Comorbidity of mental disorders and substance use: a brief guide for the primary care clinician
5.4 Major clinical issues with depression and alcohol use
- Alcohol in large quantities has mood-depressant effects.
- A depression-like set of symptoms may emerge during or after alcohol withdrawal.
- In ideal circumstances, a period of abstinence should be trialled.
- Antidepressants are effective for the treatment of depression in those with alcohol-use disorders and have shown improvement in both depression and alcohol consumption.
- However, antidepressants are less effective in situations of continued heavy drinking or where depression is mainly alcohol induced.
- CBT in depressed alcohol dependent people is associated with decreased post-treatment alcohol use.
- Naltrexone or acamprosate can be used in combination with antidepressant medications and CBT.
5.4.1 Effect of alcohol on depression
- Heavy alcohol use(17) and alcohol dependence(16) are associated with high rates of depression.
- Women more commonly drink in response to primary depression(129).
- Alcohol in large quantities has mood depressant effects and may worsen depressed mood if it is part of a Major Depressive Episode or a transient state in response to a stressor. Depression and alcohol use are therefore associated with increased risk of suicide(16, 129-131).
- The course of alcohol dependence in people with alcohol-induced depression is more severe when compared to those with depression that is independent of alcohol dependence(129).
- A depression-like set of symptoms may emerge during or after alcohol withdrawal(132).
5.4.2 Interactions between alcohol and therapeutic agents for depression
- Alcohol can exacerbate the sedative effects of sedative antidepressants including tricyclics and mirtazepine used in the treatment of depression. Alcohol toxicity may occur through the inhibition of CYPs by antidepressants involved in the metabolism of alcoholx(133).
- Interactions between antidepressants and acamprosate used to treat alcohol dependence are minimal as are interactions between antidepressants and disulfiram and naltrexone, also used to treat alcohol dependencex(134).
5.4.3 Management approaches to comorbid depression and alcohol use
- In order to fully assess the extent of depression, in ideal circumstances, a period of abstinence from alcohol should be trialled. It is worth noting that depressive symptoms may emerge both during and after alcohol withdrawal(130, 135).
- Where it is not possible to trial a period of abstinence from alcohol, the use of antidepressants is indicated. However, antidepressants will be less effective in situations of continued heavy drinking or where depression is mainly alcohol induced.
- Antidepressants will be most effective in those people with primary depression:
- Antidepressant are effective for the treatment of depression in those with alcohol use disorders and have shown improvement in both depression and alcohol consumption***(130, 135-137).
- SSRIs (fluoxetine and sertraline) are particularly well tolerated***(130, 135, 136) and may pose less risk of increased sedation than other forms of antidepressants.
- Some studies of SSRIs used to treat alcohol dependent people have shown a worsening effect on alcohol consumption in certain subtypes, in particular those with early onset problem drinking***(138, 139). Therefore, monitoring is required.
- CBT in depressed alcohol-dependent people is associated with decreased post-treatment alcohol use**(140).
- Treatments primarily aimed at alcohol dependence (in combination with SSRIs) are more effective under heavy drinking circumstances or when depression is alcohol induced****(134, 141-143).
- Acamprosate and naltrexone are both effective in the management of alcohol dependence and maintaining abstinence****(141, 144).
- Naltrexone may be more effective in those with higher depression scores***(144).
- Naltrexone has been shown to be effective in reducing alcohol consumption in individuals who have been unable to abstain from alcohol consumption despite antidepressant treatment*(134).
- Naltrexone in combination with antidepressants has been shown to reduce the number of days in which alcohol is consumed while in treatment***(145).