R E S E A R C H A R T I C L E Open Access
A pragmatic randomised trial of two
counselling models at the Swedish national
, Yvonne Forsell
, Mats Ramstedt
, Kerstin Damström Thakker
and Maria Rosaria Galanti
Background: Alcohol telephone helplines targeting alcohol consumers in the general population can extend the
reach of brief interventions while preserving in-person counselling. So far, studies of client outcomes in the setting
of alcohol helplines are scarce. This study aims to compare the 6-months alcohol-related outcomes of two
counselling models delivered at the Swedish National Alcohol Helpline.
Methods: A pragmatic randomised trial was set up at the Swedish National Alcohol Helpline. First-time callers with
current hazardous or harmful alcohol use who contacted the helpline, from May 2015 to December 2017, were invited
to participate. Clients were allocated with 1:1 ratio to two groups: (1) brief, structured intervention (n= 128), including
self-help material and one counsellor-initiated call, and (2) usual care (n= 133), i.e. multiple-session counselling using
Motivational Interviewing (MI). The primary outcome was a downward change in AUDIT risk-zone between baseline
and 6-months follow-up. The analysis followed an intention-to-treat approach.
Results: Recruitment ended in December 2017. At 6-months follow-up, 70% of the enrolled participants had data on
the outcome. In the brief, structured intervention (n= 107) 68% changed to a lower risk-level, compared to 61% in the
usual care group (n=117), yielding a risk ratio (RR) of 1.12 (95% CI 0.93 to 1.37) and risk difference of 0.08 (95% CI -0.05
to 0.20). The total AUDIT score and the scores from the AUDIT consumption questions (AUDIT-C) did not reveal any
between-group differences in the mean change at follow-up.
Conclusions: The counselling at the Swedish National Alcohol Helpline was followed by a significant decrease in
alcohol use among clients, without clear superiority for either counselling model.
Trial registration: This trial was retrospectively registered with ISRCNT.com (ID: ISRCTN13160878) 18/01/2016.
Keywords: Hazardous alcohol use, Harmful alcohol use, Drinking, Telephone helpline, Brief intervention, Counselling,
Randomised controlled trial
The high prevalence of hazardous and harmful alcohol
use and the substantial harm attributable to alcohol con-
sumption [1,2] highlights the need for easily applicable
intervention and prevention efforts directed towards at-
In part, the harm caused by alcohol could be prevented
by increasing help -seeking in the population with hazard-
ous or harmful alcohol consumption . Only a minority
seek formal treatment and help-seeking usually occurs at
arelativelylatestage[4,5], partially due to stigma, scepti-
sism toward treatment alternatives and ignorance of the
problems’severity [6,7]. Brief interventions (BI) are recog-
nised as effective and cost-effective in primary care popu-
lations [8,9]. However, the extent to which these
interventions reach the target population is limited by op-
portunistic identification ; the failure to identify at-risk
drinkers ; health professional’s attitudes and insuffi-
cient implementation strategies [12,13]. Strategies to
reach individuals that would not seek regular treatment
includes personalised digital interventions. Recently, a
Cochrane review found personalised digital behavioural
© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
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(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
* Correspondence: firstname.lastname@example.org
Department of Public Health Sciences, Karolinska Institutet, 171 77
Full list of author information is available at the end of the article
Säfsten et al. BMC Psychiatry (2019) 19:213
interventions effective for reducing hazardous or harmful
alcohol consumption compared to no or minimal inter-
ventions . However, extended counselling does not
seem to be more effective for modifying hazardous alcohol
use than brief interventions . In the context of tele-
phone helplines the effectiveness of different interventions
While telephone-based alcohol counselling via help-
lines is gaining momentum, its effectiveness has not
been evaluated with experimental studies [16,17]. The
existing studies on brief intervention using telephone
counselling typically consist of clinical populations, i.e.
not seeking help for alcohol problems per se. These
studies suggest that the telephone may be an effective
mode for alcohol counselling , a sug-
gestion supported by previous reviews on telephone
counselling in mental health and addiction [22,23]. Fur-
ther, the scant evaluation of alcohol helplines limits the
knowledge about effective models of delivery.
