New treatment strategy
We recently published the results of a double-blind, placebo-controlled, 14-week trial of 170 alcohol(Drug information on alcohol)-dependent patients with major depressive disorder. Two FDA-approved medications were evaluated, one for depression (sertraline) and one for alcohol dependence (naltrexone).22 An important aim of the study was to compare mood and drinking outcomes with the combined medications with those with placebo and with single-medication treatment. Patients received either 200 mg/d of sertraline(Drug information on sertraline), 100 mg/d of naltrexone(Drug information on naltrexone), a combination of the two, or a double placebo for 14 weeks while receiving weekly cognitive-behavioral therapy.
The sertraline-naltrexone combination produced a higher alcohol abstinence rate (53.7%; P = .001; odds ratio [OR] = 3.7) and a longer delay before relapse to heavy drinking (median delay, 98 days; P = .003; Cohen d = .54) than the other treatments: naltrexone (21.3% abstinent; delay, 29 days), sertraline (27.5% abstinent; delay, 23 days), or placebo (23.1% abstinent; delay, 26 days). A trend was also seen in the relief of depression symptoms in the medication combination group by the end of treatment (83.3% not depressed; P = .014; OR = 3.6) compared with the single-medication or placebo group.
The patients treated with an SSRI and an opiate antagonist achieved greater abstinence from alcohol, delayed relapse to heavy drinking, and relief of depression symptoms by the end of treatment than did patients who received naltrexone or sertraline alone or placebo. As with other initial findings from clinical trials, the results await replication in other settings with different patient populations and with other antidepressants.
Summary and future directions
Empirical data that support effective treatments for co-occurring depression and alcohol dependence are long overdue. Comorbid prevalence rates are formidable, and numerous reports describe patients with comorbid depression and alcohol dependence as clinically more severely ill and more difficult to keep well than patients who are either depressed or alcohol-dependent. Positive outcomes may depend on both the type and timing of the medication and psychosocial interventions needed to treat both disorders to symptom remission, as well as a solid doctor-patient relationship, attention to treatment compliance, and a commitment to treat both the alcohol dependence and the mood disorder.
While it seems logical to prescribe antidepressants for patients who are depressed, some alcohol-dependent patients—as well as some clinicians who treat them—are unwilling to use a medication. Fortunately, bias is fading as scientists learn more about treating the addicted brain with certain medications and correcting the neurobiology of addiction. Over the past 20 years, results from the majority of well-controlled trials have showed that antidepressants reduced depressive symptoms in patients with depression and alcohol dependence. However, in most of the trials, these medications had virtually no effect on reducing excessive drinking.
Recently published results of a controlled trial indicate that combining a medication to treat alcohol (naltrexone) with the antidepressant sertraline might be the optimal course of treatment for co-occurring depression and alcohol dependence.22 While these findings require replication, they provide a practical recommendation to integrate or combine 2 medications—1 for treating alcohol dependence and 1 for treating depression. 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.