Pharmacotherapy of alcoholism in patients with co-morbid psychiatric disorders

Going beyond risk factor: Childhood maltreatment and associated modifiable targets to improve life-long outcomes in mood disorders

Childhood maltreatment increases risk for mood disorders and is associated with earlier onset-and more pernicious disease course following onset-of mood disorders. While the majority of studies to date have been cross-sectional, longitudinal studies are emerging and support the devastating role(s) childhood maltreatment has on development of, and illness course in, mood disorders. This manuscript extends prior reviews to emphasize more recent work, highlighting longitudinal data, and discusses treatment studies that provide clues to mechanisms that mediate disease risk, course, relapse, and treatment response. Evidence suggesting systemic inflammation, alterations in hypothalamic-pituitary-adrenal (HPA) axis function and corticotropin-releasing factor (CRF) neural systems, genetic and other familial factors as mechanisms that mediate risk and onset of, and illness course in, mood disorders following childhood maltreatment is discussed. Risky behaviors following maltreatment, e.g., substance use and unhealthy lifestyles, may further exacerbate alterations in the HPA axis, CRF neural systems, and systematic inflammation to contribute to a more pernicious disease course. More research on sex differences and the impact of maltreatment in vulnerable populations is needed. Future research needs to be aimed at leveraging knowledge on modifiable targets, going beyond childhood maltreatment as a risk factor, to inform prevention and treatment strategies and foster trauma-informed care.

The Devastating Clinical Consequences of Child Abuse and Neglect: Increased Disease Vulnerability and Poor Treatment Response in Mood Disorders

A large body of evidence has demonstrated that exposure to childhood maltreatment at any stage of development can have long-lasting consequences. It is associated with a marked increase in risk for psychiatric and medical disorders. This review summarizes the literature investigating the effects of childhood maltreatment on disease vulnerability for mood disorders, specifically summarizing cross-sectional and more recent longitudinal studies demonstrating that childhood maltreatment is more prevalent and is associated with increased risk for first mood episode, episode recurrence, greater comorbidities, and increased risk for suicidal ideation and attempts in individuals with mood disorders. It summarizes the persistent alterations associated with childhood maltreatment, including alterations in the hypothalamic-pituitary-adrenal axis and inflammatory cytokines, which may contribute to disease vulnerability and a more pernicious disease course. The authors discuss several candidate genes and environmental factors (for example, substance use) that may alter disease vulnerability and illness course and neurobiological associations that may mediate these relationships following childhood maltreatment. Studies provide insight into modifiable mechanisms and provide direction to improve both treatment and prevention strategies.

Increased serum levels of sortilin are associated with depression and correlated with BDNF and VEGF

Neurotrophic factors have been investigated in relation to depression. The aim of the present study was to widen this focus to sortilin, a receptor involved in neurotrophic signalling. The serum sortilin level was investigated in 152 individuals with depression and 216 control individuals, and eight genetic markers located within the SORT1 gene were successfully analysed for association with depression. Genotyping was performed using the Sequenom MassARRAY platform. All the individuals returned a questionnaire and participated in a semi-structured diagnostic interview. Sortilin levels were measured by immunoassay, and potential determinants of the serum sortilin level were assessed by generalized linear models. Serum levels of brain-derived neurotrophic factor (BDNF) and vascular endothelial growth factor (VEGF) were measured in previous studies. We identified a significant increase of serum sortilin levels in depressed individuals compared with controls (P=0.0002) and significant positive correlation between serum sortilin levels and the corresponding levels of BDNF and VEGF. None of the genotyped SNPs were associated with depression. Additional analyses showed that the serum sortilin level was influenced by several other factors. Alcohol intake and body mass index, as well as depression, serum BDNF and serum VEGF were identified as predictors of serum sortilin levels in our final multivariate model. In conclusion, the results suggest a role of circulating sortilin in depression which may relate to altered activity of neurotrophic factors.

Solution-Focused Brief Therapy for Depression and Alcohol Dependence

This case study employs solution-focused brief therapy (SFBT) to alleviate depressive symptoms in an alcohol-dependent patient with comorbid personality disorder. Alcohol dependence and depression are frequent comorbid conditions in patients presenting for treatment. For some of these, personality disorders may further complicate treatment and even present a barrier to patients seeking or being offered treatment. In the case described, the patient only sought treatment after his gingivitis led to discovery of liver damage. In addition to SFBT, the patient was prescribed acamprosate to assist with abstinence from alcohol and fluoxetine for depression. Following three sessions of SFBT spaced at 1-month intervals, the patient reported maintaining abstinence from alcohol. His symptoms of depression as measured by Depression Anxiety Stress Scale reduced from severe to normal range, and he reported a reduction in the frequency and intensity of dark thoughts that had previously plagued him when sober. Outcomes were maintained 12 months following treatment.

Pharmacotherapy of alcohol use disorders and concurrent psychiatric disorders: a review

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.

Chronic mania revisited: factors associated with treatment non-response during prospective follow-up of a large European cohort (EMBLEM)

OBJECTIVE

To describe the course and outcome of patients with prospectively defined chronic mania and to identify predictors of treatment non-response.

