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.
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.
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.
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.
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.
Acknowledgment—We thank Amy Leshner for technical assistance.
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