James A. Foulds

Depression in patients with alcohol use disorders: Systematic review and meta-analysis of outcomes for independent and substance-induced disorders.

BACKGROUND In patients with an alcohol use disorder, depression is commonly categorised as independent (ID) or substance-induced (SID). It is not established whether these conditions respond differently to treatment. METHODS MEDLINE, Embase and Cochrane databases from 1980 to 2014 were searched for studies on alcohol use disorders with coexisting depressive symptoms. Meta-analyses were conducted using random effects models, to derive pooled effect estimates of the change in depression during treatment and the effect of antidepressant therapy. RESULTS Twenty-two studies met inclusion criteria for the review, of which 11/22 were included in the meta-analysis. All studies reported a large improvement in depression symptom score, most of which occurred within the first 3-6 weeks of treatment. The amount of improvement during follow up was similar in studies on ID in comparison to those in undifferentiated depression. Evidence on the outcome for SID was limited. The effect size of antidepressant therapy compared to placebo was 0.25 (0.06, 0.44) for ID and 0.08 (-0.31, 0.47) for SID or undifferentiated depression. LIMITATIONS Few studies examined the natural history and treatment response of SID. There was heterogeneity between studies, which was partly explained by baseline depression severity. CONCLUSIONS Treatment for depression co-occurring with an alcohol use disorder is associated with a large early improvement in depression, even if depression is believed to be independent of drinking. The effect of antidepressant therapy on depression in patients with alcohol use disorders is modest, with stronger evidence in ID.

A randomized trial of combined citalopram and naltrexone for nonabstinent outpatients with co-occurring alcohol dependence and major depression.

Abstract Despite the high rate of co-occurrence of major depression and alcohol dependence, the role of pharmacotherapy in their treatment remains unclear. In the new era of naltrexone for alcohol dependence, it is notable that only 1 study to date has examined the efficacy of antidepressant medication prescribed concurrently with naltrexone. We aimed to determine whether combining naltrexone with citalopram produced better treatment outcomes than naltrexone alone in patients with co-occurring alcohol dependence and depression, and to investigate whether either sex or depression type (independent or substance-induced depression) moderated treatment response. Participants were 138 depressed alcohol-dependent adults who were not required to be abstinent at the commencement of the trial. They were randomized to 12 weeks of citalopram or placebo, plus naltrexone and clinical case management. Treatment was well attended, and medications were reasonably well tolerated with high adherence rates. Substantial improvements in both mood and drinking occurred in both groups, with no significant differences between groups on any of the mood or drinking outcome measures, whether or not other variables were controlled for. No interaction effect was found for independent/substance-induced depression status, whereas there was a marginal effect found by sex, with greater improvement in 1 drinking outcome measure (percent days abstinent) in women taking citalopram. These findings suggest that citalopram is not a clinically useful addition to naltrexone and clinical case management in this treatment population. Independent/substance-induced depression status did not predict treatment response. Findings for sex were equivocal.

Depression outcome in alcohol dependent patients: an evaluation of the role of independent and substance-induced depression and other predictors.

BACKGROUND Depression commonly co-occurs with alcohol use disorders but predictors of depression treatment outcome in patients with both conditions are not well established. METHODS Outpatients with alcohol dependence and major depression (n=138) were prescribed naltrexone and randomized to citalopram or placebo for 12 weeks, followed by a 12-week naturalistic outcome phase. General linear mixed models examined predictors of Montgomery Asberg Depression Rating Scale (MADRS) score over 24 weeks. Predictors included whether depression was independent or substance-induced, and demographic, alcohol use, and personality variables (Temperament and Character Inventory subscales). RESULTS Most improvement in drinking and depression occurred between baseline and week 3. During follow-up, patients with substance-induced depression reduced their drinking more and they had better depression outcomes than those with independent depression. However, greater reduction in drinking was associated with better depression outcomes for both independent and substance-induced groups, while antidepressant therapy had no effect for either group. Baseline demographic and alcohol use variables did not predict depression outcomes. Among personality variables, high self-directedness was a strong predictor of better depression outcomes. LIMITATIONS Subjects were not abstinent at baseline. The influence of naltrexone on depression outcomes could not be tested. CONCLUSION Alcohol dependent patients with substance-induced depression have better short term depression outcomes than those with independent depression, but this is largely because they reduce their drinking more during treatment.

Harmful drinking and talking about alcohol in primary care: New Zealand population survey findings.

Foulds J, Wells JE, Lacey C, Adamson S, Mulder R. Harmful drinking and talking about alcohol in primary care: New Zealand population survey findings.

Personality Predictors of Drinking Outcomes in Depressed Alcohol-Dependent Patients

AIM To evaluate the role of personality dimensions as predictors of drinking outcomes in depressed alcohol-dependent patients. METHODS Temperament and character inventory (TCI) scores were obtained at baseline in a 24-week study of 127 depressed alcohol-dependent patients who received open-label naltrexone and were randomized to citalopram or placebo. The association between TCI personality dimensions and alcohol outcomes during follow-up was examined using general linear mixed models. RESULTS Low novelty seeking, high self-directedness and high cooperativeness predicted less alcohol consumption on drinking days during follow-up. Temperament and character variables had no effect on the percentage of days abstinent from alcohol. Depression mediated the effects of self-directedness and cooperativeness on alcohol outcomes while the effect of novelty seeking remained after adjusting for depression scores in follow-up. CONCLUSION Identifying personality characteristics at baseline predicts drinking outcomes in depressed, alcohol-dependent patients. In particular patients with high novelty seeking drank more heavily on drinking days and they may therefore need more intensive intervention to achieve good treatment outcomes.

