Relapse to alcohol use is common. It exacerbates depression and in some cases, can do so even if the relapse is just for one day. The symptoms of depression tend to worsen over the course of several days after the relapse.
Relapses to alcohol use are often associated with stopping antidepressants, although the depressogenic effects of alcohol will occur even if the person continues to use medication throughout the relapse. Nonetheless, stopping the antidepressant during relapse may further aggravate the depressogenic effect of the relapse and may contribute to treatment failure. Advise patients to continue the antidepressant even if they relapse.
If patients with a co-occurring alcohol use disorder and major depression relapse to alcohol use or experience worsened depression symptoms after a clear period of unequivocal improvement, consider the deterioration to be alcohol-related until proven otherwise.If you definitively determine that alcohol is not involved in the depression symptoms, reconsider the diagnosis or missed features of the depression (e.g., bipolar, psychotic features, other substances, medical condition) and review the current treatment plan.
Key pharmacological approaches
Avoiding benzodiazepines
Avoid or stop prescribing benzodiazepines to patients with concurrent alcohol use and major depression. Reasons include:
- Short- and long-term iatrogenic risks, including increased risk of serious falls, aspiration, cognitive impairment and death from multiple causes
- Lack of long-term efficacy
- Increased risk of misuse by patients with alcohol use disorders, due to cross-tolerance
- Increased medico-legal risk: Primary care providers are not responsible for the effects of the alcohol, but are accountable for adverse events that occur while the patient is using benzodiazepines.
- Possible diminished adherence to sustainable and effective treatments, due to immediate response to benzodiazepines.
If you have patients who are using benzodiazepines and alcohol concurrently, stop prescribing benzodiazepines via benzodiazepine taper. Organize medically managed withdrawal if a patient has been on high doses of benzodiazepines for a long period or if you are highly suspicious that the patient is taking more than prescribed.
Prescribing antidepressants
Recent evidence suggests that antidepressants should be considered even for patients who are drinking. However, the pattern of response to antidepressants can differ in the context of active alcohol use. Studies have found that response can be delayed to eight weeks and that the level of improvement is substantially diminished (Hashimoto et al., 2015; Ishikawa et al., 2013; Moak, 2003).
Suicidal ideation is an important indicator for initiating an antidepressant. Antidepressants are associated with decreased suicide risk in patients with suicidal ideation who are drinking.
When using antidepressants to treat patients with active alcohol use disorders, keep these facts in mind:
- The efficacy of the antidepressant is limited in the context of active drinking, especially in heavy drinkers.
- Lack of response to the antidepressant while a patient is drinking is often interpreted by the patient as a failure of the antidepressant; thus, the patient may be less likely to agree to a trial of a similar antidepressant in the future. Before beginning treatment, explain to the patient that alcohol use will reduce the medication's efficacy and that this lack of response should not be confused as a failure of the antidepressant.
Rates of treatment non-adherence are higher among people with alcohol use disorders, further increasing the likelihood of a limited treatment response.
If a patient is binge drinking – which in this context means drinking at a hazardous level over a number of days or longer – but does not drink daily, prescribe an antidepressant when indicated. However, try to ensure that the patient does not stop the medication during the binge. Assess for decreased frequency, intensity and duration of binges over time.
Choosing an antidepressant
The evidence to support specific treatments for co-occurring alcohol use disorders and mood disorders is limited (Beaulieu et al., 2012). The treatment choice should be informed primarily by the risks associated with available treatments, with other factors then taken into consideration. Be aware of the following key risks:
- Avoid bupropion because of the risk of seizure (the manufacturer lists at-risk or heavy alcohol use, including a history of alcohol use disorder, as a contraindication for the use of bupropion).
- Avoid mirtazapine and tricyclic antidepressants because of the potential for increased sedative effects when they are used with alcohol.Target dosages of all antidepressants should be as high as the patient can tolerate, without going over dosage limits determined by standard practice.
Medications for alcohol use disorders that are safe to use with SSRIs and SNRIs include:
- Naltrexone
- Acamprosate
- Topiramate
Duration of pharmacotherapy
Patients who have concurrent alcohol use and major depression should continue pharmacotherapy for longer than is typical for the general population – consider up to five years – because they have higher rates of relapse.
Also consider a period of five years for patients who took a long time to respond to treatment, demonstrated severe risks, were unable to work, or experienced severe functional impairment.
Non-pharmacological options
Preliminary research suggests that deep transcranial magnetic stimulation (dTMS) may be effective in patients with co-occurring major depression and alcohol use disorders (Girardi, 2015; Rapinesi et al., 2015).
Cognitive behavioural therapy and interpersonal therapy have also been shown to improve symptoms of depression in patients with alcohol use disorders (Markowitz, 2008; Riper, 2014). The impact of these interventions on alcohol use varies.
Key points about alcohol use and major depression
- Alcohol use is common in the general population, and thus in patients with major depression. Mood disorders may be associated with higher lifetime rates of alcohol use disorders.
- Alcohol can cause or exacerbate symptoms of major depression.
- The Four-Week Test can be helpful in assessing the patient's readiness for change and the effect of alcohol use on major depression.
- The stages of change model helps to determine the patient's readiness to change.
- Treating patients concurrently for the alcohol use disorder and the major depression is key.
- Eliminating alcohol use is associated with improved outcomes for depression.
- Antidepressants can be effective in treating the symptoms of depression in people with active alcohol use disorders, although the response is likely to be slower and less robust.
- Antidepressants may help to reduce alcohol use in patients with co-occurring depression.
- Antidepressants may reduce the risk of suicide in patients with concurrent alcohol use disorders and major depression who present with suicidal ideation.
- Buproprion should be avoided because of the much higher risk of seizure in patients with alcohol use disorders.
- Benzodiazepines should be avoided with patients who use alcohol regularly because they carry various risks, including increased risk of death from all causes.
- Alcohol-targeted medications can be useful adjuncts to antidepressant medication.
In Alcohol Use:
- Alcohol Use: Home
- Screening
- Assessment
- Treatment
- Managing alcohol use disorders
- Alcoholics Anonymous
- Medications for alcohol use disorders
- Managing alcohol withdrawal
- Alcoholic liver disease
- Treating unhealthy alcohol use in older adults
- Treating unhealthy alcohol use in women
- Managing alcohol use in pregnancy
- Treating co-occurring alcohol use disorders and depression
- Long-term management of co-occurring alcohol use disorder and major depression
- Tools & Resources
- References