Depression and Alcoholism , A Lethal Mix

Depression and alcohol dependence are two common disorders that frequently coexist. As a result, sorting out the various symptoms of each disorder and determining whether the symptoms of one are caused by the other often prove difficult. In turn, this uncertainty hampers decision making concerning treatment. In his review of current knowledge relating to this important issue, Dr Sawyer pointed out that progress is being made in understanding how these two disorders interact and that the data now available provide at least some basis for guiding treatment when alcoholism is the presenting disorder.

Current research generally supports the notion that when a patient with mild to moderate depressive symptoms and no history of depression begins treatment of alcohol dependence, adoption of a posture of watchful waiting is a better approach than immediate antidepressant therapy. In many heavy drinkers, depressive symptoms relent within 1 to 3 weeks after abstinence has been established. This wait-and-see approach has the advantages of minimizing unneeded treatment of depression and giving the patient a clearer message that drinking is the major problem to be dealt with. It would be a mistake, however, to adopt this approach too rigidly, since many questions about its application remain unanswered.

One of the most influential advocates of the wait-and-see approach is Dr Marc A. Schuckit, who has done some excellent work in this area. His studies, though, have focused only on male veterans who, after careful screening to exclude anyone with a significant mental health history, are admitted to an inpatient alcohol rehabilitation unit for 4 weeks. In these "primary alcoholics," depression has almost always cleared within 2 weeks, but this finding cannot be generalized to women or patients with a history of mental health problems. Work by other investigators suggests that up to one half of all women who enter a treatment program for substance abuse may have major depression. Further, relatively little is known about how depressive symptoms in outpatients and persons with multiple dependencies or a history of mental disorders react to treatment.

The fact remains that each patient’s symptoms must be evaluated and treated on an individual basis. Antidepressant therapy needs to be started sooner than 3 weeks after detoxification in alcoholics with severe symptoms of depression, suicidal ideation, or a history of depression. Compared with tricyclic antidepressants, the newer antidepressants are much safer in terms of overdose and generally do not interact with alcohol, so prescribing them carries less risk.

As Dr Sawyer noted, underrecognition and undertreatment of both depression and alcoholism are significant problems. Because of the strong inclination on the part of many physicians not to prescribe any psychotropic agent for substance-dependent patients, the risk of undertreatment of depression in alcoholics may be as real as that of overtreatment. Untreated depression is likely to undermine efforts to achieve and maintain abstinence from alcohol, resulting in overall poor outcome.

Much less is known about identifying and treating heavy drinkers when depression is the presenting problem. The National Institute of Mental Health Collaborative Depression Study clearly showed that depression does not respond to treatment in patients who are heavy drinkers.1 Therefore, aggressive treatment of alcoholism is as essential to improvement of mood in depressed patients as treatment of depression is to achievement of abstinence in alcoholics. Much more work needs to be done in this area.

When heavy drinking and depression coexist, the risk of suicide is very high, especially in unmarried or separated older white men. Treatment of either disorder alone, without therapy for the other, is ineffective. Thus, psychiatrists and other mental health professionals, chemical dependency professionals, and primary care providers must be alert to this deadly mix and respond aggressively whenever it is identified. Both disorders must be treated wherever they are encountered, whether in alcoholism treatment programs, mental health programs, or primary care clinics.

Mark L. Willenbring, MD
Director, addictive disorders section
Minneapolis Veterans Affairs Medical Center
Associate professor of psychiatry
University of Minnesota Medical School
Minneapolis

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