Erin Knox, PharmD, BCPP, Director of Experiental Education
UCI School of Pharmacy & Pharmaceutical Sciences, Irvine, CA
“The relationship between depression and alcohol use is complex. Treatment of dual diagnosis patients is challenging.”
Dr. Dana Chiulli, Pharm.D., BCPP, began her informative presentation at CPNP’s 2021 Annual Meeting with this sobering introduction, preparing the audience for a review on this often difficult to treat patient population. She described her goal of helping participants develop a framework for treating the patient with depression and alcohol use disorder (AUD).
Prevalence of Major Depressive Disorder (MDD) with AUD is estimated to be 14.1% 1, emphasizing the high likelihood that psychiatric pharmacists will encounter patients requiring treatment for these co-occurring conditions. Dr. Chiulli described the complicated relationship between these disorders that share common risk factors and similar pathophysiology: AUD increases the risk for depressive disorders, and depressive disorders increase the risk of AUD. Compared to the general population, people with AUD are 2.3 times as likely to have alcohol dependence; people with alcohol dependence are 3.7 times as likely to have MDD in the previous year 2.
Various treatment modalities may be employed, though the best response is often seen with the integrated treatment approach, entailing one unified treatment team responsible for the management of AUD and depression in a single setting. This approach has demonstrated evidence for increased retention and decreased hospitalization rates, although access to this treatment type is limited for many patients3.
Pharmacological interventions have been studied with mixed results. Dr. Chiulli presented a meta-analysis demonstrating no significant reduction in alcohol use for patients with AUD and without MDD who were treated with antidepressants4. For patients with co-occurring AUD and MDD, studies have demonstrated differing results. In one study, early initiation of antidepressants decreased risk of relapse with alcohol 5, however other trials found no difference in alcohol use for patients treated with SSRIs 4,6.
Dr. Chiulli reviewed trials evaluating medication assisted treatment (MAT) for alcohol use disorder in patients with MDD. This pharmacological intervention led to decreased depression severity and fewer drinking days with more consecutive days of absence. This trial also found that patients with depression were 7.58 times more likely to become non-depressed if they were continuously abstinent from alcohol 7.
A trial evaluating sertraline and naltrexone with cognitive behavioral therapy (CBT) found the fewest reported adverse effects with sertraline combination with naltrexone. Compared to either pharmacological intervention alone, combination therapy led to the longest time to any alcohol use and longest time to first heavy drinking.8 Dr. Chiulli pointed out that patients treated for AUD and MDD may want to pursue non-pharmacological treatment; several of these interventions were reviewed, including CBT and relapse prevention therapy.
No specific treatment guidelines are published for these co-occurring disorders; antidepressants combined with MAT are generally accepted as the best option. Additional medication pearls were reviewed by Dr. Chiulli:
An important consideration is the risk for alcohol-medication-related interactions, including the lowered seizure threshold with bupropion and TCAs, as well as the potential for enhanced psychomotor impairment. Although worsened depression has been reported with naltrexone and acamprosate, Dr. Chiulli emphasized that this is not a precaution nor contraindication for use, rather use of these medications has demonstrated improvement in depression symptomatology.
To highlight considerations in treatment selection, Dr. Chiulli presented a patient case, employing audience polling and reviewing multiple touchpoints over time to describe the consideration that went into each treatment decision.
Take home points: