Treatment of Comorbid Depression and Alcohol Use Disorders

1
Treatment of Comorbid Depression and Alcohol Use
Disorders

• An Evidence-Based Approach
• Abby L. Goldstein, Ph.D.

2
The Clinical Scenario

• 34 year old Caucasian woman presents with history
  of MDD, first episode in college, but no formal
  treatment
• Currently meets criteria for MDE
• During clinical interview, she reveals she is
  consuming 3-4 glasses of wine per day
• Started drinking in the past three months
• Has had 2 prior depressive episodes this is the
  first episode in which drinking is concurrent
• She is concerned about her depression, but does
  not feel her drinking is a problem
• Upon further inquiry, she notes that her husband
  has asked her to cut-down her drinking and that
  she drinks because it helps her feel better

3
The Question

• How would you proceed
• with treating this patient?

4
Clinical Questions

• Does she meet DSM-IV criteria for alcohol abuse?
  Is this at-risk drinking?
• Are antidepressants appropriate for comorbid
  alcohol abuse and MDD?
• Is psychotherapy appropriate?
• Should depression be treated in the context of
  alcohol abuse/use?

5
The Prevalence of AUDs Among Individuals with MDD

• Estimates of AUD diagnosis among individuals with
  MDD
• 21 current AUD diagnosis among community sample
  with MDD (Grant Hartford, 1995)
• 9 current AUD diagnosis among psychiatric sample
  (Salloum et al., 1995)
• Lifetime estimates range from 30 to 40

6
Outcomes Associated with Comorbid Depression and
AUDs

• Comorbidity associated with
• Higher rates of divorce and living alone
  (Sullivan, Fiellen, OConnor, 2005)
• Persistent depression increases risk of relapse,
  AUD prolongs course of depression, and
  comorbidity associated with greater utilization
  of health care resources (Pettinati, 2004)
• Increased risk of suicide (e.g., Conner
  Duberstein, 2004)

7
DSM-IV Substance Abuse(APA, 1994)

• Pattern of substance use leading to clinically
  significant impairment or distress
• One or more consequences within 12 months
• Failure to fulfill major role obligations
• Use in physically hazardous situations
• Recurrent substance-related legal problems
• Continued use despite persistent social or
  interpersonal problems
• Symptoms have not met criteria for dependence for
  this class of substances

8
Diagnosing Alcohol Abuse

• No specific quantity/frequency criteria for
  DSM-IV diagnosis of alcohol abuse
• NIAAA criteria for at-risk drinking
• Men gt14 drinks per week or gt4 drinks per occasion
• Women gt7 drinks per week or gt3 drinks per occasion

9
Practice Guidelines

• UMHS guidelines for depression treatment includes
  AUDs in the following ways
• Alcohol abuse identified as a risk factor for
  depression
• DO NOT USE
• Cymbalta if concurrent heavy alcohol use
• Wellbutrin if history of substance abuse (does
  not specify alcohol versus other)
• Ask CAGE questions
• Special Rx Considerations
• Address alcohol use to attempt to achieve period
  of sobriety
• If unable to achieve sobriety, treat with SSRI
• Be vigilant in assessing suicidal risk

10
Searching the Literature

• UM-MEDSEARCH
• Database All EBM Reviews
• Alcohol and (abuse or dependence) - 1573
• Major depression - 2235
• Antidepressant Medication - 314
• Combine 28
• Database Ovid Medline
• Limit EBM Reviews
• Alcohol and depress and treatment
• 44 Hits 3 recent reviews on treatment of
  depression and substance abuse disorders
• 1 identified as meeting CRD criteria and reviewed
• PSYCINFO
• Several additional reviews

11
Reviewing the EvidenceTorrens, Fonseca, Mateu,
Farre (2005)

• Systematic review and meta-analysis of SUDs with
  and without comorbid depression
• Only included randomized, double-blind,
  controlled trials
• 9 studies involving use of antidepressants for
  alcohol dependence and MDD met criteria for
  inclusion
• 5 had ns 20

12
Reviewing the EvidenceTorrens, Fonseca, Mateu,
Farre (2005)

• Improvement in depression
• 4 studies SSRIs (Overall OR 1.85, 95 CI
  0.73-4.68)
• 3 other antidepressants (Overall OR 4.15, 95
  CI 1.35-12.75)
• Reductions in drinking
• 3 studies SSRIs (Overall OR 0.93, 95 CI
  0.45-1.91)
• 3 other antidepressants (Overall OR 1.99, 95
  CI 0.78 5.08)

13
Reviewing the EvidenceNunes Levin (2004)

• Double-blind, RCTs with antidepressant vs.
  placebo groups - 8 involved AUDs
• Pooled effect size for HDS scores was 0.38
• Rates of depression response
• 52.1 for the antidepressant group
• 38.1 for the placebo group
• Examined several potential moderators of
  treatment outcome including placebo response,
  abstinence prior to treatment, gender,
  psychosocial intervention, type of antidepressant

14
Reviewing the EvidenceNunes Levin (2004)

• Conclusions Antidepressant medication exerted a
  modest beneficial effect for patients with
  combined depressive and substance use disorders
• Concurrent therapy targeting addiction is also
  indicated

15
Appraising the Evidence

• All studies used substance dependence as the
  criteria for entry what does this tell us about
  our patient?
• Very small sample sizes in many of the studies
  (e.g., ns 10 and 5 for the antidepressant and
  control groups, respectively)
• Differences in concurrent psychosocial
  interventions across groups (e.g., CBT vs.
  encouraged AA vs. inpatient) with lower effect
  sizes and higher placebo response in studies with
  manual guided interventions

16
Which Concurrent Therapies are Best?

• No studies of comparative effects of different
  psychotherapies for comorbid depression and AUDs
• Integrated interventions have demonstrated some
  efficacy for other psychiatric and SUD
  comorbidities although evidence is limited
• Using feasibility as a guide
• Largest study of psychosocial treatments for AUDs
  (project MATCH), brief MET as helpful as more
  intensive treatments

17
Motivational InterviewingBurke, Arkowitz, and
Menchola (2003)

• Review of 30 MI clinical trails 16 for alcohol
  use
• MI is superior when compared to no-treatment or
  placebo control and equivalent to other active
  treatments
• Average effect size across studies
• 0.25 frequency of consumption
• 0.53 blood alcohol concentration
• Clinical impact Reduced drinking by 56 from 36
  to 16 standard drinks per week
• Clinical utility prototypical study used 99
  minutes of MI
• Can be used as a prelude to treatment
• Briefer treatment can be combined with
  antidepressant and has been shown to be as
  effective as longer treatments

18
Whats Missing?

• Little research on alcohol abuse in the context
  of depression
• Research focus tends to be on primary AUD with
  secondary depression
• Several key questions remain
• Is any drinking okay for patients with MDD?
• How does any drinking impact pharmacological
  treatments?
• Psychotherapy outcome?
• Consistent with EBM approach, need to integrate
  research findings with clinical expertise