Depression and Bipolar Disorders in Patients With Alcohol Use Disorders
Citalopram was studied in patients randomly assigned to receive citalopram or placebo for alcohol abuse or dependence.40 Patients in the citalopram group had more days of drinking and showed little change in frequency of alcohol consumption. There was no improvement in depression severity in the citalopram group relative to the placebo group. Citalopram also has been studied in combination with naltrexone.41 Patients with depression and alcohol dependence were randomly assigned to receive either citalopram or placebo, as well as naltrexone. There were no significant differences in depression severity or drinking outcomes.
Treating depression with selective serotonin reuptake inhibitors (SSRIs) had variable results. Most SSRIs improve depression severity but largely have no effect on drinking outcomes.
Antidepressants
A meta-analysis on the efficacy of antidepressant medications in treating patients with depression and substance abuse revealed that the antidepressants had a somewhat advantageous effect.42 That finding was supported by the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study.43 About 33% of patients with citalopramtreated major depression endorsed concurrent SUD symptoms, 19% reported diagnosable alcohol use, 6% had other drug abuses, and 5% exhibited both alcohol and drug use. The groups did not differ in time needed to attain a better mood or in rate of response to citalopram.
Patients with citalopram-treated MDD and alcohol or drug abuse responded about as well as those without an SUD. However, those with alcohol and/or drug abuse had reduced rates of remission, and their remission was delayed, as compared with those without alcohol or drug abuse. There were more suicide attempts and psychiatric hospitalizations among the cohort with drug abuse.
Selective serotonin reuptake inhibitors have a reported safety advantage in treating patients with a history of excessive alcohol intake.44 Another advantage is that SSRIs are seldom abused and seldom lower seizure thresholds significantly. Deleterious effects of alcohol on motor skills or cognition are not potentiated. Adverse effects are usually mild, and overdoses are rarely dangerous.
Antidepressant medication decreased depression and diminished the amount of drinking in patients with depression who use alcohol.45 In controlled research of patients with comorbid depression and alcohol dependence, fluoxetine reduced the severity of these conditions. Substantial reductions in depressive symptoms occurred during detoxification and washout in both groups. There was a strong relationship between depression and drinking among people with depression and AUD.
Desipramine can produce similar results, with positive antidepressant drug effects on depression and drinking. Therefore, pharmacotherapy is indicated for patients with depression who abuse ethanol. Research found that alcohol-dependent patients with depression responded to desipramine.46 Desipramine yielded prolonged abstinence in patients with depression who were using alcohol but not in alcohol users without depression.
A study of imipramine use in actively drinking outpatients found decreased alcohol consumption only for those whose depression responded to treatment.47 However, there was no influence on drinking outcome. Patients whose mood improved reported decreased alcohol consumption after imipramine therapy.
Conslusion
People with co-occurring depression and alcohol dependence are optimally treated with pharmacotherapies that address each condition. One investigation randomly assigned alcohol-dependent patients with depression to 14 weeks of treatment with sertraline 200 mg/d, naltrexone 100 mg/d, a combination of the drugs, or placebo.48 The combination treatment produced the best rate of abstinence before a heavy drinking relapse. Also, fewer patients tended to be depressed in the final weeks of treatment when prescribed the combined regimen. Pharmacotherapy is the best approach for both depression and AUDs.
