Depressive Disorders

The recommendations for the management of comorbid depressive disorder from National Comorbidity Guidelines are summarised here. First line management is to provide psychoeducation about depression in the context of alcohol use with information about how to manage symptoms.  If symptoms persist, psychological interventions with a strong evidence base in the treatment of depressive disorders such as CBT, behavioural activation, cognitive therapy and interpersonal therapy can be applied. Internet delivered or e-therapy may be a convenient way to access these therapies provided progress is monitored, engagement is maintained, and care is coordinated. Then motivational interviewing and/or contingency management may be integrated to provide additional benefit. Some benefit for a disparate collection of integrated cognitive behavioural therapy programs for comorbid major depression and alcohol use disorders compared to a focus on alcohol alone was found in a recent meta-analysis. The specific cognitive behavioural therapy packages were described such as behavioural activation, cognitive therapy and interpersonal therapy. There is insufficient evidence to recommend so called third wave therapies such as acceptance and commitment therapy, mindfulness based stress reduction, and mindfulness based cognitive therapy, but these may be of use if there is insufficient response to the earlier approaches. Antidepressants are an alternative second line treatment for comorbid alcohol and depressive disorders. 

Meta-analyses of randomised controlled trials indicate that antidepressant medication has a modest beneficial effect for comorbid depressive and substance-use disorders. They are not recommended as a stand-alone treatment. Concurrent treatment directly targeting the alcohol use disorder is also indicated.  There is reasonably good evidence from a meta-analysis of RCTs that antidepressants are more effective for independent depression (that began before alcohol use disorder or persists through abstinence) than for depression that is experienced only while drinking or in withdrawal.  

Antidepressants may help relieve depressive symptoms but have little effect on reducing alcohol consumption, unless accompanied and supported by psychosocial treatment for alcohol-use disorder. 

SSRIs reduce depressive symptoms in comorbid major depression and alcohol use disorder; however, research results regarding their effectiveness in reducing alcohol consumption are conflicting. SSRIs should not be used as primary therapy to reduce alcohol consumption in comorbid depression. Tricyclic antidepressants should be used with caution in this population due to high risk of poor treatment adherence, abuse and overdose. 

Antidepressants should not be the first line of treatment in patients with comorbid alcohol use disorders, unless there is high level of suicidal ideation, severe depressive symptoms or a history of pre-existing depressive illness. Clinicians should consider potential for poor treatment compliance among people with heavy alcohol use. Psychological treatment options should be used first, integrating approaches that are aimed at reducing alcohol consumption with those targeting depressive symptoms. 

If naltrexone is used in people with depression additional monitoring may be needed to identify potential worsening in mood. Similarly, there is potential for a very rare exacerbation of mood in those taking disulfiram. Baclofen may be associated with an increase in depression. 

Chapter Recommendation Grade of recommendation
21.29 Evidence based psychosocial interventions for depression (CBT, cognitive therapy) can be integrated with motivational interviewing and/ or contingency management for depression C
21.30 Integrating psychosocial treatment for mood disorders with psychosocial treatment for alcohol- use disorder may be beneficial D
21.31 Antidepressants (sertraline, imipramine, desimparmine, & fluoxetine) are likely to reduce depression in those with comorbid depression that is independent of alcohol use with some small or inconsistent effects on alcohol use. B
21.32 Antidepressants may provide limited benefit for symptoms of depression in those whose depression only occurs during active alcohol use disorder. C
21.33 Antidepressants are not expected to benefit alcohol use and should not be prescribed to reduce alcohol use. C
21.34 When considering the use of tricyclic antidepressants in patients with major depression continuing to misuse substances, the potential benefits should be balanced against the risk of suicide GPP