Depression & Alcohol Black Dog Institute Mission: To advance - - PowerPoint PPT Presentation

Depression & Alcohol

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Black Dog Institute

Mission: To advance the understanding and management of the mood disorders through

• Research
• Clinical Services
• Community Support
• Education

The Institute is partially funded by NSW Ministry of Health and philanthropic

• support. No pharmaceutical companies have input to the program.

Clinical Services Research Education Community Support

Learning Objectives

By the completion of this module you will be able to:

• Discuss the epidemiology of co-morbid depression and problem

alcohol use

• Assess the impact of alcohol use in patients with depression
• Diagnose alcohol use disorders
• Incorporate the use of pharmacological and psychological

treatments in the management of co-morbid depression and alcohol use disorders

• Refer to appropriate services and resources, both online and in

the community, to assist people with co-morbid depression and alcohol use disorders

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Men, alcohol and depression

• In 2011-12 almost three times as many men than women aged

18 years and over consumed alcohol in quantities that posed a health risk over their lifetime

• Men are more likely to engage in externalising behaviours such

as substance use in response to negative events especially when depressed

• At least one-quarter of all suicides in Australia record alcohol

dependence as a causal factor (Begg et al. 2007).

• One psychological autopsy study found evidence of an alcohol

disorder in 68% of male suicides and 29% of female suicides

(Kolves et al. 2006).

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Alan (aged 48) and GP

Clip 1 –Alan and GP As you watch this consultation note down:

• Any information that Alan reveals that you think is

significant

• Any questions or comments the GP makes that you

think are significant

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Alan

Before we discuss a “diagnosis” for Alan:

• What would be your reaction to Alan’s presentation?
• What would be your concerns about his

presentation?

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History

What other questions would you like to ask?

• Suicide risk
• Risk of harm to others
• Use of other drugs (e.g. benzos)
• Past and present medical history
• Personal psychiatric history
• Family psychiatric history

cont...

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History

• Nutrition and exercise status
• Has Alan ceased drinking in the past – how did he

manage to do this? How long?

• Any withdrawal syndrome (esp. symptoms of

complicated withdrawal)

• What would Alan like to do about his drinking?

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Investigations

Would you perform any investigations? If so, which investigations ?

• FBC (MCV - Mean (Red Blood)Cell Volume - is

increased in 20-30% of heavy drinkers in the community)

• LFTs (GGT is increased in 30-50% of heavy drinkers in

the community)

• TSH B1/folate

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Differential Diagnosis

(i) What does Alan think is going on for him? (ii) What is the differential diagnosis for Alan? (iii) What domains of Alan’s life are affected by his alcohol use and low mood? (iv) How would you describe Alan’s alcohol use pattern?

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Terminology: In the past

(i) ICD 10:

• Non- dependent:
• Hazardous - at risk of harm
• Risky – causing actual harm
• Alcohol dependence

(ii) DSM IV:

• Alcohol Abuse
• Alcohol Dependence

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Terminology: DSM 5

DSM 5 has a single diagnosis of Alcohol Use Disorder with severity rankings of Mild/Moderate/ Severe

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Severity

What factors would determine severity?

• Frequency
• Quantity
• Duration
• Inability to control
• Impact of current use on domains of life

From the history alone, how would you rate the severity of Alan’s alcohol use disorder?

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Screening Tools

Are there any screening instruments you would use for Alan?

• DASS 21
• AUDIT (Alcohol Use Disorders Identification Kit) (ten items)
• AUDIT C (three items)

Let’s look at the AUDIT scale Alan has completed in your workbook

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AUDIT scoring

• 8 -12 : = hazardous/harmful drinking
• 13 or more: = alcohol dependence in DSM IV terminology

Alan’s score of 19 on the 10 item AUDIT indicates moderately severe alcohol use disorder

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AUDIT C

Audit C uses first 3 questions only

• Cut off for alcohol misuse: 3 for women; 4 for men
• A total of 5 or more indicates high risk drinking

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Epidemiology

A Alcohol use in Australia:

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Table 1: Alcohol use disorders in Australians aged 14 years or older Lifetime prevalence Alcohol use 87.9%* Risky drinking 20.1%* Alcohol abuse (DSM-IV) 18.3%# Alcohol dependence 3.9%#

*Adapted from 2010 National Drug Strategy Household Survey report.

