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Theory and Practice of Treatment of Concurrent Major Depressive and Alcohol Use Disorders: 7 Lessons from Clinical Practice and Research. CANADIAN JOURNAL OF ADDICTION 2021. [DOI: 10.1097/cxa.0000000000000125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Williams R, Farquharson L, Rhodes E, Dang M, Butler J, Quirk A, Baldwin DS, Crawford MJ. Impact of Substance Use Disorder on Quality of Inpatient Mental Health Services for People With Anxiety and Depression. J Dual Diagn 2021; 17:80-93. [PMID: 33048661 DOI: 10.1080/15504263.2020.1825892] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Objective: Substance use disorders are commonly comorbid with anxiety and depressive disorders and are associated with poor treatment outcomes. The mechanisms underlying this association remain unclear-one possibility is that patients with anxiety/depressive disorders and substance use disorders receive poorer treatment. Concerns have been raised about the quality of inpatient care received by patients with substance use disorders. The purspose of this research was to examine the quality of care received by inpatients with an anxiety or depressive disorder, comparing subgroups with or without a comorbid substance use disorder. Methods: This was a retrospective case-note review of 3,795 patients admitted to inpatient psychiatric wards in England. Data were gathered on all acute admissions with anxiety/depressive illness over a 6-month period, for a number of measures of quality of care derived from national standards. Association of coexisting substance use disorders with a variety of quality of care outcomes (relating to assessment, care planning, medication management, psychological therapies, discharge, crisis planning, and follow-up) was investigated using multivariable regression analyses. Results: In all, 543 (14.3%) patients in the study had a secondary diagnosis of a substance use disorder. Patients with substance use disorders were less likely to have had care plans that were developed jointly (i.e., with input from both patient and clinician; odds ratio [OR] = 0.76, 95% confidence interval [CI] [0.55, 0.93], p = .034) and less likely to have had their medication reviewed either during the admission (OR = 0.83, 95% CI [0.69, 0.94], p = .030) or at follow-up after discharge (OR = 0.58, 95% CI [0.39, 0.86], p = .007). Carers of patients with substance use disorders were less likely to have been provided with information about available support services (OR = 0.79, 95% CI [0.57, 0.98], p = .047). Patients with substance use disorders were less likely to have received adequate (at least 24 hours) notice in advance of their discharge (OR = 0.72, 95% CI [0.54, 0.96], p = .033), as were their carers (OR = 0.63, 95% CI [0.41, 0.85], p = .007). They were less likely to have a crisis plan in place at the point of discharge (OR = 0.85, 95% CI [0.74, 0.98], p = .044). There was also strong evidence that patients with substance use disorders were less likely to have been referred for psychological therapy (OR = 0.69, 95% CI [0.55, 0.87], p = .002). Conclusions: We found evidence of poorer quality of care for inpatients with anxiety and depressive disorders with comorbid substance use disorders, highlighting the need for more to be done to support these patients. Discrepancies in care quality may be contributed to the poor treatment outcomes experienced by patients with substance use disorders, and strategies to reduce this inequality are necessary to improve the well-being of this substantial patient group.
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Affiliation(s)
- Ryan Williams
- Imperial College London & College Centre for Quality Improvement, Royal College of Psychiatrists, London, UK
| | - Lorna Farquharson
- University of East London & College Centre for Quality Improvement, Royal College of Psychiatrists, London, UK
| | - Ellen Rhodes
- College Centre for Quality Improvement, Royal College of Psychiatrists, London, UK
| | - Mary Dang
- College Centre for Quality Improvement, Royal College of Psychiatrists, London, UK
| | - Jessica Butler
- College Centre for Quality Improvement, Royal College of Psychiatrists, London, UK
| | - Alan Quirk
- College Centre for Quality Improvement, Royal College of Psychiatrists, London, UK
| | - David S Baldwin
- University of Southampton, Southampton, UK & College Centre for Quality Improvement, Royal College of Psychiatrists, London, UK
| | - Mike J Crawford
- Imperial College London & College Centre for Quality Improvement, Royal College of Psychiatrists, London, UK
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Stokes PRA, Jokinen T, Amawi S, Qureshi M, Husain MI, Yatham LN, Strang J, Young AH. Pharmacological Treatment of Mood Disorders and Comorbid Addictions: A Systematic Review and Meta-Analysis: Traitement Pharmacologique des Troubles de L'humeur et des Dépendances Comorbides: Une Revue Systématique et une Méta-Analyse. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2020; 65:749-769. [PMID: 32302221 PMCID: PMC7564307 DOI: 10.1177/0706743720915420] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Addiction comorbidity is an important clinical challenge in mood disorders, but the best way of pharmacologically treating people with mood disorders and addictions remains unclear. The aim of this study was to assess the efficacy of pharmacological treatments for mood and addiction symptoms in people with mood disorders and addiction comorbidity. METHODS A systematic search of placebo-controlled randomized controlled trials investigating the effects of pharmacological treatments in people with bipolar disorder (BD) or major depressive disorder (MDD), and comorbid addictions was performed. Treatment-related effects on mood and addiction measures were assessed in a meta-analysis, which also estimated risks of participant dropout and adverse effects. RESULTS A total of 32 studies met systematic review inclusion criteria. Pharmacological therapy was more effective than placebo for improving manic symptoms (standardized mean difference [SMD] = -0.15; 95% confidence interval [95% CI], -0.29 to -0.02; P = 0.03) but not BD depressive symptoms (SMD = -0.09; 95% CI, -0.22 to 0.03; P = 0.15). Quetiapine significantly improved manic symptoms (SMD = -0.23; 95% CI, -0.39 to -0.06; P = 0.008) but not BD depressive symptoms (SMD = -0.07; 95% CI, -0.23 to 0.10; P = 0.42). Pharmacological therapy was more effective than placebo for improving depressive symptoms in MDD (SMD = -0.16; 95% CI, -0.30 to -0.03; P = 0.02). Imipramine improved MDD depressive symptoms (SMD = -0.58; 95% CI, -1.03 to -0.13; P = 0.01) but Selective serotonin reuptake Inhibitors (SSRI)-based treatments had no effect (SMD = -0.06; 95% CI, -0.30 to 0.17; P = 0.60). Pharmacological treatment improved the odds of alcohol abstinence in MDD but had no effects on opiate abstinence. CONCLUSIONS Pharmacological treatments were significantly better than placebo in improving manic symptoms, MDD depressive symptoms, and alcohol abstinence but were not better for bipolar depression symptoms. Importantly, quetiapine was not more effective than placebo in improving bipolar depression symptoms nor were SSRI's for the treatment of MDD depression. Our findings highlight the need for further high-quality clinical trials of treatments for mood disorders and comorbid addictions.
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Affiliation(s)
- Paul R A Stokes
- Department of Psychological Medicine, Centre for Affective Disorders, 34426Institute of Psychiatry, Psychology and Neuroscience, King's College London, United Kingdom.,South London and Maudsley NHS Foundation Trust, Beckenham, Kent, United Kingdom.,National Institute for Health Research (NIHR) Maudsley Biomedical Research Centre (BRC) at South London Maudsley Foundation Trust and King's College London, United Kingdom
| | - Tahir Jokinen
- Department of Psychological Medicine, Centre for Affective Disorders, 34426Institute of Psychiatry, Psychology and Neuroscience, King's College London, United Kingdom
| | - Sami Amawi
- Department of Psychological Medicine, Centre for Affective Disorders, 34426Institute of Psychiatry, Psychology and Neuroscience, King's College London, United Kingdom
| | - Mutahira Qureshi
- South London and Maudsley NHS Foundation Trust, Beckenham, Kent, United Kingdom
| | - Muhammad Ishrat Husain
- Department of Psychiatry, University of Toronto, Canada.,Centre for Addiction and Mental Health, Toronto, Canada
| | | | - John Strang
- National Institute for Health Research (NIHR) Maudsley Biomedical Research Centre (BRC) at South London Maudsley Foundation Trust and King's College London, United Kingdom.,Department of Addictions, 34426Institute of Psychiatry, Psychology and Neuroscience, King's College London, United Kingdom
| | - Allan H Young
- Department of Psychological Medicine, Centre for Affective Disorders, 34426Institute of Psychiatry, Psychology and Neuroscience, King's College London, United Kingdom.,South London and Maudsley NHS Foundation Trust, Beckenham, Kent, United Kingdom.,National Institute for Health Research (NIHR) Maudsley Biomedical Research Centre (BRC) at South London Maudsley Foundation Trust and King's College London, United Kingdom
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Li J, Wang H, Li M, Shen Q, Li X, Rong X, Peng Y. Efficacy of pharmacotherapeutics for patients comorbid with alcohol use disorders and depressive symptoms-A bayesian network meta-analysis. CNS Neurosci Ther 2020; 26:1185-1197. [PMID: 32686291 PMCID: PMC7564195 DOI: 10.1111/cns.13437] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 06/25/2020] [Accepted: 06/28/2020] [Indexed: 12/05/2022] Open
Abstract
Background We aimed to compare and rank the efficacy of different pharmacotherapeutics for patients comorbid with alcohol use disorders and depressive symptoms. Method Bayesian network meta‐analysis was performed for three different outcome parameters: alcohol use disorders (AUD) remission rate, percent abstinent days, and scores of depression scales. The surface under the cumulative ranking curves (SUCRA) was used for ranking the efficacy of interventions. Sensitivity analysis and direct pairwise analysis were conducted to validate the main results. Results A total of 68 RCTs consisting of 5890 patients were included. Disulfiram could significantly increase the AUD remission rates (OR 5.02, 1.97‐12.95) and the percent abstinent days (MD 17.08, 3.48‐30.93). Disulfiram was associated with the best efficacy in achieving remission (SUCRA 95.1%) and increasing abstinent days (SUCRA 87.6%). Noradrenaline reuptake inhibitor was significantly more efficacious than controls (SMD −2.44, −3.53 to −1.36) and have the first rank (SUCRA 99.0%) in reducing the scores of depression scales. Antiepileptics have relatively higher ranks in efficacy for both AUD and depressive symptoms. Conclusions Disulfiram was associated with the best efficacy in achieving abstinence for comorbidity patients. Noradrenaline reuptake inhibitor was demonstrated to be associated with the best efficacy in reducing scores of depression scales. Antiepileptics might be beneficial to both alcohol‐related and depressive symptoms.
