Promising new treatment options for people with co-existing alcohol-use and psychiatric disorders

Individuals who have co-existing alcohol-use and psychiatric disorders must overcome a number of significant hurdles on their way to recovery: multiple health and social problems, double the stigma, a poor response to traditional treatments, a lack of joint treatment options, and a chronic cycle of treatment entry and re-entry. Symposium proceedings published in the February issue of Alcoholism: Clinical & Experimental Research examine treatment options for this group, with a focus on four major psychiatric disorders: social anxiety disorder, depression, bipolar disorder, and schizophrenia.

"The United States has typically separated services for mental health from those associated with addictions," said Charlene E. Le Fauve, symposium organizer and health scientist administrator at the National Institute on Alcohol Abuse and Alcoholism. "Because of this separation, when a person with comorbid disorders enters one type of care, they are inadequately treated for the other condition. If one disorder goes untreated, both usually worsen and additional complications occur, which can include serious medical problems such as liver disease, HIV, or other organ damage, suicide, criminalization, unemployment, and homelessness. As a result, some individuals with comordid disorders often require high-cost services such as inpatient and emergency room care."

Symposium speakers at the June 2003 Research Society on Alcoholism meeting in Fort Lauderdale, Florida presented findings from recent trials and clinical studies:

- A selective serotonin reuptake inhibitor (SSRI) called paroxetine shows promise in the treatment of social anxiety in alcohol-dependent subjects.

"Since this was the first study to examine the effectiveness of paroxetine in this dual-diagnosis population," said Le Fauve, "we need to see if the results can be replicated by other researchers before we can determine how promising the results are."

- Response to SSRIs among individuals with co-existing alcohol dependency and depression seems to depend on various factors, including the severity of the depression, whether the depression is primary or secondary to the alcohol use, alcoholic typology (Type A or B), and gender.

"When someone is severely depressed, addicted to alcohol, needs inpatient mental health treatment, and has a history of attempting suicide," explained Le Fauve, "SSRIs are effective at improving the depression and decreasing alcohol consumption. Whereas, for alcoholics who do not need inpatient treatment because their symptoms of depression are mild to moderate, SSRIs are not very effective at treating both disorders. On the other hand," she added, "a heavy drinker who does not require formal addiction treatment may take SSRIs and notice that they will substantially reduce their alcohol intake."

Research indicates that gender may also play a role in the effectiveness of SSRIs, in that women with both alcohol and depressive disorders tend to respond better than men.

In addition, the type of alcoholic receiving SSRIs – Type A versus Type B – can influence its effectiveness in reducing alcohol consumption. Type A individuals are considered to have a less severe form of the disorder than Type B individuals: Type As become alcoholics at a later age, have less severe symptoms or fewer psychiatric problems, and have a better outlook on life than Type Bs, who become alcoholics at an early age, have a high family risk for alcoholism, demonstrate more severe symptoms, and have a more negative outlook on life than Type A individuals.

"Type B alcoholics are considered to be more severe and at greater risk for poor health outcomes," said Le Fauve. "Type B alcoholics also significantly worsen when they are treated with SSRIs when compared to Type A alcoholics. Clearly," she added, "SSRIs will not be the best method of treatment for all people who have both depression and alcoholism."

- In the first study of its kind, researchers found that an anticonvulsant, mood stabilizer called sodium valproate, used previously to treat bipolar disorder, may also be useful for both stabilizing mood states and decreasing alcohol use among bipolar alcoholics.

- Researchers have also found that treatment with the antipsychotic clozapine is associated with a decrease in alcohol and other substance use in patients with schizophrenia.

"‘Atypical’ or ‘novel’ antipsychotics are generally safer and better tolerated than older or ‘typical’ antipsychotic medicines," explained Le Fauve. "Emerging studies suggest that atypical antipsychotics can also be effective for a broad range of psychiatric syndromes beyond the primary indication of schizophrenia, such as mania, depression, anxiety, hostility and aggression. In addition, clinicians are increasingly using these medicines for conditions such as dementia, autism, developmental delay/mental retardation and personality disorders. So, it is not entirely surprising that a new atypical antipsychotic such as clozapine … may be a useful treatment modality for a broad range of non-psychotic conditions, including alcoholism."

Le Fauve noted that researchers are just beginning to unravel the complexities of how to treat people with comorbid mental illness and alcohol-use disorders. Including more people with comorbid psychiatric and substance abuse disorders in clinical research studies is an important first step, she added, to addressing the numerous issues that remain.

"We need to determine how individuals develop comorbid disorders and establish multidisciplinary teams to collaborate on the cause of these illnesses," she said. "We need to determine the role of genes and the environment in increasing risk of and/or offering protection against comorbid illnesses. We need to establish treatment approaches for comorbid conditions that take various situations, severity, gender, and alcohol subtypes into account. We need to develop better screening tools to diagnose complex comorbid disorders. We need to explore how fetal exposure to alcohol may lead to comorbid psychiatric disorders across the lifespan. Finally, we must develop comorbid training units in outpatient settings for health care providers to become credentialed mental health and addictions treatment providers."

Funding for this Addiction Science Made Easy project is provided by the Addiction Technology Transfer Center National Office, under the cooperative agreement from the Center for Substance Abuse Treatment of SAMHSA.

Articles were written based on the following published research:

Le Fauve, C.E., Litten, R.Z., Randall, C.L., Moak, D.H., Salloum, I.M., & Green, A.I. (February 2004). Pharmacological treatment of alcohol abuse/dependence with psychiatric comorbidity. Alcoholism: Clinical & Experimental Research, 28(2), 302-312.