Predictors of Antidepressant Response in Depressed Alcoholic Patients

The Role of Dissociation in the Cycle of Violence

The primary aim of this study was to examine the role of dissociation in the relationship between child maltreatment and intimate partner violence among 148 inner city women. It was proposed that dissociation would be a mediator in the relationship between child maltreatment and intimate partner perpetration. Overall, the hypothesis was supported. Findings revealed that women with a history of child maltreatment who experienced high levels of dissociation were more likely to be perpetrators of intimate partner violence than those with low levels of dissociation.

Alcohol and psychiatric comorbidity

Comorbid psychiatric disorders and drug use disorders (DUDs) are common among alcoholics (Regier, Farmer, Rae, Locke, Keith, Judd, & Goodwin, 1990; Kessler, McGonagle, Zhao, Nelson, Hughes, Eshleman, Wittchen, & Kendler, 1994). These comorbid disorders often predict a shorter time to relapse of alcoholism (Greenfield, Weiss, Muenz, Vagge, Kelly, Bello, & Michael, 1998). However, despite the prevalence and the adverse effects of this comorbidity, few controlled treatment studies have been conducted involving this dual diagnosis population (Litten & Allen, 1999). To date, most of these few studies of alcoholics with comorbid disorders have been restricted to studies of alcoholics with either comorbid major depression or comorbid anxiety disorders (Litten & Allen, 1995). The results of these trials suggest efficacy for SSRI antidepressants and tricyclic antidepressants for treating alcoholics with comorbid major depression and suggest efficacy for buspirone for treating alcoholics with comorbid anxiety disorders (Mason, Kocsis, Ritvo, & Cutler, 1996; Cornelius, Salloum, Ehler, Jarrett, Cornelius, Perel, Thase, & Black, 1997; Kranzler, Burleson, Del Boca, Babor, Korner, Brown, & Bohn, 1994). However, controlled treatment studies involving alcoholics with other comorbid disorders are almost totally lacking. Consequently, to date, no empirically proven treatment exists for most of these comorbid disorders.

Treating the substance-abusing suicidal patient

Studies concerning the treatment of substance-abusing suicidal patients are scarce despite the frequent presence of suicidal behavior among this population. Indeed, suicidality (ideation or behavior) is generally an exclusion criterion for participation in treatment studies of subjects with alcohol or drug abuse. Consequently, to date, little is known about the optimal treatment of this population. The first study involving substance-abusing suicidal patients was an open-label trial conducted in the early 1990s. This study involved 12 patients, all of whom demonstrated recent suicidal ideations and had made a lifetime suicide attempt. The results of that open-label study demonstrated significant within-group improvement in both depressive symptoms (including suicidal ideations) and level of drinking. However, substantial residual depressive symptoms and drinking persisted at the end of the trial. Also, because no placebo control group was utilized, the authors of that study could not rule out the possibility that the apparent therapeutic effect from fluoxetine was the result of the placebo effect. To date, only one double-blind, placebo-controlled study of subjects with alcohol or substance abuse has included substantial numbers of suicidal patients. The study involved 51 subjects, of whom 20 (39%) had made a suicide attempt in the current depressive episode, 31 (61%) had made a suicide attempt in their lifetime, and 46 (90%) had reported suicidal ideations in the week before hospitalization. The results of that double-blind, placebo-controlled study suggest that fluoxetine was effective in decreasing but not eliminating both the depressive symptoms (including suicidal ideations) and the level of alcohol consumption among a study group of subjects with comorbid major depressive disorder and alcohol dependence, many of whom displayed suicidal ideations. A secondary data analysis from that study suggested that cigarette smoking is also significantly decreased by fluoxetine, but the magnitude of the decrease is limited and few of these patients totally quit smoking with fluoxetine treatment alone. Another secondary data analysis from that study suggested that marijuana smoking was also significantly decreased in a subgroup of subjects who demonstrated cannabis abuse and that the magnitude of this improvement was robust. A third secondary data analysis from that study suggested that cocaine abuse acts as a predictor of poor outcome for both depressive symptoms (including suicidality) and level of alcohol use in this population. The results of a 1-year naturalistic follow-up study involving the patients from that study suggest that the benefits of fluoxetine in decreasing depressive symptoms and level of drinking persist 1 year after entering the treatment program. To date, no other double-blind, placebo-controlled studies involving substantial numbers of substance-abusing suicidal patients have been reported to either confirm or refute these findings. Further studies are clearly warranted to evaluate the efficacy of various pharmacotherapeutic agents and various psychotherapies in the treatment of substance-abusing suicidal patients.

