Depression and its treatment in alcoholics: a review

The relationship between Affective Disorder and Alcoholism is complex and has been studied extensively. Increased rates of depression are reported in alcoholics and in families of alcoholics. Some studies report that drinking behaviour may be influenced by the coexistence of depressive disorder while others indicate that depressed mood has little impact on the course and treatment of alcoholism. Some people who are depressed turn to alcohol as a form of self-medication and many of these have positive results from it, both due to the pharmacological effects of the drug and the self-limiting nature of most depressive episodes. Those with more severe depression, however, are less likely to benefit in this way. Excessive alcohol taken under such circumstances results in diminishing returns; alcohol becomes more of a contributor to the problem than a solution to it. There is no convincing evidence that drugs including anti-depressants and lithium are effective in the treatment of depressed alcoholics, except for those minority of patients where the diagnosis of primary affective disorder can be established. In such cases the indications for lithium and anti-depressant usage are similar as for non alcoholics with affective disorder. Decisions about the choice of treatment to be offered the alcoholic must be made as quickly and as accurately as possible and can only be done after a careful assessment, which may include hospitalization. It is worth noting that the pharmacologically induced depression of heavy drinking and the depression associated with the withdrawal phase may be clinically similar to the depression of primary affective disorder.     

Depression among alcoholics. Relationship to clinical and cerebrospinal fluid variables

Although depression is common among alcoholics, its determinants are poorly understood. Among 339 alcoholics, 111 (33%) had a history of major depression. Depressed, compared with never-depressed alcoholics, had a higher daily alcohol intake, more lifetime diagnoses of other anxiety and affective disorders and drug abuse, more had attempted suicide, and more reported alcoholism in both parents. Depressed alcoholics also had significantly lower cerebrospinal fluid levels of the dopamine metabolite homovanillic acid and of gamma-aminobutyric acid. Among subgroups of depressed alcoholics, secondary compared with primary depressives were more often divorced, of lower social status, with an earlier onset of alcoholism, and higher Michigan Alcohol Screening Test scores. Secondary depressives also had significantly lower cerebrospinal fluid concentrations of homovanillic acid than never depressed alcoholics. These results suggest that certain psychosocial variables, alcohol consumption, and neurochemical variables may be specifically associated with depression in alcoholics.     

Familial alcoholism in primary unipolar major depressive disorder

OBJECTIVE: Some studies have suggested relationships between depression in probands and alcoholism in relatives. Other studies have not, but some of these have used inappropriate control groups or failed to divide probands by sex. METHOD: The present study controlled for sex of probands and used several comparison groups to further explore the familial relationship between depression and alcoholism. Diagnoses for 723 directly interviewed relatives of 326 probands with primary unipolar depression were compared to diagnoses in 469 control subjects chosen by an acquaintanceship method to demographically resemble the relatives of affective disorder probands. Diagnoses in the uninterviewed relatives of both control and depressed subjects were used for comparisons as well. RESULTS: Results indicated higher rates of alcoholism in the families of depressed women but not in the families of depressed men. CONCLUSIONS: This familial association between alcoholism and depression may be the result of either genetic or environmental factors or an interaction between the two.     

Absence of visual and auditory P300 reduction in nondepressed male and female alcoholics.

BACKGROUND: The P300 component of the event-related potential has been extensively studied as a possible neurobiological risk marker for the development of alcoholism. Although P300 amplitude reduction has frequently been documented in high-risk children, studies of adult alcoholics are inconsistent. METHODS: P300 amplitude from 121 adult alcoholics was compared to 68 controls utilizing event-related potential paradigms from the auditory and visual modalities. All participants were evaluated clinically with psychiatric interviews and administered the MMPI. RESULTS: Male alcoholics did not show a reduction in amplitude in either the auditory or visual modality. Female alcoholics showed reduced P300 amplitude, but only when a comorbid lifetime diagnosis of depression was present. Similar results were found using current depressed mood (Scale 2 from the MMPI). CONCLUSIONS: No differences in P300 amplitude were found between alcoholics and controls unless comorbid depression was present. Therefore, P300 amplitude reduction seen in children at high-risk for developing alcoholism seems to represent a neurodevelopmental delay that normalizes by adulthood.     

