Assessing co-occurring alcohol problems and depression​

Assessment aids

Important information for assessment can be gleaned from:

• longitudinal, prospective follow-up
• laboratory tests for mean cell volume (MCV) and/or gamma glutamyl transferase (GGT) 
• corroborating history from family (with patient's consent).

Self-medication and co-occurring disorders

Patients with an alcohol use disorder and symptoms of major depression have either a concurrent disorder or an alcohol use disorder that is causing alcohol-induced mood disorder.

The alcohol use should not be considered "self-medication" for depression. In other words, do not assume that treating the depression will stop the alcohol use. Both the alcohol use and the major depression need to be the focus of clinical attention (Health Canada, 2001b).

Assessments of major depression, especially in cases of concurrent substance use, should consider the possibility of bipolar disorder because it has the highest rate of psychiatric comorbidity with substance use disorders.

Co-occurring alcohol use disorder and major depressive disorder amplify the risks and functional impairment associated with each condition and complicate treatment (Davis et al., 2008; Gadermann, 2012; Lynskey, 1998; Schuckit et al., 2013).

Assessing patients with symptoms of psychosis

Patients presenting with symptoms of psychosis in addition to depressive symptoms should be considered to have major depression with psychotic features unless proven otherwise.

In such cases, if the patient is actively drinking, the diagnostic possibilities are quite broad and assessment will require a prolonged time period, including observations during abstinence.

Due to the very high risk of intended and unintended harm toward self or others, clinicians should seriously consider an emergency hospital admission.

Specific symptoms of psychosis

Visual misperceptions may be related to acute alcohol-withdrawal delirium or to depression with psychotic features. Either condition is an indication for immediate hospitalization.

If you are unable to confirm that the patient has been abstinent from alcohol for at least one week, consider the need for urgent medical withdrawal management.

Persistent delusions and auditory hallucinations beyond the period of acute withdrawal are unlikely to be related to alcohol withdrawal.

Clarifying the diagnosis

In presentations involving both alcohol use and symptoms of major depression, the likelihood that the patient has concurrent alcohol use disorder and major depressive disorder, rather than alcohol-induced depression, is increased by:

• a past history of idiopathic major depression or anxiety disorders in the absence of an alcohol use disorder
• a family history of mood disorders in the absence of alcohol use disorders (Schuckit et al., 2013)
• a family history of suicide or homicide (McKenna & Ross, 1994).

Findings that do not help with assessment and clarifying the diagnosis include:

• failure to respond to treatment with a selective serotonin reuptake inhibitor – does not necessarily mean that the depression is alcohol induced
• absence of end-organ damage – does not rule out an alcohol use disorder
• normal liver function tests – do not rule out an alcohol use disorder.