Letters to the Editor
Depression and a History of Alcoholism
Dear Editor:
Depression and alcoholism are associated with considerable morbidity, disability, and mortality and cooccur more commonly than expected by chance (1–3). The results of several large epidemiologic studies have demonstrated the extent of comorbidity between depression and alcoholism (4–7). The National Comorbidity Study found an odds ratio of 2.0 between major depression and alcohol dependence (95%CI, 1.6 to 2.6) (4). Similarly, the National Longitudinal Alcohol Epidemiology Study demonstrated that 32.5% of individuals with major depression met criteria for a lifetime diagnosis of alcohol dependence, compared with only 11.2% of those who did not meet criteria for major depression (5).
A recent study compared clinical parameters in 2 groups of depression patients according to the presence or absence of a lifetime diagnosis of alcohol dependence (8). The authors found that depression patients with a lifetime diagnosis of alcohol dependence had lower Global Assessment of Functioning Scores; were more likely to have borderline, schizotypal, and paranoid personality disorders and cannabis dependence; and reported more paranoia and interpersonal sensitivity, compared with depression subjects without a history of alcohol dependence. Another recent study compared clinical parameters and cerebrospinal fluid (CSF) monoamine metabolites in depression patients with and without a history of alcoholism (9). Subjects with depression and a history of alcoholism had lower CSF homovanillic acid levels, were more likely to be tobacco smokers, and had higher lifetime aggression and current suicide ideation scale scores than did subjects suffering from depression but without a history of alcoholism. The results of these 2 studies demonstrate that individuals with depression and a history of alcoholism are more impaired than subjects with depression but no history of alcoholism. Treatments may be less effective for depression patients with a history of alcoholism than for other depression patients (3,10). In addition, individuals with a history of alcoholism may be at risk for a relapse of alcohol misuse (10). Therefore, it is important to recognize a history of alcoholism in patients with depression.
A history of alcoholism may be overlooked in primary care and psychiatric clinics. The clinician may not be able to gather the appropriate history because of the patient’s uncooperativeness. Alternatively, the clinician may fail to conduct an appropriate diagnostic interview: clinicians sometimes do not ask the most basic questions about alcohol or substance use. All depression patients should be asked about their current and past alcohol and substance use and advised to abstain from alcohol and substance use. It is important to maximize the chance of long-term sobriety in patients with depression.
References
1. Lynskey MT. The comorbidity of alcohol dependence and affective disorders: treatment implications. Drug Alcohol Depend 1998;52:201–9.
2. Miller NS. Mortality risks in alcoholism and effects of abstinence and addiction treatment. Psychiatr Clin North Am 1999;22:371–83.
3. Thase ME, Salloum IM, Cornelius JD. Comorbid alcoholism and depression: treatment issues. J Clin Psychiatry 2001;62(Suppl 20):32–41.
4. Kessler RC, Nelon CB, McGonagle KA, Liu J, Swartz M, Blazer DG. Comorbidity of DSM-III-R major depressive disorder in the general population: results from the US National Comorbidity Survey. Br J Psychiatry 1996;168(Suppl 30):17–30.
5. Grant BF, Harford TC. Comorbidity between DSM-IV alcohol use disorders and major depression: results of a national survey. Drug Alcohol Depend 1995;39:197–206.
6. Spaner D, Bland RC, Newman SC. Major depressive disorder. Acta Psychiatr Scand 1994;77(Suppl 376):7–15.
7. Ross HE. DSM-III-R alcohol abuse and dependence and psychiatric comorbidity in Ontario: results from the mental health supplement to the Ontario Health Survey. Drug Alcohol Depend 1995;39:111–28.
8. Rae AM, Joyce PR, Luty SE, Mulder RT. The effect of a history of alcohol dependence in adult major depression. J Affect Disord 2002;281–90.
9. Sher L, Oquendo MA, Li S, Huang Y, Grunebaum MF, Burke AK, and others. Lower CSF homo- vanillic acid levels in depressed patients with a history of alcoholism. Neuropsychopharmacology 2003;28:1712–9.
10. Hasin D, Liu X, Nunes E, McCloud S, Samet S, Endicott J. Effects of major depression on remission and relapse of substance dependence. Arch Gen Psychiatry 2002;59:375–80.
Leo Sher, MD
New York, New York
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