Population-based telephone counselling, combines
ease of access and anonymity with the advantages of in-
person individual counselling, thus reducing potential
barriers to treatment seeking. Last but not least, tele-
phone helplines may be cost-effective for the delivery of
The Swedish National Alcohol Helpline (SAH), operat-
ing since 2007, offers a unique possibility to study tele-
phone counselling aimed at the general population.
From the very start, a strong emphasis was put on devel-
oping and providing the most cost-effective counselling
setting. Previous observational studies at SAH offered a
suitable “proof of concept”of the usefulness of the ser-
vice [24,25]. This study seeks to move the agenda fur-
ther, comparing the effects of two counselling models on
hazardous and harmful alcohol use within the SAH. 1) A
brief structured intervention consisting of self-help ma-
terial combined with one counsellor-initiated call, and 2)
usual care, i.e. multiple-sessions of Motivational Inter-
viewing (MI) with components of cognitive behavioral
therapy (CBT). The alternative hypothesis was that the
brief structured intervention would be more effective
than usual care in promoting change in a client’s alcohol
A protocol of the trial, including full information of the
design and methods, has been published and is sum-
marised here .
A pragmatic randomised controlled trial was initiated in
2015 at the SAH. The Ethical Review Board of Stockholm,
Sweden approved the study (DNR 2014/1732–31/5), and
the corresponding protocol was registered in the ISRCTN
registry (ID: ISRCTN13160878). The analytical approach
to hypothesis testing has been changed fromthatre-
ported in the trial register from non-inferiority to super-
iority due to a lower recruitment rate then what was
expected at inception.
Recruitment of participants and random allocation
Participants were clients from the general population
seeking help at the SAH for at least hazardous alcohol
use. Counsellors assessed the eligibility of clients at their
first contact, before informing about the study. Eligible
clients who expressed interest in participating were con-
tacted by telephone within a week by trained inter-
viewers not involved in the counselling at the helpline.
The interviewers performed the following sequence of
tasks: 1) obtained formal consent, 2) conducted the
baseline interview, and 3) opened a sequentially num-
bered, sealed envelope containing the results of the
randomization algorithm and communicated the group
allocation to the participant. Clients were allocated with
1:1 ratio to the two groups. The research coordinator
prepared the envelopes containing the computer-
generated allocation sequence. Detailed information on
the randomisation and recruitment process can be found
in the study protocol . The enrolment period was
from May 27, 2015, to December 15, 2017, while the 6
months follow-up was completed between December 5,
2015 and June 20, 2018.
First-time callers or callers with a washout period of at
least 1 year since last SAH contact, that were adults
(≥18 years) who spoke Swedish and sought help for at
least hazardous alcohol use were eligible to participate
in the trial. Hazardous alcohol use was identified by the
Alcohol Use Disorders Identification Test (AUDIT),
using a cut-off of 6 and 8 points or more for women and
men respectively . Clients were excluded if the
counsellor made the assessment that a caller required
referral to treatment for severe alcohol problems or if
the client reported the concurrent use of illicit drugs, or
the suffering from severe psychiatric conditions or other
acute health problems that required medical attention.
Further, counsellors refrained from informing clients
about the study if the overall assessment at the first call
indicated that clients were not able at that time to
understand the conditions for participation in the study.
Brief structured intervention
The brief structured intervention includes a self-help
booklet and one counsellor-initiated call (i.e. proactive).
The self-help booklet is based on CBT and provides a
step-by-step guide to change alcohol use. In brief, it aims
to increase motivation to change, initiate reflection, fa-
cilitate goal-setting and self-monitoring, and provide
Säfsten et al. BMC Psychiatry (2019) 19:213 Page 2 of 10
suggestions on how to build resistance skills. The self-
help booklet was delivered by e-mail or ordinary mail or
could be downloaded from a password-protected web-
site. Two weeks after dispatching the self-help booklet a
counsellor contacted the participant. The counselling in
the proactive call was based on a brief manual with the
focus of facilitating the use of the material. Counsellors
were asked to document the delivery of the proactive
call as 1) completed according to the manual, 2) com-
pleted with other content, i.e. usual MI counselling with
other focus than the material, or 3) not completed, i.e.
not rescheduled within 2 weeks from the first contact or
could not be reached after five attempts.
