Alcohol and Depression

Conor K Farren Conorfarren.com

M.B., Ph.D., A.B.P.N. (Dipl.), F.R.C.P.I., M.R.C.Psych. Trinity College Dublin

St Patrick’s University Hospital

Bacchus discovered the juice of the grape and introduced it to mankind, stilling thereby each grief that mortals suffer from . . . sorrow's antidote.

Euripides, 407 BC, The Bacchae

Alcohol in Ireland

4th highest in EU, 11.5 L/alc/adult/annumHighest binge drinking in Europe: 34%

EU average: 10%Increased consumption by 17% in 1996-2005, tapered

since then. Increased alcohol related deaths to 1775 in 10 years:

100% increaseAlcoholic liver disease: 147% increase in 10 yearsAlcohol related diseases/injuries: 90% increase in 10

years

Interaction between Mood and AlcoholAbout 6% of the population suffers from alcohol

dependence (M>F), 7% from alcohol abuse, and 8% from heavy alcohol consumption.

About 8% of the population currently suffer from a depressive disorder. 1-2% suffer from a bipolar disorder.

Currently about 4% of the population suffer from both an alcohol problem and a mood problem.

Mood Effects of AlcoholIntoxication:

pleasant alteration in mood, diminution in anxiety symptoms.

Depression caused by the alcohol: hours later, the next day, a few days later.

For some alcoholics: a certain amount of alcohol to get depressed, only get depressed on one occasion out of 10 or 20, dependent upon the overall mood before drinking.

Suicidal Ideas: Alcohol can bring them on,can make suicidal ideas more intense disinhibited enough to try suicide, wouldn’t while sober

Effect of abstinence

At presentation, 40% of alcoholics have major depression; 50% have significant anxiety symptoms; 15% have manic or elation symptoms

After 4 weeks of sobriety, the incidence of depression goes down to 10%, the incidence of anxiety goes down to 15% and the incidence of mania goes down to <5%.

Alcohol and Suicide

25% of suicides solely attributable to alcohol

Alcohol present in 58% of completed suicides in Ireland

(Bedford et al., 2007)

International norm 38%93% of those under 30 years in Ireland

Alcohol present in 41% of episodes of deliberate self harm

Alcohol Related Mortality Rate per 100,000 1970 - 2000

0

2

4

6

8

10

12

1970 1975 1980 1985 1990 1995 2000

Suicide

Alcohol Consumptionrate

s p

er 1

00,0

00

Reasons for depression in sobrietyAlcohol withdrawal can produce significant anxiety

symptoms. Craving can present as depression. Coping with the effects of a long period of drinking –

financial, relationship, work problems. Immaturity of coping skills.

Anxiety and Alcohol

Social anxiety can lead to development of alcohol use disorder

Alcohol withdrawal is a significant cause of anxietyTrying to deal with alcohol, trying to change, can cause

anxiety. Heavy drinkers often drink to overcome an underlying

anxietyGeneralised anxietyPanic disorderPhobiaOCD

Craving for alcohol can present as anxiety; Anxiety can cause craving.

The U Turn: Sections

Why you need this book: Self-understanding

Negative emotions and how they hurt us: Anger Jealousy and envy Depression: experience and escape Fear and anxiety Criticism and hatred

•The fundamentals of self-beliefSelf belief and inferiorityPersonality and projectionTalking and communication

•The importance of relationshipsIntentPower

•The reason for it allJoy and purpose

The Dual Diagnosis Program at St Patrick’s University Hospital.

The program consists of: Lectures, both general and specific for the program, Video session, specific for the program Individual therapy sessionsAA and Dual Recovery groups. Group treatments:

Relapse prevention Dual Diagnosis 1st Step Recovery plan Discussion Group

Full time program consisting of 3 parts: - Assessment with detoxification and mood stabilisation; - Engagement with full or modified in patient program; - Aftercare for up to 6 months post discharge.

Farren and McElroy, J Affect Disorder2008, 106: 265-272

FIRESIDEFollow up. Interrelationship of diagnoses: can’t improve in

one without the other. Relapse Prevention.Education: Lectures, Videos, and Discussions. Stabilization of withdrawal and mood:

pharmacotherapy before and during program. Individuation of program. Flexibility for

retention proposes. Diagnostic equivalence. Both diagnoses

emphasised. Empowerment: Individual responsibility.

