Anxiety Disorders and Obsessive-Compulsive and Related Disorders

Anxiety disorders are common comorbidities in people with alcohol use disorder.  At risk of repeating earlier advice, it is important to separate symptoms of anxiety that are the short- or long-term effects of alcohol use disorder from anxiety disorders that have their own maintaining processes and require their own treatment.  Clinical trials for comorbid alcohol use and anxiety disorders support either a) the recommended interventions for both disorders or b) in rarer instances there is support for a combined or integrated intervention.  

Some evidence shows that the specific techniques of cognitive behavioural therapy, such as exposure to feared situations, is well tolerated by people with substance use disorders, does not lead to relapse to drug use, and indeed contributes to reductions in anxiety. 

Typical pharmacological treatments for anxiety disorders (Agoraphobia, Panic Disorder, Social Anxiety Disorder, & Generalised Anxiety Disorder) also reduce anxiety when they co-occur with alcohol use disorders but typically have not impact on alcohol consumption. 

Selective serotonin reuptake inhibitors (SSRIs) reduce symptoms of anxiety in patients with comorbid anxiety and alcohol use disorder. They are indicated for treatment of obsessive-compulsive disorder (OCD) and panic disorder in these patients. However, little good quality evidence supports their capacity to reduce alcohol intake in the longer-term in patients with comorbid anxiety disorders. 

Benzodiazepines are effective anxiolytics and are used in treatment of acute alcohol withdrawal but should not be used beyond this indication. They are not recommended in treatment of comorbid anxiety due to high risk of dependence and a potential synergistic interaction with alcohol. 

We found no clinical trials of pharmacotherapy for comorbid obsessive-compulsive and alcohol use disorder. Thus any recommendation is based upon evidence from people without comorbidity.  SSRIs are recommended for the first line treatment of OCD alone or in combination with psychological therapies. 

Combining pharmacological and psychosocial interventions may be beneficial, particularly when psychosocial interventions for alcohol use disorders are integrated with those for anxiety. 

Chapter Recommendation Grade of recommendation
21.35 Cognitive behavioural therapy, behaviour therapy, cognitive therapy, and interpersonal therapy should be considered for treatment of people with comorbid mental and alcohol use disorders because of their demonstrated effectiveness in non-comorbid cases. B
21.36 SSRIs may reduce the symptoms of anxiety in people with comorbid anxiety and alcohol use disorder without impacting on alcohol use C
21.37 Benzodiazepines are not recommended for treatment of comorbid anxiety in people with alcohol-use disorders due to high risk of dependence and a potential synergistic interaction with alcohol. GPP