title: Estimating the efficacy of Alcoholics Anonymous without self-selection bias: an instrumental variables re-analysis of randomized clinical trials.
abstract: BACKGROUND
  Observational studies of Alcoholics Anonymous' (AA) effectiveness are vulnerable to self-selection bias because individuals choose whether or not to attend AA. The present study, therefore, employed an innovative statistical technique to derive a selection bias-free estimate of AA's impact.
  
  
  METHODS
  Six data sets from 5 National Institutes of Health-funded randomized trials (1 with 2 independent parallel arms) of AA facilitation interventions were analyzed using instrumental variables models. Alcohol-dependent individuals in one of the data sets (n = 774) were analyzed separately from the rest of sample (n = 1,582 individuals pooled from 5 data sets) because of heterogeneity in sample parameters. Randomization itself was used as the instrumental variable.
  
  
  RESULTS
  Randomization was a good instrument in both samples, effectively predicting increased AA attendance that could not be attributed to self-selection. In 5 of the 6 data sets, which were pooled for analysis, increased AA attendance that was attributable to randomization (i.e., free of self-selection bias) was effective at increasing days of abstinence at 3-month (B = 0.38, p = 0.001) and 15-month (B = 0.42, p = 0.04) follow-up. However, in the remaining data set, in which preexisting AA attendance was much higher, further increases in AA involvement caused by the randomly assigned facilitation intervention did not affect drinking outcome.
  
  
  CONCLUSIONS
  For most individuals seeking help for alcohol problems, increasing AA attendance leads to short- and long-term decreases in alcohol consumption that cannot be attributed to self-selection. However, for populations with high preexisting AA involvement, further increases in AA attendance may have little impact.
authors.affiliation: Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California; Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, California; Ci2i, VAPAHCS (152-MPD), Menlo Park, California.
authors.forename: Keith
authors.initials: K
authors.lastname: Humphreys
authors.forename: Janet C
authors.initials: JC
authors.lastname: Blodgett
authors.forename: Todd H
authors.initials: TH
authors.lastname: Wagner
mesh_terms: D000436:Alcoholics Anonymous; D000437:Alcoholism / Q000453:epidemiology* / Q000628:therapy; D006801:Humans; D016032:Randomized Controlled Trials as Topic / Q000379:methods / Q000592:standards* / Q000706:statistics & numerical data; D015983:Selection Bias; D012648:Self Care / Q000379:methods / Q000592:standards* / Q000706:statistics & numerical data; D013695:Temperance; D016896:Treatment Outcome
keywords: Alcoholics Anonymous; Mutual Help Groups; Research Methods; Self-Help; Treatment Outcome