Five-year course of major depression: effects of comorbid alcoholism

The AUDIT-C: screening for alcohol use disorders and risk drinking in the presence of other psychiatric disorders

This article examines the performance of the AUDIT-C, as embedded in a large national survey, as a screener for alcohol use disorders (AUDs) and risk drinking among individuals with past-year psychopathology. The analysis is based on data collected in personal interviews from a representative population sample of US adults. The study population consisted of past-year drinkers with any past-year mood disorder (n = 2818), any past-year anxiety disorder (n = 3173), or any personality disorder (n = 4389). Screening performance was evaluated by means of sensitivity, specificity, and areas under receiver operating characteristic curves (AUCs). The AUCs for the AUDIT-C were from 0.888 to 0.893 for alcohol dependence, from 0.864 to 0.876 for any AUD, and from 0.941 to 0.951 for any AUD or risk drinking-all on a par with those observed in the general population. Among men, cut points of either > or =5 or > or =6 points (the former favoring sensitivity and the latter favoring specificity) were optimal for detecting dependence, and cut points of > or =5 points were optimal for any AUD and for any AUD or risk drinking. Among women, a cut point of > or =4 points was optimal for the outcomes of both alcohol dependence and any AUD, whereas a cut point of > or =3 points was preferable for detecting any AUD or risk drinking.

Adolescents, substance abuse, and the treatment of insomnia and daytime sleepiness

Adolescence is a time of change that can be both exciting and stressful. In this review, we focus on the central role that disturbed sleep and daytime sleepiness occupies in interactions involving substance abuse and negative health, social, and emotional outcomes. As a means of improving sleep and lowering risk for recidivism of substance abuse, we developed and implemented a six-session group treatment to treat sleep disturbances in adolescents who have received treatment for substance abuse. The components of the treatment are stimulus control instructions, use of bright light to regularize sleep, sleep hygiene education, cognitive therapy, and Mindfulness-Based Stress Reduction. Preliminary evidence indicates that participants who completed four or more sessions in the treatment program showed improved sleep and that improving sleep may lead to a reduction in substance abuse problems at the 12-month follow-up.

Follow-up Study of Anxiety Disorder and Alcohol Dependence in Comorbid Alcoholism Treatment Patients

BACKGROUND

Anxiety disorders are present in a high percentage of alcoholism treatment patients. We tested the prediction that having a comorbid anxiety disorder increases the prospective risk for relapse to drinking after alcoholism treatment. We also explored the prospective associations of specific anxiety syndromes (and depression) with drinking and anxiety outcomes.

METHODS

We assessed the diagnostic status and daily drinking patterns of 82 individuals approximately one week after they entered alcoholism treatment (baseline) and again approximately 120 days later (follow-up) (n=53).

RESULTS

Consistent with study predictions, those with a baseline anxiety disorder (approximately 55%) were significantly more likely than others to meet various definitions of drinking relapse over the course of the follow-up. Regression models showed that baseline social phobia was the single best predictor of a return to any drinking after treatment, whereas panic disorder was the single best predictor of a relapse to alcohol dependence after treatment. Having multiple anxiety disorders (versus any specific anxiety disorder) at the baseline was the strongest predictor of having at least one active ("persistent") anxiety disorder at the follow-up. Cross-sectional analysis at the follow-up showed that anxiety disorder persisted in the absence of a relapse to alcohol dependence far more often than relapse to alcohol dependence occurred in the absence of a persistent anxiety disorder.

CONCLUSIONS

Screening for comorbid anxiety disorder in alcoholism treatment patients is warranted and, where found, should be considered a marker of high relapse risk relative to that of noncomorbid patients. The capacity of specific anxiety treatment to mitigate relapse risk among comorbid patients remains an open question.

Depression syndromes with risk of alcohol dependence in adulthood: a latent class analysis

Using prospectively gathered data, we assessed whether depression is associated a risk for late-onset alcohol dependence, and whether that relationship differed by gender. The baseline interview was completed in 1981 (mean age=41.7 years, standard deviation (S.D.)=17.0, range 18-86) on a probability sample of Baltimore residents as part of the Epidemiologic Catchment Area Program. Between 1993 and 1996, the original cohort was traced (73% of the survivors were re-interviewed, n=1920). Baseline depression items were subjected to gender-specific latent class analyses prior to exploring associations between class membership and two classifications of alcohol dependence: (1) lifetime prevalence, and (2) new onset assessed at follow-up. A depression syndrome class was identified (24% of the females and 20% of the males). The odds of lifetime alcohol dependence among those in the depressive syndrome class was significantly elevated for both sexes, relative to the non-depressed class. However, no appreciable association was found for depressive syndrome with the development of alcohol dependence. In this sample of middle-aged adults, the evidence supports an association for the presence of a depressive syndrome with lifetime alcohol dependence, but not for the new onset of alcohol dependence. Other predictors of alcohol dependence identified in the analyses are discussed.

