Alcohol use disorder: one of the most prevalent mental health disorders worldwide.
TALES FROM THE CLINIC
In this installment of Tales From the Clinic: The Art of Psychiatry, we discuss alcohol use disorder (AUD) with difficult relapses. AUD is one of the most prevalent mental health disorders worldwide. This discussion examines comorbidities and barriers to treatment.
“Ms Frank” is a young woman with a history of alcohol use disorder (AUD), cocaine use disorder, posttraumatic stress disorder (PTSD), and bipolar disorder who is receiving psychiatric care at an outpatient program. She has a severe trauma history that has never been fully discussed with a therapist or psychiatrist, despite years of treatment. She has chronic suicidal thoughts after multiple previous attempts by overdose. Suicidality is increased in times of intoxication, and suicidal thoughts have never completely gone away even with the switch to lithium. She has failed more than 15 medications and is often sensitive to adverse effects.
After a significant suicide attempt and inpatient rehabilitation for 90 days, Ms Frank achieved and maintained sobriety for almost 2 years before being put into a supervisory role at her sober living facility. Some of her duties included expelling individuals who had relapsed, including those who had become her friends. She felt that “everyone relapses, anyway” and “there’s no point,” and subsequently relapsed herself with successive suicide attempts and psychiatric hospitalizations. She has since regained sobriety and gone through another 30-day rehab program. She continues to have persistent suicidal thoughts and difficulty engaging with therapy. However, she has again achieved and maintained sobriety for more than a month with a medication regimen including naltrexone monthly injectable, which reportedly helped with her cravings. She previously tried and failed naltrexone by mouth, acamprosate, and disulfiram due to adverse effects. She regularly attends Alcoholics Anonymous meetings and therapy.
Ms Frank’s history is significant for a pervasive pattern of instability in personal relationships; impulsivity; affective instability; difficulty controlling anger; and recurrent suicidal behavior, gestures, and threats that may indicate an underlying cluster B personality disorder. As she deals with these issues, she maintains a close circle of friends and is able to maintain a consistent job.
The Most Prevalent Mental Health Disorder
AUD is known to be one of the most prevalent mental health disorders worldwide. As seen in Table 1,1 according to the 2019 National Survey on Drug Use and Health (NSDUH), 7.6% of men and 4.1% of women 18 years and older have AUD.1 As the prevalence of AUD cases has continued to rise, various methods of detection have been recommended. The Alcohol Use Disorder Identification Test (AUDIT) is recommended by the World Health Organization as a screening tool to detect alcohol problems. Different AUDIT scoring thresholds are required for men and women, as research has shown that AUD in women has distinctive social and biological characteristics.
For the same amount of alcohol, women develop a higher blood alcohol concentration than men. Therefore, the Centers for Disease Control and Prevention (CDC) provides distinctive cutoffs for alcohol use and binge drinking in women vs men (Table 22). Women are more susceptible to the toxic effects of alcohol such as cognitive disorders, heart disease, and liver cirrhosis. Women also differ in their approach to the health care system, which may influence their performance on self-reported screening tests.3 Women also often display a shorter trajectory from onset of alcohol use to when they receive a diagnosis of AUD. The prevalence of AUD has steadily increased in women, resulting in a narrower gender gap in AUD diagnoses.4 These are a few of the many reasons it is imperative to utilize a lower screening threshold when assessing female patients for AUD.
Treatment Options and Barriers to Care for AUDs
Despite the increasing prevalence of AUD and the multitude of services available, national surveys consistently demonstrate low utilization of treatments (Table 35). Gender disparities in the utilization of treatment are long-standing and significant. Women have approximately one-third to one-half the odds of utilizing treatment when compared with men.6 Fears of stigmatization and beliefs that treatment is ineffective seem to play a large role across the board. In a recent study, women were found to be more likely than men to report attitudinal barriers to treatment. These barriers consisted of shame, fear of others finding out, belief that no one can help, and belief that the problem is not serious enough.7 Because women are less likely to seek help, tailored interventions are warranted.
Although underutilized, effective and safe treatment for AUD is available through psychosocial and pharmacological interventions.8 The combination of pharmacotherapy and psychotherapy (cognitive behavioral therapy, individual and group drug counseling, motivational enhancement therapy, etc) has been found to enhance outcomes for AUD. Currently, the US Food and Drug Administration (FDA)-approved drugs for AUD include disulfiram, acamprosate, and naltrexone. Disulfiram acts by blocking the metabolism of alcohol leading to an accumulation of acetaldehyde, a toxic substance that results in tachycardia, headache, nausea, and vomiting after an individual consumes alcohol. Acamprosate has been associated with decreased craving and consumption of alcohol through agonist activity at γ-aminobutyric acid receptors and inhibitory activity at N-methyl-d-aspartate receptors. Naltrexone, available in oral formulation as well as long-acting injectable form, has been shown to decrease cravings and help prevent relapse through its action as an opioid antagonist.
