Treatment of Depression in Alcohol-Dependent Patients

Summary Alcoholism is a source of enormous morbidity and mortality. Depressive disorders occur commonly in the course of alcoholism and affect its outcome. While the exact relationship of depression and alcoholism for most patients is controversial, it is probably heterogenous, with much depression resulting from the toxic effects of alcohol and at least some representing an independent disorder. Studies to date have shown that antidepressant medication is efficacious both in patients who are alcohol dependent with primary depression, and who are alcohol dependent with secondary depression which persists during abstinence. Antidepressants are not effective in reducing drinking in nondepressed patients. Among depressed patients who are alcohol dependent, antidepressants appear to decrease drinking among those whose depression responds. In the case of selective serotonin reuptake inhibitors (SSRIs), one study suggests that they may possibly also decrease drinking by a direct mechanism. Currently, SSRIs appear to be the treatment of choice for patients who are alcohol dependent with comorbid depression. Effective management of alcoholism with depression requires accurate syndromal diagnosis of depressive and other comorbid disorders. Ideally, this is done during a period of abstinence. Even when this is not possible, antidepressant treatment can be administered effectively. Careful monitoring and concurrent psychosocial treatment is essential for optimal outcomes. Treatment-resistant depression is managed as in non-comorbid cases. Treatment-resistant alcoholism may be managed by more intensive psychosocial treatment, addition of naltrexone, supervised disulfiram treatment or inpatient treatment. Future studies should further clarify the genetic relationship of the disorders and the optimal psychopharmacological and psychotherapeutic treatment strategies.