Treatment of late-life depression complicated by alcohol dependence

OBJECTIVES

Among elderly patients, mental and physical illness are often present along with alcohol dependence. The interaction between alcohol use and concurrent physical or mental disabilities is complex and complicates treatment planning. The aim of this study was to test the efficacy of naltrexone combined with sertraline for the treatment of older adults with major depression and alcohol dependence.

METHODS

The sample was 74 subjects, age 55 and older, who met criteria for a depressive disorder along with alcohol dependence. All subjects were randomly assigned to 12 weeks of naltrexone 50 mg/day or placebo. Also, all subjects received sertraline 100 mg/day and individual weekly psychosocial support. Treatment response for alcohol consumption and depression was measured during the 12 weeks of treatment.

RESULTS

At baseline, the average age of subjects was 63.4, and subjects were drinking an average of 10.7 drinks per drinking day. The overall results are encouraging; 42% of the subjects had a remission of their depression and had no drinking relapses during the trial. There was no evidence for an added benefit of naltrexone in combination with sertraline, but there was significant correlation between any alcohol relapse during the trial and poor response to depression treatment.

CONCLUSION

Patients with concurrent mental disorders, such as major depression and alcohol dependence, are increasingly prevalent in clinical practice and have been demonstrated to show poorer treatment response and higher treatment costs. The results of this trial underscore the importance of addressing alcohol use in the context of treating late-life depression.

The duration and correlates of addiction and treatment careers

While addiction is increasingly recognized as a chronic condition, little information is available on the actual duration of addiction and treatment careers. The purpose of this study was to estimate the duration and correlates of years between (a) first use and at least a year of abstinence and (b) first treatment admission and at least one year of abstinence. Data are from 1,271 of 1,326 (96%) people recruited from a stratified sequential sample of admissions to publicly funded treatment programs in a large metropolitan area. Participants were interviewed at 6, 18, 24, 36, 48, and 60 months post-intake. With an average age at the referent intake of 35 (SD = 8) years, the sample is 59% female, 87% African American, 7% Hispanic, and 5% white. The most common dependence diagnoses were for cocaine (64%), alcohol (44%), opioids (41%), and/or marijuana (14%). Using lifetime substance use and treatment histories collected at intake and subsequent treatment utilization recorded during follow-up interviews, we conducted survival analysis to estimate the time from first use and first treatment until people reported 12 months of abstinence or died (with people still using, in treatment, or dead at the last follow-up treated as right censored). During the three years after intake, 47% reached at least 12 months of abstinence. The median time from first to last use was 27 years. The median time from first treatment episode to last use was 9 years. Years to recovery were significantly longer for males, people starting use under the age of 21 (particularly those starting under the age of 15), people who had participated in treatment 3 or more times, and for people high in mental distress. The exploratory results suggest that multiple episodes of care over several years are the norm and that rather than thinking of multiple episodes in terms of "cumulative dosage," it might be better thought of as further evidence of chronicity and that we need to develop and evaluate models of longer term recovery management.

Substance use disorders in individuals with body dysmorphic disorder

BACKGROUND

Little is known about substance use disorders (SUDs) in individuals with body dysmorphic disorder (BDD). Although studies have examined SUD comorbidity in BDD, no previous studies have examined clinical correlates of SUD comorbidity.

METHOD

We examined rates and clinical correlates of comorbid SUDs in 176 consecutive subjects with DSM-IV BDD (71% female; mean +/- SD age = 32.5 +/- 12.3 years). Comorbidity data were obtained with the Structured Clinical Interview for DSM-IV. BDD severity was assessed with the Yale-Brown Obsessive Compulsive Scale Modified for BDD, and delusionality (insight) was assessed with the Brown Assessment of Beliefs Scale. Quality of life and social/occupational functioning were examined using the Social Adjustment Scale, Quality of Life Enjoyment and Satisfaction Questionnaire, Medical Outcomes Study 36-Item Short-Form Health Survey, and Range of Impaired Functioning Tool. All variables were compared in BDD subjects with and without lifetime and current SUDs. Data were collected from January 2001 to June 2003.

