Similarly, in the absence of clear evidence of a long-term major anxiety disorder that predates the onset of alcoholism or that remains intense after an extended period of abstinence, few indications exist for using medications related to anxiety for alcoholics. Panic attacks that are likely to develop during alcohol withdrawal are also likely to diminish in frequency and intensity on their own without medications (Schuckit and Hesselbrock 1994). Because little evidence exists of an increased risk for obsessive-compulsive disorder among alcoholics, pharmacological treatments aimed at this severe anxiety condition also are inappropriate in the absence of additional evidence of an independent anxiety syndrome. Although more data are needed, at least one study indicates that buspirone, a medication useful for treating a general nervous condition called generalized anxiety disorder, may be helpful to some alcoholics, especially those with high levels of anxiety symptoms that persist after abstinence (Kranzler et al. 1994). In summary, none of the three types of studies conducted (i.e., family studies, prospective investigations, and studies involving COA’s) proves an absence of a relationship between long-term anxiety or depressive disorders and alcoholism. As briefly discussed earlier in this article, the family studies are far from definitive because of difficulties in the methodologies used.
The researchers concluded that the genetic influences important in alcoholism appear to be relatively specific for that disorder and did not significantly alter the risk for additional psychiatric disorders, including major depression and major anxiety disorders. Another twin study by Mullin and colleagues1 showed no increased risk for anxiety disorders in identical twins of alcoholics with the exception of conditions (e.g., anxiety) that might have resulted from the alcoholism in the person’s twin. This article briefly reviews some of the recent literature on the complex interaction between alcohol dependence and the longer lasting anxiety or depressive disorders. The interactions between alcoholism and these disorders are evaluated by posing a series of questions, and the reader is encouraged to review the articles cited in the reference list. In keeping with the guidelines of Alcohol Health & Research World, review articles are emphasized. Readers interested in more detailed descriptions of the methods of particular studies, however, are referred to specific citations within those reviews.
- Among people in treatment for DSM-IV AUD, almost 33% met criteria for major depressive disorder in the past year, and 11% met criteria for dysthymia.
- Conversely, the three types of studies highlighted in this section indicate that if an association between alcoholism and anxiety/depressive disorders does exist, it is likely to operate in a relatively small subgroup of alcoholics.
- Although the authors rightly point out the need for additional studies to provide more conclusive evidence, my opinion is that this systematic review and NMA shows that there is no high-grade evidence for the use of pharmacological treatments in patients with co-occurring alcohol use disorders and depressive disorders.
- Data from studies of depression indicate that the substantial variability in the symptoms presented reflects a heterogeneous pathophysiology,32 yet research on heterogeneity in co-occurring AUD and depressive disorders remains limited.
- As an open-access journal, ARCR will continue to be freely available to the public and the alcohol research community.
Medication trials
Finally, the etiology, course, and treatment of both AUD and depression differ substantially by gender. Women have been underrepresented in much of the research on co-occurring AUD and depressive disorders, particularly in the early research on this topic. The research needs more representation of women to increase understanding of the sex differences and to better characterize the mechanisms underlying women’s heightened vulnerability for depressive disorders.
In my opinion, it would also be reasonable to conduct sensitivity analyses excluding the pre-DSM-III studies and reporting the findings of the sensitivity analyses in Appendix Tables. In light of these reviews, I am afraid that we will not be able to accept the manuscript for publication in the journal in its current form, but we would like to consider a revised version that addresses the reviewers’ and editors’ comments. Obviously we cannot make any decision about publication until we have seen the revised manuscript and your response, and we plan to seek re-review by one or more of the reviewers. Given this complexity, clinicians must also consider alcohol-induced depression (AID), which can present similarly to MDD but typically resolves with sustained abstinence. After much consideration, NIAAA leadership and journal staff have made the decision that ARCR will transition to an online-only publication format in 2020.
Table 3. Summary of risks of bias across studies.
Easily grasped and intuitive terms such as “low, moderate and high confidence” allow the reader to easily understand the ratings. It would be helpful if the effect sizes (ORs and SMDs) were also contextualized in the same easily grasped language; e.g., small, medium and large. If the work is to be of value to the field, the reader should be able to more easily understand the size of the effects using intuitive anchors (again, small, medium or large) and, where possible, variable or person specific references (e.g., number needed to treat; NNT). It’s one thing to know how confident we should be in an effect and it’s another thing to know if the size of the effect is large enough to affect policy/practice. Only by considering these parameters together can policy and clinical decisions be made in an optimally informed way. Throughout the main text and appendix materials, the studies are identified by “Author Year”, but the studies themselves are not included in the list of eReferences.
Using a representative prospective study, we examine multiple aspects pertaining to MDD+AUD comorbidity, with a focus on the relation between disorders across periods (adolescence, early adulthood, adulthood) and cumulative impairments by age 30. As for depression co-existing with alcohol dependence, Jordans et al. 17 evaluated the use of psychotherapy combined with anti-depressants for patients with depression and alcohol dependence. They showed that psychotherapy addition would improve treatment success rates, especially when delivered by community-based counselors, after one year of follow-up.
