Diagnosis and Treatment of Alcohol-Dependent Patients With Comorbid Psychiatric Disorders

Alcohol Research & Health, Spring, 1999 by Vania Modesto-Lowe, Henry R. Kranzler

Psychiatric disorders occur more often among alcoholics than among the general population. The psychiatric disorders that alcoholics most frequently experience include mood disorders (e.g., depression), anxiety disorders, and antisocial personality disorder. The evaluation of psychiatric symptoms in alcoholic patients is complicated by the multiple relationships that exist among heavy drinking, psychiatric symptoms, and personality factors. For example, alcoholics with co-occurring depression may he at greater risk of psychosocial problems, relapse, and suicide. Conversely, heavy drinking may produce or worsen symptoms of depression or anxiety. Although clinical experience provides general guidance for treating these patients, further research is needed to develop effective psychosocial and pharmacological therapies aimed at specific combinations of psychiatric and addictive disorders. KEY WORDS: diagnosis; treatment; AODD (alcohol and other drug dependence); behavioral and mental disorder; dual diagnosis; co morbidity; epidemiology; drug therapy; psychotherapy; literature review

Epidemiologic and clinical studies suggest that an alcoholic involved in treatment is statistically at high risk for a psychiatric disorder compared with the general population. Conversely, certain psychiatric disorders are often accompanied by alcohol abuse or alcohol dependence (Meyer 1986). The psychiatric disorders that occur most frequendy and that have been studied most in alcoholics are mood disorders (e.g., depression), anxiety disorders, and antisocial personality disorder (ASPD).

The presence of comorbid psychiatric disorders in alcoholic patients has clinical and prognostic implications. For instance, alcoholics with comorbid depression may be at greater risk of psychosocial and interpersonal problems, treatment noncompliance, alcoholic relapse, and attempted and completed suicide (Kranzler et al. 1998). Additionally, heavy drinking may produce or worsen depressive or anxiety symptoms. Research also indicates that alcoholics with ASPD start drinking at an earlier age and develop symptoms of dependence sooner than alcoholics without ASPD (Hesselbrock et al. 1992).

Together, these findings suggest that patients diagnosed with an alcohol-use disorder should undergo thorough psychiatric assessment. Conversely, patients seen in psychiatric settings should be routinely evaluated for the presence of an alcohol-use disorder. However, the evaluation of psychiatric symptoms in alcoholic patients can present a challenge to the clinician because of the complexity of the relationships between heavy drinking, psychiatric symptoms, and personality factors.

This article explores the extent of comorbidity between psychiatric disorders and alcohol-use disorders, describes research on the nature of comorbid relationships, and suggests general treatment considerations as well as treatment strategies aimed at specific comorbidities. The article also considers pharmacological and psychosocial approaches, both separately and in combination.

EPIDEMIOLOGY

Of the various epidemiologic studies that have examined comorbidity among alcoholics sampled from the general population, the National Comorbidity Survey (NCS) provides a representative sample and covers psychiatric disorders comprehensively (Kessler et al. 1994). This community survey of more than 8,000 respondents showed that among women, 72.4 percent of those who abused alcohol and 86.0 percent of those who were alcohol dependent had a comorbid lifetime psychiatric or drug-use disorder (Kessler et al. 1997). Among men, the comparable figures for alcohol abuse and alcohol dependence were 56.8 percent and 78.3 percent, respectively (Kessler et al. 1997). The NCS also shows that anxiety and mood disorder were the most common comorbid disorders among female alcoholics, whereas drug-use disorders and ASPD were the most common comorbid psychiatric disorders among male alcoholics (Kessler et al. 1997). Despite some gender differences, NCS shows that for both sexes, the association between alcohol dependence and a nxiety disorders, mood disorders, and ASPD was significantly elevated over what might be expected by chance.

High rates of comorbid lifetime psychiatric disorders also have been observed in alcoholic patients in clinical settings. Powell and colleagues (1982) found that 63 percent of 565 male inpatient alcoholic veterans met lifetime criteria for a comorbid psychiatric diagnosis. The most common comorbid diagnosis was depression (42 percent), followed by mania (20 percent) and ASPD (20 percent). Similarly, in a study of 321 inpatient alcoholics, Hesselbrock and colleagues (1985) found that 75 percent of men and 80 percent of women received one or more lifetime comorbid diagnoses. Drug abuse was the most prevalent lifetime diagnosis (45 percent), followed by ASPD (41 percent), major depression (38 percent), phobia (27 percent), obsessive-compulsive disorder (12 percent), panic disorder (10 percent), mania (4 percent), and schizophrenia (2 percent).