Treating major depression with the belief that once the depression improves the patient will be able to stop drinking does not work (Kranzler et al., 1995). Treatment must address both issues concurrently (Health Canada, 2001b).
In cases of treatment-refractory or repeatedly-relapsing major depression, consider advising patients to completely eliminate alcohol use, regardless of their stated level of alcohol use. The rationale for this suggestion is based on the following facts:
- Even relatively small amounts of alcohol can have a negative effect on treatment outcome for some patients.
- The clinician's ability to confirm the actual amounts of alcohol a patient consumes is very uncertain.
- Abstinence from alcohol is not associated with any health risks.Alcohol use does not help to manage depression.
The simplest approach is to advise patients who have major depression that is responding poorly to treatment to abstain from alcohol.
Starting treatment
Assess risks
Concurrent alcohol use and major depression markedly increase the risk of intended and unintended harm to self and others. Intended risks include suicide, homicide and self-injury. Unintended risks include motor vehicle accidents, involvement with child welfare services and workplace injuries.
Major depression–related risks:
- Suicide
- Homicide
- Child welfare
- Driving
Alcohol-related risks:
- Driving
- Child welfare (see the College of Physicians and Surgeons of Ontario's mandatory reporting policy for suspected child abuse and related child welfare issues)
- Suicide risk, homicide risk or inability to care for self; consider emergency admission if warranted.
Initiate treatment
- Order blood work (complete blood count [CBC], gamma glutamyl transferase [GGT]).
- Initiate the Four-Week Test (see below).
- Book the next appointment, ideally in one to two weeks if the patient does not present as severely impaired or with risk-related symptoms.
At the next visit (one to two weeks):
- Review blood work
- Perform additional physical exam, as indicated
- Repeat review of safety risks
The Four-Week Test
This test helps to assess the patient's level of alcohol use and readiness to change. It also helps to determine whether the patient's symptoms of depression are alcohol-related or idiopathic.
The Four-Week Test has been identified as a "clinical pearl," based on clinical experience and several key studies (Brown & Schuckit, 1988; Schuckit, 2006; Schuckit & Irwin, 1995), but it has not been validated through peer-reviewed empirical research.
The test is performed as follows:
- Indicate that you are concerned about the patient's symptoms of depression and that alcohol has a negative effect on depression.
- Advise the patient to avoid using alcohol for four weeks as the first step in reducing the symptoms of depression.
The response to your request indicates the patient's readiness to change. How the patient's symptoms of depression respond to the four weeks of abstinence indicates the relationship between the person's alcohol use and depression.
The patient may respond to your request for a four-week trial of abstinence in one of three possible ways:
1. The patient declines.
What this means:
This response suggests that the patient is precontemplative with respect to changing alcohol use and that the patient may have an alcohol use disorder.
What to do:
Wait for opportunities to encourage and foster the patient's contemplation of the negative effects of alcohol use on depression. Use opportunistic brief interventions.
Consider assessing the patient's alcohol history in greater depth, including appropriate physical exams and investigations.
2. The patient agrees to discontinue alcohol use for four weeks but returns to inform you of an unsuccessful attempt.
What this means:
This situation suggests that the patient is in the preparation stage of change and may have an alcohol use disorder. It also suggests that the patient will need help making changes to their alcohol use.
What to do:
- When possible, schedule several visits for motivational interventions with you or members of your team.
- If you do not have the resources, suggest that the patient connect with a mutual aid group such as Alcoholics Anonymous.
- Book regular monthly visits to track the patient's progress around alcohol use and to monitor functioning and depression symptoms.
- Consider prescribing medications for reducing alcohol use, such as naltrexone, acamprosate or topiramate.
- Consider starting an SSRI, especially for patients with suicidal ideation and a history of suicide attempts.
3. The patient abstains from alcohol for at least four weeks.
This response will result in one of three possible outcomes:
- Depression symptoms completely resolve. This suggests that the depression was alcohol-induced. The next step is relapse prevention for the patient's alcohol use. Relapse prevention can include regular visits to reinforce and maintain the improvements or attending a mutual aid group such as Alcoholics Anonymous.
- The patient reports incomplete symptom improvement and your assessment confirms significant residual symptoms beyond sleep disturbance. Sleep disturbance and headache can persist for up to one year after a patient with an alcohol use disorder achieves abstinence. Incomplete improvement of depressive symptoms most likely indicates concurrent depression and alcohol use disorders. In this situation, the patient simultaneously begins alcohol relapse prevention and further depression treatment (the first intervention for depression was eliminating alcohol use).
- There is minimal to no improvement in depression symptoms or in daily functioning. This suggests idiopathic major depression with a low probability of concurrent alcohol dependence, although concurrent at-risk alcohol use cannot be completely ruled out. Initiate treatment for the depression immediately, and advise the patient against resuming alcohol use, pending functional and symptomatic remission of the depression.
Treating patients with suicidal ideation
Consider hospitalization
Patients who are using alcohol and have suicidal ideation are at increased risk of death by suicide. You should seriously consider hospital ED psychiatric assessment for these patients, including the possibility of involuntary admission.
Initiate antidepressant medication
For patients with suicidal ideation who are using alcohol but who do not currently require hospital admission, initiate an antidepressant if you are confident that the patient is motivated to take medication despite the alcohol use. Antidepressants may reduce suicidal ideation even if they do not significantly improve other symptoms of depression.
Exercise caution in selecting an antidepressant for patients who are using alcohol. Avoid antidepressants that carry an overdose risk, such as nortriptyline, venlafaxine, duloxetine, mirtazapine or bupropion. Also avoid benzodiazepines because they are contraindicated for patients who are using alcohol.
Supported self-care
Prescribe moodgym to patients who have access to the Internet. The program teaches people cognitive behavioural therapy (CBT) skills for preventing and coping with depression.
Although moodgym has not been specifically tested in patients with comorbid alcohol use disorders, evidence for the program's efficacy in treating major depression is strong and other studies have demonstrated the efficacy of computer-based cognitive behavioural therapy in patients with concurrent alcohol use disorder and major depression (Andersson et al., 2014; Dedert et al., 2013; Kay-Lambkin et al., 2009; McNaughton, 2009).
The Mind Over Mood workbook is a useful self-help tool that teaches patients CBT techniques. It is an inexpensive intervention that requires minimal clinical resources.
In some cases, you may decide to start with Mind Over Mood because the patient is ambivalent about using medication.
Clinicians without CBT training can support patients who are using self-help interventions by arranging regular brief follow-ups to confirm adherence, track progress and address the patient's questions (Andersson et al., 2014; Dedert et al., 2013).
It is best to initiate one intervention at a time to avoid diluting the patient's motivation across several interventions. Add the next intervention after the patient is fully adhering to the existing intervention. This is especially important with patients who have concurrent alcohol use and depression, because the patient is already engaged in both changing alcohol use and treating the depression.
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