Data Availability
However, Tables 1 & 2 seem to indicate that there were a number of (mostly pre-1980) studies included where ascertainment of AUD did not follow any version of the DSM (eg, Butterworth 1971, “alcoholic”; Zielinski 1979, “alcoholic”, etc.). It is also worth considering whether these pre-1980 studies that did not use structured diagnoses should also be excluded in sensitivity analyses (like the pre-DSM-III studies described above). Similar results have been generated from some, but not all, studies of alcoholism in relatives of patients with severe anxiety disorders. For example, an evaluation of 1,047 adult relatives of 193 subjects with severe anxiety disorders revealed no increased risk of alcohol use disorder and depressive disorders pmc alcoholism among the relatives, with the exception of the relatives of those patients who had exceptionally early onsets of their psychiatric disorders (Goldstein et al. 1994).
MeSH terms
- It is possible, however, that some of these studies might have excluded subjects with more severe anxiety or depressive disorders from the original samples, and consequently more work in this area is required (Kushner 1996).
- Co-occurring alcohol use disorder (AUD) and major depressive disorder (MDD) are prevalent and complex conditions in clinical practice.1 The bidirectional relationship between alcohol use and depression complicates diagnosis and treatment.
- These steps should be considered even if the patient’s depressive disorder is a relatively short-lived alcohol-induced state.
- Certain ongoing treatment studies also are further evaluating the potential usefulness of buspirone, some specific anti-depressants, and other medications that affect brain chemicals as potential components for treating alcoholism.
- Two pharmacological intervention studies (7%) reported data on 4 intervention classes, while no psychological intervention studies reported data on health-related quality of life.
- Further to this, the majority of studies included in the review had a length of treatment ≤ 12 weeks, restricting the interpretation of the results over the long term.
In light of these reviews, we will not be able to accept the manuscript for publication in the journal in its current form, but we would like to invite you to submit a revised version that addresses the reviewers’ and editors’ comments fully. You will appreciate that we cannot make a decision about publication until we have seen the revised manuscript and your response, and we expect to seek re-review by one or more of the reviewers. Between the other active treatments and placebo could be explained by insufficient study duration, insufficient power and by poor quality in the reporting of harmful effects or events. In my opinion, the findings of these sensitivity analyses can be reported in detail in Appendix Tables. R1 points out (comment #2) the limitations of aggregating findings across editions of the DSM. I am in agreement that this aggregation is problematic but feel less strongly that the solution is to exclude them.
Statistical analyses
The inclusion criteria were mentioning data on the outcomes of depression treatment in either SUD of different agents or alcohol dependence or both. Afterward, we evaluated references of the selected trials to identify any related articles. Finally, we gathered the required data sets from the final record of eligible articles and summarized.
Next, we selected data from eligible studies and then revised them through the Excel sheet. We reviewed any articles published by one research group investigating similar variables for any possible duplication. CBT, cognitive behavioral therapy; CI, confidence interval; IPT, interpersonal therapy; OR, odds ratio; SMS, self-management support.
Substance use disorder (SUD) is a condition that is prevalent in all age groups at all socio-economic levels 1. It has been defined as using a psychoactive agent, which results in high levels of stress and functional disabilities 2. It is also a contributor to a wide range of psychological and physical disorders, most commonly severe depression 3.
Figure 2. Overall and Gender-Specific Associations between MDD and AUD from Adolescence to Adulthood.
The authors conclude that the available evidence suggests potential benefits of TCAs (tricyclic antidepressants) for depressive symptoms, and SSRIs (selective serotonin reuptake inhibitors) for total drinking and functional status. Although the authors rightly point out the need for additional studies to provide more conclusive evidence, my opinion is that this systematic review and NMA shows that there is no high-grade evidence for the use of pharmacological treatments in patients with co-occurring alcohol use disorders and depressive disorders. Regarding psychological interventions, the available data provided by the review are very limited, which prevents any conclusion on the comparative effectiveness of these interventions to be drawn. We included parallel group (individually or cluster) randomized controlled trials (RCTs) only. Studies had to include adult participants (at least 50% were 18 years of age or older) with clinical diagnoses for both an AUD and depressive disorder according to Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Classification of Diseases (ICD) criteria.
They also review the challenges to effective treatment and emphasize the importance of treating of both conditions. In Alcohol Use Disorder and Schizophrenia or Schizoaffective Disorder, Archibald and colleagues explore schizophrenia spectrum disorders and their high co-occurrence with AUD. They describe how shared neurobiological mechanisms may explain the co-occurrence of these disorders. These authors suggest that combining pharmacologic interventions with other therapeutic modalities may address both issues more effectively.
These populations experience disparities in access to care for AUD and depressive disorders but are underrepresented in studies of these disorders. Future research that leverages novel technologies, such as ecological momentary assessment and multimodal neuroimaging, will enhance our understanding of the interactions between mood and alcohol use and how those interactions may influence the nature, course, and treatment of co-occurring AUD and depressive disorders. Assessment of co-occurring AUD and depressive disorders using dimensional measures rather than discrete, categorical measures will be critical to understanding the full spectrum of severity of these conditions, including subclinical presentations. Diagnoses of MDD and AUD, as well anxiety disorders, disruptive behavior disorders (DBD), and other substance use disorders (SUD; excluding tobacco dependence) were obtained from standardized diagnostic interviews.