Farren and McElroy, J Affect Disorder2008, 106: 265-272

Depression (N=101) (M= 54, F=47)

Bipolar (N=88) (M=43, F=45)

Age 44.7 41.6

Education 14.0 13.7

Length of stay 37.1 ** 46.5 **

Previous admissions 1 * 1.7 *

F. Hx of alcohol abuse 59.4% 67%

F. Hx of psychiatric disorder 49.5%** 69.3%**

Suicide attempt 29.7% 34.1%

Illegal drug use 23.8% 34.1%

Prescription drug abuse 24.8% 29.5%

Demographics

* p<0.05** p<0.01

Mood Disorder Symptoms Depression - BDI

05

1015202530

Baseli

ne

Dischar

ge

6 mon

th

2 yea

r

DepressionBPAD

Farren CK, Snee L , McElroy S: J Stud Alcohol Drugs,

2011, 72: 872-880

Mood Disorder SymptomsAnxiety - BAI

05

1015202530

Baseli

ne

Dischar

ge

6 mon

th

2 yea

r

DepressionBPAD

Drinking Outcomes: Self Report

Drinking Days

05

1015202530354045

Baseline 6 months 1 Year 2 Year

DepressionBPAD

Units per Drinking Day

02468

101214

Baseline 6Months

1 Year 2 year

DepressionBPAD

Depre ssion Bipolar

Base 3 mths 6mths 2 years Baseline 3 mths 6 mths 2 years

No. drink days

40.96 5.46 37.39 6.32

Units per day

11.55 3.92 12.28 6.68

Abstinent 0% 70.3% 50.7% 57.3 % 0% 60.2% 49.3% 53.7 %

Drinking Outcomes

Predictive Relapse Factors at 3 Months.

Farren and McElroy, Alcohol and Alcoholism, 2010, 45 (6): 527-533.

B S.E Exp (B) 95%C.I for EXP(B)Lower-upper

Sig.

Organised aftercare on discharge 2.200 .466 .111 .045-.277 <.01

BAI on admission -.040 .020 .961 .924-.998 <.05.

Audit score at admission .062 .030 1.064 1.001-1.128 <.05

Family psych history -.660 .418 .517 .228-1.172 N.S

BDI score at admission -.040 .026 .961 .910-1.022 N.S

Unemployed 2.241 1.718 .106 .004-3.620 N.S

Predictive Relapse Factors at 6 Months.

Farren and McElroy, Alcohol and Alcoholism, 2010, 45 (6): 527-533.

B S.E Exp (B) 95%C.I for EXP(B)Lower-upper

Sig.

Organised aftercare on discharge1.766 .459 .171 .070-.421 <.01

BAI on admission-.010 .017 .990 .958-1.02 N.S

Audit score on admission.060 .030 1.06 1.01-1.13 <.05

Family psychiatric history -.813 .414 .444 .197-1.00 <.05

BDI score Discharge.036 .027 1.04 .984-1.09 N.S

OCDS score on admission-.040 .031 .961 .903-1.02 N.S

DAST score on admission-.061 .053 .941 .848-1.04 N.S

Drug History 1.417 .653 4.13 1.15-14.8 <.05

5-year follow up of AUD with Affective Disorder

Total Sample

VariableBaselinen = 205

3 monthsn = 196

6 monthsn = 155

2 yearsn = 144

5 yearsn =114

% abstinent – 66.3% 55.2% 45.1% 51.8%

No. of drink days 39 3.5 7.9 7.6 10.9

Units per dayAUDIT

Illegal drug usePres. misuse

12.1 22.2

28.8%25.5%

3 –

–

3.8 –

––

5.3 7

7%2.8%

5.7 5.5

1.8% 3.5%

Of those who were non- abstinent at 3 months 5 years

% Light Drinkers

93.8 %

Light DrinkersAbstinence

53.6%39.3%

Farren, Murphy and McElroy, Alcoholism: Clinical and Experimental Research: In Press

Supportive Text Messaging For Depression And Comorbid Alcohol Use Disorder:

Single-blind Randomised Trial

Mobile phone text message technology has the potential to improve outcomes for patients with depression and co-morbid

Alcohol Use Disorder (AUD).

Aims

To perform a randomised rater-blinded trial to explore the effects of supportive text messages on mood and abstinence outcomes for patients

with depression and co-morbid AUD.

Agyapong V, Ahern S, McLoughlin D, Farren CKJ Affect Disorder, 2012

Methods

Participants (n=54) with a DSM IV diagnosis of unipolar depression and AUD

Completion of the in-patient dual diagnosis treatment programme

Randomised to receive twice daily supportive text messages (n = 26) or a fortnightly thank you text message (n = 28) for three months.

Primary outcome measures were : Beck’s Depression Inventory (BDI-II) scores and Cumulative Abstinence Duration (CAD) in days at three

months. Trial registration: NCT0137868.