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Affiliation(s)
- Jiande Li
- Department of Neurology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Hongxuan Wang
- Department of Neurology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Mei Li
- Department of Neurology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Qingyu Shen
- Department of Neurology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Xiangpen Li
- Department of Neurology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Xiaoming Rong
- Department of Neurology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Ying Peng
- Department of Neurology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Malignant Tumour Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
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Iqbal MN, Levin CJ, Levin FR. Treatment for Substance Use Disorder With Co-Occurring Mental Illness. FOCUS: JOURNAL OF LIFE LONG LEARNING IN PSYCHIATRY 2019; 17:88-97. [PMID: 31975963 DOI: 10.1176/appi.focus.20180042] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Substance use disorder is a highly prevalent condition, leading to significant morbidity, mortality, and burden on the health care system. Substance use disorders are overrepresented among individuals with a mental illness. The term "dual diagnosis" was introduced by the World Health Organization in the mid-1990s and refers to the co-occurrence of a substance use disorder with mental illness-a more recently used term is "co-occurring disorders." In the past decade, substantial progress has been made toward expanding psychotherapeutic and pharmacotherapeutic treatments for treating co-occurring disorders. Yet management remains a challenge among clinicians and has been a source of confusion and considerable controversy. This review describes the epidemiology and treatment of co-occurring disorders, with a focus on major depressive disorder, anxiety disorders, and attention-deficit hyperactivity disorder. Substance use may make diagnosis of the underlying psychiatric condition difficult, and a period of abstinence may be necessary. Findings from efficacy studies of medications used to treat co-occurring disorders are reviewed, as are results of preliminary studies of newer treatments, such as topiramate, ketamine, noninvasive brain stimulation, and deep brain stimulation. Treatment recommendations that combine medications and psychosocial interventions are summarized.
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Affiliation(s)
- Muhammad N Iqbal
- Division on Substance Use Disorders, New York State Psychiatric Institute, College of Physicians and Surgeons of Columbia University, New York (all authors); Department of Psychiatry, College of Physicians and Surgeons of Columbia University, New York (F. Levin)
| | - Charles J Levin
- Division on Substance Use Disorders, New York State Psychiatric Institute, College of Physicians and Surgeons of Columbia University, New York (all authors); Department of Psychiatry, College of Physicians and Surgeons of Columbia University, New York (F. Levin)
| | - Frances R Levin
- Division on Substance Use Disorders, New York State Psychiatric Institute, College of Physicians and Surgeons of Columbia University, New York (all authors); Department of Psychiatry, College of Physicians and Surgeons of Columbia University, New York (F. Levin)
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Hillemacher T, Frieling H. Pharmacotherapeutic options for co-morbid depression and alcohol dependence. Expert Opin Pharmacother 2019; 20:547-569. [DOI: 10.1080/14656566.2018.1561870] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Thomas Hillemacher
- Department of Psychiatry and Psychotherapy, Paracelsus Medical University, Nuremberg, Germany
| | - Helge Frieling
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
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Pharmacological and Psychological Treatments for Comorbid Alcohol Use Disorder and Depressive Disorder: a Review. CURRENT ADDICTION REPORTS 2018. [DOI: 10.1007/s40429-018-0213-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Agabio R, Trogu E, Pani PP. Antidepressants for the treatment of people with co-occurring depression and alcohol dependence. Cochrane Database Syst Rev 2018; 4:CD008581. [PMID: 29688573 PMCID: PMC6494437 DOI: 10.1002/14651858.cd008581.pub2] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Alcohol dependence is a major public health problem characterized by recidivism, and medical and psychosocial complications. The co-occurrence of major depression in people entering treatment for alcohol dependence is common, and represents a risk factor for morbidity and mortality, which negatively influences treatment outcomes. OBJECTIVES To assess the benefits and risks of antidepressants for the treatment of people with co-occurring depression and alcohol dependence. SEARCH METHODS We searched the Cochrane Drugs and Alcohol Group Specialised Register (via CRSLive), Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase from inception to July 2017. We also searched for ongoing and unpublished studies via ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (apps.who.int/trialsearch/).All searches included non-English language literature. We handsearched references of topic-related systematic reviews and the included studies. SELECTION CRITERIA Randomized controlled trials and controlled clinical trials comparing antidepressants alone or in association with other drugs or psychosocial interventions (or both) versus placebo, no treatment, and other pharmacological or psychosocial interventions. DATA COLLECTION AND ANALYSIS We used standard methodological procedures as expected by Cochrane. MAIN RESULTS We included 33 studies in the review (2242 participants). Antidepressants were compared to placebo (22 studies), psychotherapy (two studies), other medications (four studies), or other antidepressants (five studies). The mean duration of the trials was 9.9 weeks (range 3 to 26 weeks). Eighteen studies took place in the USA, 12 in Europe, two in Turkey, and one in Australia. The antidepressant included in most of the trials was sertraline; other medications were amitriptyline, citalopram, desipramine, doxepin, escitalopram, fluoxetine, fluvoxamine, imipramine, mianserin, mirtazepine, nefazodone, paroxetine, tianeptine, venlafaxine, and viloxazine. Eighteen studies were conducted in an outpatient setting, nine in an inpatient setting, and six in both settings. Psychosocial treatment was provided in 18 studies. There was high heterogeneity in the selection of outcomes and the rating systems used for diagnosis and outcome assessment.Comparing antidepressants to placebo, low-quality evidence suggested that antidepressants reduced the severity of depression evaluated with interviewer-rated scales at the end of trial (14 studies, 1074 participants, standardized mean difference (SMD) -0.27, 95% confidence interval (CI) -0.49 to -0.04). However, the difference became non-significant after the exclusion of studies with a high risk of bias (SMD -0.17, 95% CI -0.39 to 0.04). In addition, very low-quality evidence supported the efficacy of antidepressants in increasing the response to the treatment (10 studies, 805 participants, risk ratio (RR) 1.40, 95% Cl 1.08 to 1.82). This result became non-significant after the exclusion of studies at high risk of bias (RR 1.27, 95% CI 0.96 to 1.68). There was no difference for other relevant outcomes such as the difference between baseline and final score, evaluated using interviewer-rated scales (5 studies, 447 participants, SMD 0.15, 95% CI -0.12 to 0.42).Moderate-quality evidence found that antidepressants increased the number of participants abstinent from alcohol during the trial (7 studies, 424 participants, RR 1.71, 95% Cl 1.22 to 2.39) and reduced the number of drinks per drinking days (7 studies, 451 participants, mean difference (MD) -1.13 drinks per drinking days, 95% Cl -1.79 to -0.46). After the exclusion of studies with high risk of bias, the number of abstinent remained higher (RR 1.69, 95% CI 1.18 to 2.43) and the number of drinks per drinking days lower (MD -1.21 number of drinks per drinking days, 95% CI -1.91 to -0.51) among participants who received antidepressants compared to those who received placebo. However, other outcomes such as the rate of abstinent days did not differ between antidepressants and placebo (9 studies, 821 participants, MD 1.34, 95% Cl -1.66 to 4.34; low-quality evidence).Low-quality evidence suggested no differences between antidepressants and placebo in the number of dropouts (17 studies, 1159 participants, RR 0.98, 95% Cl 0.79 to 1.22) and adverse events as withdrawal for medical reasons (10 studies, 947 participants, RR 1.15, 95% Cl 0.65 to 2.04).There were few studies comparing one antidepressant versus another antidepressant or antidepressants versus other interventions, and these had a small sample size and were heterogeneous in terms of the types of interventions that were compared, yielding results that were not informative. AUTHORS' CONCLUSIONS We found low-quality evidence supporting the clinical use of antidepressants in the treatment of people with co-occurring depression and alcohol dependence. Antidepressants had positive effects on certain relevant outcomes related to depression and alcohol use but not on other relevant outcomes. Moreover, most of these positive effects were no longer significant when studies with high risk of bias were excluded. Results were limited by the large number of studies showing high or unclear risk of bias and the low number of studies comparing one antidepressant to another or antidepressants to other medication. In people with co-occurring depression and alcohol dependence, the risk of developing adverse effects appeared to be minimal, especially for the newer classes of antidepressants (such as selective serotonin reuptake inhibitors). According to these results, in people with co-occurring depression and alcohol dependence, antidepressants may be useful for the treatment of depression, alcohol dependence, or both, although the clinical relevance may be modest.
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Affiliation(s)
- Roberta Agabio
- University of CagliariDepartment of Biomedical Sciences, Section of Neuroscience and Clinical PharmacologyCagliariItaly
| | - Emanuela Trogu
- Cagliari Public Health TrustDepartment of PsychiatryASL CagliariCagliariSardiniaItaly09128
| | - Pier Paolo Pani
- Sardinia Protection Health TrustSassari Social‐Health AreaSassariSardiniaItaly
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Abstract
The prevalence of coexisting substance misuse and psychiatric disorder (dual diagnosis, comorbidity) has increased over the past decade, and the indications are that it will continue to rise. There have simultaneously been unprecedented developments in the pharmacological treatment of alcohol, opiate and nicotine misuse. Here we evaluate the evidence on the use of some of these treatments in dual diagnosis (with psychotic, mood and anxiety disorders). The evidence base is limited by the exclusion of mental illness when pharmacological agents for substance misuse are evaluated and vice versa. We set the available information within the context of the psychosocial management of comorbid substance misuse and mental illness, and the framework for service delivery recommended by UK national policy.
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Comorbidity of Alcohol Use Disorder and Depression: A Case Report and Review of the Literature. ADDICTIVE DISORDERS & THEIR TREATMENT 2017. [DOI: 10.1097/adt.0000000000000106] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Soyka M, Kranzler HR, Hesselbrock V, Kasper S, Mutschler J, Möller HJ. Guidelines for biological treatment of substance use and related disorders, part 1: Alcoholism, first revision. World J Biol Psychiatry 2017; 18:86-119. [PMID: 28006997 DOI: 10.1080/15622975.2016.1246752] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
These practice guidelines for the biological treatment of alcohol use disorders are an update of the first edition, published in 2008, which was developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). For this 2016 revision, we performed a systematic review (MEDLINE/PUBMED database, Cochrane Library) of all available publications pertaining to the biological treatment of alcoholism and extracted data from national guidelines. The Task Force evaluated the identified literature with respect to the strength of evidence for the efficacy of each medication and subsequently categorised it into six levels of evidence (A-F) and five levels of recommendation (1-5). Thus, the current guidelines provide a clinically and scientifically relevant, evidence-based update of our earlier recommendations. These guidelines are intended for use by clinicians and practitioners who evaluate and treat people with alcohol use disorders and are primarily concerned with the biological treatment of adults with such disorders.
