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Comorbidity of mental disorders and substance use: a brief guide for the primary care clinician

6.4 Major clinical issues with anxiety disorders and alcohol use

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• Alcohol use and anxiety disorders frequently co-occur and exacerbate each other.
• Individuals should be encouraged to reduce or cease alcohol use so that anxiety symptoms can be better evaluated.
• Anxiety associated with alcohol withdrawal should be allowed to subside, before making a diagnosis of anxiety disorder.
• However, anxiety may be a feature of the post-withdrawal state lasting for several months (up to 12 months).
• SSRIs are also effective in alcohol dependent people with anxiety.
• CBT should be given prior consideration over benzodiazepine therapy.
• Disulfiram, naltrexone and acamprosate used to treat alcohol dependence are unlikely to interact with antidepressants if these are being used.
• Acamprosate, naltrexone and benzodiazepines do not appear to interact with one another.
• Successful treatment of either anxiety or alcohol use disorder with CBT does not necessarily result in a positive outcome for the accompanying comorbid disorder.
• Pharmacotherapies such as naltrexone, acamprosate and disulfram are effective in the management of alcohol dependence and maintaining abstinence and are effective in individuals with comorbid anxiety.

6.4.1 Effects of alcohol on anxiety disorders

• Alcohol use and anxiety disorders frequently co-occur(^{10, 18-23)}.
• Problematic alcohol use and anxiety exacerbate each other, leading to increased severity of both the anxiety disorder and alcohol use⁽²²⁶⁾.
• The short-term relief in symptoms that alcohol gives people with anxiety is a strong motivator for continued alcohol use^{(10, 18, 22, 226)}.
• However, as dependence develops, this ultimately leads to increased anxiety:
  • Alcohol withdrawal produces anxiety.
  • Excessive alcohol use can result in environmental situations or disruptions that cause anxiety⁽²²⁶⁾.
• Higher anxiety sensitivity (people with increased levels of sensitivity to anxiety who do not have a diagnosable anxiety disorder) is highly predictive of alcohol use disorders⁽²²⁷⁾.
• Higher levels of anxiety are more indicative of relapse to drinking alcohol⁽²²⁸⁾.

6.4.2 Interactions between alcohol and therapeutic agents for anxiety disorders

• Alcohol can exacerbate the sedative effects of any sedative agents (including tricyclic antidepressants, mirtazepine, and benzodiazepines used in the treatment of anxiety^x.
• Alcohol toxicity may occur through:
  • The inhibition of CYPs by sedative antidepressant involved in the metabolism of alcohol⁽¹³³⁾.
  • An increase in sedation as a result of combinations of alcohol and benzodiazepines?.
• Disulfiram used to treat alcohol dependence will increase the plasma concentrations of diazepam leading to possible increases in sedation and overdose^x.
• Disulfiram, naltrexone and acamprosate used to treat alcohol dependence are unlikely to interact with antidepressants if these are being used^x(229).
• Acamprosate, naltrexone and benzodiazepines do not appear to interact with one another^x(230).

6.4.3 Management approaches to comorbid anxiety disorders and alcohol use

• Due to the anxiety-provoking effect of alcohol, and vice versa, individuals should be encouraged to reduce or cease alcohol use so that anxiety symptoms can be better evaluated⁽²²⁶⁾.
• Clinicians should allow sufficient time for anxiety associated with alcohol withdrawal to subside, before making a diagnosis of anxiety disorder^{(226, 231)}.
• However, anxiety may be a feature of the post-withdrawal state lasting for several months (up to 12 months).
• If large quantities of alcohol are being consumed, then inpatient withdrawal or detoxification with benzodiazepines should always be considered to avoid and manage seizure risk. Concerns about benzodiazepine dependence should not prevent controlled prescribing for withdrawal states.
• Benzodiazepine use should be monitored and minimised as those with substance use disorders are at a greater risk of abusing benzodiazepines⁽¹⁹⁶⁾.
• Successful treatment of either anxiety or alcohol use disorder with CBT does not necessarily result in a positive outcome for the accompanying comorbid disorder***⁽²³¹⁾. That is outcomes for the two sets of problems are somewhat independent. However, CBT can be effective in:
  • Improving alcohol-related outcomes in people with anxiety and alcohol dependence and is more effective in those who drink less***^{(226, 231, 232)}.
  • Reducing symptoms of anxiety****^{(196, 202)} in those with additional alcohol-related problems***⁽²³¹⁾. CBT should be given prior consideration over benzodiazepine therapy.
• SSRIs may be effective in reducing anxiety****^(205-218).
• SSRIs are also effective in alcohol dependent people with anxiety***⁽²³³⁾ in situations where behavioural therapy is not possible or unsuccessful.
• Consistent with the situation with depression and alcohol dependence, SSRIs may even improve drinking outcomes in those with less severe alcohol dependence^{(220, 234)}.
• However, 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)} and therefore requires monitoring.
• Pharmacotherapies such as naltrexone, acamprosate and disulfram are effective in the management of alcohol dependence and maintaining abstinence, and are effective in individuals with comorbid anxiety****^{(141, 144, 235-237)}.

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