#National Survey of Mental Health and Wellbeing, Teesson et al, 2010

Alcohol Depression

B Alcohol use and Depression: Prolonged heavy drinking:

• 80% depressive symptoms
• 30-40% major depression
• 5-10% depression persisting weeks after abstinence

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Epidemiology

C Other co-morbidities:

1.

Very high incidence of anxiety disorders in alcohol use disorder

2.

Complex trauma

3.

Other substance abuse D Depression and alcohol use:

• In the 2000 National Survey of Mental Health and Wellbeing,

around 17% of those with depression met criteria for an alcohol use disorder (12 month)

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Primacy

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Which is Alan’s primary disorder? Is this important?

• Although establishing the primary disorder can be helpful in

terms of management decisions and prognosis, in practice it is

• ften not possible to determine primacy
• Where possible a period of 3-4 weeks abstinence can help

ascertain if anxiety and depression are predominantly alcohol related

• Uncertainty regarding primacy need not preclude effective

treatment

• The focus is best shifted to a model that views the conditions as

concurrent with an integrated treatment approach

Back to Alan

• A. What would Alan be expecting from this consultation?
• B. What would you hope to achieve in this consultation?
• C. How would you explain to Alan your assessment of his

situation so far?

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Psycho-education

What psycho-educational messages would you impart at this stage?

• Safe drinking guidelines
• Symptoms of depression
• Impact of alcohol intake on mood
• Impact of low mood on alcohol intake
• Effective treatment is available
• Change is possible
• Alcohol withdrawal syndrome
• Role of good nutrition, esp. thiamine

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Fostering hope

• People with co-morbid depression and alcohol use disorder

can benefit from brief and simple interventions

• Patients and clinicians can hold attitudes of hopelessness

around change and recovery which may discourage active engagement in treatment

• Creating a dialogue of hope and positivity can help counter

these attitudes

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Arranging follow-up

When would you see Alan again? Is there anything you could ask Alan to do between visits? Why would keeping a diary be useful? What would you want him to record ?

• Looking at best mood and worst mood, strongest cravings and

least cravings and starting to make links between these

• Can start with simple task such as rating mood and number of

drinks and slowly include other observations How would you “sell” Alan the idea of charting his mood and drinking for the week?

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Alcohol & Mood Diary

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Day

Best / Worst

Time Situation Mood 1 - 10 Cravings 1 - 10 ETOH Use Monday

Best Worst

Tuesday

Best Worst

Wednesday

Best Worst

Thursday

Best Worst

Friday

Best Worst

Saturday

Best Worst

Sunday

Best Worst

Next Visit

One week later Alan has returned. His blood tests revealed an elevated GGT (150) and an MCV of 101 He has completed his mood/drink diary What are your thoughts looking at Alan’s mood/ drink diary?

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Motivation

• What would be Alan’s level of motivation to address his alcohol

and mood issues?

• What is important to Alan and could underpin his motivation to

change?

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Stages of change

What are the stages of change?

• Pre-contemplation
• Contemplation
• Preparation
• Action
• Maintenance

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Stages of Change

• What is the significance of the stage of change?

Although a person’s stage of change has not be shown to be predictive of treatment outcomes it can provide a useful information in terms of management planning

• How could you enhance Alan’s motivation for change?

Motivational Interviewing

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Eliciting Pros and cons:

(i) Alcohol:

• What do you like about drinking?
• What don’t you like about drinking?
• What do you like about the idea of quitting?
• What don’t you like about the idea of quitting?

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Eliciting Pros and cons:

(ii) Depression

• What is good about leaving the depression as it is?
• What is not so good?
• What would be good about treating and recovering from the

depression?

• What would be not so good?

