Treating Adolescents With Major Depression and an Alcohol Use Disorder

TREATMENT
Psychotherapy studies

Some recent studies have suggested that several forms of psychotherapy may be promising in treating adolescent AUDs and other SUDs. These types of psychotherapy include several forms of family therapy, such as functional family therapy, multidimensional family therapy, multisystemic therapy, and the community reinforcement approach. Other promising forms of treatment in this population include motivational interviewing, cognitive-behavioral therapy, the 12-step approach, and contingency management reinforcement. However, the studies used in evaluating those therapies consisted primarily of patients without comorbidities, so their applicability to patient samples with comorbidities remains unclear.

A recent review of adolescent substance abuse treatment studies evaluated the effectiveness of 5 main psychotherapy treatment modalities: family-based and multisystemic intervention, behavioral therapy, cognitive-behavioral therapy, pharmacotherapy, and 12-step approaches.¹⁵ The authors concluded that the results of those studies looked promising for cognitive-behavioral therapy and family-based and multisystemic therapies for adolescents with SUDs but that various methodologic limitations made it difficult to evaluate whether one treatment approach is clearly more effective than another.

Similarly, Kaminer¹⁶ concluded that virtually no studies have documented the differential efficacy of various therapies for treating adolescent AUDs and other SUDs and that no clear optimal dosage or length of treatment has been identified. These conclusions also apply to adolescents with comorbidities, since far less treatment research has been conducted involving these adolescents than adolescents with AUDs or SUDs but without comorbidities.

To date, there have been no reported adequately powered randomized placebo-controlled trials comparing various pharmacotherapies for the treatment of adolescents with comorbid major depression and AUD. Only 3 studies have evaluated the efficacy of any SSRI antidepressant in adolescents with depression and AUDs or SUDs, and all of these have used fluoxetine(Drug information on fluoxetine) as the study drug.^11,17,18 In the study by Riggs and colleagues,¹⁷ patients displayed either cannabis abuse or cannabis dependence and conduct disorder in addition to an AUD and MDD. The study was an open-label trial involving 8 adolescent boys. All were treated with 20 mg/d of fluoxetine for 7 weeks. Of the 8 adolescents, 7 demonstrated marked improvement in depressive symptoms and wished to continue to take fluoxetine after the trial. The study was conducted in a residential treatment center, so the patients could not drink alcohol(Drug information on alcohol) or use substances. The authors of the study concluded that fluoxetine appeared to be safe and effective in treating adolescents with MDD and substance dependence.

A double-blind placebo-controlled study involving 126 adolescents with comorbidities was recently conducted by the same research group.¹⁹ The findings from that study showed that fluoxetine had a good safety profile in adolescents with comorbidities and that it had greater efficacy than placebo did in treating depression in adolescents with comorbid SUDs. At the end of the treatment trial, past 30-day drug use had decreased significantly in both treatment groups, but the difference between the treatment groups was not significant.

Our group conducted a pilot study of fluoxetine in adolescents with comorbid major depression and AUD.¹¹ The study included a 12-week acute-phase trial involving 13 patients and a 5-year follow-up study. Data from the acute-phase (12-week) trial suggest that fluoxetine may be promising for treating both the depressive symptoms and the excessive alcohol use of adolescents with comorbidities. No patients displayed side effects from fluoxetine, and none became hypomanic or manic during the treatment trial. Data at 1-, 3-, and 5-year follow-ups suggest that continued treatment is often needed to prevent recurrences of major depression. The promising results of these preliminary studies involving adolescents with comorbidities are consistent with the results of our previous double-blind placebo-controlled trials in adults with comorbidities.²⁰

Clark and colleagues²¹ demonstrated a 3-fold increase from 1991 to 2000 in the use of antidepressant medication in adolescents with comorbid AUD and MDD. These striking increases in the use of antidepressants among adolescents have occurred despite the lack of empiric evidence supporting or refuting the effectiveness of these medications for treating comorbid disorders in this age group.

Co-occurring disorders are the norm rather than the exception among adolescents with AUDs, and depressive disorders are the most common of the comorbid psychiatric disorders in adolescents. The use of medication for the treatment of this population has increased dramatically in the last 10 years, despite the relative paucity of empiric evidence regarding the safety and effectiveness of these treatments.

Available data in the adult literature are inadequate to fully assess the safety and efficacy of the various treatments of AUDs in combination with various comorbid disorders, and the data that are available are particularly lacking in information concerning adolescents with these dual diagnoses. This lack of data is particularly problematic because treatments that are effective for adults with comorbidities are not necessarily safe and effective for adolescents with comorbidities. Acute-phase studies and long-term follow-up studies are warranted to clarify the safety and efficacy of various psychotherapy and pharmacotherapy treatments for comorbid adolescents. The results of several ongoing studies by our group will become available in the next few years.

Unfortunately, no treatment recommendation can be made at this time. Currently, double-blind placebo-controlled studies are the only recognized basis on which to make recommendations concerning treatment. Clinical experience without double-blind placebo-controlled studies is not considered sufficient evidence for making treatment recommendations. To date, no double-blind placebo-controlled studies dealing with this topic have been completed and published.

Dr Cornelius is professor of psychiatry and pharmaceutical sciences, Dr Bukstein is associate professor of psychiatry, and Dr Clark is associate professor of psychiatry and pharmaceutical sciences in the department of psychiatry at the University of Pittsburgh School of Medicine. The authors report that they have no conflicts of interest regarding the subject matter of this article.