Depression and Bipolar Disorders in Patients With Alcohol Use Disorders
Substance-induced depression also increases the risk for suicide. In 602 patients with substance dependence, depression was classified as occurring before dependence, during abstinence, or during substance use.13 Depression increased the risk for suicide in 34% of patients
who had already attempted suicide at least once. Compared with depression absent substance abuse, depression preceding substance use was associated with high vulnerability to additional psychopathology, depressive episodes that were more severe and greater in number, and more suicide attempts. Substance dependence predicted severity of suicidal intent, and abstinence predicted number of attempts.
Psychiatric hospitalizations often involve patients with a history of suicidal thinking or behavior and substance-induced depression. Clinicians can make reliable assessments of the degree to which a presenting psychiatric syndrome is substance-induced.14 These patients require addiction treatment, including outpatient addiction services capable of caring for suicidal persons. These individuals also are more likely to be homeless, unemployed, and uncooperative.15
Taking a psychiatric history and making a detailed inquiry into potential suicidal behavior, recent substance abuse, and current mood symptoms are warranted in persons with depression and/or SUD. Close follow-up is especially important for depressed patients likely to relapse into alcoholism soon after hospital discharge. Failure to recognize MDD or a bipolar disorder in such a patient may result in more relapses, recurrence of mood episodes, and elevated risk of completing suicide.16
Bipolar Clinical Considerations
There is a lack of clarity regarding the effect of moderate-to-excessive alcohol use on the course of bipolar disorders. There is a negative effect on patients with alcohol-induced bipolar depression. In a study of group therapy patients with bipolar disorder co-occurring with substance dependence, data indicated that number of days of alcohol use predicted development of depression a month later.17 These findings were associated with heavy alcohol consumption. In these patients, substantial drinking increased the risk of a depressive episode. In another study, comorbid SUDs were correlated with suboptimal treatment compliance.18 The authors of a 1998 literature review concluded that comorbid SUD makes bipolar symptoms more severe.19
A number of studies have failed to confirm a negative effect of alcohol on bipolar depression.20 There were no differences in 1-year course and outcome between bipolar patients with different alcohol use levels (abstinence, incidental use, moderate abuse, excessive consumption). Other investigators concluded that SUDs were not associated with slower recovery from depression but could contribute to a higher risk of switching to a manic, mixed, or hypomanic state.21
Substance use disorders are associated with increased suicidal behavior in people with a bipolar disorder. The risk of attempted suicide is about double for these patients relative to bipolar patients who do not abuse alcohol.22 Of those who abuse drugs, 14% to 16% complete suicide.23
Psychotherapy
Reportedly, integrated cognitive behavioral therapy (CBT) provided better substance abuse outcomes compared with 12-step programs.24 There also was less substance abuse within the year after CBT. Integrated psychosocial treatment for patients with a mood disorder and substance abuse should involve simultaneous treatment of the 2 conditions. A sequential approach addresses the primary concern and subsequently treats the comorbid disorder, whereas a parallel approach manages both at the same time but in different surroundings. In both approaches, conflicting therapeutic ideologies are a potential difficulty. Given the multiple treatment locations and separate appointments, scheduling problems are an additional difficulty. Coexisting illnesses also are important to consider in the clinical treatment for bipolar patients. As with individual treatments, group therapies take either a sequential approach (more acute disorder treated first) or a parallel approach (disorders treated simultaneously but in separate settings).
Integrated group therapy (IGT) considers patients as having a single diagnosis, focuses on commonalities between relapse and recovery, and reviews the relationship between both conditions. One study compared IGT and treatment as usual in subjects with comorbid bipolar and AUD.25 The IGT group evidenced fewer days of alcohol use. Other research compared IGT with group drug treatment and found that IGT subjects were more likely to remain abstinent.26 This type of psychotherapy showed promise in a meta-analysis of integrated treatment in patients with depression and SUDs.26
Compared with placebo, sertraline/CBT combined treatment reduced alcohol consumption on drinking days.27 This combination was effective in reducing depression, especially in females.
Acceptance and commitment therapy (ACT) combines mindfulness and behavioral change to increase psychological flexibility. The goal in ACT is for patients to become more accepting of their unpleasant feelings. In a study of alcohol abusers with affective disorders, those treated with ACT, compared with controls, had higher abstinence rates and lower depression scores.28
Phamacotherapy and Bipolar Disorder
Even when bipolar symptoms were resolved with use of mood-stabilizing medications, usually some alcohol use continued, though no association was found between bipolar disorder and AUDs.29 With patients’ illness severity and ethanol consumption rated weekly over 7 years, no temporal correlation was found between drinking alcohol and bipolar symptoms.
Similarly, in a study, relief of depressive bipolar symptoms did not result in less frequent alcohol relapse.30 One hundred fifteen outpatients with bipolar disorder and AUD were randomly assigned to either 12 weeks of quetiapine therapy or placebo. Patients in the quetiapine group experienced significant improvement in mood, but sobriety was not enhanced.
Two studies indicated trends of reduced drinking with use of prescribed alcohol-deterrent drugs. An investigation that compared naltrexone with placebo did not reach statistical significance, but naltrexone was reasonably effective in reducing alcohol consumption and craving.31 A report on patients with bipolar disorder treated with acamprosate also did not identify any significant differences in alcohol drinking prognosis.32 Nevertheless, acamprosate was well tolerated and seemed to confer some clinical benefit.
There is a paucity of research focused on patients with bipolar disorder and substance dependence.33 In one trial, patients with bipolar disorder and a diagnosis of alcohol dependence were randomly assigned to receive either valproate or placebo.34 Valproate therapy decreased the number of heavy consumption days and drinks per drinking day in these patients. In a study of 362 patients with bipolar disorder and alcohol dependence treated with lithium or valproic acid, there was no change in drinking days despite adding quetiapine to the regimen.35
Pharmacotherapy and Depression
Lithium is not effective for patients with MDD and AUD. Lithium treatment for depressed patients with alcohol dependence did not improve abstinence, alcohol-related hospitalizations, or severity of either condition.36
Aripiprazole is an antipsychotic that partially agonizes dopamine receptors. Dopamine implicates reward circuitry and has a role in AUDs. Aripiprazole was used as an adjunctive intervention in a randomized trial of 35 patients with comorbid alcohol dependence and depression.37 There was less depression in both the aripiprazole plus escitalopram group and the escitalopram group. Imaging showed a change in activity in the left cingulate gyrus in the patients with comorbid alcohol dependence and MDD. The action of aripiprazole may be mediated through the anterior cingulate cortex.
Research on patients with alcohol dependence treated with fluoxetine found decreased Hamilton Depression Rating Scale (HDRS) scores but no change in alcohol consumption.38
Sertraline diminishes depressive symptoms in abstinent alcoholics. In one study, depressed, recently abstinent alcohol users were randomly assigned to receive sertraline 100 mg daily or placebo.39 Significant improvement was noted in HDRS and Beck Depression Inventory scores at 3- and 6-week intervals.
