ReviewDepression in patients with alcohol use disorders: Systematic review and meta-analysis of outcomes for independent and substance-induced disorders
Introduction
Patients entering treatment for an alcohol use disorder often have high levels of depressive symptoms (Davidson, 1995; Schuckit, 1995). These symptoms typically improve rapidly with treatment (Baker et al., 2013; Brown, 1988; Davidson, 1995; Kiefer and Barocka, 1999; Schuckit, 1985, Schuckit, 1995) but in spite of this, comorbid depression predicts worse outcomes in alcohol treatment (Lejoyeux and Lehert, 2011, Pettinati, 2013) and heavy drinkers have an increased risk of future depression even if they cut down (Hasin and Grant, 2002). Knowing which groups of patients are more or less likely to improve during treatment would allow scarce treatment resources to be allocated more effectively, but to date the ability to predict patient outcomes accurately has been limited.
An early approach to guide treatment and predict depression outcome in patients with an alcohol disorder was to classify depression as primary or secondary according to whether it developed before or after the onset of heavy drinking (Schuckit, 1985). In the 1990's, the typology evolved to also incorporate information about a past history of depression during abstinence (Schuckit et al., 1997). The term independent was used for depression that began before the onset of alcohol dependence or during sustained abstinence while depressive syndromes occurring only during a period of active alcohol dependence were labelled substance-induced (Schuckit et al., 1997). Structured clinical assessment tools such as the Structured Clinical Interview for DSM (SCID) (Spitzer et al., 1992) and the Psychiatric Research Interview for Substance and Mental Disorders (PRISM) (Hasin et al., 1996) have helped to operationalise these definitions and introduce greater diagnostic reliability.
It has been argued that the distinction between independent depression (ID) and substance-induced depression (SID) has important implications for treatment and prognosis: SID is considered a self-limiting condition that remits with abstinence while ID requires specific depression treatment (Pettinati, 2013; Schuckit, 1985; Schuckit et al., 1997). In particular the view has been put forward that ID, but not SID, responds to antidepressant medication (Schuckit, 2006) but the evidence for this has not been systematically evaluated.
This review aimed to answer the following questions:
- i.
In depressed patients with an alcohol use disorder, how much do depressive symptoms improve during treatment for depression?
- ii.
Do patients with ID and SID have different patterns of treatment response?
- iii.
Does antidepressant efficacy differ between patients with ID and SID?
Section snippets
Selection criteria
Studies were chosen according to the following criteria:
- 1.
Studies reported longitudinal data on alcohol use and depression in adults over at least 8 weeks.
- 2.
Change in mean score on a validated depression scale was reported.
- 3.
Subjects had an active alcohol use disorder (alcohol dependence or alcohol abuse) diagnosed according to DSM or ICD criteria.
- 4.
Mean baseline score ≥10 on the 17-item Hamilton Depression Rating Scale (HDRS) (Hamilton, 1960), or equivalent severity on another depression rating scale.
Search results and quality of studies
The search yielded 22 individual studies included in the systematic review. Table 1 presents a summary of these studies.
Twenty studies were randomized trials, of which 18 were pharmacotherapy studies and two investigated non-pharmacological treatments. The remaining two studies were open label pharmacotherapy trials.
Of the 22 studies, 16 studies clearly presented data at baseline and follow-up for the intention-to-treat sample. Follow-up completion rates in these studies ranged from 48% to 93%
Findings
In patients with an alcohol use disorder and depressive symptoms, the mean level of depression improved considerably in the first 3–6 weeks of treatment, and it reached a plateau by about 3 months. The amount of improvement was consistent across studies on subjects with high levels of depression at baseline, and equated to a reduction in symptom score of about two standard deviations from baseline to follow-up, or around 10–15 points on the Hamilton Depression Rating Scale.
Studies on ID showed
Role of funding source
Not applicable.
Conflict of interest
The authors declare no conflict of interest.
Acknowledgements
The authors wish to thank Sean Zloch for assistance with figure editing.