DSM-5 alcoholism: A 60-year perspective

Alcohol continues to be the western world’s favourite recreational drug, use of which induces a compelling state of anxiolytic euphoria for several hours in most people. Overuse of alcohol is associated with a range of negative health and social consequences. These consequences relate to both the highly intoxicating and aggressogenic nature of alcohol in the short-term (Parrott and Zeichner, 2002), and toxicity from chronic overuse, with about half of alcohol deaths due to acute effects and the other half chronic illness (Connor et al., 2005), including cancers, which account for at least 25% of all alcohol-related deaths. Alcoholism has been the most commonly used term to describe the behavioural pattern of alcohol overuse in clinical practice. We use the term ‘alcoholism’ here to encompass the series of changes in formal diagnostic systems over the past 60 years since the publication of the Diagnostic and Statistical Manual of Mental Disorders, First Edition (DSM-I) in 1952. From DSM-I to DSM-IV there have been two main shifts in diagnostic conception of alcoholism (Sellman, 1994); DSM-5 represents a third, which is a return to the 1960s unitary formulation of alcoholism (Figure 1).

The association between material living standard and psychological distress: Results from a New Zealand population survey

Background: People with a low material living standard experience more psychological distress than those with a high living standard, but previous studies suggest the size of this difference is modest. Aim: To measure the association between living standard and psychological distress using a multidimensional measure of living standard, the Economic Living Standard Index (ELSI). Methods: Adults aged 25–64 years (n = 8,465) were selected from a New Zealand community survey. Logistic regression models were used to compare household income and ELSI scores as risk factors for high psychological distress, defined as a K10 score of 12 or over. Results: In the population, the prevalence of high psychological distress was 5.8%. The prevalence of high distress increased steeply with decreasing living standard. In the most deprived decile according to ELSI score, 24.3% had high distress, compared to 0.8% in the least deprived decile. For household income, high distress was present in 15.9% of people in the lowest decile and 2.2% of the highest decile. In fully adjusted models, ELSI score remained significantly associated with high distress but household income was not. Conclusion: The mental health disparity between those at opposite ends of the social spectrum is very large. Comprehensive measures such as the ELSI give a more accurate estimate of this disparity than household income.

Novel CYP2D6 and CYP2C19 variants identified in a patient with adverse reactions towards venlafaxine monotherapy and dual therapy with nortriptyline and fluoxetine.

We present a case report of novel variants of CYP2D6 and CYP2C19 identified in a patient who experienced adverse effects during antidepressant therapy. CYP2D6 DNA sequencing revealed that the patient was most likely an intermediate metabolizer, owing to the presence of a novel variant (2579C>T), which gives rise to a premature stop codon in exon 5. Because defects in CYP2C19 may also be important, we sequenced the promoter region and all exons of CYP2C19 and identified a cluster of three novel variants (-13G>A, 7C>T and 10T>C) around exon 1, as well as the more common CYP2C19*2 allele. The presence of multiple genetic lesions in CYP2C19 implies that this patient is potentially a CYP2C19 poor metabolizer, and this was confirmed by haplotype analysis. Combined impairment of CYP2D6 and CYP2C19 activities, we believe, may have contributed to the development of the observed drug responses in the present report.

Personality disorder and alcohol treatment outcome: systematic review and meta-analysis

BackgroundPersonality disorders commonly coexist with alcohol use disorders (AUDs), but there is conflicting evidence on their association with treatment outcomes.AimsTo determine the size and direction of the association between personality disorder and the outcome of treatment for AUD.MethodWe conducted a systematic review and meta-analysis of randomised trials and longitudinal studies.ResultsPersonality disorders were associated with more alcohol-related impairment at baseline and less retention in treatment. However, during follow-up people with a personality disorder showed a similar amount of improvement in alcohol outcomes to that of people without such disorder. Synthesis of evidence was hampered by variable outcome reporting and a low quality of evidence overall.ConclusionsCurrent evidence suggests the pessimism about treatment outcomes for this group of patients may be unfounded. However, there is an urgent need for more consistent and better quality reporting of outcomes in future studies in this area.

Prescribed Psychotropic Medication Use in Patients Receiving Residential Addiction Treatment

A high level of prescribed antidepressant use has been reported in patients receiving specialized addiction treatment (Knudsen et al ., 2007) despite uncertainty about which, if any, of these patients will benefit from this medication. We aimed to investigate patterns of antidepressant and other prescribed psychotropic medication use among patients attending short-term residential addiction treatment. Data were obtained retrospectively from clinical files for all patients admitted over a 12-month period. For patients with two or more admissions, only the first admission was considered. Patients predominantly had a severe alcohol or other substance use disorder, were psychiatrically stable and had either completed medical detoxification or did not require it. Diagnoses were made at admission according to DSM-5 criteria using a non-structured clinical interview conducted by a single experienced addiction clinician. Diagnoses were informed by existing information from medical and psychiatric records. Patients’ current prescribed medications were recorded at admission. In …