After the proactive call, no further contacts were initi-
ated by the counsellor. However, clients were not pro-
hibited from calling the SAH again if they felt the need
to do so. If additional contacts were initiated by the cli-
ent, usual counselling was provided.
The usual care at the SAH builds on MI with compo-
nents of CBT. The purpose is to promote clients motiv-
ation to change, develop resistance skills and prevent
relapses. The sessions vary in number, duration and
mode, (i.e. reactive or proactive), and is determined by
the counselling need of each client. The counselling is
tailored according to the stage of change of the client
(contemplation, preparation, action and maintenance).
In case of a fifth session the counsellor and the client
make a joint evaluation of whether the client has
reached his or her alcohol-related goals or if there is a
need for further support. When necessary either a max-
imum of two additional reactive calls may be offered or
the client is referred to a specialised treatment provider.
After each session the core content and the client’s
alcohol-related goals are registered in an electronic rec-
ord, to enable consistent counselling between sessions.
Data was collected by structured interviews at baseline
and at 6 months follow-up. At baseline, the interview
covered questions of demographics (sex, age, education,
employment, and living arrangements), and social sup-
port. Additional information included co-morbidity, in-
dicators of general health, and help-seeking for alcohol-
related problems (past 6 months). To screen for major
depressive episodes (MDE, past 2 weeks) and generalized
anxiety disorder (GAD, past 6 months), the measured
mental-health problems, two sections of the M.I.N.I.
(Mini-International Neuropsychiatric Interview M.I.N.I.)
were used [28,29]. Indicators of general health status
were: sick-leave during the past 6 months, and self-
assessed health, the latter measured by “How would you
rate your overall health status?”in which responses were
collapsed into three alternatives: ‘Very good to Good’,
‘Fair’,‘Bad to Very bad’). Motivation to change was
measured at baseline as it could be a predictor of the
outcome [31,32]. This was measured by the Readiness
to change ruler ranging from 0 to 10, where 10 defines
very high degree of readiness . At baseline, AUDIT
was primarily completed at the first call, since this scale
is usually administered at the SAH as an essential tool
for the diagnosis of the severity of alcohol problems. In
some cases when AUDIT was not completed at the first
call, it was administered in the subsequent baseline
interview. Data retrieved from the client record at the
helpline included AUDIT score at baseline and number
and length of calls. A call was considered a counselling
session if it lasted at least 5 min. AUDIT was re-
administrated at the 6-month follow-up interview. Inter-
viewers who performed the follow-up interviews were
blinded as to the participant’s experimental group.
Outcome definition and measures
Problematic alcohol use was measured by the Alcohol
Use Disorders Identification Test (AUDIT) . AUDIT
is a validated instrument, sensitive to problematic alco-
hol use in the lower end of the spectrum [33,34]. Risk
levels were based on cut-offs described in the Swedish
AUDIT manual: ‘low-risk use’(score 0–5 women; 0–7
men), ‘hazardous use’(score 6–13 women; 8–15 men),
‘harmful use’(score 14–17 women; 16–19 men), and
‘probable dependence’(score ≥18 women; ≥20 men)
. Further, the AUDIT-C was used to assess frequency
and quantity of drinking. This measure includes the first
three questions of the AUDIT instrument and has a
maximum score of 12.
The primary outcome was defined as any downward
shift in AUDIT risk level at 6 month follow-up, i.e. a
‘downward change in risk level compared to baseline’.
An upward shift or no change in risk level was defined
as ‘no downward change in risk level’. Secondary out-
come measures were: 1) change to low risk level accord-
ing to the AUDIT cut-offs, 2) mean change in the total
AUDIT score, and 3) mean change in AUDIT-C at 6-
month follow-up, this latter representing a measure of
current alcohol use.
