Review
Psychological interventions for alcohol misuse among people with co-occurring depression or anxiety disorders: A systematic review

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Abstract

Objective

Depression, anxiety and alcohol misuse frequently co-occur. While there is an extensive literature reporting on the efficacy of psychological treatments that target depression, anxiety or alcohol misuse separately, less research has examined treatments that address these disorders when they co-occur. We conducted a systematic review to determine whether psychological interventions that target alcohol misuse among people with co-occurring depressive or anxiety disorders are effective.

Data sources

We systematically searched the PubMed and PsychINFO databases from inception to March 2010. Individual searches in alcohol, depression and anxiety were conducted, and were limited to ‘human’ published ‘randomized controlled trials’ or ‘sequential allocation’ articles written in English.

Study selection

We identified randomized controlled trials that compared manual guided psychological interventions for alcohol misuse among individuals with depressive or anxiety disorders. Of 1540 articles identified, eight met inclusion criteria for the review.

Data extraction

From each study, we recorded alcohol and mental health outcomes, and other relevant clinical factors including age, gender ratio, follow-up length and drop-out rates. Quality of studies was also assessed.

Data synthesis

Motivational interviewing and cognitive–behavioral interventions were associated with significant reductions in alcohol consumption and depressive and/or anxiety symptoms. Although brief interventions were associated with significant improvements in both mental health and alcohol use variables, longer interventions produced even better outcomes.

Conclusions

There is accumulating evidence for the effectiveness of motivational interviewing and cognitive behavior therapy for people with co-occurring alcohol and depressive or anxiety disorders.

Introduction

Epidemiological surveys consistently indicate that depressive, anxiety and alcohol use disorders frequently co-occur (Farrell et al., 2001, Grant et al., 2004, Kessler et al., 2003). Studies conducted in the United States and Australia have found that individuals with alcohol dependence are three to four times more likely to have a concurrent affective or anxiety disorder compared to the general population (Degenhardt et al., 2001, Grant et al., 2004). Even higher rates of comorbid disorders are found within treatment settings. In a large population study, 32.8% of participants with alcohol use disorders who sought treatment were found to have comorbid depression and 33.4% were found to have a comorbid anxiety disorder (Grant et al., 2004). Such high rates are problematic as co-occurring alcohol, depressive and anxiety disorders have been associated with a broad range of negative outcomes, including more severe depressive and anxiety symptoms and suicidal ideation, poorer social functioning and increased service utilization (Sullivan et al., 2005). In terms of treatment outcomes, while individuals with and without comorbid conditions improve, those with co-occurring conditions continue to drink more, have poorer physical and mental health outcomes, and display poorer functioning following treatment (Mills et al., 2009).

Psychological treatments for unipolar depression, anxiety and alcohol use disorders have separately been shown to be effective. Meta-analyses examining randomized controlled trials (RCTs) of cognitive behavior therapy (CBT) for adult unipolar depression, anxiety or alcohol disorders have found that CBT is superior to waitlist and untreated controls, as well as pharmacotherapy (Dobson, 1989, Gloaguen, 1989, Hofmann and Smits, 2008, Magill and Ray, 2009, Norton and Price, 2007, Stewart and Chambless, 2009). During the last 30 years, there has been a significant paradigm shift from the dichotomous concept of ‘normal drinking’ versus an ‘alcohol use disorder’ to the concept of a spectrum of hazardous to harmful drinking, delineated as ‘alcohol misuse’ (Saunders and Lee, 2000). Two meta-analytic reviews have found evidence for the efficacy of brief (often one session) motivational interviewing (MI) interventions for alcohol misuse, with one finding a medium effect in non-treatment seeking populations and a small to moderate effect in treatment seekers (Hettema et al., 2005, Moyer et al., 2002).

Although there have been numerous trials examining the effectiveness of psychological interventions for unipolar depression, anxiety disorders and alcohol misuse separately, relatively few have been conducted for individuals with depressive or anxiety disorders and comorbid alcohol misuse. Nevertheless, a number of recent reviews have demonstrated the effectiveness of psychological interventions for co-occurring substance misuse and unipolar depression (assessed via diagnostic interview or ratings/questionnaires with cut-off scores indicative of a clinical disorder), dysthymia or anxiety disorders. Hesse (2009) reported that integrated psychological treatments that combine treatment for substance use disorders and co-occurring depression or dysthymia into one program had superior outcomes in terms of the percentage of days abstinent compared with treatment for substance use disorder alone. Similarly, Hides et al. (2010) found support for the efficacy of CBT over no treatment control conditions among patients with co-occurring unipolar depression or dysthymia and substance misuse (including alcohol). Baillie and Sannibale (2007) reviewed clinical trials for co-occurring anxiety and substance use disorders and concluded that standard care for substance use had the best outcomes for those with more than moderate substance dependence in five of the six studies reviewed.

No previous studies have systematically examined the efficacy of psychological interventions for patients with unipolar depression, dysthymia or anxiety disorders and co-occurring alcohol misuse specifically (rather than substance misuse per se). This is important because treatment may be differentially effective according to the type of substance misuse. Baker et al. (2009a), for example, found brief interventions were effective for alcohol misuse but only somewhat effective for cannabis misuse in people with severe mental disorders. In this article, we systematically review the evidence from RCTs of psychological intervention for co-occurring alcohol misuse among people with unipolar depression, dysthymia or anxiety disorders and provide recommendations for clinical management and future research.

Section snippets

Method

The study search protocol included RCTs of psychological interventions for co-occurring alcohol misuse among people with mood or anxiety disorders. Inclusion and exclusion criteria were established prior to the literature search. Included studies were required to employ diagnostic criteria for mood (unipolar depression or dysthymia) or anxiety disorders; to utilize a treatment manual and to report data on alcohol use outcomes. Psychological interventions were operationalized as

Trials of psychological interventions

Eight RCTs have reported alcohol use outcomes following manual-led psychological interventions for alcohol misuse among people with mood or anxiety disorders. These comprise two trials among samples with depression, one in a sample with dysthymia, two among inpatient samples with mixed diagnoses, one in a sample with social phobia, one in a sample with social phobia or agoraphobia and one in a sample with agoraphobia or panic disorder. Details of these studies and PEDro scores are provided in

Conclusions

This review highlights the limited research available to inform psychological treatment approaches for co-occurring alcohol misuse and depression or anxiety disorders. While this review may have been improved by conducting a more complete search of the literature (e.g., by accessing unpublished and/or non-English language studies), there is evidence that psychological interventions (MI/CBT) are effective for treating co-occurring mood or anxiety disorders and alcohol misuse. Even brief

Role of funding source

Amanda Baker is supported by a NHMRC Fellowship (510702). Leanne Hides is supported by a QUT Vice Chancellor's Senior Research Fellowship, while Louise Thornton and Sarah Hiles are supported by Australian Postgraduate Awards. The funding sources provided no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.

Conflict of interest

Dan Lubman has received speaker honoraria from Astra Zeneca, Bristol Myers Squibb, Eli Lilly, Janssen, and Pfizer. All other authors declare that they have no conflicts of interest.

Acknowledgments

None.

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