Advances in addiction neurobiology have led to the development of the FDA-approved medications previously mentioned. However, substance abuse retail medication sales remain relatively small when considering the size of the population that could benefit. According to the 2019 NSDUH, approximately 7.3% of individuals 18 years and older with AUD received any treatment in the past year, and 0.3% of patients with AUD were prescribed an FDA-approved medication for AUD (Figure9).
Individuals with AUD are unlikely to initially seek help from specialty providers. The best chance of identifying AUD usually occurs within the primary care setting; however, the recognition of AUD remains low in such settings.10 Studies have identified reasons such as limited time, limited organizational capacity, fear of losing patients, and feelings of incompetency regarding treatment of AUD as potential barriers regarding identification of AUD in primary care.11 Within primary care settings, there is evidence to support the effectiveness of AUD screening, brief interventions, and referral to specialized treatment. However, the implementation of models for identifying and treating AUD in primary care remain inadequate.10 Effective treatment may be more widely utilized if measures are taken to increase primary care participation, destigmatize AUD, and address inaccurate attitudes about treatment efficacy.
Not only is AUD associated with many physical illnesses, but it also often occurs with other mental health disorders. Significant associations exist with other substance use disorders, major depressive disorder, generalized anxiety disorder, panic disorder, PTSD, bipolar disorder, specific phobias, and antisocial and borderline personality disorders. Comorbid psychiatric conditions in patients with AUD tend to lead to increased risk of suicide, lower rates of treatment retention, shorter period before relapse, greater number of hospital admissions, and overall poorer clinical course.12
When formulating treatment plans for patients with cooccurring disorders, it is imperative to determine the chronology of onset of the diseases. The clinical course tends to be determined by the primary diagnosis. Comorbidity has particularly important clinical implications in cases where psychiatric symptoms increase the risk for suicide. AUD in patients with depressive disorder is associated with increased suicidality.11 Personality traits that are often associated with increased risk for alcohol abuse (impulsivity, negative emotionality, and antagonism) are also characteristics of borderline personality disorder (BPD) and antisocial personality disorder (ASPD).13
Although these disorders are highly comorbid and result in poorer prognosis when they occur together, there are limited treatments that target the symptoms of both BPD and AUD. There is promising evidence that some anticonvulsants (eg, topiramate, lamotrigine) and second-generation antipsychotics (eg, aripiprazole, olanzapine) may reduce the anger, impulsivity, and mood lability present in BPD. Similarly, there are also studies suggesting that these same medications may also reduce alcohol craving and consumption.14 It should be noted that these medications are not FDA approved for BPD or AUD.
Modified psychotherapies (eg, dynamic deconstructive therapy, dialectical behavior therapy, dual focus schema therapy) have been developed for the treatment of comorbid AUD and BPD; however, there is limited evidence to support the efficacy of these modalities on treating symptoms of both disorders concurrently. Only dynamic deconstructive psychotherapy has been specifically tested on patients with both AUD and BPD. Evidence shows that although this therapy may be successful in treating symptoms of BPD, its efficacy in reducing alcohol consumption may not be sustained long term.
The efficacy of the other 2 models in the treatment of AUD has not yet been established.13 Due to the lack of sufficient evidence, psychotherapies for ASPD are limited.13 Although there is sparse evidence to support pharmacotherapy for ASPD, medications can be used to treat symptoms of the disease such as aggression and impulsivity.15
In order to effectively treat AUD, an awareness and utilization of evidence-based treatment options is imperative. Furthermore, barriers to seeking care in this particular population require special consideration when formulating treatment plans.
Dr Hanif is a PGY 3 general psychiatry resident at Menninger Department of Psychiatry and Behavioral Sciences at the Baylor College of Medicine in Houston, Texas. She plans to pursue a fellowship in forensic psychiatry after graduation. Dr Aldrich is a psychiatry resident at Baylor College of Medicine. Dr Parks is an addiction psychiatrist at Baylor College of Medicine and the Director of the Consult Liaison Psychiatry service at the Ben Taub General Hospital- Harris Health System- Houston, Texas.
1. 2019 National Survey on Drug Use and Health. Table 5.4B – Alcohol use disorder in past year among persons aged 12 or older, by age group and demographic characteristics: percentages, 2018 and 2019. Substance Abuse and Mental Health Services Administration. Accessed January 5, 2022. https://www.samhsa.gov/data/sites/default/files/reports/rpt29394/NSDUHDetailedTabs2019/NSDUHDetTabsSect5pe2019.htm
2. Alcohol use basics. Centers for Disease Control and Prevention. Updated December 30, 2019. Accessed January 5, 2022. https://www.cdc.gov/alcohol/fact-sheets.htm
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5. 2019 National Survey on Drug Use and Health. Table 5.11B – Received alcohol use treatment in past year among persons aged 12 or older, by age group and demographic characteristics: percentages, 2018 and 2019. Substance Abuse and Mental Health Services Administration. Accessed January 5, 2022. https://www.samhsa.gov/data/sites/default/files/reports/rpt29394/NSDUHDetailedTabs2019/NSDUHDetTabsSect5pe2019.htm
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