The analysis was carried on as a modified intention-to-
treat analyses (ITT), i.e. participants with outcome infor-
mation at 6-month follow-up were analysed according
to their randomly allocated counselling model, irrespect-
ive of the counselling received. To assess the impact of
attrition a sensitivity analysis was performed assuming
that AUDIT risk level among those lost to follow-up did
Säfsten et al. BMC Psychiatry (2019) 19:213 Page 3 of 10
not change or was worsened as compared to their base-
line score; and by the last observation carried forward
(LOCF) scenario, i.e. assuming that participants lost to
follow-up did not change their baseline AUDIT score.
A descriptive analysis of the implementation of the two
counselling models was also conducted. Baseline charac-
teristics of participants in the two trial groups are pre-
sented as percentages for categorical variables and as
means and standard deviations (SD) for continuous vari-
ables. The distribution of selected characteristics at base-
line in the two trial groups was reviewed in order to assess
the success of the random assignment. We used general
linear models (GLM) as we did not adjust for any covari-
ates, assuming differences in baseline characteristics to
arise by chance. The treatment effect was estimated as risk
ratio (RR) using the probability of downward change in
AUDIT risk level as the outcome (pre-specified); as well
as risk difference (RD) and 95% confidence interval (CI).
Additionally, we estimated the risk ratio (RR) and 95%
confidence interval (CI) using the probability of change to
low risk level at follow-up as the outcome. Further, we
analysed the between-groups difference in the mean
change in AUDIT and AUDIT-C score from baseline to
follow-up using a t-test. The level of conventional
statistical significance was set to p= 0.05. All analyses
were performed using Stata 14.1.
In total 1796 first time callers were screened for eligibility
during the recruitment period (see Fig. 1). Of these, 816
met the eligibility criteria and were informed about the
study, and 320 (39% of the eligible) agreed to participate
and were randomised. Out of the randomised participants,
224 participants could be followed-up for outcome infor-
mation at 6-month. In the brief structured intervention
68% were retained while 72% were retained in usual care.
Participants with missing AUDIT score (n=2) or low-risk
use (n= 2) at baseline were excluded from further analysis.
Tabl e 1shows the baseline characteristics of retained
participants by trial group, as compared to those not
followed. The not followed participants tended to be
younger and employed. Additionally, the proportion
defined as ‘probably dependent’was higher among par-
ticipants lost to follow-up (66%) than among those who
completed the 6-month follow-up (49%), Table 2.
Tabl e 2shows that the trial groups were balanced at
baseline based on demographic characteristics with the
only exception being self-assessed general health, i.e.
Fig. 1 Flowchart over the recruitment, randomisation and follow-up
Säfsten et al. BMC Psychiatry (2019) 19:213 Page 4 of 10
good to excellent health was more frequently reported
in the brief structured intervention (71% vs 59%). The
readiness to change ruler (range 1–10), similarly indi-
cated high motivation in the two groups mean (sd);
brief structured intervention 9.3 (1.6) vs usual care 9.3
(1.2). About one-third of the sample displayed MDE or
GAD at baseline (brief structured intervention 27% vs
usual care 33%). AUDIT risk levels at baseline were
similar between the two groups. In the analytical sam-
ple it was defined as hazardous for 18% vs 21%, as
harmful for 33% vs 31% and as probable dependence
for 50% vs 48% of the participants in the brief struc-
tured intervention and usual care respectively. Add-
itional file 1display sociodemographic and health
related characteristics by trial group for the complete
In the brief structured intervention, 73% of the partici-
pants in the analytical sample received the proactive call ac-
cording to the protocol and 5% received a modified
proactive call. Among the retained participants, the mean
number (sd) of contacts recorded at the SAH was 1.8 (0.8)
in the brief structured intervention, and 3.4 (2.4) in usual
care. The time spent in counselling was on average 43 (26)
minutes in the brief structured intervention and 89 (76) mi-
nutes in the usual care.
