Mr. G, age 38, is an investment banker referred for evaluation of an alcohol use disorder. Three years ago his internist diagnosed Mr. G with major depression and prescribed a selective serotonin reuptake inhibitor. Mr. G’s mood has improved, but his drinking is out of control and is affecting his work and marriage.
Mr. G describes his father as an alcoholic and says he has noticed worrisome similarities in himself. Since his teenage years, he recalls always being able to drink more than his peers. Amnesia episodes began in college during heavy drinking days and now occur almost weekly. Most recently his driver’s license was suspended after he was arrested for driving while impaired by alcohol.
He has attempted to stop drinking 3 times in the last 6 months and feels frustrated because he continues to relapse. During his last quit attempt, he remained abstinent for 3 months and believes his mood was unchanged during that time.
For motivated patients such as Mr. G, National Institute on Alcohol Abuse and Alcoholism (NIAAA) guidelines (updated in 2007) consider medications first-line treatment for alcohol dependence, along with psychotherapies and mutual-help groups such as Alcoholics Anonymous.1 Medications with evidence of efficacy include FDA-approved disulfiram, naltrexone, and acamprosate, and off-label topiramate.
Each drug’s pharmacology is different; some may be beneficial during early abstinence, whereas others are more effective for maintaining abstinence. Because many physicians have had little or no experience using these medications,2,3 we discuss dosing recommendations and side effect profiles—important clinical differences to guide drug selection and administration.
Alcohol dependence: Diagnostic criteria
Alcohol use disorders describe a maladaptive pattern of alcohol use that causes clinically significant impairment or distress. Alcohol dependence is manifested by ≥3 of the following symptoms in a 12-month period:
- Tolerance
- Withdrawal
- Often drinking alcohol in larger amounts or over a longer time period than intended
- Persistent desire or unsuccessful efforts to cut down or control alcohol use
- Spending a great deal of time in activities necessary to obtain, use, or recover from alcohol’s effects
- Giving up or reducing important social, occupational, or recreational activities because of alcohol use
- Continuing alcohol use despite knowing you have a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.
Source: Adapted from DSM-IV-TR
CASE CONTINUED: Which came first?
When Mr. G presented with depressive symptoms, his internist informed him that alcohol’s effects can mimic depression and advised him to cut back his consumption. Mr. G temporarily reduced his drinking but continued to experience depressed mood, sleep disturbances, difficulty concentrating, fatigue, and poor appetite. The internist then prescribed escitalopram, 10 mg/d, and Mr. G says his depressive symptoms improved. He has not attempted suicide or required psychiatric hospitalization.
Mr. G’s diagnosis of alcohol dependence is based on evidence in the last 12 months of tolerance, repeated loss of control over the amount he drinks, multiple failed attempts to stop drinking, repeated negative consequences to his work productivity and personal relationships, and continued drinking despite knowing that alcohol consumption sometimes intensifies his mood symptoms (Box). Physiological dependence is unlikely because he did not experience withdrawal during a recent period of abstinence.
The mood component. Particularly in psychiatric patients, alcohol dependence often coexists with and affects the treatment of other psychopathologies:
- 1 in 3 adults experience an alcohol use disorder during their lifetimes.4
- 1 in 3 adults with an alcohol use disorder have a comorbid psychiatric disorder.5
- Alcohol dependence doubles the risk of major depression and triples the lifetime risk of any mood disorder.4
- Mood symptoms appear after the onset of a substance use disorder.
- Mood symptoms are absent during abstinence.
- Mood symptoms are consistent with the effects of the drug being used.6
In evaluating Mr. G’s drinking history, you determined that his mood symptoms began before he started consuming alcohol regularly and have persisted during periods of abstinence. Thus, primary MDD is a more likely diagnosis than substance-induced MDD.