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Affiliation(s)
- Michael Soyka
- a Psychiatric Hospital Meiringen , Meiringen , Switzerland.,b Department of Psychiatry , Ludwig-Maximilians-University , Munich , Germany.,c Medicalpark Chiemseeblick , Bernau , Germany
| | - Henry R Kranzler
- d Crescenz VAMC , University of Pennsylvania and VISN 4 MIRECC , Philadelphia , PA , USA
| | | | - Siegfried Kasper
- f Department of Psychiatric Medicine , University of Vienna, Vienna , Austria
| | - Jochen Mutschler
- a Psychiatric Hospital Meiringen , Meiringen , Switzerland.,g Psychiatric Hospital University of Zürich, Zürich , Switzerland
| | - Hans-Jürgen Möller
- b Department of Psychiatry , Ludwig-Maximilians-University , Munich , Germany
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Using patient self-reports to study heterogeneity of treatment effects in major depressive disorder. Epidemiol Psychiatr Sci 2017; 26:22-36. [PMID: 26810628 PMCID: PMC5125904 DOI: 10.1017/s2045796016000020] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BACKGROUNDS Clinicians need guidance to address the heterogeneity of treatment responses of patients with major depressive disorder (MDD). While prediction schemes based on symptom clustering and biomarkers have so far not yielded results of sufficient strength to inform clinical decision-making, prediction schemes based on big data predictive analytic models might be more practically useful. METHOD We review evidence suggesting that prediction equations based on symptoms and other easily-assessed clinical features found in previous research to predict MDD treatment outcomes might provide a foundation for developing predictive analytic clinical decision support models that could help clinicians select optimal (personalised) MDD treatments. These methods could also be useful in targeting patient subsamples for more expensive biomarker assessments. RESULTS Approximately two dozen baseline variables obtained from medical records or patient reports have been found repeatedly in MDD treatment trials to predict overall treatment outcomes (i.e., intervention v. control) or differential treatment outcomes (i.e., intervention A v. intervention B). Similar evidence has been found in observational studies of MDD persistence-severity. However, no treatment studies have yet attempted to develop treatment outcome equations using the full set of these predictors. Promising preliminary empirical results coupled with recent developments in statistical methodology suggest that models could be developed to provide useful clinical decision support in personalised treatment selection. These tools could also provide a strong foundation to increase statistical power in focused studies of biomarkers and MDD heterogeneity of treatment response in subsequent controlled trials. CONCLUSIONS Coordinated efforts are needed to develop a protocol for systematically collecting information about established predictors of heterogeneity of MDD treatment response in large observational treatment studies, applying and refining these models in subsequent pragmatic trials, carrying out pooled secondary analyses to extract the maximum amount of information from these coordinated studies, and using this information to focus future discovery efforts in the segment of the patient population in which continued uncertainty about treatment response exists.
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Magruder KM, Sonne SC, Brady KT, Quello S, Martin RH. Screening for Co-Occurring Mental Disorders in Drug Treatment Populations. JOURNAL OF DRUG ISSUES 2016. [DOI: 10.1177/002204260503500310] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Substance abuse treatment organizations are universally faced with the problem of co-occurring psychiatric disorders among the clients they serve. A first step is assessment of such comorbid conditions; however, the time constraints in front-line substance abuse treatment organizations make extensive clinical assessments almost impossible. The development and validation of a brief screening tool for psychiatric disorders in individuals with substance use disorders (SUDs) could have enormous implications for clinical practice. We assessed the performance characteristics of the Psychiatric Diagnostic Screening Questionnaire (PDSQ) and the Conners' Adult ADHD Rating Scale (CAARS) against the Structured Clinical Interview for DSM-IV (SCID-IV) in 120 patients admitted to SUD treatment. Patients were randomly assigned to receive either the SCID or PDSQ. In general, the PDSQ and CAARS performed well. There were no statistically significant performance differences by order of administration, gender, or drug use in past month. For the GAD subscale, Caucasian patients had higher levels of agreement than non-Caucasian patients.
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Affiliation(s)
- Kathryn M. Magruder
- Acting Associate Chief of Staff for Education at the V.A. Medical Center in Charleston, S.C. and a tenured associate professor at the Medical University of South Carolina in the Departments of Psychiatry and Behavioral Sciences and Biometry and Epidemiology
| | - Susan C. Sonne
- A research associate professor in the Department of Psychiatry and Behavioral Sciences, Clinical Neuroscience Division, Medical University of South Carolina
| | - Kathleen T. Brady
- A board-certified psychiatrist specializing in addiction psychiatry and a professor of psychiatry at the Medical University of South Carolina
| | - Susan Quello
- Currently project coordinator of the Pearson Center for Alcoholism and Addiction Research in the Department of Neuropharmacology at The Scripps Research Institute
| | - Renée Hebert Martin
- Received a doctorate in Biostatistics from the Medical University of South Carolina in 2001
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Arora S, Vohora D. Comparative Evaluation of Partial α2 -Adrenoceptor Agonist and Pure α2 -Adrenoceptor Antagonist on the Behavioural Symptoms of Withdrawal after Chronic Alcohol Administration in Mice. Basic Clin Pharmacol Toxicol 2016; 119:202-9. [PMID: 26867012 DOI: 10.1111/bcpt.12566] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 01/28/2016] [Indexed: 12/22/2022]
Abstract
As an addictive drug, alcohol produces withdrawal symptoms if discontinued abruptly after chronic use. Clonidine (CLN), a partial α2 -adrenergic agonist, and mirtazapine (MRT), an antagonist of α2 -adrenoceptor, both clinically aid alcohol withdrawal. Considering different mechanisms of action of the two drugs, this study was designed to see how far these two mechanistically different drugs differ in their ability to decrease the severity of ethanol withdrawal syndrome. The effect of CLN and MRT on ethanol withdrawal-induced anxiety, depression and memory impairment was analysed using EPM, FST and PAR tests, respectively. Animals received distilled water, ethanol and/or either of the drugs (CLN and MRT) in different doses. Relapse to alcohol use was analysed by CPP test. Animals received ethanol as a conditioning drug and distilled water, CLN or MRT as test drug. CLN and MRT both alleviated anxiety in a dose-dependent manner. MRT (4 mg/kg) was more effective than CLN (0.1 mg/kg) in ameliorating the anxiogenic effect of alcohol withdrawal. However, CLN treatment increased depression. It significantly decreased swimming time and increased immobility time, whereas MRT treatment decreased immobility time and increased climbing and swimming time during abstinence. The effect was dose dependent for both drugs. The results of PAR test show that CLN treatment worsens working memory. Significant increase in SDE and TSZ and decrease in SDL were observed in CLN-treated animals. MRT treatment, on the other hand, improved working memory at both doses. Further, both CLN and MRT alleviated craving. A significant decrease in time spent in the ethanol-paired chamber was seen. MRT treatment at both doses showed better effect than CLN in preventing the development of preference in CPP test. These findings indicate a potential therapeutic use and better profile of mirtazapine over clonidine in improving memory, as well as in alleviating depression, anxiety and craving associated with alcohol withdrawal.
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Affiliation(s)
- Shivani Arora
- Department of Pharmacology, Faculty of Pharmacy, Jamia Hamdard University, New Delhi, India
| | - Divya Vohora
- Department of Pharmacology, Faculty of Pharmacy, Jamia Hamdard University, New Delhi, India
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Stoutenberg M, Rethorst CD, Lawson O, Read JP. Exercise training - A beneficial intervention in the treatment of alcohol use disorders? Drug Alcohol Depend 2016; 160:2-11. [PMID: 26652900 PMCID: PMC6083864 DOI: 10.1016/j.drugalcdep.2015.11.019] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2015] [Revised: 11/13/2015] [Accepted: 11/17/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND A growing body of evidence suggests that exercise training may have multiple beneficial effects in individuals with mental health or substance use disorders. Yet, relatively little knowledge exists regarding the benefits of exercise training to augment treatment for alcohol use disorders (AUDs). PURPOSE The purpose of this narrative review is to present a summary of the growing body of published literature supporting exercise training as a treatment strategy for individuals with AUDs. We will provide evidence on the myriad of ways in which exercise may exert a positive effect on AUD outcomes including stress, anxiety, impulsivity, and depression. Further, we will explore how these mechanisms share common neurobiological pathways. The role of exercise in enhancing the social environment and increasing individual self-efficacy to reduce excess and/or inappropriate alcohol consumption will also be discussed. DISCUSSION We will conclude with a description of completed investigations involving exercise training and provide suggestions for next steps in this innovative field of study.
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Affiliation(s)
- Mark Stoutenberg
- Department of Public Health Sciences, University of Miami Miller School of Medicine, 1120 NW 14th Street, Clinical Research Building, Suite 1008, Miami, FL 33136, USA.
| | - Chad D. Rethorst
- Department of Psychiatry, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Olivia Lawson
- Department of Public Health Sciences, University of Miami Miller School of Medicine, 1120 NW 14th Street, Clinical Research Building, Suite 1008, Miami, FL 33136, USA
| | - Jennifer P. Read
- Department of Psychology, The State University of New York at Buffalo, 213 Park Hall, Buffalo, NY 14260, USA
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Donoghue K, Rose A, Coulton S, Milward J, Reed K, Drummond C, Little H. Double-blind, 12 month follow-up, placebo-controlled trial of mifepristone on cognition in alcoholics: the MIFCOG trial protocol. BMC Psychiatry 2016; 16:40. [PMID: 26912003 PMCID: PMC4765152 DOI: 10.1186/s12888-016-0757-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 02/18/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Increased levels of cortisol during acute alcohol withdrawal have been linked to cognitive deficits and depression. Preclinical research found that the glucocorticoid Type II receptor antagonist, mifepristone, prevented some of the neurotoxic effects of withdrawal and memory loss. Clinical trials have shown mifepristone effective in the treatment of depression. This study aims to examine the extent to which the glucocorticoid Type II receptor antagonist, mifepristone, when given to alcohol dependent males during the acute phase of alcohol withdrawal, will protect against the subsequent memory loss and depressive symptoms during abstinence from alcohol. METHODS/DESIGN The study is a Phase 4 therapeutic use, "Proof of Concept" trial. The trial is a double-blind randomised controlled clinical trial of mifepristone versus inactive placebo. The trial aims to recruit 120 participants referred for an inpatient alcohol detoxification from community alcohol teams, who meet the inclusion criteria; 1) Male, 2) Aged 18-60 inclusive, 3) alcohol dependent for 5 or more years. A screening appointment will take place prior to admission to inpatient alcohol treatment units to ensure that the individual is suitable for inclusion in the trial in accordance with the inclusion and exclusion criteria. On admission participants are randomised to receive 600 mg a day of mifepristone (200 mg morning, afternoon and evening) for 7 days and 400 mg for the subsequent 7 days (200 mg morning and evening) or the equivalent number of placebo tablets for 14 days. Participants will remain in the trial for 4 weeks (at least 2 weeks as an inpatient) and will be followed up at 3, 6 and 12 months post randomisation. Primary outcome measures are cognitive function at week 3 and 4 after cessation of drinking and symptoms of depression over the 4 weeks after cession of drinking, measured using the Cambridge Neuropsychological Test Automated battery and Beck Depression Inventory, respectively. Secondary outcome measures are severity of the acute phase of alcohol withdrawal, alcohol craving, symptoms of protracted withdrawal and maintenance of abstinence and levels of relapse drinking at follow-up. DISCUSSION The current trial will provide evidence concerning the role of glucocorticoid Type II receptor activation in cognitive function and depression during acute alcohol withdrawal and the efficacy of treatment with mifepristone. ISRCTN ISRCTN54001953, Registered 29th September 2011.