In the group receiving the brief structured interven-
tion 68% displayed a downward shift in AUDIT risk level
at follow-up compared to 61% in the group receiving the
usual care, (Table 3). Consequently, the probability of
downward change was 12% higher in the brief structured
group than in the usual care group but the confidence
intervals included the null (RR 1.12, 95% CI 0.93 to
1.37). The mean decrease in AUDIT score was 7.9 in the
brief structured intervention and 7.1 in the usual care
group, with a between-group difference of 0.8 points
(95% CI −1.0 to 2.8) (Table 3). Regarding alcohol con-
sumption, the mean change in AUDIT C displayed no
between-group differences 0.2 (−0.5 to 0.9) (AUDIT C),
(Table 3). The proportion who changed to low-risk was
30% in the brief structured intervention and 26% in the
usual care (RR 1.17, 95% CI 0.76 to 1.78), (data not
shown in the table). In the total sample 8% (n= 19) were
abstainers at follow-up, and 6% (n= 13) had changed to
a higher risk level, with no difference between the
Since the attrition was similar in the two counselling
groups the risk ratio in the alternative scenario (i.e. lost
to follow-up did not change or was worsened as com-
pared to their baseline score) was close to that obtained
in the available case ITT analysis (RR 1.08; 95% CI 0.85
to 1.38). In the LOCF scenario, the mean difference be-
tween groups remained in the same direction as in the
ITT analysis in-between group difference 0.4 points (−
1.14 to 1.95).
Table 1 Sociodemographic characteristics at baseline of the followed participants by trial group, and the not followed participants
Brief structured intervention
Usual care n= 117 Total sample n= 224 Not followed
Age (mean, sd)
48.5 ± 13.9 49.7 ± 13.8 49.1 ± 13.8 45.6 ± 13.0
Sex, n (%)
Women 31 (29.0) 29 (24.8) 60 (26.8) 36 (37.5)
Men 76 (71.0) 88 (75.2) 164 (73.2) 60 (62.5)
Employment status, n (%)
Unemployed 26 (24.5) 37 (32.2) 63 (28.5) 13 (13.7)
Employed 80 (75.5) 78 (67.8) 158 (71.5) 82 (86.3)
Education, n (%)
Primary 12 (11.4) 9 (7.8) 21 (9.6) 9 (9.4)
Secondary 33 (31.4) 50 (43.5) 83 (37.7) 45 (46.9)
Post-secondary 60 (57.1) 56 (48.7) 116 (52.7) 42 (43.8)
Living arrangement, n (%)
Living alone (yes) 26 (24.3) 27 (23.1) 53 (23.7) 18 (18.8)
Cohabiting with partner (yes) 70 (65.4) 76 (65.0) 146 (65.2) 70 (72.9)
Living with children (yes) 42 (39.3) 33 (28.2) 75 (33.5) 39 (40.6)
Social support during crisis, n (%)
Always 3 (2.8) 7 (6.0) 10 (4.5) 9 (9.4)
Occasionally 23 (21.7) 33 (28.4) 56 (25.2) 23 (24.0)
Never 80 (75.5) 76 (65.5) 156 (70.3) 64 (66.7)
Numbers may not sum up to the total because of a few missing values
Säfsten et al. BMC Psychiatry (2019) 19:213 Page 5 of 10
Figure 2shows the proportion of downward, up-
ward and no change in AUDIT risk zones by baseline
risk level and intervention group. Hazardous users
were more likely to shift to low-risk use in the brief
structured intervention than in the usual care group,
while the proportion downward shift in harmful and
probable dependent risk levels was similar between
In this pragmatic trial of counselling at the SAH, there
was no evidence of superiority of either intervention
Table 3 Risk ratio and risk difference of transition to lower AUDIT category and change in AUDIT mean scores from baseline to 6
month follow-up, Intention to treat analysis (ITT)
AUDIT risk level at follow-up % Change in AUDIT risk level
n l II III IV % Risk ratio (95% CI) Risk difference (95% CI)
Brief structured intervention 107 29.9 40.2 13.1 16.8 68.2 1.12 (0.93 to 1.37) 0.08 (−0.05 to 0.20)
