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