Unit 1 Alcohol:dependence withdrawal depression and other mental health disorders Developed by Dr Ad

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Unit 1 Alcohol dependence
withdrawal depression and othermental
healthdisordersDeveloped by Dr Adam R
Winstock MRCP MRCPsych FAChAM
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Prevalence of use

• Average Australian aged 15 and over consumed 9L
  pure ethanol in 2000/01
• Australia ranked 23rd in the world in per capita
  alcohol consumption
• Although wine and spirits consumption increased
  over the last decade, just over half of alcohol
  is consumed as beer
• 4 of the global health burden is due to alcohol

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Death

• gt30,000 Australians died from risky/ heavy
  drinking in the decade 1992-2001
• 20 cirrhosis
• 15 car accidents
• 7 cancer
• 7 suicide
• More died from acute effects than chronic

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Patterns of use, metabolism and blood alcohol
levels
150
Concentration of alcohol in the blood after 6
units of alcohol (48mg of alcohol)
100
blood alcohol (MG/100ML)
50
s
s
0
4
8
hours
s
s
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Rate of decrease of concentration of alcohol in
the blood in heavy, social naïve drinkers
BAC
100
80
60
40
Heavy drinker
Social drinker
20
Naïve drinker
4
2
1
3
5 hours
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Effects of alcohol on behaviour

• Increased risk of
• accidents

15 times
Those most susceptible to alcohol
10 times
Those least susceptible to alcohol
5 times
10 50
100 150
Blood alcohol concentration (mg/100ml)
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Risk factors for alcohol use disorders

• Genetic
• Personal risk vs protective factors
• Psychological vulnerability, trauma, abuse
• Psychiatric illness
• Occupation
• Availability
• Experience
• Community
• Culture

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Alcohol related presentations in primary care

• Hypertension
• Fatigue/ insomnia
• Nausea/ indigestion/ diarrhoea/ reflux/
  pancreatitis
• Irritability and anxiety
• Depression/ labile mood/ anger
• Worsening of psoriasis
• Absentee days (especially Mondays)
• Relationship/ parenting problems
• Reduced libido/ fertility/ sexual dysfunction
• Repeated accidents/ violence/ trauma
• Driving under the influence of alcohol

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Acute Complications

• Account for over 50 of the harm associated with
  drinking
• Most not found in dependent drinkers
• Road traffic accidents, other trauma, physical/
  sexual assault
• Violence, crime, unprotected sex, suicide,
  drowning, burns, arrhythmias
• Public disorder

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Screening for alcohol

• CAGE questionnaire good for heavy/ dependent
  drinkers, but tends to miss many of those with
  less severe alcohol use disorders
• Have you ever felt you should Cut down on your
  drinking?
• Have people Annoyed you by criticising your
  drinking?
• Have you ever felt bad or Guilty about your
  drinking?
• Have you ever had a drink first thing in the
  morning to steady your nerves or to get rid of a
  hangover (Eye opener)?

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The AUDIT

• 10 item self complete screening tool
• for dependent and hazardous drinking
• May be used to assist in the delivery
• of brief intervention

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Biological markers

• GGT widely available sensitive blood test. Half
  life of abnormal levels is 2 weeks (has a role in
  monitoring through serial measures with feedback
  and may have some prognostic value)
• Aminotransferase AST ALT gt1.5 suggests
  alcoholic liver disease
• MCV Non-specific e.g. nutritional, drugs, liver
  disease
• (Bone marrow toxicity and macrocytosis / t1/2
  60 days,
• Increased even when folate/B12 normal)
• CDT (Carbohydrate Deficient Transferrin) most
  sensitive and specific marker of heavy drinking
  (NB not rebated under Medicare)

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Assessing alcohol use
Consumption amount x frequency x duration
Other substance use?
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A typical day

• What time do they wake up? When? Why? How do
  they feel?
• (low mood, responsibility, withdrawal,
  craving)
• Time to first use, evidence of withdrawal and
  relief use
• Day activities, kids, food, drug use, drug
  seeking, social
• network, risk behaviours and pleasures
  (neglect of other
• activities, primacy of drug using and seeking
  behaviour, continued use despite risks)
• Evening activities, relationships,
  accommodation, sleep-
• insomnia, sleep hygiene

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Alcohol history

• Drinking history/alcohol related problems
• Previous treatments
• Circumstances surrounding relapse
• Family history
• Risk assessment

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Risk assessment

• Ask about past episodes of violence
• Relationship to drug use/ withdrawal
• Context dependent/ independent
• Relationship to command hallucinations
• Other drug use
• Access to weapons or medication
• Intent - specificity of threat

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Assessment putting it all together

• Is your patient drinking above recommended
  healthy levels?
• If so is he or she
• Drinking at hazardous / harmful levels?
• Dependent? (a lot or a little)
• Willing to attempt change?
• If dependent
• Is a withdrawal syndrome likely?
• Is there a co-existing mental illness?
• Is there any immediate risk?