Usual care 117 25.6 40.2 14.5 19.7 60.7 Reference
n Baseline mean
Mean difference (95%CI) Mean difference between groups (95% CI)
Brief, structured intervention 107 19.7 (5.8) 11.7 (6.9) −7.9 (−9.3 to −6.4) 0.87 (−1.0 to 2.8)
Usual care 117 19.1 (5.7) 12.1 (7.3) −7.1 (−8.4 to −5.7)
AUDIT C score
Brief, structured intervention 107 7.8 (2.2) 5.0 (2.8) −2.8 (−3.3 to −2.3) 0.20 (−0.53 to 0.92)
Usual care 117 7.6 (2.0) 5.0 (2.8) −2.6 (−3.1 to −2.1)
AUDIT risk levels: I ‘low risk’II ‘hazardous III ‘harmful IV ‘probable dependence’
Table 2 Baseline AUDIT score and health-related characteristics of the followed (analytical sample) participants by trial group and
not followed participants
Brief structured intervention n= 107 Usual care n= 117 Total sample n= 224 Not followed n=96
mean (sd) 19.6 ± 5.2 19.1 ± 5.8 19.4 ± 5.5 20.9 ± 6.0
AUDIT risk level, n (%)
a, b, d
Low risk 0 0 0 2 (2.1)
Hazardous 19 (17.8) 25 (21.4) 44 (19.6) 13 (13.8)
Harmful 35 (32.7) 36 (30.8) 71 (31.7) 17 (18.1)
Probable dependence 53 (49.5) 56 (47.9) 109 (48.7) 62 (66.0)
Readiness ruler (1–10) mean (sd) 9.3 ± 1.6 9.3 ± 1.2 9.3 ± 1.4 9.6 ± 1.1
MDE & GAD, n (%)
28 (26.7) 38 (33.0) 66 (30.0) 35 (37.6)
Self-assessed health, n (%)
Very poor to poor 3 (2.8) 4 (3.4) 7 (3.1) 7 (7.3)
Fair 28 (26.2) 44 (37.6) 72 (32.1) 25 (26.0)
Good to excellent 76 (71.0) 69 (59.0) 145 (64.7) 64 (66.7)
Past 6-month sick-leave, n (%)
0–7 days 68 (80.0) 77 (88.5) 145 (84.3) 67 (78.8)
≥8 days 17 (20.0) 10 (11.5) 27 (15.7) 18 (21.2)
Past 6-month help-seeking for alcohol problems, n (%)
(yes) 12 (11.3) 17 (14.5) 29 (13.0) 19 (19.8)
Other care (yes) 7 (6.5) 10 (8.5) 17 (7.6) 14 (14.6)
Medication for alcohol dependence (yes) 5 (4.7) 9 (7.7) 14 (6.3) 9 (9.4)
Number may not sum up to the total because of a few missing values
AUDIT score (women; men) 1 (0–5; 0–7), 2 (6–13; 8–15) 3 (14–17; 16–19) 4 (18–40;20–40)
Major depressive episode and generalized anxiety disorder
n= 94, including baseline AUDIT scores below the threshold for hazardous use (n=2)
Säfsten et al. BMC Psychiatry (2019) 19:213 Page 6 of 10
(brief structured intervention or usual care) towards the
other. However, the results of the downward shift in
AUDIT risk level indicated a trend in favour of the
less labour intensive structured intervention. Both
groups in this trial reduced their AUDIT risk levels
indicating reductions in hazardous and harmful alco-
hol use over time. Overall, about 2/3 of the partici-
pants changed to a lower AUDIT risk level, and
about 1/3 changed to low-risk in the two counselling
groups at 6 months follow-up.
Population-based telephone helplines are nowadays
widely implemented for the counselling of problematic al-
cohol use. However, scientific evaluations of their potential
to change alcohol consumption are rare , and have
mainly described the services , or been observational
[24,35]. While the effectiveness of telephone counselling in
smoking cessation is well-documented , we found only
one comparable trial aiming to evaluate a population-based
telephone counselling for problematic alcohol use . In
contrast to our findings, Signor et al. found that brief MI
counselling was more effective than the control condition
(self-help booklet combined with brief advice) for abstin-
ence at 6 months follow-up (70% vs 41%). However, this
study suffered from high attrition (77%); also, the partici-
pants had severe alcohol problems at inception and often
reported the concurrent use of illicit drugs .
