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Alcohol hampers depression Tx. (Practical Psychopharmacology).

Many depressed patients use alcohol heavily, so effective treatment must address alcohol abuse, as well as depression.

In fact, the lifetime prevalence of alcohol dependence or abuse in depressed patients is double that of the general population.

Although the distinction often is made between "primary" depression, which precedes alcohol abuse, and "secondary" depression, which follows it chronologically, "from a clinical perspective, it doesn't make much difference. Both [forms] must be treated in concert," said Dr. Edgar P. Nace, clinical professor of psychiatry at the University of Texas, Dallas.

The comorbidity first must be diagnosed. Often, patients present with depression, and the extent of their drinking is unappreciated--at least until treatment fails. "One common reason that patients don't respond to antidepressants is an underlying, unrecognized alcohol or drug problem," said Dr. Ihsan M. Salloum, associate professor of psychiatry at the University of Pittsburgh. "Screening for alcohol and other substance use should be part of the initial work-up."

The standard recommendation--4 weeks of abstinence before depression in an alcohol-abusing patient is diagnosed and treated--often is shortened in practice. An argument can be made for starting treatment with antidepressants even before the patient stops drinking, especially if the mood disorder is severe and debilitating or suicidality is part of the picture, Dr. Salloum said.

Many of the newer antidepressants don't interact with alcohol, lessening safety concerns, and there are data suggesting that certain agents, notably selective serotonin reuptake inhibitors (SSRIs), may help patients reduce drinking as well, he said.

But whatever the sequence, treatment should emphasize alcohol abstinence. Studies have found that even "normal" use of alcohol--two drinks per day for men, one for women--lessens the efficacy of antidepressants and worsens depression, said Dr. Richard J. Frances, president and medical director of Silver Hill Hospital, New Canaan, Conn.

Treatment for depression largely follows the format used for patients who do not have problems with substance abuse; some allowances have to be made for side effect and compliance issues that may be particularly problematic.

This most often means an SSRI is the first-line choice. In the absence of suggestive prior experience with an antidepressant, "I would probably lean toward citalopram because it may have fewer side effects," Dr. Nace said. When insomnia is a problem, paroxetine or mirtazapine may be helpful, he added.

Anxiety often is prominent, particularly in the early days of abstinence. In this situation, Dr. Nace often starts with venlafaxine "I also have the sense that it works quicker for some people."

Dr. Salloum said he would tend toward paroxetine and mirtazapine for depressed, anxious patients, while Dr. Frances suggested the addition of buspirone.

The risk of seizures makes bupropion a less than optimum choice, but "I would not hesitate to use it if that's what works," and there is no personal or family seizure history, Dr. Nace said. He noted that the peak occurrence of alcohol-related seizures is 24-48 hours after the last drink.

Antidepressant dosing for this population may need to be more flexible than for patients who have uncomplicated depression. While a gradual titration schedule is advisable, a relatively high dose may ultimately be required, reflecting liver enzyme induction that can follow years of drinking, Dr. Salloum said.

Possible bipolarity should not be overlooked, particularly in patients who show significant mood lability, or "who relapse into drinking after a period of antidepressant therapy," which may reflect conversion to mania, Dr. Frances said. Family history and previous responses to antidepressants should be investigated closely. "These patients may be helped by a mood stabilizer"--lithium or an anticonvulsant, he said.

Adjunctive lithium, in particular, is worth considering for patients with a history of suicidality, Dr. Nace said.

Regardless of which depression treatment is chosen, substance use must be addressed as well. The two fronts complement each other: Not only does abstinence promote antidepressant efficacy, but a reduction in depressive symptoms facilitates cooperation with addiction treatment, enabling patients to make better use of psychosocial approaches, such as 12-step programs, Dr. Frances said.

While the antimedication bias once widespread in such programs has diminished considerably in recent decades, "there still are some sponsors who don't relate well to mentally ill patients," and patients may need help in seeking out a sponsor who is "sophisticated and understands that both addiction and depression can be brain diseases," he said.

Pharmacotherapy for addiction and depression can be concurrent. "I'd add naltrexone to an antidepressant if a patient is still drinking heavily," Dr. Salloum said. He is directing a randomized controlled trial of this approach, which has led to a significant reduction in alcohol use in small, open-label studies.

There appears to be no interaction or change in blood levels of either drug when they are used in combination, he said.

Dr. Nace noted that certain issues may come to the fore in the treatment of depression in this population. "It's important to keep up the morale of the patient," he said, describing a woman who discontinued medication, with unfortunate results. She was convinced that her depression represented a "character flaw" that would not afflict her if she more assiduously followed her 12-step program.

Psychoeducation about the biologic nature of depression may be particularly important with such patients, he said. Also, individuals who have abused alcohol or drugs for years may be desensitized to their emotions, and their subjective mood reports may be less revealing than their interactions with others. Collateral sources, such as a spouse, can be extremely helpful in tracking the course of the disorder and treatment response in these cases.

Patients with substance use problems are likely to require more time and attention than those with uncomplicated depression. "Psychiatrists should appreciate that they provide a holding environment through office contact ... and have the flexibility to see them more often or for longer than managed care might desire," he said.

A good cost-effectiveness case can be made that added contact reduces the risk of relapse, hospitalization, or the need for intensive outpatient programs. "I'm not getting any arguments from insurers if I want to see these patients more frequently," Dr. Nace said.
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Author:Sherman, Carl
Publication:Clinical Psychiatry News
Geographic Code:1USA
Date:May 1, 2002
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