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Affiliation(s)
- Kim Donoghue
- Addictions Department, National Addiction Centre, Institute of Psychiatry, King's College London, 4 Windsor Walk, London, SE5 8BB, UK.
| | - Abigail Rose
- Department of Psychological Sciences, University of Liverpool, 2.32, Eleanor Rathbone Building, Bedford Street South, Liverpool, L69 7ZA, UK.
| | - Simon Coulton
- Centre for Health Service Studies, University of Kent, Canterbury, Kent, CT2 7NF, UK.
| | - Joanna Milward
- Addictions Department, National Addiction Centre, Institute of Psychiatry, King's College London, 4 Windsor Walk, London, SE5 8BB, UK.
| | - Kylie Reed
- Addictions Department, National Addiction Centre, Institute of Psychiatry, King's College London, 4 Windsor Walk, London, SE5 8BB, UK.
| | - Colin Drummond
- Addictions Department, National Addiction Centre, Institute of Psychiatry, King's College London, 4 Windsor Walk, London, SE5 8BB, UK.
| | - Hilary Little
- Addictions Department, National Addiction Centre, Institute of Psychiatry, King's College London, 4 Windsor Walk, London, SE5 8BB, UK.
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Chan P, Yomen K, Turcios J, Richman M. Prescription for antidepressant in reducing future alcohol-related readmission in patients suffering from depression and alcohol use disorder: a retrospective medical record review. SUBSTANCE ABUSE TREATMENT PREVENTION AND POLICY 2015; 10:48. [PMID: 26690941 PMCID: PMC4687098 DOI: 10.1186/s13011-015-0045-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 12/16/2015] [Indexed: 12/13/2022]
Abstract
Background Patients suffering from major depressive disorder are more likely to suffer from alcohol use disorder. The data is inconclusive for the effectiveness of antidepressant treatment of patients suffering from both illnesses in regards to improving sobriety and reducing alcohol-related healthcare expenses such as hospitalizations. The objective of this study is to determine if a new prescription of an antidepressant upon inpatient discharge is associated with a reduction in the number of future acute alcohol-related hospital readmissions to the same institution in patients suffering from major depressive disorder and alcohol-use disorder. Methods A retrospective, medical record review study was conducted at a publicly-supported hospital in Sylmar, CA. A query was performed for adult patients admitted between 1/1/2005–12/31/2013 who had ICD-9 codes for both alcohol-use disorder and depression. Index admission was the first hospitalization in which the patient was currently consuming alcohol and had depression as identified by physician documentation as a problem. Acute alcohol-related admissions were those for alcohol intoxication or withdrawal (indicating current alcohol use). Patients were excluded if they were receiving an antidepressant on index admission, <18 years old, no patient data available, or not currently consuming alcohol; 139 patients met inclusion criteria. Multivariate logistical regression analysis was performed on the primary predictive variable of discharge prescription of an antidepressant along with other independent variables for alcohol readmissions: homelessness, family history of alcohol use disorder, and smoking. Results Discharging patients with a prescription of an antidepressant was not associated with a reduction in acute alcohol-related readmission. There was no difference in acute alcohol-related readmissions between patients discharged with (44.6 %) versus without (47.0 %) a prescription for an antidepressant (p = 0.863). The median number of days between index admission and first readmission for those discharged on an antidepressant was 141 days while those who were not was 112 days (p = 0.284). Conclusion Discharging patients suffering from both alcohol-use disorder and major depressive disorder with a prescription for an antidepressant is not associated with a reduction in future readmissions, nor significantly increase the number of days to readmission. The study does not support the concept of antidepressants in reducing acute alcohol-related readmissions.
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Affiliation(s)
- Patrick Chan
- Western University of Health Sciences, 309 E. 2nd St, Pomona, CA, 91766, USA.
| | - Katie Yomen
- University of California Los Angeles Medical Center, 757 Westwood Plaza, Room B531, Los Angeles, CA, USA.
| | - Jennifer Turcios
- Kaiser Permanente Baldwin Park, 1011 Baldwin Park Blvd, Baldwin Park, CA, USA.
| | - Mark Richman
- Department of Emergency Medicine, North Shore-LIJ Long Island Jewish Medical Center, 270-05 76th Ave, New Hyde Park, NY, 11040, USA.
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Foulds JA, Adamson SJ, Boden JM, Williman JA, Mulder RT. Depression in patients with alcohol use disorders: Systematic review and meta-analysis of outcomes for independent and substance-induced disorders. J Affect Disord 2015; 185:47-59. [PMID: 26143404 DOI: 10.1016/j.jad.2015.06.024] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Revised: 06/11/2015] [Accepted: 06/14/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND In patients with an alcohol use disorder, depression is commonly categorised as independent (ID) or substance-induced (SID). It is not established whether these conditions respond differently to treatment. METHODS MEDLINE, Embase and Cochrane databases from 1980 to 2014 were searched for studies on alcohol use disorders with coexisting depressive symptoms. Meta-analyses were conducted using random effects models, to derive pooled effect estimates of the change in depression during treatment and the effect of antidepressant therapy. RESULTS Twenty-two studies met inclusion criteria for the review, of which 11/22 were included in the meta-analysis. All studies reported a large improvement in depression symptom score, most of which occurred within the first 3-6 weeks of treatment. The amount of improvement during follow up was similar in studies on ID in comparison to those in undifferentiated depression. Evidence on the outcome for SID was limited. The effect size of antidepressant therapy compared to placebo was 0.25 (0.06, 0.44) for ID and 0.08 (-0.31, 0.47) for SID or undifferentiated depression. LIMITATIONS Few studies examined the natural history and treatment response of SID. There was heterogeneity between studies, which was partly explained by baseline depression severity. CONCLUSIONS Treatment for depression co-occurring with an alcohol use disorder is associated with a large early improvement in depression, even if depression is believed to be independent of drinking. The effect of antidepressant therapy on depression in patients with alcohol use disorders is modest, with stronger evidence in ID.
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Affiliation(s)
- James A Foulds
- Department of Psychological Medicine, University of Otago, Christchurch, New Zealand.
| | - Simon J Adamson
- Department of Psychological Medicine, University of Otago, Christchurch, New Zealand
| | - Joseph M Boden
- Christchurch Health and Development Study, University of Otago, Christchurch, New Zealand
| | - Jonathan A Williman
- Biostatistics and Computational Biology, Department of Public Health and General Practise, University of Otago, Christchurch, New Zealand
| | - Roger T Mulder
- Department of Psychological Medicine, University of Otago, Christchurch, New Zealand
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Schoonover K, Burton MC, Larson SA, Cha SS, Lapid MI. Depression and alcohol withdrawal syndrome: is antidepressant therapy associated with lower rates of hospital readmission? Ir J Med Sci 2015; 185:573-579. [PMID: 25916789 DOI: 10.1007/s11845-015-1304-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2015] [Accepted: 04/18/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Alcohol withdrawal syndrome (AWS) is a frequent cause of admission to acute care hospitals and many of these patients have a history of depression. AIM Our objective was to determine if antidepressant use in patients with a history of depression is associated with lower rates of hospital readmission for AWS. METHODS A retrospective study was performed of patients admitted with AWS between January 1, 2006 and December 31, 2008 to an academic tertiary referral hospital. RESULTS Three hundred and twenty-two patients were admitted with AWS during the study period. One hundred and sixty-one patients (50 %) had no history of depression, 111 patients (34 %) had a history of depression and antidepressant use, and 50 patients (16 %) had a history of depression and no antidepressant use. There was no significant difference in the number of hospitalizations for AWS between these three groups. Patients with a history of depression on antidepressant medication were more likely to be retired or work disabled compared to the other two groups (p < 0.05). The antidepressant class most commonly used was SSRI (63 %). CONCLUSION Our study highlights the high frequency of depression and antidepressant use in patients admitted with AWS to an acute care hospital. As alcohol withdrawal is associated with increased morbidity and mortality and depression is common in those with alcohol use disorder, further research is necessary to clarify the optimal treatment of comorbid depression and alcohol use disorder in reducing these revolving door admissions.
