Comorbid Depression and Alcohol Dependence

New Approaches to Dual Therapy Challenges and Progress

By Helen M. Pettinati, PhD and William D. Dundon, PhD | June 9, 2011

Dr Pettinati is a Research Professor in the department of psychiatry and Division Director in the Center for Studies of Addiction and the Treatment Research Center at the University of Pennsylvania School of Medicine in Philadelphia. Dr Dundon is Director of Operations and Clinical Services in the Center for Studies of Addiction and the Treatment Research Center. Dr Pettinati reports that she receives research support from Alkermes, Inc. Dr Dundon reports no conflicts of interest concerning the subject matter of this article.

Diagnostic difficulties

Identifying the cause of the depression in individuals with alcohol(Drug information on alcohol) dependence has been thought to be important for determining the course of the disorder and the optimal treatment approach. For example, if the depressive symptoms are clearly related to alcohol use, then an antidepressant may not have any therapeutic impact beyond what abstinence would achieve. In some cases, depressive symptoms will spontaneously remit with abstinence from alcohol. In such cases, antidepressant pharmacotherapy may be an unnecessary cost and may be burdensome to the patient. However, it is often difficult to distinguish a substance-induced depression from major depression in the presence of alcohol dependence because the clinical symptoms of a substance-induced depression can appear identical to those seen in major depression.

Prolonged abstinence from alcohol can be of great value in making a distinction. Indeed, Brown and Schuckit¹¹ demonstrated a significant drop in depressive symptoms for those with primary alcohol dependence who completed a 4-week inpatient program. Nonetheless, many patients have difficulty in abstaining from alcohol during outpatient treatment and eventually may drop out of treatment because of continued drinking and/or deepening depression. To this point, Greenfield and colleagues¹² demonstrated that untreated depression—whether primary or secondary—predicted worse drinking outcomes. Finally, while depression may precede or be precipitated by alcohol dependence, implying causation, there may be common risk factors for depression and for alcohol dependence. These include stressful events, psychological trauma, and genetic vulnerability that lead to co-occurring expression, without one disorder causing the other.

DSM-IV-TR distinguishes between major and substance-induced depressive episodes and related disorders. For a depressive episode to be considered substance-induced, the depressed mood and/or diminished interest and pleasure must occur during (or within 1 month of) periods of intoxication or withdrawal and symptoms cannot be better explained by an independent mood disorder. A careful history can help make the differential diagnosis.

The following scenarios strongly suggest an independent mood disorder (eg, major depression):

• The mood disturbance precedes alcohol use

• The mood disturbance persists following prolonged abstinence (at least 1 month)

• Depressive symptoms occur in excess of those typically seen considering the quantity and frequency of alcohol consumption

Several large studies that carefully assessed DSM-IV criteria have shown that the prevalence of primary, independent depressive disorders (eg, major depression) are more common than substance-induced disorders in individuals with alcohol use disorders.^10,13 Furthermore, women who are alcohol-dependent and depressed are more likely to have an independent mood disorder than a substance-induced disorder.¹³

Today in the United States, alcohol dependence is almost always treated in an outpatient setting, where continued drinking and poor treatment attendance can be major obstacles to observing periods of abstinence. Clinicians are typically expected to decide how to treat depression in patients who are actively drinking, without benefit of observing that patient during an extended period of abstinence. Interview techniques that have been developed to help clinicians determine the origin of a patient’s depression have demonstrated reliability and validity in academic settings.^14-16 However, little is known of the utility of these techniques in general practice.

Further studies are needed to elucidate a way to make accurate diagnoses of major depressive disorder and substance-induced depression in the presence of current alcohol dependence. It would be beneficial to know precisely under what conditions antidepressant therapy would yield optimal outcomes for treating comorbid depression and alcohol dependence.

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by Chevies Newman | October 26, 2012 9:53 PM EDT

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.

by Chevies Newman | October 26, 2012 9:46 PM EDT

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...

by Karen Fowler | October 24, 2012 8:04 AM EDT

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.

by Peter Weiser | October 18, 2012 10:48 AM EDT

"...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.

by Barrie March | October 11, 2011 11:32 AM EDT

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..

Also in this Special Report

Introduction: Comorbidity, Cognition, and Pharmacotherapies

Combined Pharmacotherapies and Behavioral Interventions for Alcohol Dependence

Novel Therapies for Cognitive Dysfunction Secondary to Substance Abuse

Comorbid Depression and Alcohol Dependence

Comorbid Depression and Alcohol Dependence

New Approaches to Dual Therapy Challenges and Progress

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