Psychosocial treatment for major depression and alcohol(Drug information on alcohol) dependence
There have been 3 approaches to psychosocial interventions for treating comorbid disorders:
• Sequential: treating the primary disorder initially, followed by treating the other disorder
• Parallel: treating both disorders at the same time but in different settings
• Integrated: simultaneously treating both disorders
Although research and experience have been limited, integrated approaches have been shown to be superior to other approaches.17 Hesse18 identified only 5 randomized clinical trials that focused on the treatment of comorbid substance abuse and depressive disorders: those trials showed that integrated treatment programs had statistically superior alcohol and drug outcomes compared with addiction treatment only. Measures of depression outcomes and treatment retention also appeared to favor integrated treatment programs, although these results did not reach statistical significance.
Research has been sparse on integrated psychosocial approaches and even less information is available on how to use pharmacotherapy for co-occurring major depression and alcohol dependence. Moreover, no evidence-based guide exists on how to integrate psychosocial and pharmacotherapy approaches in depressed alcohol-dependent patients. Major depression is generally responsive to pharmacological treatment, and antidepressants can be lifesaving for individuals at risk for suicide. However, studies that supported FDA approvals for these antidepressants typically excluded patients with comorbid alcohol dependence. Thus, the depression literature does not adequately address questions such as: Are antidepressants actually effective for reducing depressive symptoms in this patient population? Will antidepressants help reduce alcohol drinking, either directly or indirectly, by reducing depression? Would an antialcohol medication, singly or in combination with an antidepressant, reduce clinical symptoms for either or both disorders?
Historically, long-term drinkers were denied medications (except for detoxification) because of long-standing stigmas about alcohol-dependent patients taking any medications (“treating a drug with a drug”). Fortunately, this attitude is fading as scientists impart knowledge to professionals and the public about the possibilities of correcting the neurobiology of addiction by treating the addicted brain with certain medications. In addition, there are legitimate safety concerns about the potential interaction of medications with alcohol, or the potential for antidepressant overdose in depressed intoxicated patients.
The advent of SSRIs, many of which are FDA-approved, mitigated many of the safety concerns about depressed alcohol-dependent patients taking antidepressants. If a patient drinks alcohol or feels suicidal, SSRIs are better tolerated and are generally thought to be safer than, for example, tricyclic antidepressants (TCAs). In addition, the frequency of adverse effects is relatively low and the severity of most ad-verse effects is mild or moderate. Investigators have been more willing to examine the efficacy of SSRIs in alcohol-dependent patients, and clinicians have been more likely to prescribe SSRI medications than drugs in other classes for depression in alcohol-dependent patients because of the safety profile of these agents.
The Table summarizes the results of recent, well-controlled, double-blind, placebo-controlled studies of pharmacotherapies for comorbid depression and alcohol dependence. Typically, these trials have provided antidepressant medication and some form of weekly psychosocial treatment or counseling. (See also earlier reviews by Nunes and Levin19 and Pettinati.20)
Six of the 9 studies (67%) that compared an antidepressant medication with placebo found a relationship between the medication and reductions in depressive symptoms, irrespective of type of antidepressant (eg, TCAs, SSRIs). Only 3 of the 9 studies (33%) found an advantage for the medication over placebo in reducing drinking in depressed alcohol-dependent patients. In the largest (N = 345) multicenter trial of sertraline(Drug information on sertraline) (50 to 150 mg/d for 10 weeks), the drug provided no advantage over placebo in reducing depressive symptoms, nor did it reduce drinking, compared with placebo.21 Because of this trial’s size, the results challenged those of all the other trials, indicating that antidepressants alleviate depression in depressed patients with alcohol dependence.