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Affiliation(s)
- K Schoonover
- Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - M C Burton
- Department of Medicine, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA
| | - S A Larson
- Department of Internal Medicine, University of Texas Medical Branch, 301 University Blvd, Galveston, TX, 77555, USA
| | - S S Cha
- Division of Biostatistics, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - M I Lapid
- Department of Psychiatry, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
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21
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Nunes EV, Covey LS, Brigham G, Hu MC, Levin FR, Somoza E, Winhusen T. Treating nicotine dependence by targeting attention-deficit/ hyperactivity disorder (ADHD) with OROS methylphenidate: the role of baseline ADHD severity and treatment response. J Clin Psychiatry 2013; 74:983-90. [PMID: 24229749 PMCID: PMC3946795 DOI: 10.4088/jcp.12m08155] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2012] [Accepted: 02/11/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To determine whether treatment of attention-deficit/hyperactivity disorder (ADHD) with osmotic-release oral system (OROS) methylphenidate promotes abstinence from smoking among smokers with ADHD who have greater severity of ADHD symptoms at baseline or greater improvement in ADHD during treatment. METHOD This is a secondary analysis of data from a randomized, double-blind, 11-week trial conducted between December 2005 and January 2008 at 6 clinical sites; the original trial was sponsored by the National Drug Abuse Clinical Trials Network. Adult cigarette smokers (aged 18-55 years) who met DSM-IV criteria for ADHD were randomly assigned to OROS methylphenidate (72 mg/d) (n = 127) or matching placebo (n = 128). All participants received nicotine patches (21 mg/d) and weekly individual smoking cessation counseling. Logistic regression was used to model prolonged abstinence from smoking (ascertained by self-report and breath carbon monoxide testing) as a function of treatment, baseline ADHD Rating Scale-IV (ADHD-RS) score, change in ADHD-RS score during treatment, and their interactions. RESULTS Treatment interacted with both ADHD-RS score at baseline (P = .01) and change in ADHD-RS score during treatment (P = .008). Among patients with higher ADHD-RS scores (> 36) at baseline and the most improvement in ADHD during treatment (ADHD-RS change score ≥ 24), 70.0% of those who took OROS methylphenidate achieved abstinence from smoking compared to 36.8% of those who took placebo (P = .02). In contrast, among patients with the lowest ADHD-RS baseline scores (≤ 30), 30.3% of those who took OROS methylphenidate achieved abstinence from smoking compared to 60.7% of those who took placebo (P = .02). CONCLUSIONS OROS methylphenidate, in combination with nicotine patch, may be an effective treatment for nicotine dependence among smokers with more severe ADHD and more robust response of ADHD symptoms to medication. OROS methylphenidate may be counterproductive among smokers with lower severity of ADHD. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT00253747.
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Affiliation(s)
- Edward V. Nunes
- Columbia University, Department of Psychiatry, New York, NY, New York State Psychiatric Institute, New York, NY,Corresponding Author: Edward V. Nunes, M.D. New York State Psychiatric Institute 1051 Riverside Drive, Unit 51, Room 3717 New York, NY 10032 phone: 212-543-5581 fax: 212-543-5326
| | - Lirio S. Covey
- Columbia University, Department of Psychiatry, New York, NY, New York State Psychiatric Institute, New York, NY
| | - Gregory Brigham
- Maryhaven, Inc., Columbus, OH, University of Cincinnati College of Medicine, Department of Psychiatry and Behavioral Neuroscience, Cincinnati, OH
| | - Mei-Chen Hu
- Columbia University, Department of Psychiatry, New York, NY
| | - Frances R. Levin
- Columbia University, Department of Psychiatry, New York, NY, New York State Psychiatric Institute, New York, NY
| | - Eugene Somoza
- University of Cincinnati College of Medicine, Department of Psychiatry and Behavioral Neuroscience, Cincinnati, OH, Cincinnati Veterans Affairs Medical Center, Cincinnati, OH
| | - Theresa Winhusen
- University of Cincinnati College of Medicine, Department of Psychiatry and Behavioral Neuroscience, Cincinnati, OH
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Placebo group improvement in trials of pharmacotherapies for alcohol use disorders: a multivariate meta-analysis examining change over time. J Clin Psychopharmacol 2013; 33:649-57. [PMID: 23857312 PMCID: PMC4076955 DOI: 10.1097/jcp.0b013e3182983e73] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Placebo group improvement in pharmacotherapy trials has been increasing over time across several pharmacological treatment areas. However, it is unknown to what degree increasing improvement has occurred in pharmacotherapy trials for alcohol use disorders or what factors may account for placebo group improvement. This meta-analysis of 47 alcohol pharmacotherapy trials evaluated (1) the magnitude of placebo group improvement, (2) the extent to which placebo group improvement has been increasing over time, and (3) several potential moderators that might account for variation in placebo group improvement. METHOD Random-effects univariate and multivariate analyses were conducted that examined the magnitude of placebo group improvement in the 47 studies and several potential moderators of improvement: (a) publication year, (b) country in which the study was conducted, (c) outcome data source/type, (d) number of placebo administrations, (e) overall severity of study participants, and (f) additional psychosocial treatment. RESULTS Substantial placebo group improvement was found overall and improvement was larger in more recent studies. Greater improvement was found on moderately subjective outcomes, with more frequent administrations of the placebo, and in studies with greater participant severity of illness. However, even after controlling for these moderators, placebo group improvement remained significant, as did placebo group improvement over time. CONCLUSIONS Similar to previous pharmacotherapy placebo research, substantial pretest to posttest placebo group improvement has occurred in alcohol pharmacotherapy trials, an effect that has been increasing over time. However, several plausible moderator variables were not able to explain why placebo group improvement has been increasing over time.
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Sannibale C, Teesson M, Creamer M, Sitharthan T, Bryant RA, Sutherland K, Taylor K, Bostock-Matusko D, Visser A, Peek-O'Leary M. Randomized controlled trial of cognitive behaviour therapy for comorbid post-traumatic stress disorder and alcohol use disorders. Addiction 2013; 108:1397-1410. [PMID: 25328957 DOI: 10.1111/add.12167] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Aims This study aimed to test the efficacy of integrated cognitive behaviour therapy (CBT) for coexisting post traumatic stress disorder (PTSD) and alcohol use disorders (AUD). Setting Clinics across Sydney, Australia.Design Randomized controlled trial of 12 once-weekly individual sessions of either integrated CBT for PTSD and AUD(integrated therapy, IT; n = 33) or CBT for AUD plus supportive counselling (alcohol-support, AS; n = 29). Blind assessments were conducted at baseline and post-treatment and at 5 [standard deviation (SD) = 2.25] and 9.16(SD = 3.45) months post-treatment. Participants Sixty-two adults with concurrent PTSD and AUD. Measurements Outcomes included changes in alcohol consumption (time-line follow-back), PTSD severity [clinician-administered PTSD scale (CAPS)], alcohol dependence and problems, and depression and anxiety. Findings Reductions in PTSD severity were evident in both groups. IT participants who had received one or more sessions of exposure therapy exhibited a twofold greater rate of clinically significant change in CAPS severity at follow-up than AS participants [IT60%, AS 39%, odds ratio (OR): 2.31, 95% confidence interval (CI): 1.06, 5.01]. AS participants exhibited larger reductions than IT participants in alcohol consumption, dependence and problems within the context of greater treatment from other services during follow-up. Results lend support to a mutually maintaining effect between AUD and PTSD. Conclusions Individuals with severe and complex presentations of coexisting post-traumatic stress disorder(PTSD) and alcohol use disorders (AUD) can derive substantial benefit from cognitive behaviour therapy targeting AUD, with greater benefits associated with exposure for PTSD. Among individuals with dual disorders, these therapies can generate significant, well-maintained treatment effects on PTSD, AUD and psychopathology.
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Affiliation(s)
- Claudia Sannibale
- National Drug and Alcohol Research Centre, University of New SouthWales, Sydney, NSW, Australia
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A randomized, controlled, pilot study of acamprosate added to escitalopram in adults with major depressive disorder and alcohol use disorder. J Clin Psychopharmacol 2012; 32:787-96. [PMID: 23131884 PMCID: PMC3794470 DOI: 10.1097/jcp.0b013e3182726764] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We sought to examine the efficacy and safety of acamprosate augmentation of escitalopram in patients with concurrent major depressive disorder (MDD) and alcohol use disorders. Twenty-three adults (43% female; mean ± SD age, 46 ± 14 years) were enrolled and received 12 weeks of treatment with psychosocial support; escitalopram, 10 to 30 mg/d; and either acamprosate, 2000 mg/d (n = 12), or identical placebo (n = 11). Outcomes included change in clinician ratings of depressive symptoms, MDD response and remission rates, changes in frequency and intensity of alcohol use, retention rates, and adverse events. Twelve subjects (acamprosate, n = 7; placebo, n = 5) completed the study. There was significant mean reduction in ratings of depressive symptoms from baseline in both treatment arms (P < 0.05), with no significant difference between the groups. Those in the acamprosate group had a 50% MDD response rate and a 42% remission rate, whereas those in the placebo arm had a 36% response and remission rate (not significant). Those assigned to acamprosate had significant reduction in number of drinks per week and drinks per month during the trial, whereas those assigned to placebo demonstrated no significant change in any alcohol use parameter, but the between-group difference was not significant. There were no significant associations between change in depressive symptoms and change in alcohol use. Attrition rates did not differ significantly between the 2 arms. Acamprosate added to escitalopram in adults with MDD and alcohol use disorders was associated with reduction in the frequency of alcohol use. The present study was not powered to detect superiority versus placebo. Further study in a larger sample is warranted.
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Lev-Ran S, Balchand K, Lefebvre L, Araki KF, Le Foll B. Pharmacotherapy of alcohol use disorders and concurrent psychiatric disorders: a review. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2012; 57:342-9. [PMID: 22682571 DOI: 10.1177/070674371205700603] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Alcohol use disorders (AUDs) are among the most prevalent psychiatric disorders. Epidemiologic studies have shown a high prevalence of concurrent psychiatric disorders among people with AUDs as well as a higher prevalence of AUDs in people with psychiatric disorders than in the general population. Though psychiatric patients with concurrent AUDs are at increased risk for morbidity and mortality, they are commonly undertreated for their alcohol-related disorders. The efficacy of pharmacotherapy for AUDs is well documented. Our paper reviews the common pharmacotherapies available for AUDs and focuses on the available research regarding treatment of AUDs among psychiatric populations with mood, anxiety, and psychotic disorders. Despite the high prevalence of concurrent AUDs and psychiatric disorders, very limited information has been collected using a randomized controlled trial design targeting those concurrent conditions. Several prevalent psychiatric disorders have not been studied when co-occurring with AUDs. Further research of pharmacological treatments for concurrent AUDs and psychiatric diagnoses is urgently needed.
