Comorbid Depression and Alcohol Dependence
Comorbid Depression and Alcohol Dependence
Patients who are seen in clinical practice commonly have multiple problems, yet efficacy data often reflect treatment of a single illness. Thus, it is useful to know how standard treatment approaches need to be modified for comorbid disorders. This article briefly describes prevalence, assessment, clinical features, and treatment of comorbid major depression and alcohol dependence.
Evidence from clinical treatment trials and changes made in the delivery of treatment from inpatient to outpatient settings bring into question the long-held view that patients with co-occurring depression and alcohol dependence must achieve abstinence from alcohol before treatment of depression can begin. Historically, there were good reasons for adhering to this view.
There are real concerns about medication interactions with alcohol in patients who were still drinking. Also, depressive symptoms can be brought on by excessive alcohol use, which makes it difficult to separate a substance-induced depression from an independent disorder of clinical depression. Traditionally, placing patients in 28-day inpatient settings, which helped patients abstain from alcohol, easily permitted an independent depressive disorder to be identified and treated. This practice is much less of an option in today’s US health care environment, and this has challenged us to rethink our clinical management of these patients.
Both major depression and alcohol dependence carry a significant risk for the development of the other. Severity in one disorder is associated with severity in the other.1-4 Moreover, alcohol dependence prolongs the course of depression, and persistent depression during abstinence from alcohol is a risk factor for relapse to heavy drinking.5-9 Thus, logic dictates that both disorders be identified and managed concurrently and aggressively. Integrated psychosocial outpatient treatment programs and the ability to treat alcohol and depression simultaneously have reinforced the need to revisit the traditional management of comorbid major depression and alcohol dependence more formally.
Prevalence
Recent estimates of the co-occurrence of these disorders in the general population are derived from the National Epidemiologic Survey on Alcohol and Related Conditions, a large-scale, nationally representative survey using DSM-IV diagnostic criteria.10 Data were collected on a sample of 43,093 adults (18 years and older) who were interviewed between 2001 and 2002 to determine lifetime and current (past 12 months) DSM-IV diagnoses. For those with a diagnosis of current alcohol dependence, the prevalence rate for an independent major depressive disorder was 20.5%. These alcohol-dependent individuals were 3.7 times more likely to have major depression than those without alcohol dependence. For those individuals with a current alcohol use disorder (abuse or dependence) who were seeking treatment, 40.7% had at least 1 current independent mood disorder.
What is already known about treating alcohol dependence and comorbid depression?
? Prevalence rates of co-occurring psychiatric and substance dependence disorders are formidable, and numerous reports describe individuals with both major depression and alcohol dependence as clinically more severely ill and more difficult to keep well than those who either are depressed or are alcohol-dependent. Over the past quarter of a century, results from well-controlled trials have demonstrated that antidepressant medications can reduce depressive symptoms in some persons who suffer from both major depression and alcohol dependence. However, the majority of these trials demonstrated that these medications had virtually no effect on reducing excessive drinking.
What new information does this article add?
? This article reports on a recently published controlled trial that indicated that the combination of a medication to treat alcohol dependence (eg, naltrexone) and an antidepressant (eg, sertraline) might be the optimal course of treatment for patients with co-occurring depression and alcohol dependence.
What are the implications for psychiatric practice?
? Combining a medication to treat alcohol dependence (eg, naltrexone) with an antidepressant (eg, sertraline) with some basic psychosocial support and advice for both disorders can provide an aggressive approach to treating patients with co-occurring depression and alcohol dependence.
"...This combined pharmacotherapy, with some platform counseling that integrates support and advice for both disorders, can provide an aggressive approach to treating co-occurring depression and alcohol dependence."
The efficacy of both drugs on their own for treating depression and alcohol abuse is rather weak. The authors give little credit to the effective therapy of motivational therapy combined with CBT on both alcohol abuse and depression.
Single drug abuse, especially just alcohol abuse, is rare in this culture. "Medical"and recreational use of marijuana is widespread and very rarely does one in actual clinical practice see a "pure alcoholic."
In my opinion the article is overly simplistic and as such not particularly helpful in clinical practice.
HI, I have been nursing since 1986 and it saddens me that we are still talking about treating dual diagnosis. This was a topic and an obvious solution for me since 1986. Why does practice still need to keep educating professionals of this importance. Why are systems still only treating the one at time. Holistic approach is not new. It makes me sad. I am tired of hearing "we are now going to treat both", "we are now going to set up a practice that includes both". Yet the system does not. I live in NS and it seems like things have gone backwards for those struggling with mental health issues and addiction issues.
The thinking on addiction, in general, was also dramatically altered with the successful use of suboxone for those with opiod addiction. The paradigm may shift, for some, to one of less use and less problematic use. Topirimate and 5Ht-3 antagonists also demonstrate promise in drinking reduction; Physical dependence is probably a different physiologic burdon in which complete abstinence would be essential.
Naltrexone reduces satisfaction by blocking opiod receptors. Drinking becomes less pleasurable long enough to get the reward mechanism retuned. It is not antabuse.
Consider the at risk drinker, say 4 solid cocktails a night, who has anxiety and issues of insomnia. There is no apnea or legal problems. Alcohol and benzos both target GABA neurons. Would a long acting benzo, say 1 mg of clonazepam, help control the insomnia and reduce the drinking or is there a greater risk of worsening the problem? Would the addition of topirimate, Mirtazapine, and naltrexone along with the benzo at night help reduce the risk of progression.
I deal with the medications not hammerring too hard on the booze. I see much more opiod dependence and combined substance use as Peter below has said. In contrast, I thought the article good. It brings to light the interconnectedness of the brain that by blocking opiod receptors, satisfaction is diminished from a gabanergic drug. A life of exclusion is difficult to imagine for any addict. The old model of "higher power" therapy must accomidate broadening scientific views. Addiction psychiatry is not easy, but one cannot really begin the pharmacology until the opiod issue is managed. Suboxone is a godsend and plugs in the gap.
I wonder what happens to alcohol use in those with comorbid addictions treated with an opiod partial agonist?
If it decreases, well, uh, just maybe suboxone...
PS
I meant to say it is difficult to determine medicine requirements long term until the opiod "hole" is plugged. Certainly one can and should do whatever appropriate in the short term.
Either bupripion or stimulant drugs in combination with naltrexone would make more sense from a physiologic standpoint for the treatment of depression in the active alcoholic than do TCAs or SSRIs..