RESULTS

48.9% of BDD subjects (N = 86) had a lifetime SUD, 29.5% had lifetime substance abuse, and 35.8% had lifetime substance dependence (most commonly, alcohol dependence [29.0%]). 17% (N = 30) had current substance abuse or dependence (9.1% reported current substance abuse, and 9.7% reported current dependence). 68% of subjects with a lifetime SUD reported that BDD contributed to their SUD. There were far more similarities than differences between subjects with a comorbid SUD and those without an SUD, although those with a lifetime SUD had a significantly higher rate of suicide attempts (p = .004).

CONCLUSION

These preliminary results suggest that SUDs are very common in individuals with BDD. Subjects with and without a comorbid SUD were similar in most domains that were examined.

Natural history of depression in traumatic brain injury11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated

OBJECTIVE

To examine prospectively the rates, risk factors, and phenomenology of depression over 3 to 5 years after traumatic brain injury (TBI).

DESIGN

Inception cohort longitudinal study.

SETTING

Level I trauma center.

PARTICIPANTS

Consecutive admissions of 283 adults with moderate to severe TBI.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Center for Epidemiologic Studies Depression (CES-D) Scale.

RESULTS

The rates of moderate to severe depression ranged from 31% at 1 month to 17% at 3 to 5 years. With 1 exception, the relation between brain injury severity and depression was negligible. Less than high school education, preinjury unstable work history, and alcohol abuse predicted depression after injury. Examination of CES-D factors indicate that, in addition to somatic symptoms, both depressed affect and lack of positive affect contribute to elevated CES-D scores.

CONCLUSIONS

High rates of depressive symptoms cannot be dismissed on grounds that somatic symptoms related to brain injury are mistaken for depression. Depressed affect and lack of positive affect are also elevated in persons with TBI. Preinjury psychosocial factors are predictive of depression and knowing them should facilitate efforts to detect, prevent, and treat depression after TBI.

Alleles of a functional serotonin transporter promoter polymorphism are associated with major depression in alcoholics

BACKGROUND

Serotonergic neurotransmission has been implicated in the pathogenesis of both alcohol dependence and mood disorders and may therefore be important in understanding the pathophysiology of comorbid alcohol dependence and major depression. Studies of the association of these disorders with a functional polymorphism in the promoter region of the gene encoding the serotonin transporter protein (locus SLC6A4) have yielded inconsistent results. Because the convergence of these disorders may provide a refined phenotype, we examined the association of serotonin (5-HT) transporter linked polymorphic region (5-HTTLPR) alleles to comorbid alcohol dependence and major depression.

METHODS

A sample of 296 European American and 16 African American patients with comorbid alcohol dependence and major depression was recruited from treatment studies. The control group included 260 European Americans and 43 African Americans; all were screened to exclude the presence of a mood or substance use disorder. DNA isolated from whole blood was polymerase chain reaction-amplified, and genotypes were assigned on the basis of agarose gel size fractionation.

RESULTS

The frequency of the short allele in the patient group was in the range of those previously reported for samples with unipolar depression but was significantly more common than among controls (short allele frequency of cases, 45.8%; controls, 39.8%; chi(2)(1) = 4.02; p = 0.045).

CONCLUSIONS

With respect to the frequency of the short allele at the SLC6A4 locus (5-HTTLPR), major depression in alcoholics is similar to major depression in nonalcoholics. Further efforts to characterize depressed alcoholics and to examine genetic predictors of response to antidepressant treatment seem warranted.

Comorbid psychiatric disorders in late life depression

In late life depression, common comorbid psychiatric disorders are alcohol use, anxiety, and personality disorders. Elderly depressed patients are three to four times more likely to have an alcohol use disorder compared with nondepressed elderly subjects, with a prevalence of 15%-30% in patients with late life major depression. While the presence of a comorbid alcohol use disorder may worsen the prognosis for geriatric depression, limited data suggest that successful treatment of depression combined with reducing alcohol use leads to the best possible outcomes. Most studies show that the overall prevalence of anxiety disorders, particularly panic disorder and obsessive-compulsive disorder, is low in geriatric depression, but generalized anxiety disorder may not be uncommon. It remains unclear if the presence of a comorbid anxiety disorder impacts on the treatment and prognosis of late life major depression. Personality disorders occur in 10%-30% of patients with late life major depression or dysthymic disorder, particularly in patients with early onset depressive illness. Cluster C disorders, including the avoidant, dependent, and obsessive-compulsive subtypes predominate, while Cluster B diagnoses, including borderline, narcissistic, histrionic and antisocial, are rare. Overall, the research database on comorbid psychiatric disorders in major and nonmajor late life depression is relatively sparse. Since comorbid psychiatric disorders affect clinical course and prognosis, and may worsen long-term disability in late life depression, considerably more research in this field is needed.