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Affiliation(s)
- Shaul Lev-Ran
- Translational Addiction Research Laboratory, Addictions Program, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
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Hauser SR, Getachew B, Taylor RE, Tizabi Y. Alcohol induced depressive-like behavior is associated with a reduction in hippocampal BDNF. Pharmacol Biochem Behav 2011; 100:253-8. [PMID: 21930150 DOI: 10.1016/j.pbb.2011.08.014] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2011] [Revised: 08/10/2011] [Accepted: 08/13/2011] [Indexed: 12/17/2022]
Abstract
Strong positive correlation between depression and alcoholism is evident in epidemiological reports. However, a causal relationship for this co-morbidity has not been established. We have observed that chronic daily exposure to a relatively high dose of alcohol can induce depressive-like behavior in rats and that pretreatment with nomifensine or imipramine can block the "depressogenic" effects of alcohol. Since brain derived neurotrophic factor (BDNF) is considered to play an important role in depressive-like behaviors and its elevation, particularly in the hippocampus, appears to be critical for the action of many antidepressants, we hypothesized that: 1. WKY rats, a putative animal model of depression, will show a lower hippocampal BDNF compared to their control Wistar rats, 2. Alcohol-induced depressive like behavior will be associated with a significant decrease in hippocampal BDNF and 3. Treatments with antidepressants will normalize hippocampal BDNF. These postulates were verified by measuring hippocampal BDNF in Wistar and WKY rats at baseline, following chronic (10 day) treatment with alcohol and combination of alcohol with nomifensine or imipramine. Alcohol was administered via inhalation chamber (3 h/day) such that a blood alcohol level of approximately 150 mg% was achieved. Nomifensine (10 mg/kg) or imipramine (10 mg/kg) was administered i.p. daily immediately after alcohol exposure. BDNF was measured by standard ELISA kit. The results support a role for central BDNF in depressogenic effects of alcohol and antidepressant effects of nomifensine and imipramine. Moreover, depression per se as manifested in WKY rats may be associated with a reduction in hippocampal BDNF.
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Affiliation(s)
- Sheketha R Hauser
- Department of Pharmacology, College of Medicine, Howard University, Washington, DC 20059, United States
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Hobbs JDJ, Kushner MG, Lee SS, Reardon SM, Maurer EW. Meta-analysis of supplemental treatment for depressive and anxiety disorders in patients being treated for alcohol dependence. Am J Addict 2011; 20:319-29. [PMID: 21679263 DOI: 10.1111/j.1521-0391.2011.00140.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Approximately half of those receiving treatment for an alcohol use disorder (AUD) also suffer with an anxiety or depressive (internalizing) disorder. Because all internalizing disorders mark a poor alcohol treatment outcome, it seems reasonable to supplement AUD treatment with a psychiatric intervention when these disorders co-occur with AUD. However, this conclusion may be faulty given that the various possible interrelationships between AUD and internalizing disorders do not uniformly imply a high therapeutic yield from this approach. Unfortunately, the studies conducted to date have been too few and too small to resolve this important clinical issue with confidence. Therefore, we used a meta-analytic method to synthesize the effects from published randomized controlled trials examining the impact of supplementing AUD treatment with a psychiatric treatment for co-occurring internalizing disorder (N = 15). We found a pooled effect size (d) of .32 for internalizing outcomes and .22 for a composite of alcohol outcomes; however, the alcohol outcomes effect sizes were greater than this for some specific outcome domains. Subgroups that differed in terms of internalizing outcomes included treatment type (medication vs. cognitive behavioral therapy) and treatment focus (anxiety vs. depression). There was also a trend for the studies with better internalizing disorder outcomes to have better alcohol outcomes. These results indicate that clinical outcomes (both psychiatric and alcohol-related) could be somewhat improved by supplementing AUD treatment with psychiatric treatment for co-occurring internalizing disorder.
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Affiliation(s)
- Jennifer D J Hobbs
- Department of Psychiatry, University of Minnesota, Minneapolis, 55454, USA
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Pani PP, Trogu E, Amato L, Davoli M. Antidepressants for the treatment of depression in alcohol dependent individuals. Hippokratia 2010. [DOI: 10.1002/14651858.cd008581] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Pier Paolo Pani
- Health District 8 (ASL 8) Cagliari; Social-Health Division; Cittadella della Salute, padiglione C via Romagna 16 Cagliari Sardinia Italy 09127
| | - Emanuela Trogu
- Health District 8 (ASL 8) Cagliari; Social-Health Division; Cittadella della Salute, padiglione C via Romagna 16 Cagliari Sardinia Italy 09127
| | - Laura Amato
- ASL RM/E; Department of Epidemiology; Via di Santa Costanza, 53 Rome Italy 00198
| | - Marina Davoli
- ASL RM/E; Department of Epidemiology; Via di Santa Costanza, 53 Rome Italy 00198
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Cuijpers P, van Straten A, Hollon SD, Andersson G. The contribution of active medication to combined treatments of psychotherapy and pharmacotherapy for adult depression: a meta-analysis. Acta Psychiatr Scand 2010; 121:415-23. [PMID: 19922522 DOI: 10.1111/j.1600-0447.2009.01513.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Although there is sufficient evidence that combined treatments of psychotherapy and pharmacotherapy are more effective for depression in adults than each of the treatments alone, it remains unclear what the exact contribution of active medication is to the overall effects of combined treatments. This paper examines the contribution of active medication to combined psychotherapy and pharmacotherapy treatments. METHOD Meta-analysis of randomised controlled trials comparing the combination of psychotherapy and pharmacotherapy with the combination of psychotherapy and placebo. RESULTS Sixteen identified studies involving 852 patients met our inclusion criteria. The standardised mean difference indicating the differences between the combination of psychotherapy and pharmacotherapy and the combination of psychotherapy and placebo was 0.25 (95% CI: 0.03-0.46), which corresponds to a numbers-needed-to-be-treated of 7.14. No significant differences between subgroups of studies were found. CONCLUSION Active medication has a small but significant contribution to the overall efficacy of combined treatments.
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Affiliation(s)
- P Cuijpers
- Department of Clinical Psychology and EMGO Institute, VU University Amsterdam, Amsterdam, the Netherlands.
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Salloum I, Douaihy A, Williams L. Diagnostic and Treatment Considerations: Bipolar Patients with Comorbid Substance Use Disorders. Psychiatr Ann 2008. [DOI: 10.3928/00485713-20081101-09] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Nunes EV, Levin FR. Treatment of Co-occurring Depression and Substance Dependence: Using Meta-analysis to Guide Clinical Recommendations. Psychiatr Ann 2008; 38:nihpa128505. [PMID: 19668349 DOI: 10.3928/00485713-20081101-05] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Edward V Nunes
- Columbia University College of Physicians and Surgeons, and N.Y. State Psychiatric Institute, New York
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Soyka M, Kranzler HR, Berglund M, Gorelick D, Hesselbrock V, Johnson BA, Möller HJ, Soyka M, Kranzler HR, Berglund M, Gorelick D, Hesselbrock V, Johnson BA, Möller HJ, THE WFSBP TASK FORCE ON TREATMENT G. World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Substance Use and Related Disorders, Part 1: Alcoholism. World J Biol Psychiatry 2008; 9:6-23. [PMID: 18273737 DOI: 10.1080/15622970801896390] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
These practice guidelines for the biological treatment of substance use disorders were developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). The goal during the development of these guidelines was to review systematically all available evidence pertaining to the treatment of substance use disorders, and to reach a consensus on a series of practice recommendations that are clinically and scientifically meaningful based on the available evidence. These guidelines are intended for use by physicians evaluating and treating people with substance use disorders and are primarily concerned with the biological treatment of adults suffering from substance use disorders. The data used to develop these guidelines were extracted primarily from various national treatment guidelines for substance use disorders, as well as from meta-analyses, reviews and randomized clinical trials on the efficacy of pharmacological and other biological treatment interventions identified by a search of the MEDLINE database and Cochrane Library. The identified literature was evaluated with respect to the strength of evidence for its efficacy and then categorized into four levels of evidence (A-D). This first part of the guidelines covers the treatment of alcohol dependence; Part 2 will be devoted to the treatment of drug dependence.
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Affiliation(s)
- Michael Soyka
- Psychiatric Hospital Meiringen, Meiringen, Switzerland
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Altintoprak AE, Zorlu N, Coskunol H, Akdeniz F, Kitapcioglu G. Effectiveness and tolerability of mirtazapine and amitriptyline in alcoholic patients with co-morbid depressive disorder: a randomized, double-blind study. Hum Psychopharmacol 2008; 23:313-9. [PMID: 18327889 DOI: 10.1002/hup.935] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Studies indicate that serotoninergic and noradrenergic pathophysiological mechanisms may underlie both alcohol abuse/dependence and depressive disorder. The purpose of this study was to evaluate and compare the effectiveness and tolerability of two serotonergic and noradrenergic antidepressant drugs-mirtazapine and amitriptyline, for the treatment of patients with alcohol dependence co-morbid with depressive disorder in a randomized, double-blind treatment setting. METHODS Forty-four patients were included in the study. Twenty-four patients were randomized to mirtazapine and twenty to amitriptyline groups. Thirty-six of them completed the study. The 17-item Hamilton Depression Rating Scale (HDRS), the Spielberger State-Trait Anxiety Inventory (STAI) and alcohol craving questionnaire were used at baseline and, at days 7, 14, 28, 42, and 56 to estimate the effectiveness of the antidepressant treatment. Michigan Alcoholism Screening Test (MAST) was used in the assessment of alcohol dependence. The tolerability was assessed with the Udvalg for Kliniske Undersogelser Side Effect Rating Scale (UKU). RESULTS There was significant improvement in HDRS and alcohol craving scores with both the drugs. However there were no statistical differences between treatment groups. Mirtazapine was tolerated better than amitriptyline treatment. CONCLUSIONS The treatment with either mirtazapine or amitriptyline resulted with the reduction of HDRS and craving scores. The side-effect profile of mirtazapine was relatively favorable in our study.
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Abstract
Co-occurring psychiatric and alcohol use disorders can have devastating personal and societal effects, yet little evidence exists to guide clinical treatment. In the face of scant data, individual practitioners must rely instead on professional experience and those limited practice guidelines that currently exist. The American Psychiatric Association (APA) advises that failure to treat a concurrent psychiatric disorder reduces the likelihood that the treatment for a substance use disorder (SUD) will be effective. Indeed, the effects of nontreatment were demonstrated in a prospective study assessing alcohol-dependent patients for 1 year following hospitalization for alcohol dependence, in which untreated depression was directly associated with a shorter time to first drink. The results also showed that among those patients with depression (Slide 1), taking antidepressants at the time of discharge increased the likelihood of an individual remaining abstinent during the follow-up period.