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Dependence

• Three or more criteria present
• Psychological
• Craving/Compulsion to drink
• Loss of control
• Physical
• Tolerance
• Withdrawal symptomsrelief drinking
• Behavioural
• Alcohol takes priority over all other activities
• Persistent drinking despite harm
• Reinstatement after abstinence

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Natural history of dependence

• Peak ages 20 45 years
• A chronic relapsing condition
• Exists on a spectrum of severity
• The most severe and the least severe have the
  best outcomes
• 5 return to stable controlled drinking without
  treatment

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Alcohol withdrawal

• Common
• Exists on spectrum
• Easy to manage well
• Also easy to manage less well
• Early identification ideal
• Routine management
• Risk factors for severe withdrawal
• D.Ts/ seizures and management
• After detox

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Progress of untreated withdrawal
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Planning for withdrawal

• Timing, what support is available?
• Relief drinking drives continued use in some
  people
• Fear of withdrawal may prevent a person trying to
  stop drinking
• Predicted severity determines best location for
  undertaking withdrawal
• Contraindications for out patient detox
• FITS, DTs, EPILEPSY, ELDERLY, MENTALLY ILL,
  SOCIAL, ACUTE PHYSICAL ILLNESS

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Range of detoxification intervention
GP/ Shared care
Out-patient
In-Patient
Severely dependent Failed outpatient
detox Unsupportive home environment, Withdrawal
complications, seizures, DTs, intercurrent
physical illness, mental/ physical problems
Problematic, Requires daily supervision
Uncomplicated, supported
Spectrum of interventions
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A simple guide to assessing severity of
withdrawal and estimating dose regimes using
diazepam

• Wake up with or woken by withdrawals and drink
  immediately severe 15-20mg q.i.d
• Wake up a bit crook, no drink until a few hours
  (2 - 4) after waking 10-15mg q.i.d
• Fine on waking, not crook till later, first drink
  late afternoon/night 10mg q.i.d or less
• What did they need last time?
• Identify Day 1 total, then give in 4 divided
  doses in reducing fashion over next 5 -7 days
• Note Consider past withdrawal experience, level
  of consumption, use of other drugs, other co
  morbidity, weight, gender

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Outpatient withdrawal management

• Diazepam regime (example)

NSW Health Clinical Detoxification Guidelines

• Can be modified according to response
• Daily review ideal
• Alcohol Withdrawal Scale score should stay below
  5 (CIWA-AR lt10)

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The psychiatric history

• Screen for mood- anxiety/ psychotic symptoms may
  be prompted at any typical day enquiry
• Identify current duration or recent progression
  of symptoms
• Note possible overlap of acute and post acute
  drug effects and biological/ emotional symptoms
  of depression
• Identify past diagnosis, treatment (compliance,
  adverse effects and responsiveness)
• Any previous in-patient episodes or scheduling?
• Past history of self harm/ violence?

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The relationship between alcohol use and mental
illness

• Having a psychiatric diagnosis triples the risk
  for alcohol dependence
• Alcohol dependents
• 7 x substance use disorder
• 3 x nicotine dependence
• 2 - 3 x mood/ anxiety disorder (panic/ anxiety/
  social phobia/ PTSD/ OCD)
• 3 - 5 x suicide risk
• Moderate alcohol consumption is compatible with
  acceptable treatment outcomes

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Alcohol use disorders comorbid with anxiety,
depression and drug use disorders Findings from
the Australian National Survey of Mental Health
Well Being 1997

• 12 month prevalence of comorbidity between DSM-IV
  alcohol use disorders (abuse or dependence) and
  anxiety, affective and drug use disorders in the
  Australian general adult population
• One-third of respondents with alcohol use
  disorder met criteria for at least one comorbid
  mental disorder in the previous 12 months
• 10 times more likely to have a drug use disorder,
  4 times more likely to have an affective disorder
  and 3 times more likely to have an anxiety
  disorder
• Higher rates of disability and health service
  utilisation in those with both an alcohol use
  disorder and a co morbid mental disorder

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Whats the evidence for managing those with co
morbid alcohol use and mood disorders?