Age of alcoholism onset. I. Relationship to psychopathology

Numerous attempts have been made to subdivide populations of alcoholics into homogeneous subgroups. Although no consensus has been reached about the characteristics of these subgroups, a number of classification schemes have identified a subgroup of patients with a high genetic loading for alcoholism, an early onset of alcoholism, a severe course, and coexisting psychiatric problems consisting of aggressive tendencies or criminality. In a recent typology proposed by Cloninger on the basis of adoption studies, this subgroup has been classified as type 2. Another group of patients who were found to differ in their mode of inheritance and clinical characteristics was classified as type 1. The identification of etiologically homogeneous subgroups is easier in studies of adoptees than in studies of individuals who were not adopted. In an attempt to divide alcoholics into two groups of individuals presenting type 1 and type 2 characteristics, we used as a criterion the age of alcoholism onset because type 2 alcoholics as well as their fathers had been found to abuse alcohol at a younger age than type 1 patients. Patients with an onset of alcoholism before their 20th birthday were found to have a significantly higher incidence of paternal alcoholism and were twice as likely to have been incarcerated for crimes involving physical violence. We also observed other features not previously described in this patient subgroup. Patients who started abusing alcohol in their teens were three times as likely to be depressed and four times as likely to have attempted suicide as patients with a later onset of alcohol abuse.     

Frontostriatal and limbic dysfunction in late-life depression.

Studies using diverse methods have documented frontostriatal and limbic dysfunction occurring in late-life depression. Although such impairments may result from aging-induced brain changes unrelated to depression, there are at least two reasons to suggest that they play a pathogenetic role in geriatric depression. First, frontostriatal dysfunction has been identified in at least some younger depressed subjects without known neurological abnormalities. Second, frontostriatal dysfunction may be associated with poor short- and long-term outcomes of late-life depression. Relating frontostriatal and limbic dysfunction to the course of late-life depression is an appropriate way for investigating its pathophysiological relevance, given that no biological test can be used as a validating criterion. However, this approach has experimental limitations. Studies of the course of late-life depression may be influenced by selective survival of depressed patients with favorable prognosis; factors peripherally related to the biology of depression, for example, physical handicaps; and clinical factors with unclear relationship to specific biological abnormalities, for example, personality disorders. Nonetheless, studies comparing depressed patients with control subjects complemented with studies of course of illness can bring to bear the rapidly evolving cognitive-neuroscience and brain-imaging techniques in an investigation of the networks responsible for predisposing, precipitating, and perpetuating late-life depression.     

Anxiety disorders. Relationships to other psychiatric illness

Considerable evidence suggests that patients with anxiety disorders have secondary depression, and somewhat less evidence suggests that secondary alcoholism is seen in anxiety disorder. Such illnesses as manic-depressive disorder, schizophrenia, and hysteria are likely to be associated with secondary anxiety syndromes. Considerable data support the idea that within families of anxiety disorder patients alcoholism is seen more frequently than would be expected by chance and that within families of alcoholics anxiety disorders are seen more frequently than would be expected by chance. These findings suggest a difference in expressivity for the same familial propensity.     

Depressive symptoms among hospitalized and posthospitalized alcoholics in Yugoslavia

Two clinical samples of male and female alcoholics undergoing inpatient hospital and posthospital treatment in Zagreb, Yugoslavia, were evaluated for depressive symptomatology and extent of alcoholism, using self-report measures (Zung Self-Rating Depression Scale and Michigan Alcohol Screening Test). Higher levels of depressive symptoms and lower alcoholism scores were reported for the hospital group, in comparison with the posttreatment "Clubs of Treated Alcoholics" group. In the hospital, no significant relationships were found between levels of depression and extent of alcoholic indicators. In the club group, however, those alcoholics who remained depressed (at minimal or mild levels) are also those who perceived themselves as having greater consequences from the alcoholism. The cultural context and psychosocial drinking and postdrinking environments of the alcoholics and their families appear to be important factors in the decline of depressive symptoms among treated, abstinent alcoholics, as well as in the retention of such symptoms among a subset of the sober alcoholics. This suggests that treatment should place a high priority on reordering the social and personal life of the alcoholic and his or her family while also retaining whatever nondrinking social ties that the alcoholic had developed and valued before treatment.     

Integrated treatment of comorbid depression and substance use disorders.

