by the Australian Bureau of Statistics. The Centre of Research Excellence in Mental Health and Substance Use is funded by the National Health and Medical Research Council. The National Drug and Alcohol Research Centre is supported by funding from the Australian Government under the Substance Misuse Prevention and Service Improvements Grants Fund.
Contributors
Dr Chapman conceptualised the research question in consultation with the other authors and drafted the initial manuscript. Dr Chapman and A/Prof Slade conducted the analysis. All authors took an active role in interpreting the results and revising the manuscript. All authors have seen and approved the final version of the manuscript.
Conflict of interest
No conflict declared.
Acknowledgements
The authors would like to thank the NSMHWB reference group for their input in the survey's design. The authors would also like to thank all those who participated in the survey.
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