The effect of a history of alcohol dependence in adult major depression

We examined 180 patients with a principal diagnosis of Major Depression, with or without a lifetime diagnosis of alcohol dependence. In the ever-dependent group, the GAF was lower; cannabis dependence higher; and Borderline, Schizotypal and Paranoid personality disorders more common. They reported more paranoia and interpersonal sensitivity on the Hopkins Symptom Checklist and more friction and interpersonal behaviour on the Social Adjustment Scale. On the Temperament and Character Inventory, novelty seeking was higher and persistence and cooperativeness lower. PBI scores and family histories did not differ significantly. Treatment outcome did not vary, except that subjects with lifetime alcohol dependence and current heavy drinking did less well.

Detection of substance use disorders in patients presenting with depression

Comorbidity between substance use disorders and major depression may complicate the treatment and adversely affect the outcome of either disorder. This study examines the frequency with which patients presenting with depression are evaluated for a substance use disorder in a university-based family medicine residency program. A retrospective chart review was performed to identify 200 patients age 18 and older, seen between June 1, 1989, and June 1, 1999, who were diagnosed with depression (DSM IV code 300.4 or 311.0). The records were divided into two strata based on whether they were seen by resident or faculty physicians. The records were then reviewed for evidence of substance use screening. The overall percentage of patients with depression and evaluated for substance use disorders was calculated, and further stratified as to gender, age, previous psychiatric diagnosis, and previous substance use disorder diagnosis. Family physicians evaluated outpatients with a diagnosis of depression for substance use disorders only 24.5% of the time. Faculty evaluated depressed patients 18%, compared to residents doing so in 31% of patients. Male patients were evaluated 34.7% as compared to 21.2% of females. Patients over age 70 were screened at a rate of only 10.7%. Given the observed prevalence of substance use disorders in patients with a diagnosis of depression is between 40 and 50%, our finding that our depressed patients were evaluated for substance use disorders only 24.5% of the time, suggests that family physicians may be missing a significant number of patients with comorbid disease.

A longitudinal study of the order of onset of alcohol dependence and major depression

Alcohol dependence and major depression commonly occur together; however, few studies have assessed prospectively the magnitude of the risk that one disorder imparts on the subsequent occurrence of the other. We used data from the first two waves of the Epidemiologic Catchment Area community survey (n=14480) to estimate the odds of either major depression or alcohol dependence being followed by the other disorder after 1 year of follow-up. The odds of developing major depression associated with low, medium, and high levels of alcoholic symptoms at baseline were 1.66, 3.98, and 4.32 for females (P<0.001), and 1.19, 2.49, and 2.12 for males (P=0.026). Conversely, odds ratios indicating the 1-year follow-up risk of incident alcohol dependence within low, medium, and high categories of baseline depressive symptomatology were 2.75, 3.52, and 7.88 for females (P<0.001) and 1.50, 1.41, and 1.05 for males (P=0.091). Individuals with alcohol dependence appeared more likely to meet lifetime diagnostic criteria for both disorders after 1 year than individuals with depression. These results suggest that both alcohol dependence and major depression pose a significant risk for the development of the other disorder at 1 year.

Impact of comorbidity on a cognitive-behavioral group treatment for adolescent depression

OBJECTIVE

Examine hypotheses concerning the negative impact of lifetime psychiatric comorbidity on participation in, and benefit from, a cognitive-behavioral group treatment for depression in adolescents (e.g., greater severity at intake, less recovery and more recurrence, less participation in treatment).

METHOD

Across two previous studies conducted between 1986 and 1993, 151 depressed adolescents (aged 14-18) were randomly assigned to one of three treatment conditions (two active treatments and a waitlist control) and followed for 24 months posttreatment. Forty percent of participants had one or more lifetime comorbid diagnoses at intake.

RESULTS

Comorbid anxiety disorders were associated with higher depression measure scores at intake and greater decrease in depression scores by posttreatment. Overall lifetime comorbidity was unrelated to diagnostic recovery, but lifetime substance abuse/dependence was associated with slower time to recovery. Participants with attention-deficit and disruptive behavior disorders were more likely to experience depression recurrence posttreatment. Associations between comorbidity and participation or therapy process measures were nonsignificant.

