Eric W. Maurer

Meta-analysis of supplemental treatment for depressive and anxiety disorders in patients being treated for alcohol dependence.

Approximately half of those receiving treatment for an alcohol use disorder (AUD) also suffer with an anxiety or depressive (internalizing) disorder. Because all internalizing disorders mark a poor alcohol treatment outcome, it seems reasonable to supplement AUD treatment with a psychiatric intervention when these disorders co-occur with AUD. However, this conclusion may be faulty given that the various possible interrelationships between AUD and internalizing disorders do not uniformly imply a high therapeutic yield from this approach. Unfortunately, the studies conducted to date have been too few and too small to resolve this important clinical issue with confidence. Therefore, we used a meta-analytic method to synthesize the effects from published randomized controlled trials examining the impact of supplementing AUD treatment with a psychiatric treatment for co-occurring internalizing disorder (N = 15). We found a pooled effect size (d) of .32 for internalizing outcomes and .22 for a composite of alcohol outcomes; however, the alcohol outcomes effect sizes were greater than this for some specific outcome domains. Subgroups that differed in terms of internalizing outcomes included treatment type (medication vs. cognitive behavioral therapy) and treatment focus (anxiety vs. depression). There was also a trend for the studies with better internalizing disorder outcomes to have better alcohol outcomes. These results indicate that clinical outcomes (both psychiatric and alcohol-related) could be somewhat improved by supplementing AUD treatment with psychiatric treatment for co-occurring internalizing disorder.

The prevalence and clinical implications of self-medication among individuals with anxiety disorders.

Alcohol dependence (AD) is more likely to occur among individuals with rather than without an anxiety disorder. Self-medication theory (SMT) holds that drinking behavior is negatively reinforced when alcohol temporarily reduces anxiety and that the resulting escalation of drinking increases the risk for AD. We set out to empirically scrutinize SMT using the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) dataset. We found that only a minority (about 20%) of anxiety disordered individuals endorsed drinking to control anxiety symptoms. This minority drank more alcohol, had a higher cross-sectional rate of AD, and was at higher risk for developing new AD over four years compared to anxiety disordered non-self-medicators and individuals with no anxiety disorder. Consistent with SMT, increased prospective risk for AD among self-medicators is partially mediated by an increased level of alcohol use. Understanding the processes that promote and inhibit self-medication should be a priority for anxiety disorder researchers.

Hybrid Cognitive Behavioral Therapy Versus Relaxation Training for Co-Occurring Anxiety and Alcohol Disorder: A Randomized Clinical Trial

OBJECTIVE Treatment for alcohol use disorder (AUD) is far less effective for those with a co-occurring anxiety disorder. Surprisingly, adding an independent anxiety treatment to AUD treatment does not substantially improve the poor alcohol outcomes of these patients. This may reflect the lack of attention from independent treatments to the dynamic interaction of anxiety symptoms with alcohol use and drinking motivation. On the basis of this view, we assembled a cognitive behavioral therapy (CBT) program designed to both reduce anxiety symptoms and weaken the links between the experience of anxiety and the motivation to drink. METHOD 344 patients undergoing residential AUD treatment with current social phobia, generalized anxiety disorder, or panic disorder were randomly assigned to receive either the CBT or an active comparison treatment, progressive muscle relaxation training (PMRT). Assessments took place immediately following treatment and 4 months later (n = 247). RESULTS As predicted, the CBT group demonstrated significantly better alcohol outcomes 4 months following treatment than did the PMRT group. Although both groups experienced a substantial degree of anxiety reduction following treatment, there were no significant group differences immediately after treatment and only a slight advantage for the CBT group 4 months after treatment. CONCLUSIONS These findings suggest that specific interventions aimed at weakening the association between the experience of anxiety and drinking motivation play an important role in improving the alcohol outcomes of these difficult-to-treat patients beyond that of anxiety reduction alone.

Anatomic correlates of deep brain stimulation electrode impedance

Background The location of the optimal target for deep brain stimulation (DBS) of the subthalamic nucleus (STN) remains controversial. Electrode impedance affects tissue activation by DBS and has been found to vary by contact number, but no studies have examined association between impedance and anatomic location. Objectives To evaluate the relationship between electrode impedance and anatomic contact location, and to assess the clinical significance of impedance. Methods We gathered retrospective impedance data from 101 electrodes in 73 patients with Parkinsons disease. We determined contact location using microelectrode recording (MER) and high-field 7T MRI, and assessed the relationship between impedance and contact location. Results For contact location as assessed via MER, impedance was significantly higher for contacts in STN, at baseline (111 Ω vs STN border, p=0.03; 169 Ω vs white matter, p<0.001) and over time (90 Ω vs STN border, p<0.001; 54 Ω vs white matter, p<0.001). Over time, impedance was lowest in contacts situated at STN border (p=0.03). Impedance did not vary by contact location as assessed via imaging. Location determination was 75% consistent between MER and imaging. Impedance was inversely related to absolute symptom reduction during stimulation (−2.5 motor portion of the Unified Parkinsons Disease Rating Scale (mUPDRS) points per 1000 Ω, p=0.01). Conclusions In the vicinity of DBS electrodes chronically implanted in STN, impedance is lower at the rostral STN border and in white matter, than in STN. This finding suggests that current reaches white matter fibres more readily than neuronal cell bodies in STN, which may help explain anatomic variation in stimulation efficacy.