Comorbidity of alcoholism and psychiatric disorders: an overview

Alcohol Research & Health, Spring, 2002 by Ismene L. Petrakis, Gerardo Gonzalez, Robert Rosenheck, John H. Krystal

Antianxiety Medications. Several medications are available and effective in treating anxiety disorders. These include benzodiazepines; TCAs; SSRIs; and other serotonergic medications (i.e., medications that affect serotonin receptors), such as buspirone. Benzodiazepines are widely used for anxiety disorders, but some of their properties make their use controversial in patients with comorbid alcohol use disorders and anxiety disorders. For example, benzodiazepines have an abuse liability themselves and they can potentiate the motor and cognitive impairment associated with alcohol use. Despite these factors, little empirical evidence exists to suggest that these medications are unsafe for dual diagnosis patients. Clinically prudent treatment should include careful consideration of effective alternatives before prescribing benzodiazepines. If clinically indicated, benzodiazepines should be prescribed only after careful diagnosis, with close followup, including monitoring of abstinence and determination of contin ued need.

Both TCAs and SSRIs have been found effective in treating anxiety disorders, but their use in dually diagnosed patients has not been formally investigated. Because of their relatively minor side effects, the SSRIs often are the first line of treatment for anxiety disorders. Given recent evidence of their efficacy in treating alcohol use and depressive symptoms in dually diagnosed patients (Cornelius et al. 1995; 1997 a, b), further study of these medications in this population seems warranted. Similarly, a small open-label study has shown that the SSRIs may be effective in ameliorating anxiety symptoms as well as alcohol consumption in patients with comorbid PTSD and alcoholism (Brady et al. 1995).

Other medications used for PTSD patients include the monoamine oxidase inhibitors (MAOIs) and anticonvulsants. MAOIs should be used with caution. It is imperative that patients taking these medications avoid foods and beverages containing the chemical tyramine -- for example, beer on tap, red wines, liqueurs, overly ripe foods, salami, and aged cheeses. Patients actively abusing alcohol may be unable to adhere to this dietary restriction because of impaired judgment. The anticonvulsants are more promising because there is some evidence that they may be effective in treating anxiety disorders (Myrick et al. 2001). Their potential effectiveness as an alternative to benzodiazepines in the treatment of alcohol withdrawal suggests a role for them in the initiation of abstinence with comorbid patients. Although this application has only been reported anecdotally, this line of research is promising.

The serotonergic drug buspirone has been formally evaluated in several double-blind, placebo-controlled trials for patients with comorbid generalized anxiety disorder and alcohol dependence. Although several of these clinical studies suggested that buspirone reduced anxiety symptoms and one suggested that it reduced alcohol use, other studies reported that it had no effect in reducing anxiety or alcohol use (Myrick et al. 2001). These mixed results have left clinicians appropriately skeptical about the utility of this medication in this population.