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Managing alcohol problems and co-occuring anxiety, depression and psychosis

© 2010 CAMH and St. Joseph's Health Centre, Toronto

Can antidepressants help patients with alcohol dependence and mood disorders?

In controlled trials of SSRIs and other antidepressants in patients with both alcohol dependence and depression, antidepressants have been shown to improve mood and, in patients who continue to drink, to cause modest overall reductions in alcohol consumption (Nunes & Levin, 2004). Antidepressant therapy should be combined with addiction counselling, self-help groups and other treatment modalities.

How should I prescribe antidepressants to patients with alcohol dependence?

If the patient is able to abstain, it is better to wait at least three to four weeks before beginning antidepressant treatment. If the patient has an alcohol-induced mood or anxiety disorder, it will quickly resolve with abstinence.

If the patient is unable to stop drinking, antidepressants may be tried, especially if the patient is likely to have a primary mood or anxiety disorder.This should be considered if the patient:

  • has a strong family history of depression or anxiety
  • reports persistent depression or anxiety even during prolonged periods of abstinence
  • reports that depression or anxiety symptoms usually precede a binge.

Caution

When prescribing antidepressants, consider the following:

  • Bupropion lowers the seizure threshold; avoid using it in patients at risk for alcohol withdrawal.
  • Tricyclic antidepressants may be arrhythmogenic, and an overdose can cause seizures and fatal arrhythmias; use them with considerable caution in patients with alcohol dependence who are at high risk for seizures, arrhythmias (e.g., cardiomyopathy) or suicide.
  • SSRIs as a class may be disinhibiting, particularly when combined with alcohol; monitor their effects closely in the first few weeks of treatment.
  • SSRIs may increase the sedating effects of alcohol, particularly early in treatment.

Can benzodiazepines help patients with alcohol dependence and anxiety disorders?

Except for acute alcohol withdrawal, there is little evidence to support a therapeutic role for benzodiazepines in the management of alcohol dependence, and there is considerable evidence for harm. Patients who are dependent on substances and who are prescribed benzodiazepines do not have higher addiction recovery rates, but they do have higher rates of benzodiazepine abuse (Brunette et al., 2003). Benzodiazepine use is associated with an increased risk of falls, motor vehicle accidents and trauma, particularly in older adults (Ray et al., 2000; Longo et al., 2000), hepatic encephalopathy (Blei & Córdoba, 2001) and declines in cognitive function in older adults (Paterniti et al., 2002; Barker et al., 2004).

Guidelines

  • Avoid initiating long-term benzodiazepine therapy in patients with alcohol dependence, except perhaps in cases of severe generalized anxiety disorder that is refractory to other treatments.
  • Patients who are currently abusing benzodiazepines should be tapered off them and referred for addiction treatment.
  • Patients who are on therapeutic doses of benzodiazepines and are not abusing them should have a careful trial of tapering, particularly if they are at high risk for falls (i.e., older adults, very heavy binge drinkers).

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