CONCLUSIONS

Although some outcomes were worse for some comorbid diagnoses, the reassuring overall conclusion is that the presence of psychiatric comorbidity is generally not a contraindication for the use of structured group cognitive-behavioral interventions for depressed adolescents.

Nefazodone treatment of major depression in alcohol-dependent patients: a double-blind, placebo-controlled trial

Depression is the most common comorbid psychiatric illness in patients with alcohol dependence. This double-blind study tested the efficacy of nefazodone versus placebo for the treatment of depression in actively drinking alcohol-dependent patients who were also participating in weekly group treatment for alcoholism. Sixty-four subjects with major depression disorder and alcohol dependence with a history of at least one prior episode of depression when not drinking were randomly assigned to receive 12 weeks of either nefazodone or placebo and participated in a weekly psychoeducational group on alcoholism. Subjects were assessed every 2 weeks for depression, anxiety, side effects, and drinking frequency. Subjects taking nefazodone were significantly more likely to complete the study (62%) than those taking placebo (34%). Analyses of covariance using drinks per week as a time-dependent covariate showed lower Hamilton Rating Scale for Depression scores at week 8 for end-point analysis and at weeks 8 and 12 for completers. The endpoint analysis demonstrated a significantly greater response in the nefazodone group (48%) than in the placebo group (16%). Both groups showed a similarly significant decrease in the average number of alcoholic drinks consumed per day over the course of the study. Although the number of adverse effects was significantly greater for the nefazodone group, there were no severe adverse events, and nefazodone was well tolerated. Nefazodone is a safe and effective antidepressant to use in a population of alcohol-dependent patients with depression who have a high degree of comorbidity. Nefazodone treatment was superior to placebo in alleviating depression in these patients but did not add any advantage over the psychoeducational group in terms of drinking outcomes.

Mood Disorders in Neurologic Illness

Patients with neurologic illness frequently develop secondary mood disorders that are broadly categorized as unipolar or bipolar. Accurate diagnosis is essential because the treatment of unipolar disorders is markedly different from that of bipolar disorders. Aggressive treatment of mood disorders improves quality of life, reduces morbidity and mortality, and may prevent worsening of both psychiatric and neurologic disease. Antidepressants and psychotherapy are both effective for patients suffering from depressive disorders. Choice of antidepressant depends on the patient's particular symptom complex; medication side effects, which may exacerbate the underlying neurologic condition; potential interactions with other drugs; and costs. Bipolar disorder associated with neurologic illness typically requires treatment with mood stabilizers such as lithium, divalproex sodium, carbamazepine, or verapamil. Although psychotherapy in combination with pharmacologic therapy improves the outcome in bipolar illness, psychotherapy alone is not effective for this condition. Electroconvulsive therapy is an effective treatment for both depression and mania. It may have particular usefulness in Parkinson's disease, for which it has been shown to improve the movement disorder itself. Treatment of bipolar disorder, psychotic depression, or refractory depression is complicated and should be referred to a psychiatrist.

The effect of comorbid alcoholism on recurrence in affective disorder: a case register study

BACKGROUND

Studies of the effect of comorbid alcoholism on the risk of recurrence in affective disorder have given contradictory results.

METHOD

Using survival analysis, the rate of recurrence was calculated in a case register study including all hospital admissions with primary affective disorder in Denmark during 1971-1993. The rate of recurrence was estimated following each new affective episode.

RESULTS

In all, 20 350 patients were discharged after first admission with a main diagnosis of affective disorder of depressive or manic/circular type. Among these, 518 patients (2.6%) had an auxiliary diagnosis of alcoholism. Patients with a current auxiliary diagnosis of alcoholism had increased rate of recurrence following the first three affective episodes but not following subsequent episodes compared with patients without auxiliary diagnoses. The effect of alcoholism declined with the number of episodes. In contrast, no effect was found of other auxiliary diagnoses on the rate of recurrence.

CONCLUSION

Rehospitalisation data suggest that concurrent alcoholism increases the risk of recurrence of affective episodes during the initial course of unipolar and bipolar disorder but has no effect on recurrence later in the course of the illnesses.

LIMITATION

The data relate to re-admissions rather than recurrence.

CLINICAL RELEVANCE

The study emphasises that alcoholism has a deteriorating effect on the course of affective disorder.