Co-occurring MDD and Problematic Alcohol Use

Abstract

Major depressive disorder (MDD) and problematic alcohol use often co-occur. Unfortunately, the presence of these two conditions is associated with worse short-term and long-term complications. In this chapter, we will review definitions of problematic alcohol use, describe the nature of co-occurring depressive symptoms and problematic alcohol use (i.e., prevalence and consequences), review treatment models for these co-occurring conditions, and provide an example of a protocol examined in several research studies.

FAQs: Common Questions and Answers

• Q1. What is the best approach with a patient reporting drinking over the recommended guidelines?

• A1. Evidence suggests that many patients seeking treatment for depression may also engage in heavy alcohol use. Clinicians should therefore systematically inquire about alcohol consumption during intake and throughout the course of treatment. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) recommends brief intervention with individuals with “at risk” drinking or “heavy drinking,” defined as drinking 5 drinks on any day or 14 per week for men and drinking more than 3 drinks on any day and 7 per week for women [76]. Patients may not be aware that their drinking is considered “at risk,” and education on NIAAA-recommended guidelines and on the risk associated with higher alcohol use is an important first step of treatment. Clinicians should carefully review all possible consequences that patients may have already experienced due to their alcohol consumption, including health-related problems, relationship problems (i.e., arguments with friends or significant others), legal problems (e.g., DUI), and employment problems (e.g., missing days at work).

• Given the low insight often associated with problematic drinking, clinicians may use MI techniques [1], which follow five general principles: express empathy through reflective listening, develop discrepancy between clients’ goals or values and their current behavior, avoid argument and direct confrontation, adjust to client resistance rather than opposing it directly, and support self-efficacy and optimism. Clinicians may also adopt communication techniques consistent with the spirit of MI, such as reflective statements, affirmation, evocation, and use statements that highlight discrepancies between the patient current behaviors and his/her goals. These principles are characterized by the brief intervention structure of FRAMES which refers to the use of Feedback, Responsibility for change lying with the individual, Advice-giving, providing a Menu of change options, Empathic counseling style, and the enhancement of Self-efficacy [77]. Thus, clinicians may focus on enhancing discrepancies between alcohol use and personal goals and collaboratively identify drinking goals that fall within the recommended guidelines and may be consistent with patients’ goals. Progressively, depression and alcohol use would be addressed in conjunction, highlighting their association and strengthening the patient’s motivation to not engage in heavy drinking.

• Q2. What is the best setting for treating co-occurring depression and alcohol misuse?

• A2. One important clinical consideration to be mindful of when treating patients with co-occurring MDD and problematic alcohol use is that these patients often have low insight into the problems associated with their drinking behavior [78] and thus may have low motivation to change. Often their goal for treatment is to only reduce their alcohol consumption. Hence, patients with problematic alcohol use may not be willing to attend specialty clinics serving patients with co-occurring MDD and SUD because they are not interested in abstinence (often required in these programs) and because they may not want to interface with patients with severe addictive behaviors with whom they may not identify. Patients with problematic alcohol use may be more open to receiving treatment in general outpatient psychiatry clinics focusing on depression and related conditions (e.g., anxiety). Moreover, whereas patients with SUD often attend more intensive outpatient (e.g., intensive outpatient, partial hospitalization) programs, once-weekly treatment sessions may be an appropriate level of care for individuals with MDD and co-occurring problematic alcohol use (i.e., milder forms of AUD) [62, 63]. As such, it has been argued that treating problematic alcohol use among those with MDD may be an ideal strategy to address this high-risk behavior because these patients do not seek treatment for their alcohol use but are interested in treatment for MDD.

• Q3. When is it better to adopt a sequential versus integrated treatment approach?

• A3. Research has generally shown that integrated treatment is associated with better outcomes for patients with co-occurring depression and alcohol problems. However, if clinicians do not have experience in treating problematic drinking and/or the treatment setting lacks necessary resources, it is advisable to refer the patient for a short course of MI by a clinician who is well versed in this method. As noted above, neglecting to address the problematic alcohol use may also prevent improvement of mood symptoms.

• Q4. What is the best way to assess for problematic alcohol use?

• A4. The Task Force on Recommended Alcohol Questions, a task force of NIAAA’s Council, developed minimum sets of downward compatible alcohol consumption questions, and they recommended sets of 3, 4, 5, and 6 items presented here which resulted from the work of that task force. They recommend asking a minimum of three questions including frequency of drinking in the past year (e.g., “During the last 12 months, how often did you usually have any kind of drink containing alcohol?”), number of drinks consumed on a typical drinking day in the past 12 months (e.g., “During the last 12 months, how many alcoholic drinks did you have on a typical day when you drank alcohol?”), and frequency of heavy drinking in the past 12 months (e.g., “During the last 12 months, how often did you have five or more drinks [males] or four or more drinks [females] containing any kind of alcohol in within a 2-hour period?”). The four-item set adds a question about the maximum number of drinks consumed in a 24-h period in the past year (e.g., “During your lifetime, what is the maximum number of drinks containing alcohol that you drank within a 24-hour period?”), and the five-item set adds a question about maximum drinks in a 24 h period in the respondent’s lifetime (e.g., “During the last 12 months what is the maximum number of drinks containing alcohol that you drank within a 24-hour period?”). The six-item set adds a question, immediately following the item about maximum drinks in a 24-h period in the past 12 months, which asks about the frequency of consuming this maximum number of drinks in the past 12 months (e.g., “During the last 12 months, how often did you drink this largest number of drinks?”) [79].

• Similarly, the Alcohol Use Disorders Identification Test (AUDIT) [38] is a self-report screening tool extensively used to identify individuals with problematic drinking. The AUDIT is a ten-item screening questionnaire with three questions inquiring about amount and frequency of drinking, three questions on alcohol dependence, and four on problems caused by alcohol. All the items are scored using a Likert scale from 1 to 5, and total scores range from 0 to 40. Norms have been developed for this instrument, but overall the authors advise to provide alcohol education in the case of scores between 0 and 7, simple advice with scores between 8 and 15, and simple advice plus brief counseling and continued monitoring in the case of scores between 16 and 19 [38].

• Q5. What is the difference between having treatment goals of abstinence and moderate drinking?

• A5. In the presence of heavy episodic drinking, the common approach is a harm reduction strategy in which the goal consists of engaging in alcohol consumption within recommended guidelines. Most individuals with problematic alcohol use initially are not open to abstain from alcohol use, making alcohol reduction the most feasible goal. Some patients may be unable to reduce drinking even though they do not meet criteria for AUD because of inability to control themselves. In those cases, it is recommended clinicians review the pros and cons of abstinence with the patient. There is debate as to whether a harm reduction strategy would be appropriate for severe AUD, but that is outside the scope of the current chapter focused on MDD and less severe forms of AUD [80, 81].