Alcohol and Depression

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Dr Conor Farren's presentation the relationship between alcohol and mental health issues, including depression, in Ireland. Dr Farren is a Consultant Psychiatrist at St Patrick’s University Hospital and a Senior Clinical Lecturer at Trinity College Dublin.

This presentation was given at Alcohol Action Ireland's conference, Facing 'The Fear': Alcohol and Mental Health in Ireland, on November 20, 2013.

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Alcohol and Depression

  1. 1. 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
  2. 2. 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
  3. 3. Alcohol in Ireland  4th highest in EU, 11.5 L/alc/adult/annum  Highest 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% increase  Alcoholic liver disease: 147% increase in 10 years  Alcohol related diseases/injuries: 90% increase in 10 years
  4. 4. Interaction between Mood and Alcohol  About 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.
  5. 5. Mood Effects of Alcohol  Intoxication:  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
  6. 6. 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%.
  7. 7. 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
  8. 8. Alcohol Related Mortality Rate per 100,000 1970 - 2000 12 rates per 100,000 10 8 Suicide 6 Alcohol Consumption 4 2 0 1970 1975 1980 1985 1990 1995 2000
  9. 9. Reasons for depression in sobriety  Alcohol 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.
  10. 10. Anxiety and Alcohol     Social anxiety can lead to development of alcohol use disorder Alcohol withdrawal is a significant cause of anxiety Trying to deal with alcohol, trying to change, can cause anxiety. Heavy drinkers often drink to overcome an underlying anxiety  Generalised anxiety  Panic disorder  Phobia  OCD  Craving for alcohol can present as anxiety;  Anxiety can cause craving.
  11. 11. 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
  12. 12. •The fundamentals of self-belief Self belief and inferiority Personality and projection Talking and communication •The importance of relationships Intent Power •The reason for it all Joy and purpose
  13. 13. 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 sessions AA 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 Disorder 2008, 106: 265-272
  14. 14. FIRESIDE  Follow 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 Disorder 2008, 106: 265-272
  15. 15. Demographics 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% * p<0.05 ** p<0.01
  16. 16. Mood Disorder Symptoms Depression - BDI 30 25 20 15 10 5 0 ar ye 2 on th 6 m ge ha r D isc Ba se l in e Depression BPAD Farren CK, Snee L , McElroy S: J Stud Alcohol Drugs, 2011, 72: 872-880
  17. 17. Mood Disorder Symptoms Anxiety - BAI 30 25 20 15 10 5 0 r ye a 2 on th 6 m ge ha r D isc Ba se l in e Depression BPAD
  18. 18. Drinking Outcomes: Self Report Drinking Days Units per Drinking Day 45 40 35 30 25 20 15 10 5 0 Depression BPAD 14 12 10 8 6 4 2 0 Depression BPAD Baseline Baseline 6 months 1 Year 2 Year 6 1 Year Months 2 year
  19. 19. Drinking Outcomes Depre ssion Base 3 mths Bipolar 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% 57.3 % 0% 70.3% 50.7% 60.2% 49.3% 53.7 %
  20. 20. Predictive Relapse Factors at 3 Months. 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. .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 Audit score at admission Farren and McElroy, Alcohol and Alcoholism, 2010, 45 (6): 527-533.
  21. 21. Predictive Relapse Factors at 6 Months. B Organised aftercare on discharge BAI on admission Audit score on admission Family psychiatric history BDI score Discharge OCDS score on admission DAST score on admission Drug History S.E Exp (B) 95%C.I for EXP(B) Lower-upper Sig. 1.766 .459 .171 .070-.421 <.01 -.010 .017 .990 .958-1.02 N.S .060 .030 1.06 1.01-1.13 <.05 -.813 .414 .444 .197-1.00 <.05 .036 .027 1.04 .984-1.09 N.S -.040 .031 .961 .903-1.02 N.S -.061 .053 .941 .848-1.04 1.417 .653 4.13 1.15-14.8 N.S <.05 Farren and McElroy, Alcohol and Alcoholism, 2010, 45 (6): 527-533.
  22. 22. 5-year follow up of AUD with Affective Disorder Total Sample Baseline n = 205 3 months n = 196 6 months n = 155 2 years n = 144 5 years n =114 % abstinent – 66.3% 55.2% 45.1% 51.8% No. of drink days 39 3.5 7.9 7.6 10.9 12.1 22.2 3 – 3.8 – 5.3 7 5.7 5.5 28.8% 25.5% – – – 7% 2.8% 1.8% 3.5% Variable Units per day AUDIT Illegal drug use Pres. misuse Of those who % Light Drinkers were non- abstinent at 3 months 93.8 % 5 years Light Drinkers Abstinence 53.6% 39.3% Farren, Murphy and McElroy, Alcoholism: Clinical and Experimental Research: In Press
  23. 23. 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 CK J Affect Disorder, 2012
  24. 24. 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.
  25. 25. 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.
  26. 26. Primary Outcomes Measure Baseline Post-treatment p-value Text message group Beck’s Depression Inventory-II Cumulative Abstinence Duration Control group Text message group Control group 31.58 31.99 8.6 * 16.6 0.003 88.3 79.3* 0.08
  27. 27. Secondary Outcomes Measure Baseline Text Control message group group Post-treatment Text Control message group group p-value 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 20 % 16 % 0.12 43.0 30.4 0.49 1.13 6.9 0.10 GAF Scale Proportion continuously Abstinent Days to first drink Units alcohol per day 25.0 20.7
  28. 28. Conor K Farren, Jennie Milnes, Kathryn Lambe, Sinead Ahern
  29. 29. The Setting  Inpatient 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.
  30. 30. The Therapy  5 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
  31. 31.  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.
  32. 32. Typical CCBT Programme Screens Types of Drinkers: Reasons for Drinking 90 80 Social Drinker Interpersonal Conflict 70 60 50 40 30 20 10 0 Testing Personal Emotional Drinker Control Drinker
  33. 33. FIGURE 1 APPROACHED (n = 102) Ineligible (n = 22) Declined (n = 25) RANDOMISED (n = 55) INTERVENTION (n = 31) EXCLUDED FROM ANALYSIS (n = 11) Did not complete protocol Discharged AMA (n = 2) Early discharge (n = 2) 60% completion of protocol (n = 1) Computer issues (n = 3) Withdrawal from study Withdrew (n = 1) Insufficient information for analysis (n = 2) INCLUDED IN ANALYSIS (n = 20) CONTROL (n = 24) EXCLUDED FROM ANALYSIS (n = 9) Did not complete protocol Withdrew (n = 3) Early discharge (n = 2) Computer issues (n = 1) Ineligible Depression diagnosis (n =1) Change of Tx programme (n =2) INCLUDED IN ANALYSIS (n = 15) )
  34. 34. No. of Drinking Days 70 60.63 60 51.27 Days 50 40 Baseline 30 3 months 20 10 8.56 3 0 CCBT group Control group
  35. 35. Units per Drinking Day 30 25 24.34 23.08 Units 20 Baseline 15 3 months 10 5.94 5 0 CCBT group 4.79 Control group
  36. 36. Alcohol Misuse and Diabetes  Alcohol Misuse is the Diabetes of Psychiatry  They are both your “Friends for Life”  They are managed not cured.  They should be managed under 3 headings: Diabetes Complications Oral Meds: Antabuse, Anti-craving Anti-craving Injection Diet Recovery Activity: e.g. AA Exercise Behavioral Oral Meds Insulin Injection Medical Alcohol Misuse Avoidance of Risk: e.g. Pubs CV Disease Anxiety PV Disease Depression Diabetic coma Bipolar Disorder

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