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Johnson BA. Update on neuropharmacological treatments for alcoholism: scientific basis and clinical findings. Biochem Pharmacol 2007; 75:34-56. [PMID: 17880925 PMCID: PMC2359153 DOI: 10.1016/j.bcp.2007.08.005] [Citation(s) in RCA: 172] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2007] [Revised: 08/02/2007] [Accepted: 08/06/2007] [Indexed: 12/16/2022]
Abstract
The past decade has seen an expansion of research and knowledge on pharmacotherapy for the treatment of alcohol dependence. The Food and Drug Administration (FDA)-approved medications naltrexone and acamprosate have shown mixed results in clinical trials. Oral naltrexone and naltrexone depot formulations have generally demonstrated efficacy at treating alcohol dependence, but their treatment effect size is small, and more research is needed to compare the effects of different doses on drinking outcome. Acamprosate has demonstrated efficacy for treating alcohol dependence in European trials, but with a small effect size. In U.S. trials, acamprosate has not proved to be efficacious. Research continues to explore which types of alcohol-dependent individual would benefit the most from treatment with naltrexone or acamprosate. The combination of the two medications demonstrated efficacy for treating alcohol dependence in one European study but not in a multi-site U.S. study. Another FDA-approved medication, disulfiram, is an aversive agent that does not diminish craving for alcohol. Disulfiram is most effective when given to those who are highly compliant or who are receiving their medication under supervision. Of the non-approved medications, topiramate is among the most promising, with a medium effect size in clinical trials. Another promising medication, baclofen, has shown efficacy in small trials. Serotonergic agents such as selective serotonin reuptake inhibitors and the serotonin-3 receptor antagonist, ondansetron, appear to be efficacious only among certain genetic subtypes of alcoholic. As neuroscientific research progresses, other promising medications, as well as medication combinations, for treating alcohol dependence continue to be explored.
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Affiliation(s)
- Bankole A Johnson
- Department of Psychiatry and Neurobehavioral Sciences, University of Virginia, P.O. Box 800623, Charlottesville, VA 22908-0623, USA.
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To Screen or Not to Screen: Conceptual Issues in Screening for Psychiatric Disorders in Psychiatric Patients with a Focus on the Performance of the Psychiatric Diagnostic Screening Questionnaire. Int J Ment Health Addict 2007. [DOI: 10.1007/s11469-007-9099-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Abstract
BACKGROUND Comorbid substance use and mental illness is prevalent and often results in serious consequences. However, little is known about the efficacy of treatments for patients with dual diagnosis. METHODS This paper reviews both the psychosocial and medication treatments for those diagnosed with a substance-related disorder and one of the following disorders: (a) depression, (b) anxiety disorder, (c) schizophrenia, (d) bipolar disorder, (e) severe mental illness, and (f) nonspecific mental illness. We made no restriction of study design to include all published studies, due to the dearth of studies on treatments of patients with dual diagnosis. RESULTS Fifty-nine studies were identified (36 randomized-controlled trials; RCT). Limited number of studies, especially RCTs, have been conducted within each comorbid category. This review did not find treatments that had been replicated and consistently showed clear advantages over comparison condition for both substance-related and other psychiatric outcomes. CONCLUSIONS Although no treatment was identified as efficacious for both psychiatric disorders and substance-related disorder, this review finds: (1) existing efficacious treatments for reducing psychiatric symptoms also tend to work in dual-diagnosis patients, (2) existing efficacious treatments for reducing substance use also decrease substance use in dually diagnosed patients, and (3) the efficacy of integrated treatment is still unclear. This review provides a critique of the current state of the literature, identifies the directions for future research on treatment of dual-diagnosis individuals, and calls for urgent attention by researchers and funding agencies to conduct more and more methodologically rigorous research in this area.
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Affiliation(s)
- Quyen Q Tiet
- Center for Health Care Evaluation, VA Palo Alto Health Care System, Palo Alto, California 94025, USA.
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38
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Brown SA, Glasner-Edwards SV, Tate SR, McQuaid JR, Chalekian J, Granholm E. Integrated cognitive behavioral therapy versus twelve-step facilitation therapy for substance-dependent adults with depressive disorders. J Psychoactive Drugs 2007; 38:449-60. [PMID: 17373561 DOI: 10.1080/02791072.2006.10400584] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
In a randomized trial, this study compared the longitudinal outcome patterns of veterans (N = 66) with substance use disorders and major depressive disorder receiving standard pharmacotherapy and either 12-Step Facilitation Therapy (TSF) or disorder-specific Integrated Cognitive Behavioral Treatment (ICBT). Depression and substance use were assessed at intake, during and after treatment using the Hamilton Depression Rating Scale and the Time Line Follow Back. Reductions in depression during treatment were comparable between the two treatment groups; however, their posttreatment patterns were distinct. While ICBT participants evidenced a steady linear decline in depression through six months posttreatment, a quadratic trend characterized TSF participants, for whom depression declined during treatment, but increased throughout posttreatment follow-up. During treatment, TSF participants used substances less frequently relative to those in ICBT; however, reductions in substance use were more stable through six months posttreatment among those in ICBT relative toTSF. While both interventions produced improvement in depression and substance use during treatment, ICBT may yield more stable clinical outcomes once treatment ceases.
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Affiliation(s)
- Sandra A Brown
- Department of Psychology, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA 92093-0109, USA.
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39
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Ostacher MJ. Comorbid alcohol and substance abuse dependence in depression: impact on the outcome of antidepressant treatment. Psychiatr Clin North Am 2007; 30:69-76. [PMID: 17362804 DOI: 10.1016/j.psc.2006.12.009] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Major depressive disorder often co-occurs with substance use disorders, especially alcohol use disorders, and the course of each of these problems seems be complicated by the other. Diagnosing and treating these patients is challenging. A significant difficulty for clinicians is deciding whether to treat a mood episode in a patient who has current substance use or a substance use disorder, and what is the optimal treatment for that patient. This article discusses the prevalence of depressive and substance use disorder, the course of illness of comorbid depression and substance use disorders, and treatment response.
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40
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Goldstein BI, Diamantouros A, Schaffer A, Naranjo CA. Pharmacotherapy of alcoholism in patients with co-morbid psychiatric disorders. Drugs 2006; 66:1229-37. [PMID: 16827599 DOI: 10.2165/00003495-200666090-00005] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
There has been an exponential increase in recent years of literature pertaining to the treatment of individuals with alcohol use disorders and co-morbid psychiatric disorders. Patients with mood and anxiety disorders in particular have a very high prevalence of alcoholism. Alcoholism confers significant morbid risks to patients with psychiatric disorders, and vice versa, including markedly increased risk of suicide. Only recently have studies examined the impact of various psychiatric medications on alcohol use among patients with these disorders. Evidence supporting the benefits of antidepressants for co-morbid alcoholism and depression continues to mount. Although these studies have demonstrated benefits in terms of quantitative decreases in the volume and frequency of consumption, the benefits in terms of remission from alcoholism have yet to be shown conclusively. The first randomised, controlled trial involving subjects with co-morbid alcoholism and bipolar disorder was recently conducted, yielding promising results for valproate in this population. The literature regarding co-morbid alcoholism and anxiety disorders has also seen recent progress, particularly in the study of post-traumatic stress disorder (PTSD). A placebo-controlled study of sertraline suggests some benefit in terms of alcohol use among individuals with early-onset PTSD and less severe alcohol dependence. Atypical antipsychotics such as olanzapine and quetipaine have been examined in several open studies of subjects with alcoholism co-morbid with a variety of psychiatric conditions including bipolar disorder, PTSD and schizophrenia. This paper selectively reviews the evidence that is currently available for the pharmacological management of alcoholism among persons with co-morbid psychiatric illness. Effectiveness, safety and tolerability are considered, and directions for future study are discussed.
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Affiliation(s)
- Benjamin I Goldstein
- Department of Psychiatry, Sunnybrook and Women's College Health Sciences Centre, University of Toronto, Toronto, Canada
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41
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Rao U. Links between depression and substance abuse in adolescents: neurobiological mechanisms. Am J Prev Med 2006; 31:S161-74. [PMID: 17175411 DOI: 10.1016/j.amepre.2006.07.002] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2005] [Revised: 06/29/2006] [Accepted: 07/13/2006] [Indexed: 11/15/2022]
Abstract
Adolescence is a high-risk period for development of both depressive and substance use disorders. These two disorders frequently co-occur in adolescents and are associated with significant morbidity and mortality. Given the added economic and psychosocial burden associated with the comorbid condition, identification of risk factors associated with their co-occurrence is of great public health importance. Research with adult animals and humans has indicated several common neurobiological systems that link depressive and addictive disorders. Given the ongoing maturation of these systems throughout adolescence and early adult life, it is not clear how these neurobiological processes influence development and progression of both disorders. A better understanding of the pathophysiological mechanisms leading to the onset and course of these disorders during adolescence will be helpful in developing more effective preventive and treatment strategies, and thereby allow these youth to reach their full potential as adults.
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Affiliation(s)
- Uma Rao
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas 75390-9101, USA.
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Abstract
Pharmacological relapse prevention in alcoholism is a rather new clinical field with few drugs being available. Acamprosate, acting predominantly via glutamatergic pathways, and the opioid receptor antagonist naltrexone, were both shown to be efficient in improving rates for continuous abstinence, and not relapsing to heavy drinking in a number of clinical trials and meta-analyses. There are conflicting data on both drugs, especially for acamprosate, according to some recent US studies. However, overall, the evidence is good. Both drugs are approved in most European countries and the US. Efficacy data for disulfiram are mixed; it is a second-line medication compared with other drugs, and is probably most effective when used in a supervised setting. Recently, anticonvulsants including carbamazepine and topiramate have been discussed as possible anti-craving drugs, but there is still limited evidence for their efficacy. Although there is a significant comorbidity for alcoholism with affective disorder, anxiety and schizophrenia, relatively few controlled clinical trials have been performed in this area. Tricyclics have been found to be more effective than serotonin reuptake inhibitors in improving depressive symptoms in these patients.
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Affiliation(s)
- Michael Soyka
- Private Hospital Meiringen, P.O.Box 612, CH-3860 Meiringen, Switzerland.
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Abstract
The literature on the diagnosis and treatment of depression is reviewed to arrive at recommendations for clinical practice, future research, and models of service delivery. The DSM-IV criteria are found to provide a sound basis for diagnosis, and a review of placebo-controlled trials of antidepressant medications among substance-dependent patients suggests medication is effective in the setting of careful diagnosis, preferably during a currently observed abstinent period. Clinical recommendations offered for the approach to patients with co-occurring depression and substance dependence include the following: 1) Initiate treatment for substance dependence and encourage abstinence; 2) Conduct a careful psychiatric history and apply DSM-IV criteria for primary or substance-induced depression; 3) If depression meets diagnostic criteria and persists despite treatment of substance use disorder, treat the depression. Future research should include trials of psychotherapeutic or behavioral treatments, studies of treatment algorithms and of integrated systems of care, and studies of methods for disseminating diagnostic and treatment methods in an effort to diminish traditional boundaries between the skill sets of mental health and substance abuse clinicians.