OBJECTIVE: The goals of this 6-month prospective study were to evaluate the effect of a current diagnosis of depression on the course and outcome of addiction treatment and to determine whether patients with depression received or required additional treatment compared with those without depression. METHOD: On entering addiction treatment, 75 men and 45 women with substance use disorders were assessed by clinical and semistructured interviews, Global Assessment Scale, Hamilton Rating Scale for Depression, Beck Depression Inventory, and revised 90-item Symptom Checklist. RESULTS: Forty-three patients (35.8%) met DSM-IV criteria for a current depressive disorder at intake into addiction treatment. The depressed patients had significantly (p < .0001) higher levels of psychopathology at intake. However, contrary to previous studies, they fared as well as the nondepressed patients in terms of all addiction outcome measures and all indicators of psychiatric status at 6 months. During the 6-month follow-up period, the depressed patients received more treatment than the nondepressed patients. Specifically, they had more psychiatric appointments, and they were more likely to require inpatient detoxification and to be prescribed new antidepressant medication regimens. CONCLUSION: Depression comorbidity may not have had a negative impact on the course and outcome of addiction treatment because the dual disorder was identified at the initial assessment, and integrated psychiatric care was available. It may be that additional treatment compensated for greater psychopathology among dual-disorder patients.     

Peripheral thyroid dysfunction in depression.

The involvement of the thyroid gland and thyroid hormones is generally believed to be important in the aetiopathogenesis of major depression. Major support comes from studies in which alterations in components of the hypothalamic-pituitary-thyroid (HPT) axis have been documented in patients with primary depression. However, screening thyroid tests are often routine and add little to the diagnostic evaluation. Overt thyroid disease is rare among depressed inpatients. The finding that depression often co-exists with autoimmune subclinical thyroiditis suggests that depression may cause alterations in the immune system, or that in fact it could be an autoimmune disorder itself. The outcome of treatment and the course of depression may be related to thyroid status as well. Augmentation of antidepressant therapy with the co-administration of thyroid hormones (mainly T3) is a well-documented treatment option for refractory depressed patients. Review of the literature suggests that there are no conclusive data on the role of thyroid function in depression. It is clear that depression is not characterised by an overt thyroid dysfunction, but it is also clear that a subgroup of depressed patients may manifest subtle thyroid abnormalities, or an activation of an autoimmune process. There is a strong possibility that the presence of a subtle thyroid dysfunction is a negative prognostic factor for depression and may demand specific therapeutic intervention.     

Diagnostic subgroups of antisocial alcoholics: outcome at 1 year

Of 233 alcoholics initially evaluated and subdivided into groups with an additional diagnosis of antisocial personality disorder (ASP) only (N = 38), ASP plus drug abuse (N = 30), ASP plus major depressive disorder (N = 18), and those with no additional diagnosis (N = 147), 205 were followed up 1 year later. The ASP plus drug group, although younger and having fewer years of alcoholism, did worse in the 1-year follow-up on many indicators of alcoholism severity compared with the other antisocial groups and the alcoholism only group. The ASP plus depressed group demonstrated marked improvement on measures of psychopathology and alcoholism severity over the course of 1 year such that they were comparable on these measures at 1-year follow-up to the other antisocial groups. These findings may indicate that the ASP/drug alcoholic has a poor long-term prognosis compared with the ASP only alcoholic, while the ASP/depressed patient has a disorder comparable in prognosis to the ASP only alcoholic.     

Female alcoholics. IV. Marital situation and husbands.

Little research on the husbands of alcoholic women has been reported. A few studies have shown that they often are alcoholics or are suffering from other psychiatric diseases. The present study describes 51 men, married to female alcoholics, as regards alcoholism, other psycho-social disturbances and mortality, and accounts for the marital situation after an observation period of 6-12 years. A comparison is made with a control group of married male alcoholics. About 50% of the husbands were shown to be alcoholics, 14% had been treated for psychiatric diseases and more than 10% were disabled due to somatic diseases. At the end of the observation period, one-third of both patient groups were still married, one half of the male and one-third of the female patients were divorced. Twenty per cent of the marriages among the male patients and 35% of those among the female patients had been terminated by death. Ten female alcoholics and 14 husbands died, which is a significant excess mortality for both sexes. Mortality among the husbands was higher than expected due to cirrhosis of the liver and diseases of the circulatory system.     

