Depression comorbid alcohol abuse

Patients with bipolar disorder have a high risk of suicide. Factors that increase that risk are early age at disease onset, high number of depressive episodes, comorbid alcohol abuse, personal history of antidepressant-induced mania, and family history of suicidal behavior.15 In those with bipolar disorder, 1 of 5 suicide attempts are lethal, in contrast to 1 of 10 to 1 of 20 in the general population. 

Anxiety and dissociative symptoms (e.g., sense of numbing or absence of emotional responsiveness, derealization, depersonalization, inability to recall important features of the event) emerging within 1 month after exposure to a traumatic stressor are classified as ASD. Symptoms of ASD are experienced during or immediately after the trauma, last for at least 2 days, and resolve within 4 weeks. The age of onset and course of PTSD are variable. PTSD can occur at any age. The presentation is not predictable because symptoms are related to the duration and intensity of the trauma, the presence of other psychiatric disorders, and how the patient deals with the trauma. The average duration of symptoms in patients in treatment is about 36 months. In those not receiving treatment, symptoms can last for a mean of 5 years. About one-third of patients with PTSD have a poor prognosis for recovery. About 80% of patients with PTSD have a concurrent depression or anxiety disorder. Over half of men with PTSD suffer from comorbid alcohol abuse or dependence. About 20% of patients with PTSD attempt suicide. ... 

Grant BF, Harford TC Comorbidity between DSM-IV alcohol use disorders and major depression results of a national survey. Drug Alcohol Depend 39 197-206, 1995 Grant BF, Dawson DA, Stinson FS, et al The 12-month prevalence and trends in DSM-IV alcohol abuse and dependence United States, 1991-1992 and 2001-2002. Drug Alcohol Depend 74 223-234, 2004a... 

Similarly, covert substance abuse is also common in depression (Akiskal 1982 MacEwan and Remick 1988) and a leading cause of TRD. In a survey of 6,355 patients with substance abuse, M. S. Gold et al. (1994) found that 43.7% had a lifetime prevalence of major depression. Not only does comorbid substance abuse lead to TRD, but the presence of resulting hepatic disease alters antidepressant pharmacokinetics, making these patients more difficult to treat (Ciraulo and Jaffe 1981 Ciraulo et al. 1988 Mason and Kocsis 1991). In this regard, SSRls may offer some advantages over other antidepressants. One recent study of alcoholic patients with depression found a modest advantage for an SSRI over a TCA (G. Invernizzi et al. 1994). 

Although depression is the most prominent comorbid illness, a variety of other psychiatric conditions may be associated with panic disorder, for example, agoraphobia [60% of patients with panic disorder], other anxiety disorders (20%), and drug and alcohol abuse [15%] [Klerman 1992). 

Posttraumatic stress disorder (PTSD) is another anxiety disorder that can be characterized by attacks of anxiety or panic, but it is notably different from panic disorder or social phobia in that the initial anxiety or panic attack is in response to a real threat (being raped, for example) and subsequent attacks are usually linked to memories, thoughts, or flashbacks of the original trauma. The lifetime incidence of PTSD is about 1%. Patients have disturbed sleep and frequent sleep complaints. Comorbidities with other psychiatric disorders, especially depression and drug and alcohol abuse, are the rule rather than the exception. The DSM-IV diagnostic criteria are given in Table 9—11. 

Drug treatments for PTSD (Fig. 9—8) have until recently focused upon treating the associated comorbidities, especially depression. Because of the high degree of concomitant drug and alcohol abuse, benzodiazepines are usually best avoided. 

In addition to these subtypes, it is important to keep in mind that many, if not most, borderline personalities have comorbid Axis I disorders—especially common are major depression and substance abuse. These coexisting disorders always complicate the picture and must be dealt with in any approach to treatment. In particular, longitudinal studies following the course and outcome of borderline personality disorders over the life span suggest very clearly that those patients who continue to do poorly are those who continue to abuse alcohol and other substances. Thus treatment of chemical dependency problems must be addressed. 

Bipolar mixed episode (previously known as mixed state, dysphoric mania, or depressive mania) is defined as the simultaneous occurrence of manic and depressive symptoms. Mixed mood states occur in up to 40% of all episodes, and are more common in younger and older patients and in females. Mixed episodes are often difficult to diagnose and treat because of the fluctuating clinical presentation. Patients with mixed states often have comorbid alcohol and substance abuse, severe anxiety symptoms, a higher suicide rate, and a poorer... 

Benzodiazepines are prescribed commonly for SAD. Clonazepam is the most extensively studied benzodiazepine for the treatment of generalized SAD. " Clonazepam improved fear and phobic avoidance, interpersonal sensitivity, fears of negative evaluation, and disability measures. " Adverse effects included sexual dysfunction, unsteadiness, dizziness, and poor concentration. " Clonazepam is often prescribed in conjunction with an antidepressant, psychotherapy, or both for initial symptom relief. Comorbid alcohol or substance abuse are contraindications to the use of benzodiazepines. Other limitations of clonazepam therapy include lack of efficacy in depression and difficulty with discontinuation. Because of the risk of dependency, benzodiazepines should be reserved for patients at a low risk of substance abuse, those who require rapid relief of symptoms, or those who have not responded to other therapies. 

Patients with OCD often have comorbid depression, anxiety disorders, and alcohol abuse or dependence. It is a chronic illness in most patients, with severity of symptoms varying in intensity over time. Many patients with OCD have significantly impaired QOL and ability to function. ... 

It is considered a second-line agent for GAD because of inconsistent reports of efficacy, delayed onset of effect, and lack of efficacy for comorbid depressive and anxiety disorders (e.g., panic disorder or SAD). It is the agent of choice in patients who fail other anxiolytic therapies or in patients with a history of alcohol or substance abuse. It is not useful for situations requiring rapid antianxiety effects or as-needed therapy. 

Children with PTSD may be more likely to have comorbid conditions because traumatic insults occur in developmentally sensitive periods. Early life trauma is particularly toxic in its effects on development. Adults with severe sexual abuse histories exhibit high rates of debilitating disorders such as depression, anxiety disorders, alcoholism, substance abuse, and personality disorders (Herman and Van der Kolk, 1987 Putnam and Trickett, 1993). 

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