• Variable
• Co morbid populations usually excluded from
  research trials on both mood and alcohol
  medications
• M gt F
• Limited follow up (12 weeks typical)
• Many are dealt with in primary care
• Many undetected

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Impact of alcohol on depression (and vice versa)

• Impact is variable
• Major depressive episodes occur 2 - 3 x more
  frequently in
• alcohol dependent patients than in general
  population
• Depression ? poor prognosis for achieving
  abstinence
• from alcohol
• Active alcohol dependence ? poor prognosis for
• remission for depression
• Reasons for co morbidity.not mutually exclusive

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Alcohol and depression

• Many classifications
• Nice and simple
• Primary alcoholics with secondary depression
• Symptomatic alcoholics with premorbid depression
  (Schukit 2006)

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Diagnostic problems

• Timing and nature of presentation
• Who and where they present to
• Client attribution, self diagnosis and requests
• Health care provider wants to helps (needs to
  feel they are doing something)
• What is the key?
• - A very good assessment -

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Assessment of patients with depression and
alcohol disorders

• Primacy of diagnosis
• Age of onset of different syndromes
• Temporal association between substance use and
  the mood disorder
• Impact of treatment on the course of both
  conditions
• Abstinence periods, relapse triggers
• Retrospective patient information problemsrecall
  bias, cognitive impairment
• Collateral informants
• Assessment of risk and risk factors

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Why careful assessment of mood after abstinence
is important

• Resolution of depressive symptoms with abstinence
  (2 - 4 wk) is important
• Obviates need for anti depressants (side effects,
  cost, utilisation of scant resources- CBT)
• Resolution of depression can act as a major
  motivational incentive for maintaining abstinence
  
• A prescription may suggest to the current drinker
  that mood improvement is possible while drinking
  continues

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Factors supportive of a primary alcohol dependent
disorder (with a secondary depressive disorder)

• Onset of alcohol dependence before the
  development of depression 
• Remission from depressive symptoms following
  periods of abstinence from alcohol (gt 1 month),
  without anti depressants 
• A positive family history of alcohol dependence  
• Male 
• Earlier age of onset of alcohol dependence 
• The presence of other substance use disorders 

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Factors supportive of a primary depressive
disorder (with symptomatic alcoholism)

• Onset of depression before the development of
  alcohol dependence 
• No remission from depression despite periods of
  abstinence from alcohol (gt 1 month)
• A positive family history of affective disorder 
• Female
• Later age of onset of alcohol dependence 
• The absence of other substance use disorders
• Pre morbid depressive personality disorder

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Decision pathways First presentation or
uncertainty over primary diagnosis
       
Motivate patient to achieve abstinence-detoxificat
ion support if required.
Monitor mood symptoms for 2-4 weeks following
cessation of drinking
Depression resolves
Depression continues
                 
                                 
Support continued abstinence, feedback mood
improvement in relation to abstinence.
Commence anti depressant treatment Compliance
therapy/support
Monitor response and document treatment
progression in notes for future reference.
In case of relapse consider alcohol specific
pharmacotherapy.
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Anti depressant medication efficacy and
abstinence from alcohol

• Evidence for efficacy of desipramine, imipramine
  and fluoxetine, citalopram in treating depressed
  alcoholics abstinent
• Successful treatment of depression associated
  with increased sobriety
• Most studies show impact of anti depressants on
  drinking through effect on mood
• More severely depressed patients show more
  positive response to anti depressants

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Mixing medication and alcohol

• Metabolism/ hepatic impact
• Increased sedation
• Ataxia/ amnesia/ accidents
• Toxicity and overdose
• Compliance
• - Dont forget to inform patients-

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Timing the commencement of treatment in the
alcohol dependent patient

• GPs are often faced with apparently depressed
  drinkers
• seeking treatment for depression
• Commencing anti depressant treatment in a
  current drinker
• may be problematic- both in terms of making an
  accurate
• diagnosis and assisting in the patient making
  an accurate
• attribution as to the cause of their
  depressive symptoms
• Probable poor response ? therapeutic nihilism
• In those with premorbid depression, anti
  depressants should
• usually be commenced after withdrawal, but
  (when closely
• monitored) may be commenced earlier
• Generally wait 2-4 weeks following withdrawal
  then reassess
• mood and treat if depressed

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Role of alcohol pharmacotherapies

• If abstinence results in resolution of mood
  Support abstinence
• Acamprosate supports abstinence
• Disulfiram supports abstinence
• Naltrexone supports reduction in consumption
• Tend to work in those who take them!
• Wide variation in response and compliance

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Newer agents in the management of alcohol
dependence

• Carbamazepine, valproate, topirimate and
  vigabatrin - redress the GABA / glutamate
  imbalance associated with withdrawal
• Carbamazepine - has been shown to be effective
  for mild to moderate withdrawal
• Valproate - although not useful for seizure,
  prophylaxis may reduce withdrawal severity and
  amount of benzodiazepines required
• Topiramate - early promising studies, reduces
  withdrawal and increases abstinent days

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What is early /or brief intervention (BI)?