Affective Disorders in Alcoholism

The author examined affeotive disorders and other related symptoms (atypical chronic depressive state, suicide and self-destructive behavior) in 141 male alcoholics to evaluate the relationship between alcoholism and affective disorders. The results were: five cases (3.5%) with primary affective disorder (2 with circular type, 1 with depressed type and 2 with involutional melancholia), nine with atypical chronic depression (4 with depressive neurosis and 5 with depressive paranoid reaction), one with successful suicide and three with prominent self-destructive behavior on excessive drinking. The incidence of primary affective disorder in alcoholism approximates to 2 to 4 percent in Japan, and is a little lower than that of U.S.A or of Europe. A characteristic of the clinic for alcoholism was the frequent presentation of atypical or chronic depression. This was usually diagnosed as depressive neurosis or depressive personality disorder, and some developed to a transient paranoid state with excessive drinking. The rate of suicide in alcoholism seems to be lower in Japan than in Western countries: approximately a few percent in a few years in this country and 7 to 8 percent in Western countries. Those cases with prominent self-destructive behavior were young alcoholics. They had underlying personality disorders and complicated life histories.     

Alcoholism and depression (Note apropos of a survey using Beck's inventary]

The authors summarize recent works that correlate depression and alcoholism. They give the result of an inquiry: 38 patients (7 women and 31 men) admitted for alcoholism were given the Beck inventory for measuring depressio;. Most of the men (18) were not voluntary for entering hospital; they were not depressed clinically and in the results of the Beck inventory (mean score=12,1). 13 men were voluntary for treating their alcoholism, most of them were clearly depressed (mean score=23.3). There is a good concordance between clinical data and Beck scores. This reminds us that depression may masquerade as alcoholism.     

Types of alcoholics, I. Evidence for an empirically derived typology based on indicators of vulnerability and severity.

An empirical clustering technique was applied to data obtained from 321 male and female alcoholics to identify homogeneous subtypes having discriminative and predictive validity. The clustering solution identified two "types" of alcoholics who differed consistently across 17 defining characteristics in the male and female samples. One group, designated type A alcoholics, is characterized by later onset, fewer childhood risk factors, less severe dependence, fewer alcohol-related problems, and less psychopathological dysfunction. The other group, termed type B alcoholics, is characterized by childhood risk factors, familial alcoholism, early onset of alcohol-related problems, greater severity of dependence, polydrug use, a more chronic treatment history (despite their younger age), greater psychopathological dysfunction, and more life stress. The two types also differed with respect to treatment outcome assessed prospectively at 12 and 36 months. The results are consistent with historical and contemporary typological theories that have postulated similar subgroups of alcoholics. The findings suggest that an empirically derived, multivariate typology of alcoholism has theoretical implications for explaining the heterogeneity among alcoholics and may provide a useful basis for predicting course and estimating treatment response.     

Alcoholism treatment, severity of alcohol-related medical complications, and health services utilization

In efforts to contain costs and efficiently allocate resources, evaluation studies in alcoholism have increasingly assessed the effect of treatment on the use of health services through comparisons of treated and untreated alcoholics. The success of this approach requires that evaluators identify and adjust for differences between these two groups, thereby decreasing the likelihood that health utilization outcomes are attributed to the effects of treatment when in fact they may be related more to unidentified group differences. Using a sample of 63,873 hospitalized alcoholics, this study focused on one critical group difference, the severity of alcohol-related medical complications. Comparisons between treated alcoholics who either completed alcoholism treatment or detoxification only and untreated alcoholics with either primary medical/surgical or psychiatric diagnoses demonstrated the following: (a) untreated alcoholics with medical/surgical diagnoses were more likely to have severe alcohol-related medical complications than the other groups; (b) a positive linear relationship between health services utilization in the previous year and the severity of medical complications existed for all groups, except untreated alcoholics with psychiatric diagnoses; and (c) untreated alcoholics with psychiatric diagnoses with the most severe complications used fewer health services than any of the other three groups. Differences between treated and untreated alcoholics in both severity of medical complications and previous health utilization patterns demonstrate the need to identify and adjust for these factors in evaluation studies that examine the outcomes of alcoholism treatment.     