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MHTP for Alan

• Alan has indicated he is not yet ready to give up alcohol but

may consider reducing his intake

• He agrees to complete a Mental Health Treatment Plan

together with the GP and accept a referral to a psychologist under the Better Access program

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Skills Practice

In pairs:

• GP and Alan are completing the Mental Health Treatment Plan

together.

• In this skills practice the GP works collaboratively with Alan to

decide:

• Patient needs/main issues – What are the problem issues for

Alan?

• Goals – What are Alan’s goals for treatment?

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Lifestyle changes

In both depression and alcohol use disorder there are clear benefits to:

• Good nutrition (including thiamine and multivitamin

supplementation)

• Physical exercise
• Improving sleep hygiene

These are goals that many find as acceptable starting points for change

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? Abstinence

(i) Does Alan need to be abstinent for treatment to continue?

• Although abstinence may be the preferred outcome for Alan, he

can still engage in effective treatment despite not being abstinent (ii) Can Alan’s mental health improve if he continues to drink?

• Although abstaining from alcohol would clearly benefit Alan’s

mental health, he can still work towards mental wellness while not abstinent

• Trials have shown that clinical work with people who are

currently depressed and currently drinking is still effective

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Getting started

What are some early steps Alan could take to reduce his drinking?

• Introducing concept of “alcohol free days” as a start (see next slide)
• Set concrete goals including which days, number, size and type
• f drinks

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Reducing alcohol intake

What challenges would Alan face in becoming abstinent or reducing his alcohol intake? (1) Need to consider the safety of abstaining from alcohol:

• Alan would need to be advised that he may go into alcohol

withdrawal when he ceases drinking.

• Advise of signs of alcohol withdrawal and when to seek

assistance In your materials we have included an excerpt from The Treatment of Alcohol Problems A Review of the Evidence 2009 as well as criteria for home detoxification The management of alcohol withdrawal is not within scope of our program today.

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Managing cravings

(2) Alan would need to recognise some of his triggers for drinking as well as learning skills to manage cravings. These can be combined to create a craving plan What strategies would help Alan to manage alcohol cravings?

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At the psychologist - the integrated approach

• The integrated approach: using already familiar psychological

strategies with a new emphasis on the interplay between alcohol and the mood

• Let’s look at some examples:

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Group activity

(1) Behavioural activation

• What are the principles of the use of behavioural activation in

the treatment of depression?

• How could this be expanded to factor in the role of alcohol in

the narrowing of the behavioural spectrum?

• Give an example of an activity based goal for Alan

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ABC

(2)ABC (i) How could thought monitoring help Alan? (ii) Alan has noticed that on days where he achieves very little at work he often ends up stopping for a drink on the way home Complete the following for Alan in this scenario:

• A. Situation
• B. Thoughts
• C1. Feelings
• C2. Behaviour

How would working through this be helpful for Alan?

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Meta-cognitions

• (3) Metacognitions – thought about our thoughts

What would be some meta-cognitions that would link Alan’s thought patterns to his behaviour?

– I can’t stand thinking this way – I need to stop or get rid of these thoughts – These thoughts are driving me crazy

• Intolerance of unwanted thoughts and negative beliefs about

the presence of unwanted thoughts can lower mood and trigger drinking.

• Identifying and challenging these metacognitions can further

assist Alan in changing his behaviour

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Mindfulness

(4) Mindfulness

• In what way would learning and practicing mindfulness skills be

helpful for Alan?

• Mindfulness skills have been shown to be effective in reducing

depressive symptoms and substance abuse.

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Medication

• Alan has returned to the GP for a review after 6 sessions. He

has been applying the skills he is acquiring in his sessions with the psychologist. However, his mood remains low and he is still drinking daily

• Would you consider prescribing medication for Alan?
• Which medication/s would you prescribe?

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Antidepressant

What factors would you weigh up in deciding on the use of anti- depressant medication?

• Severity of the depression
• Sub-type of the depression
• Suicidality
• Access to non-pharmacological treatment
• Response to non-pharmacological treatment

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Antidepressant

Will an antidepressant work in someone who is drinking heavily?