References (65)
- et al.
Six-months outcomes of a randomised trial of supportive text messaging for depression and comorbid alcohol use disorder
J. Affect. Disord.
(2013) Psychological interventions for alcohol misuse among people with co-occurring depression or anxiety disorders: a systematic review
J. Affect. Disord.
(2012)- et al.
Randomized controlled trial of MICBT for co-existing alcohol misuse and depression: outcomes to 36-months
J. Subst. Abuse Treat.
(2014) - et al.
When does change begin following screening and brief intervention among depressed problem drinkers?
J. Subst. Abuse Treat.
(2013) - et al.
Psychological interventions for alcohol misuse among people with co-occurring depression or anxiety disorders: a systematic review
J. Affect. Disord.
(2012) - et al.
Does comorbid substance use disorder impair recovery from major depression with SSRI treatment? An analysis of the STAR*D level one treatment outcomes
Drug Alcohol Depend.
(2010) - et al.
Depression outcome in alcohol dependent patients: an evaluation of the role of independent and substance-induced depression and other predictors
J. Affect. Disord.
(2015) - et al.
Assessing the quality of reports of randomized clinical trials: is blinding necessary?
Control. Clin. Trials
(1996) Treatment of late-life depression complicated by alcohol dependence
Am. J. Geriatr. Psychiatry
(2005)Comorbid alcohol and substance abuse dependence in depression: Impact on the outcome of antidepressant treatment
Psychiatr. Clin. N. Am.
(2007)
Antidepressant treatment of co-occurring depression and alcohol dependence
Biol. Psychiatry
The 16-Item Quick Inventory of Depressive Symptomatology (QIDS), clinician rating (QIDS-C), and self-report (QIDS-SR): a psychometric evaluation in patients with chronic major depression
Biol. Psychiatry
The prevalence and impact of alcohol problems in major depression: a systematic review
Am. J. Med.
Mirtazapine for patients with alcohol dependence and comorbid depressive disorders: a multicentre, open label study
Prog. Neuro-Psychopharmacol. Biol. Psychiatry
Severity classification on the Hamilton depression rating scale
J. Affect. Disord.
A randomized trial of combined citalopram and naltrexone for nonabstinent outpatients with co-occurring alcohol dependence and major depression
J. Clin. Psychopharmacol.
Effectiveness and tolerability of mirtazapine and amitriptyline in alcoholic patients with co-morbid depressive disorder: a randomized, double-blind study
Hum. Psychopharmacol.: Clin. Exp.
Beck depression inventory (BDI)
Arch. Gen. Psychiatry
A randomized controlled trial of cognitive-behavioral treatment for depression versus relaxation training for alcohol-dependent individuals with elevated depressive symptoms
J. Stud. Alcohol Drugs
Changes in depression among abstinent alcoholics
J. Stud. Alcohol Drugs
Initial depression and subsequent drinking during alcoholism treatment
J. Stud. Alcohol Drugs
Fluoxetine in depressed alcoholics: a double-blind, placebo-controlled trial
Arch. Gen. Psychiatry
Diagnosis of depression in alcohol dependence: changes in prevalence with drinking status
Br. J. Psychiatry
Lithium treatment of depressed and nondepressed alcoholics
JAMA: J. Am. Med. Assoc.
Meta-analysis of experiments with matched groups or repeated measures designs
Psychol. Methods
Antidepressant drug effects and depression severity: a patient-level meta-analysis
JAMA
Sertraline for the prevention of relapse in detoxicated alcohol dependent patients with a comorbid depressive disorder: a randomized controlled trial
Alcohol Alcohol.
A rating scale for depression
J. Neurol. Neurosurg. Psychiatry
Major depression in 6050 former drinkers: association with past alcohol dependence
Arch. Gen. Psychiatry
Psychiatric research interview for substance and mental dfisorders (PRISM): reliability for substance abusers
Am. J. Psychiatry
Nefazodone treatment of comorbid alcohol dependence and major depression
Alcohol.: Clin. Exp. Res.
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