Findings indicate that patients with co-occurring major depression and alcohol dependence might be optimally treated with combination pharmacotherapies that address each condition.
In the present study, more depressed, alcohol-dependent patients treated with the combination of sertraline (200mg/day) and naltrexone (100mg/day) achieved complete abstinence with treatment and significantly delayed relapse to heavy drinking, compared to a group taking single-medication treatments, namely, naltrexone, sertraline, or placebo. Secondary drinking analyses (no heavy drinking; time to first drink) supported primary drinking outcome results. There were also fewer serious adverse event reports in the medication combination group, essentially indicating that fewer patients required hospitalizations for alcohol detoxification or rehabilitation.
Also, illustrated that the time to relapse to heavy drinking, and to any drinking, portray relatively dramatic response differences early in treatment between the medication combination treatment versus the other three treatment groups. While a medication response before 2 weeks is inconsistent with the typical time it takes to observe an antidepressant mood response, little is known about the time it may take for drinking behavior to respond to an antidepressant in depressed, alcohol-dependent patients.
While all patient groups showed a clinical reduction in depressive symptoms, there was a trend for more patients to not be depressed in the last 3 treatment weeks if they had received the medication combination (sertraline and naltrexone), than if they were in the group of single-medication treatments, namely, naltrexone, sertraline, or placebo. The depression outcome findings were surprising in light of selected prior literature that reported that depressed, alcohol-dependent patients had a more robust reduction in depressive symptoms with an antidepressant than placebo. However, this study found no advantage for sertraline alone in depressive symptom reduction, and, potentially, portrayed a tendency for sertraline to have a slower mood improvement rate over the 14 weeks compared to the other treatment groups. A tentative observation from our depression outcome results, which do support those of the published multi-site sertraline study (11
), is that there may be relatively little advantage in prescribing an antidepressant alone for depressed patients who are also alcohol dependent. Nonetheless, all patients had clinically significant reductions in depressive symptoms, which could be attributable to all patients receiving weekly CBT sessions. Alternatively, this study’s clinical sample might have had less of a problem with depression than with drinking, which is not easily captured by the measures we use to assess patients’ pre-treatment profiles.
Study limitations are that patients agreed to participate in a research study, and, may be different from non-research, clinical patients. Additionally, the treatment setting is an outpatient substance dependence treatment facility, and it is likely that depressed, alcohol-dependent patients who seek treatment at this type of facility are different from those who seek treatment at a general psychiatric or specialty depression clinic. Also, these study patients’ responses to sertraline and/or naltrexone cannot be generalized to other antidepressants or to other medications approved for treating alcohol dependence. Finally, we do not know if the ameliorative, short-term effects of our treatments are sustainable. Both of these disorders can be life-long illnesses.
In summary, the co-occurrence of depression and alcohol dependence is highly prevalent and difficult to treat successfully. This study’s findings suggest that these patients would benefit from a combination of an antidepressant and a medication for alcohol dependence. More medication-combination patients achieved abstinence from alcohol in treatment compared to a patient group taking single-medication or placebo treatments. Also, the medication-combination patients were not depressed at the end of treatment. These findings require replication before recommending changes in current clinical practices for treating co-occurring depression and alcohol dependence.