• Studies have shown that antidepressants can be effective in

alleviating depressive symptoms but have no effect on reducing alcohol intake

• The lift in mood can be a useful impetus to then work on other

issues

• An SSRI is generally the anti-depressant of choice.
• Tricyclic antidepressants are best avoided in in view of sedation

and lack of safety in overdose.

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Medications for alcohol dependence

Which medications are used to treat alcohol dependence? Naltrexone:

– opioid receptor agonist – blocks mu receptor – reduces reward via reduced dopamine response – decreases rate of relapse in heavy drinkers – increases days of abstinence in alcohol dependence

Start day 3-7 after withdrawal Treat for 3-6 months (up to one year)

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Naltrexone

Not suitable for patients requiring opioid pain relief Not to be used in acute hepatitis or hepatic failure Concomitant antidepressant use is safe 50mg once daily Start at 25mg for one week then increase

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Acamprosate

• Modulates GABA and glutamate function (neurotransmitters in

withdrawal)

• Helpful in maintaining abstinence
• Increases the number of days abstinent
• More effective in motivated patients as tds dosing
• Can combine with antidepressant
• Contraindicated in renal insufficiency or hepatic failure
• 333mg 2 tablets three times a day started soon after withdrawal

(days 3-7)

• Treat for 3-6 months

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Medication

Be aware of the PBS authority indications for naltrexone and acamprosate:

• For use within a comprehensive treatment program for alcohol

dependence with the goal of maintaining abstinence

• Acamprosate is a streamlined authority script 2665

Antabus and Baclofen require close supervision and monitoring Best used in specialist services

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Referrals

What other referrals, services or websites could assist Alan?

• Alcoholics Anonymous – 12 step program
• Useful website to help people understand what is involved in

AA www.aa.org.au What is your experience of referring people to AA?

– Multiple meetings in multiple locations – Concept of sponsor helpful for some – Variation between different groups

Al-Anon for families (including Alateen) www.al-anon.org/australia

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Referrals

• SMART recovery groups – CBT based program

 Building and maintaining motivation  Coping with urges  Problem solving  Life Balance

Mix of substance issues and goals smartrecoveryaustralia.com.au

• GROW – peer supported programs for growth and personal

development for people with mental health illness www.grow.net.au

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Online treatment

Online treatment programs for depression and alcohol use disorder:

• SHADES Treatment – in collaboration with a health professional

http://shadetreatment.com

• On Track -

www.ontrack.org.au/web/ontrack/programs/alcoholanddepres sion

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OnTrack

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Useful Websites

• National Drug and Alcohol Research Centre

http://ndarc.med.unsw.edu.au/resources

• Government alcohol guidelines

http://www.nhmrc.gov.au/your-health/alcohol-guidelines

• Australian Drug Information Network - alcohol and drug search

directory http://www.adin.com.au/help-support-services

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Community Drug and Alcohol Teams

• more complex presentations
• multiple psychosocial contributors
• requiring an element of inpatient care
• benefit from a team approach

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Relapse

Alan has now been abstinent for 3 months and his mood has been steadily improving.

• What is the risk that Alan will relapse?
• How would Alan react to a relapse?
• What are the important factors in preventing relapse?

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Creating a Wellbeing Plan:

Identifying:

• Strategies that assist in maintaining wellness
• Situations (thoughts, events, people etc) that can trigger

relapse

• Early warning signs that signal lowering mood and increased

alcohol intake

• Action to take when relapse occurs

Relapse is common and not a sign of failure Each relapse is an opportunity to learn more about the challenges

• f staying well

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Summary

• Depression and alcohol use disorder are commonly co-morbid
• Primary care clinicians have a central role in identifying and

managing this co-morbidity

• An integrated approach managing the two conditions

concurrently is effective in improving mood and reducing alcohol use

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Evaluation and Reinforcing Activity

• Please complete your evaluation form prior to leaving.
• You may complete the Reinforcing Activity at the end of the

workshop or return it to us within the next fortnight Thank You

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