Title: Treatment of Comorbid Depression and Alcohol Use Disorders
1Treatment of Comorbid Depression and Alcohol Use
Disorders
- An Evidence-Based Approach
- Abby L. Goldstein, Ph.D.
2The 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
3The Question
- How would you proceed
- with treating this patient?
4Clinical 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?
5The 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
6Outcomes 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)
7DSM-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
8Diagnosing 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
9Practice 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
10Searching 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
11Reviewing 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
12Reviewing 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)
13Reviewing 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
14Reviewing 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
15Appraising 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
16Which 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
17Motivational 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