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Affiliation(s)
- Edward V Nunes
- New York State Psychiatric Institute, 1051 Riverside Drive (Unit 51), New York, NY 10032, USA.
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Yoon SJ, Pae CU, Kim DJ, Namkoong K, Lee E, Oh DY, Lee YS, Shin DH, Jeong YC, Kim JH, Choi SB, Hwang IB, Shin YC, Cho SN, Lee HK, Lee CT. Mirtazapine for patients with alcohol dependence and comorbid depressive disorders: a multicentre, open label study. Prog Neuropsychopharmacol Biol Psychiatry 2006; 30:1196-201. [PMID: 16624467 DOI: 10.1016/j.pnpbp.2006.02.018] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Major depressive disorder and alcohol dependence are common and serious mental illnesses. There is a great interest in discovering useful treatments for both mood symptoms and alcohol abuse in those patients with depressive disorders and comorbid alcohol dependence. The primary purpose of this study was to evaluate the effectiveness and tolerability of mirtazapine for the treatment of patients with alcohol dependence comorbid with a depressive disorder in an open label, naturalistic multicentre treatment setting. The 17-item Hamilton Depression Rating Scale (HDRS), the Hamilton Anxiety Rating Scale (HARS) and the Clinical Global Impression-Severity (CGI-S) scale were measured at baseline and at weeks 4 and 8 for the assessment of treatment effectiveness. Alcohol craving was measured using the Obsessive Compulsive Drinking Scale (OCDS) and the Visual Analog Scale for Craving (VAS). This study showed a statistically significant reduction of the scores on the HDRS (13.9+/-7.3, p<0.0001), HARS (10.8+/-7.2, p<0.0001) and the CGI-S (1.7+/-1.0, p<0.0001) from baseline to the endpoint (week 8). The OCDS and VAS scores were also decreased significantly by 42.3% and 53.2% (9.0+/-10.0, p<0.0001; 2.5+/-2.4, p<0.0001, respectively). The number of patients with a 50% reduction or more in the HDRS and HARS scores was 103 (72.0%) and 106 (74.1%) at the endpoint, respectively. Adverse events related to mirtazapine were observed in 10% or more of the patients in this study. In conclusion, the results from this naturalistic study suggest that the use of mirtazapine for the patients with alcohol dependence comorbid with depressive disorder is accompanied by clinical improvement in their mood and alcohol craving.
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Affiliation(s)
- Su-Jung Yoon
- Department of Psychiatry, St. Paul's Hospital, College of Medicine, The Catholic University of Korea, Republic of Korea
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Nunes EV, Rounsaville BJ. Comorbidity of substance use with depression and other mental disorders: from Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) to DSM-V. Addiction 2006; 101 Suppl 1:89-96. [PMID: 16930164 DOI: 10.1111/j.1360-0443.2006.01585.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIMS To arrive at recommendations for addressing co-occurring psychiatric and substance use disorders in the development of the Diagnostic and Statistical Manual of Mental Disorders fifth edition (DSM-V) criteria. METHODS Synthesis of findings of other papers from a consensus conference and from the literature on diagnosis and treatment of co-occurring psychiatric and substance use disorders. Most of the relevant studies examine co-occurring depression. RESULTS The diagnosis and treatment of psychiatric syndromes that co-occur with substance use disorders has been a source of controversy, fueled in part by limitations of pre-DSM-IV nosologies. The DSM-IV scheme of classifying co-occurring disorders as primary (also referred to as independent) or substance-induced has promise in terms of good predictive validity, although pertinent longitudinal and treatment studies are limited. The substance-induced category answers the need of clinicians for a way to categorize patients with clinically significant psychiatric symptoms that occur in the setting of ongoing substance use. CONCLUSIONS DSM-V should retain the primary (independent) and substance-induced categories. In DSM-IV these categories are broadly defined and leave much to clinical judgement. Existing data sets should be brought to bear to refine the criteria, making them more detailed with clearer anchor points and more specificity around particular substances and psychiatric syndromes. More longitudinal studies and clinical trials are also needed. Looking beyond DSM-V, co-occurring psychiatric syndromes are likely to be important in the quest for a nosology founded on pathophysiology.
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Affiliation(s)
- Edward V Nunes
- New York State Psychiatric Institute and Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York, USA.
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46
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Abstract
This study investigated the temporal course of improvement in PTSD and alcohol dependence symptoms among individuals participating in a 12-week outpatient treatment study. Participants were 94 individuals with comorbid PTSD and alcohol dependence enrolled in a double-blind, placebo-controlled medication trial. Outcome measures included PTSD symptoms (as measured by the Clinician Administered PTSD Scale, Impact of Events Scale, and Civilian Mississippi Scale for PTSD) and alcohol use severity (as measured by the Time Line Follow Back). Study completion rates were significantly higher for individuals who demonstrated improvement in both disorders. Improvements in PTSD had a greater impact on improvement in alcohol dependence symptoms than the reciprocal relationship. Improvement in hyperarousal PTSD symptoms, in particular, was related to substantially improved alcohol use. Examination of the temporal course of symptom improvement revealed that alcohol symptoms tended to start improving either before or in conjunction with PTSD symptoms. Although preliminary in nature, these findings suggest that co-occurring PTSD symptoms may have a strong impact on alcohol dependence treatment outcome, and that PTSD treatment may be important to optimizing outcomes for patients with comorbid PTSD and alcohol dependence.
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Affiliation(s)
- Sudie E Back
- Medical University of South Carolina, Department of Psychiatry, Charleston, South Carolina 29425, USA
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47
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Abstract
Research involving suicidal alcoholics is scarce despite the frequent presence of suicidal ideation and behavior among alcoholics. Unfortunately, suicidal ideation is a common exclusion criterion from participation in most studies that are relevant to this population. This article addresses identifying, evaluating, and treating people with alcohol abuse or dependence who display suicidal ideation or suicidal behavior. The state of the art is reviewed regarding interventions, including acute stabilization and specific medications for alcoholism and depression with a special focus on the selective serotonin reuptake inhibitors. Appropriate hospitalization, discharge, and family involvement are discussed. Finally, gaps in knowledge are identified with a focus on priorities and directions for future research.
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Affiliation(s)
- Jack R Cornelius
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
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48
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Raby WN, Carpenter KM, Aharonovich E, Rubin E, Bisaga A, Levin F, Nunes EV. Temperament characteristics, as assessed by the tridimensional personality questionnaire, moderate the response to sertraline in depressed opiate-dependent methadone patients. Drug Alcohol Depend 2006; 81:283-92. [PMID: 16182468 DOI: 10.1016/j.drugalcdep.2005.07.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2005] [Revised: 07/26/2005] [Accepted: 07/27/2005] [Indexed: 11/18/2022]
Abstract
During a randomized, double-blind, placebo controlled study of the effects of sertraline in depressed methadone-maintained patients, 82 completed the tridimensional personality questionnaire (TPQ) to assess whether temperament dimensions can affect treatment-related changes in mood and drug use. Mood outcome significantly differed according to scores on the reward dependence scale (RD). Low RD participants displayed a significantly better mood response to sertraline than high RD participants. Participants with high harm avoidance (HA) scores were more likely to be abstinent at the end of the 12 week trial of sertraline than low HA participants. High persistence (P) participants were less likely to be abstinent at the end of the 12-week trial. These results suggest that temperament dimensions may be important for identifying substance dependent patients more likely to benefit from pharmacological interventions for comorbid depressive disorders.
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Affiliation(s)
- Wilfrid Noel Raby
- Substance Treatment and Research Service (S.T.A.R.S.), Division on Substance Abuse, Department of Psychiatry, New York State Psychiatric Institute and Columbia University, 1051 Riverside Drive, NYC, NY 10032, USA.
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Kranzler HR, Mueller T, Cornelius J, Pettinati HM, Moak D, Martin PR, Anthenelli R, Brower KJ, O'Malley S, Mason BJ, Hasin D, Keller M. Sertraline treatment of co-occurring alcohol dependence and major depression. J Clin Psychopharmacol 2006; 26:13-20. [PMID: 16415699 DOI: 10.1097/01.jcp.0000194620.61868.35] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Major depressive disorder occurs commonly in association with alcohol dependence, both in clinical samples and in the community. Efforts to treat major depressive disorder in alcoholics with antidepressants have yielded mixed results. This multicenter, double-blind, placebo-controlled trial of sertraline was designed to address many of the potential methodological shortcomings of studies of co-occurring disorders. METHOD Following a 1-week, single-blind, placebo lead-in period, 328 patients with co-occurring major depressive disorder and alcohol dependence were randomly assigned to receive 10 weeks of treatment with sertraline (at a maximum dose of 200 mg/d) or matching placebo. Randomization was stratified, based on whether initially elevated scores on the 17-item Hamilton Depression Rating Scale declined with cessation of heavy drinking, resulting in a sample of 189 patients with Hamilton Depression Rating Scale scores > or =17 (group A) and 139 patients with Hamilton Depression Rating Scale scores < or =16 (group B). RESULTS Both depressive symptoms and alcohol consumption decreased substantially over time in both groups. There were no reliable medication group differences on depressive symptoms or drinking behavior in either group A or B patients. CONCLUSION Despite careful attention to methodological considerations, this study does not provide consistent support for the use of sertraline to treat co-occurring major depressive disorder and alcohol dependence. The high rate of response among placebo-treated patients may help to explain these findings. Further research is needed to identify efficacious treatments for patients with these commonly co-occurring disorders.
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Affiliation(s)
- Henry R Kranzler
- Department of Psychiatry, University of Connecticut School of Medicine, Farmington, CT 06030-2103, USA.
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Abstract
There is a paucity of epidemiological data regarding the effects of substance use dependence (SUD) on the course of depression. This study analyzed data from the National Comorbidity Survey (NCS). Among respondents with lifetime SUD and unipolar depression, current SUD increased the risk (OR = 2.9) of past year depression and anxiety disorders (OR = 2.2).
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Affiliation(s)
- Vito Agosti
- Substance Use Research Center, New York State Psychiatric Institute, New York, New York 10032, USA.
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