Behavioural and emotional problems in children of alcoholic mothers and fathers

 The Child Behavior Check List (CBCL) was used to compare a sample of 103 Danish children of alcoholics (CoA) to a Danish population-based sample (N = 780). The CoA had a significantly greater incidence of symptoms on 17 of the 118 CBCL items. Compared to the reference population, daughters of alcoholics were more impaired than sons of alcoholics on most CBCL measures. In families with maternal alcoholism daughters had higher internalising and depression scores than sons, and in families with paternal alcoholism, sons had higher internalising and depression scores than daughters. The CoA also had a significantly greater risk of scoring above the 95th percentile on internalising behaviour, depression symptoms and socially deviant behaviour. On all CBCL dimensions, almost half of the CoA samples functioned as well as the average of the reference population. The results from this study suggest that CoA should be regarded as a risk group but with very heterogeneous consequences in response to parental alcoholism. Accepted: 29 November 1999     

Depression spectrum disease versus pure depressive disease. Clinical, personality, and course differences

In a group of 191 women admitted to the University of Iowa Psychiatric Hospital for depression over a 45-year period and selected on the basis of alcoholism or antisocial personality, vs. depression, in a parent, 105 probands fit into the depression spectrum group (parental alcoholism or antisocial personality) and 86 into the pure depression group (parental depression). Few differences were found between the presenting clinical pictures (including precipitating factors) of the two groups; but depression spectrum patients and pure depressive patients showed study differences in the areas of personal problems and personality as well as course of illness. The depression spectrum patients were significantly less likely to have loss of interest in usual activities as a symptom at index admission. They were significantly more likely to have had a history of sexual problems, to have been divorced or separated before, to have been described as irritable, and to report having previously been depressed. They are nonetheless significantly more likely to recover completely and have no relapse of depression. The pure depression group were significantly more likely to have depressed sisters, and suicide was much more frequent in their ill parents. Thus, important personality and course differences separate depressive spectrum disease from pure depressive disease;     

The cost of depression-complicated alcoholism: health-care utilization and treatment effectiveness

Clinical and epidemiologic evidence suggests that alcoholism complicated by concurrent or a lifetime history of depression is slower to remit and more prone to relapse than uncomplicated alcoholism. Consequently, alcoholics with a history of depressive illness, on average, are likely to use more health care and to have higher treatment costs than those without depression complications. This article contrasts evidence of the suitability of three models for predicting the impact of depression on an alcoholic's health-care use: a null model (assuming no differences), a cumulative-effect model (arguing for a linear increase associated with comorbid depression), and a synergistic model (wherein alcoholism complicated with depression is qualitatively as well as quantitatively different than uncomplicated alcoholism). To test these models, health-care costs and utilization of 491 "pure" alcoholics (those with no history of depression diagnosis) and 199 depression-complicated alcoholics, who received alcohol treatment while enrolled in a self-insured health-care program of a major U.S. manufacturing company, were compared. Results are discussed in terms of the implications for cost containment and the likelihood of relapse among the depression-complicated alcoholism group.     

Reappraisal of the association between the DRD2 gene, alcoholism and addiction.

We analysed the impact of the TaqI A1 allele of the D2 dopamine receptor gene on the risk for alcoholism, trying to depict three explanations frequently proposed to explain discrepancies in association and linkage studies: that the A1 allele may act as a marker rather than as a vulnerability factor, that stratification biases and unevaluated controls may explain positive results, and that the A1 allele is modifying the phenotype rather than increasing the risk for alcoholism. We thus tested another (dinucleotide STRP) marker within the DRD2 gene, selected a new homogenous sample of 113 alcoholic patients and 49 unaffected controls strictly matched for ethnic origins, and systematically assessed both samples with a semi-structured interview to detect (in both samples) alcohol dependence, but also such related traits as specificities of complications. The frequency of the A1 allele was not significantly different between alcoholics and controls but when comparing different subgroups of alcoholics, the A1 allele was significantly more frequent in alcoholic patients with somatic complications (OR = 3.00, CI[1.37-6.62]), social and professional complications (OR = 2. 72, CI[1.25-5.90]), or with co-morbid dependence (OR = 2.88, 95% IC [1.16-7.15]). The association for co-morbid dependence and somatic complications was also positive when taking into consideration both STRP and TaqIA polymorphisms. The A1 allele does not increase the risk for alcoholism per se in our sample, but may be involved in a related trait which is partially dependent on the diagnosis of alcoholism, through a disequilibrium with another close mutation.