A dual diagnosis typology to improve diagnosis and treatment of dual disorder patients

A dual diagnosis typology was developed with three subtypes. Type I is a primary psychiatric disorder with substance use only when psychiatrically symptomatic (self-medication). Type II is a primary substance use disorder with substance-induced psychiatric symptoms. Type III is psychiatric and substance use disorders of long duration that are co-occurring or present at different times. Type III is considered the "true" dual disorder state. This typology was found to be reliable and have consensual validity. It was used with a standardized interview and clinical interview plus questions designed to determine the subtype with patients in psychiatric and substance abuse outpatient programs and with state hospital inpatient dual disorder patients. The dual disorder subtypes found in the psychiatric outpatient programs were: Type I, 21%; Type II, 9%; and Type III, 70%. In the substance abuse programs were found: Type I, none; Type II, 37%; and Type III, 63%. The subtypes in the state psychiatric patients were: Type I, 14%; Type II, 47%; and Type III, 39%. This method was found to be relatively easy to apply; it also increased staff interest in the dual disorder population and improved differential diagnoses and targeted interventions.

Placebo-controlled study of sertraline in depressed recently abstinent alcoholics

BACKGROUND

Depression is common among recently abstinent alcoholics; however, its treatment has been little studied.

METHODS

Thirty-six depressed recently abstinent alcoholics were randomized in a 6-week double-blind placebo-controlled trial of sertraline 100 mg daily.

RESULTS

There was a significant group x time interaction for both the Hamilton Depression Rating Scale (HDRS) and the Beck Depression Inventory (BDI). For the HDRS there were significant differences between the sertraline and placebo groups at weeks 3 and 6 and for the BDI at week 3. Also, patients receiving sertraline had significantly lower mean posttreatment HDRS and BDI scores than patients receiving placebo. Furthermore, significantly more of the patients receiving sertraline obtained a Clinical Global Impression rating of "very much improved."

CONCLUSIONS

Depressed recently abstinent alcoholics benefit from antidepressant medication.

Psychiatric comorbidity in pathological gambling: a critical review

OBJECTIVE

To critically review the current literature on pathological gambling as regards the significant psychiatric comorbidities associated with it.

METHOD

The authors synthesized information found via electronic searches (MEDLINE) and bibliographic-directed searches in over 60 publications.

RESULTS

Pathological gamblers frequently have comorbid substance use disorders. In addition, a subset appear to have comorbid antisocial personality disorder, but they represent a minority when compared with those people who have acquired their antisocial traits as a consequence of their gambling behaviour. A comorbidity with the mood disorders is probable, but methodological concerns and inconsistencies with the data prevent further delineation of this. Emerging research for other disorders possibly associated with pathological gambling is also reviewed.

CONCLUSION

Pathological gambling is associated with significant psychiatric comorbidity. Recommendations for future research are described.

Dual diagnosis in primary care. Detecting and treating both the addiction and mental illness

The initial phase of treatment includes engaging the patient in a discussion about the doctor's concerns and providing patients with information about the problems as well as the possibility of change. Treatment of dual disorders often requires a heightened awareness of the consequences of the problem and the development of a realistic plan for change. The treatment plan must attempt to evaluate and treat the addiction and the psychiatric and medical illnesses.