METHOD

EMBLEM is a 2-year prospective, observational study of bipolar disorder treatment outcomes conducted in 14 European countries. Patients with a manic/mixed episode were assessed and prospectively followed for 1 year. Clinical scales (Clinical Global Impressions-Bipolar Disorder (CGI-BP) overall, mania, and depression; Young Mania Rating Scale (YMRS); and five-item Hamilton Depression Rating Scale (HAM-D-5)) and medication taken were systemically recorded. Treatment adherence and outcome measures were also captured. Chronic mania (non-response) was defined as not achieving more than one point improvement on CGI-BP mania scale during up to 12-month follow-up. The analysis was conducted with 3373 patients who had at least two CGI-BP mania ratings available.

RESULTS

A total of 15% of patients fulfilled criteria for chronic mania. Compared to those who responded to treatment, chronic mania was associated with lower severity of mania symptoms at baseline (OR = 0.44, 95% CI 0.37-0.52), shorter duration of current episode before treatment start (OR = 0.71, 95% CI 0.52-0.96), more delusions/hallucinations at baseline (OR = 1.12, 95% CI 1.03-1.22), less socially active (OR = 0.52, 95% CI 0.39-0.70) and greater occupational impairment (OR = 1.54, 95% CI 1.01-2.35) by multivariate statistical analysis.

CONCLUSIONS

Rather than severity or duration of manic symptoms, factors associated with chronicity in mania are the presence of psychotic symptoms and issues related to social and occupational functioning.

Treatment of alcohol dependence in patients with co-morbid major depressive disorder--predictors for the outcomes with memantine and escitalopram medication

Background

Alcohol dependence comorbid with major depressive disorder poses a major challenge in the clinical setting. The results in the treatment with selective serotonin re-uptake inhibitors have been conflicting. Thus, we compared in alcohol-dependent patients with co-morbid major depressive disorder the selective serotonin re-uptake inhibitor escitalopram to a compound that acts on different transporter system and may reduce craving, the glutamate receptor antagonist memantine.

Methods

Eighty alcohol-dependent patients comorbid with major depressive disorder in municipal alcohol clinics were randomized 1:1 to receive memantine 20 mg or escitalopram 20 mg in a double-blind manner. During the 26-week study period patients continued their routine treatment at the clinics. Abstinence was not required but encouraged. The patients attended visits weekly during the first month, and then at 3 and at 6 months. Outcome measures were Alcohol Use Disorders Identification Test (AUDIT), Obsessive Compulsive Drinking Scale (OCDS) and Drinking Diary.

Results

The completion rate was high in both groups, especially among the patients who had been abstinent at the beginning of the study. However, among those patients who were not abstinent at baseline, 47% in both groups discontinued the study. Numbers of abstinent days were high in both groups throughout the study. Alcohol consumption measured by the AUDIT QF (quantity-frequency) score was significantly reduced in both groups, as was the craving for alcohol measured by the OCDS. Early age at first alcohol intoxication predicted poor treatment outcomes in patients treated with escitalopram, and the same was seen with the early onset of the first depressive episode. The same predictive effects were not found in patients treated with memantine.

Conclusion

Our results indicate that both memantine and escitalopram are useful adjunct medications for the treatment of alcohol dependence co-morbid with major depression. Memantine was at least as effective with regard to drinking as escitalopram. We believe that a direct comparison of memantine, with the commonly used escitalopram, can provide useful information for clinicians on the treatment of alcohol dependency co-morbid with MDD.

Trial registration

ClinicalTrials.gov Identifier # NCT00368862

Evidence-based pharmacotherapy for mood and anxiety disorders with concurrent alcoholism

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.

[Management of comorbid bipolar disorder and alcohol dependence]

Recent studies confirm the clear association between bipolar disorders and alcohol abuse and dependence. Lifetime prevalence of disorders associated with alcohol abuse or dependence appears to be 3 to 4 times higher in patients with bipolar disorders than in the general population. Lifetime prevalence of mood disorders in alcohol-dependent subjects is approximately 10 times higher than in the general population. Despite the strength of this association, there is little information about specific management that takes into account both disorders and their interaction. One study shows that valproate may reduce excessive alcohol consumption in bipolar alcohol-dependent patients, especially because of its stabilizing and anticonvulsant effects. Based on this study, the American Psychiatry Association (APA) recently suggested the use of valproate in the treatment of patients with comorbid bipolar disorder and alcohol dependence.

Ethanol-BDNF interactions: still more questions than answers

Brain-derived neurotrophic factor (BDNF) has emerged as a regulator of development, plasticity and, recently, addiction. Decreased neurotrophic activity may be involved in ethanol-induced neurodegeneration in the adult brain and in the etiology of alcohol-related neurodevelopmental disorders. This can occur through decreased expression of BDNF or through inability of the receptor to transduce signals in the presence of ethanol. In contrast, recent studies implicate region-specific up-regulation of BDNF and associated signaling pathways in anxiety, addiction and homeostasis after ethanol exposure. Anxiety and depression are precipitating factors for substance abuse and these disorders also involve region-specific changes in BDNF in both pathogenesis and response to pharmacotherapy. Polymorphisms in the genes coding for BDNF and its receptor TrkB are linked to affective, substance abuse and appetitive disorders and therefore may play a role in the development of alcoholism. This review summarizes historical and pre-clinical data on BDNF and TrkB as it relates to ethanol toxicity and addiction. Many unresolved questions about region-specific changes in BDNF expression and the precise role of BDNF in neuropsychiatric disorders and addiction remain to be elucidated. Resolution of these questions will require significant integration of the literature on addiction and comorbid psychiatric disorders that contribute to the development of alcoholism.