Our study indicated that a brief structured intervention
including a self-help material and one proactive call might
be as beneficial as the more counselling intensive counter-
part. Bibliotherapy is a recognised method to reduce alco-
hol consumption [37,38], especially when coupled with
feedback sessions [39,40]. However, a recent study found
no additional effects by adding MI telephone sessions to
bibliotherapy alone among self-referred problematic alco-
hol users, without severe dependence . In this study,
interventions led to similar reductions in alcohol use, with
constant improvements seen between post-treatment and
12 months. However, the sample size was small (n=111),
thus differences between groups may have not been de-
tected . With the exception of these studies, telephone
counselling for problematic alcohol use has primarily been
studied in RCTs of clinical populations identified by
screening interventions in healthcare settings including
participants with lower problem severity than among cli-
ents contacting the SAH [18,19].
There are several potential explanations of the null find-
ing in this study. First, the effect of the two counselling
models might truly be comparable. In fact, many clients
calling the SAH are likely to be highly motivated to change
their behaviour, and probably already started the process of
change before the first contact. Highly motivated individ-
uals may benefit from a structured intervention that offers
planning and support to implement personal strategies to
reach their goals. Second, at the initial contact, many partic-
ipants were screened for alcohol use and received assess-
ment feedback from a counsellor, which might have
enhanced motivation and thus constitute an active inter-
vention component per se. Thus, the effect might be due to
assessment reactivity rather than the added intervention
components [42,43]. Third, the low sample size may have
entailed low power to detect small differences between
groups as statistically significant.
Despite that the intended target population of the
SAH consists of problematic alcohol users at the lower
Fig. 2 Change in AUDIT risk level (%) between baseline and 6 month follow-up, by intervention group
Säfsten et al. BMC Psychiatry (2019) 19:213 Page 7 of 10
end of the spectrum , a high proportion of partici-
pants was classified as probably dependent at baseline,
reflecting the average level of problematic alcohol con-
sumption in SAH clients overall. Similar to previous
studies, the attrition was related to the severity of prob-
lematic drinking . This suggests that clients with
‘probable dependence’would benefit from other support
strategies than those offered at the helpline.
Strengths and limitations
The retention in this study was reasonably high com-
pared to previous studies in the field [16,45], with no
differential loss to follow-up between the two counsel-
ling groups. The similar retention between experimental
groups, besides reassuring about selection bias also sug-
gests that both counselling models were acceptable to
many of the SAH clients. The study protocol was imple-
mented as planned, and the delivery of the brief, struc-
tured intervention was ascertained by regular meetings
between the employees at SAH and the study team. Fur-
ther, the personnel conducting the interviews were not
part of the SAH and blinded to the client’s group assign-
ment. The random allocation was concealed.
Limitations of this study include the low recruitment
rate, as only 46% of first-time callers were assessed as
eligible. This was due to a “service-based”screening,
which left great freedom of decision to each counsellor
at the SAH. In fact, counsellors assessed the eligibility of
each caller not only based on the pre-defined criteria,
but also taking into account the complexity of the prob-
lem presented by the individual at the moment of the
call. For instance, clients who were too emotionally dis-
turbed at the time of the call, or who reported serious
social consequences of their drinking calling for immedi-
ate actions, such as involvement of minors were judged
unreceptive to questions about the study, therefore dis-
carded as not eligible. Of the eligible and only 39% par-
ticipated. Besides resulting in a small sample size, this
selection certainly limits the generalizability of the re-
sults. However, age and alcohol use profile of the partici-
pants in this study were comparable to those of the
overall SAH clients .