Sample Messages

Monitor changes in your mood; develop a list of personal warning signs

If you are having a good day, share your joy with others. If you are having a bad day, share it with others and accept their help.

Stick to your treatment plan; take your medication as prescribed and keep your appointments.

Keep Sobriety as a number one priority and you will reach your goals.

Make a list of 5 people you can call if you are craving. Make sure you carry their numbers with you all the time.

AA meetings are crucial; attend regularly; if you don’t like a particular AA meeting, shop around until you find one that suits you.

Measure Baseline Post-treatment p-value

Text message

group

Control group

Text message

group

Control group

Beck’s Depression Inventory-II

31.58 31.99 8.6 * 16.6 0.003

Cumulative Abstinence Duration

88.3 79.3* 0.08

Primary Outcomes

GAF Scale 48.2 48.6 89.8* 76.1 0.001

OCDS 26.0 23.7 8.4 6.8 0.40

Alcohol Self -Efficacy Scale 38.9 43.9

79.5 * 72.3 0.09

Proportion continuously Abstinent

20 % 16 % 0.12

Days to first drink 43.0 30.4 0.49

Units alcohol per day 25.0 20.7 1.13 6.9 0.10

Measure Baseline Post-treatment p-value

Text message

group

Control group

Text message

group

Control group

Secondary Outcomes

COMPUTERISED COGNITIVE BEHAVIOURAL THERAPY FOR AUD:

A PILOT PLACEBO-CONTROLLED TRIAL.

Conor K Farren,

Jennie Milnes, Kathryn Lambe, Sinead Ahern

The SettingInpatient 4-week rehabilitation programme, based

at St Patrick’s University Hospital. Patients were recruited from the inpatient group,

following detoxification and initiation onto the Alcohol and Chemical Dependence Programme.

The programme consists of education groups, individual therapy sessions, self help groups, plus educational lectures.

A comparison group of cognitive computer exercises was used as a placebo, for a similar number of sessions. This consisted of basic mental arithmetic exercises.

The Therapy5 X 50 minute therapy sessions were developed

using the CBT manual for Project MATCH as a basis.

Topics covered include: an interactive exploration of emotions relating to

triggers for drinking episodes; inaccurate thinking associated with AUD; feelings around alcohol use, and the development

of strategies to deal with distressing feelings; education about relapse, prevention strategies; craving induction and craving reduction strategies

Each session had an appropriate case history presented to the patient, based upon their original allocation to a personal drinking pattern.

At the end of each session, the patient was given standardised feedback via computer about their answers to questions,

Also given specific therapeutic instructions via computer regarding what would be helpful for their recovery.

Both groups were followed for 3 months after discharge, with measurement of drinking outcomes.

Social Drinker

Testing Personal Control

Emotional Drinker Drinker

Interpersonal Conflict

0

10

20

30

40

50

60

70

80

90

Types of Drinkers: Reasons for Drinking

Typical CCBT Programme Screens

FIGURE 1

INTERVENTION(n = 31)

EXCLUDED FROM ANALYSIS (n = 11)Did not complete protocolDischarged AMA (n = 2)Early discharge (n = 2)60% completion of protocol (n = 1)Computer issues (n = 3)Withdrawal from studyWithdrew (n = 1)Insufficient information for analysis (n = 2)

INCLUDED IN ANALYSIS

(n = 20)

CONTROL(n = 24)

INCLUDED IN ANALYSIS

(n = 15))

EXCLUDED FROM ANALYSIS (n = 9)Did not complete protocolWithdrew (n = 3)Early discharge (n = 2)Computer issues (n = 1)IneligibleDepression diagnosis (n =1)Change of Tx programme (n =2)

RANDOMISED(n = 55)

APPROACHED(n = 102)

Ineligible (n = 22)Declined (n = 25)

0

10

20

30

40

50

60

70

60.63

51.27

8.56

3

Baseline3 months

CCBT group Control group

Days

No. of Drinking Days

0

5

10

15

20

25

30

23.0824.34

5.944.79

Baseline3 months

CCBT group Control group

Un

its

Units per Drinking Day

Alcohol Misuse and Diabetes

Alcohol Misuse is the Diabetes of PsychiatryThey are both your “Friends for Life”They are managed not cured. They should be managed under 3 headings:

Medical

Behavioral

Complications

Diabetes Alcohol MisuseOral Meds Oral Meds: Antabuse, Anti-craving

Insulin Injection Anti-craving Injection

Diet Recovery Activity: e.g. AA

Exercise Avoidance of Risk: e.g. Pubs

CV Disease Anxiety

PV Disease Depression

Diabetic coma Bipolar Disorder