Some contamination of the experimental groups may
have occurred since the counsellors interacting with the
clients were the same in both groups. However, the aver-
age number and length of the sessions were substantially
higher in the usual care group, confirming that the brief,
structured intervention was less labour intensive, as ex-
pected. Additionally, the documentation of the content
in the proactive call did not indicate major deviations
from the study protocol. As in most trials of behavioural
modification the endpoints in this study rely on self-
reported data, thus are potentially prone to information
bias. However, the follow-up assessment was conducted
by interviewers not involved in the counselling, which
should at least limit the risk of socially desirable reports.
The main outcome measure AUDIT has traditionally
been scored as a three-factor screening instrument, how-
ever a review of studies support a two factor model; pat-
terns of intake/consumption (item 1–3) and alcohol
problems (item 4–9) . Therefore a change in the
AUDIT score may not necessarily depend on changes in
alcohol consumption, which is instead captured by the
AUDIT-C subscale. This was included as an additional
sensitivity analysis, yielding results in line with those ob-
tained from the complete AUDIT.
As this was a trial enrolling callers who sought help for
alcohol use at a well-established service, a no-treatment
control condition was considered unethical. Therefore,
the conclusions of this study apply to the model of the
counselling, and not to the effectiveness of the helpline in
comparison with other counselling settings or a no-
treatment control group.
A brief structured intervention did achieve favourable
changes in problematic alcohol use among clients of the
Swedish National Alcohol Helpline that were similar to
those of a more labour intensive MI-based telephone
counselling. Both approaches were followed by significant
changes in clients’AUDIT risk levels, comparable to the
effect of other interventions. The results suggest that both
approaches are feasible and acceptable for clients seeking
help at the helpline.
Additional file 1: Table S1. Baseline characteristics by trial group.
Table S2. Baseline AUDIT score and health-related characteristics by trial
group. Sociodemographic characteristics Baseline AUDIT score and
health-related characteristics of the participants at baseline by trial group,
total sample. (DOCX 17 kb)
AUDIT: Alcohol Use Disorders Identification Test; CBT: Cognitive behavioral
therapy; CI: Confidence interval; GAD: Generalized anxiety disorder;
M.I.N.I.: Mini-international neuropsychiatric interview; MDE: Major depressive
episodes; MI: Motivational Interviewing; RD: Risk difference; RR: Risk ratio;
SAH: Swedish National Alcohol Helpline; Sd: Standard deviation
We want to thank the counsellors at the Swedish National Alcohol helpline
for their effort in recruiting clients, as well as all the SAH clients who
participated in the study. Further, we would like to thank the former project
coordinator Suvi Virtanen for her great efforts at the study start-up.
MRG conceived and designed the study and critically revised the manuscript.
ES performed the statistical analyses, interpreted the data and drafted the
manuscript. YF, MR and KDT provided technical advice and participated in
the interpretation and the discussion of the results. All authors read and
approved the final version of the manuscript.
Säfsten et al. BMC Psychiatry (2019) 19:213 Page 8 of 10
The study was supported by the Public Health Agency of Sweden (grant No.
05576–2014-6.2), and SRA Systembolagets råd för alkoholforskning (grant No.
4–5/2018). The funders had no role in study design, data collection and
analysis, interpretation of data, writing of the manuscript or decision to
Availability of data and materials
The datasets generated and/or analysed during the current study are not
publicly available due to ethical reasons but are available from the
corresponding author on reasonable request.
Ethics approval and consent to participate
Ethical approval was permitted by the Ethical Review Board of the
Stockholm region (DNR 2014/1732–31/5). Consent to participate was
obtained verbally by interviewers. In order to respect the participant’s wish
to not disclose their contact with the helpline in their social environment,
and also in order to minimize non-response. The consent procedure was ap-
proved by the Ethical Review Board. All participants gave their consent to
Consent for publication
The authors declare that they have no competing interests.
Department of Public Health Sciences, Karolinska Institutet, 171 77
Centre for Epidemiology and Community Medicine,
Stockholm Health Care District, Stockholm County Council, 104 31
Department of Clinical Neuroscience, Karolinska
Institutet, 171 77 Stockholm, Sweden.
The Swedish Council for Information
on Alcohol and Other Drugs (CAN), 107 25 Stockholm, Sweden.
Received: 2 December 2018 Accepted: 25 June 2019
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