• Proactive, often opportunistic identification
• Brief advice or counseling at point of detection
• Targets non dependent drinkers

Hazardous Harmful
Dependent
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The use of psychological therapies

• Psychological treatments for depression (CBT)
  are effective in both improving depression and
  in reducing alcohol consumption (Brown et al
  1997)
• May be offered as adjunct to medication- to
  enhance both compliance and outcome
• May be provided as first line if patient
  preference, this option is dependent upon
  availability of resources
• Stepped approach, first try one then add
  another
• Family involvement ideal

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Alcohol and suicide

• 5 - 10 of alcoholics die by suicide (c.f 6 for
  those with
• affective disorders) Inskip et al 1998
• 30 - 50 of completed suicides meet criteria for
  alcohol use disorder
• Which alcoholics commit suicide ?
• Past history of attempts, primary depressives,
  heavier drinkers,
• younger age of onset, alcohol related medical
  problems, longer duration,
• co morbid substance abuse, family history, M gt F
• When do they commit suicide ?
• During a depressive episode
• During a binge episode (20 - 30 when
  intoxicated)

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Suicide- why the link?

• As a result of
• Intoxication
• Withdrawal - DTs
• Personal/ social consequences, physical
• illness, exacerbation of mental illness
• Increase F (20) n gt M (4)
• Hopelessness/ negative affect

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Post Traumatic Stress Disorder (PTSD) and alcohol

• PTSD more commonly precedes substance use
  disorder in females (follows it in men)
• Post trauma, alcohol use is common to alleviate
  anxiety/ irritability/ depression
• Trauma ? immediate surge in endorphin that
  provides immediate narcotic comfort
• Hrs/ days post trauma- endorphin withdrawal ?
  emotional distress- PTSD
• Alcohol increases endorphins compensating for
  post trauma deficiency ? provides relief

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PTSD and alcohol

• PTSD-adaptive hyper-vigilance through
  sensitisation of CRF/NA systems augment stress
  response
• Sedative/ hypnotics/ alcohol interrupt this
  augmentation. reduce hyper-arousal (early
  negative reinforcement)
• Dependence-withdrawal-physiological
  arousal-exacerbate PTSD-relapse of substance use
• Severity of PTSD symptoms (hyper arousal/
  re-experience) associated with greater drug abuse
  severity

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Personality disorder alcohol

• Alcohol is associated primarily with Cluster C
  
• (Anxious/ dependent/ anakastic)
• Higher rates of drop-out from treatment
• More difficult to work with
• Under - diagnosed by case workers
• Poor social function
• Increased rates of crime
• Increased axis 1 diagnosis
• Generally poorer treatment outcome

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Bipolar Disorder

• Rates of co morbidity are even higher in those
  with bipolar disorder (gt40)
• Higher rates of hospitalisations, shorter
  remissions, more dysphoria and a poorer clinical
  outcome
• Manic episodes associated with alcohol
  consumption can be staggering
• Mood stabilisers may have a dual role

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Residual Sleep Disorders

• Tend to improve with time, especially over the
  first 3 months
• Sleep hygiene
• Behavioral treatments
• - Avoid benzodiazapines -

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Summary

• Take a good alcohol history from every patient
  you see
• Provide feedback to all patients
• Develop a joint treatment plan in consultation
  with patients
• Provide adequate support/ referral to assist a
  reduction in use
• Consider co morbid conditions- depression/ other
  substance use/ sleep hygiene
• Defer diagnosis of depression and commencement of
  anti depressants in most until after 2 - 4 weeks
  withdrawal (unless good evidence of past
  treatment responsive depressive illness)
• Consider anti-craving agents, CBT, AA and family
  support
• Monitor with it serial liver function tests
• Review and reassess at regular intervals

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End of Slide Show
The Can Do Initiative Managing Mental Health
and Substance Use in General Practice
Overview Session A Definitions prevalence
Session B Assessment history taking Session
C Common explanations Unit 1 Alcohol Unit
2 Benzodiazepines Unit 3 Cannabis Unit 4
Amphetamines Unit 5 Opioids and pain Unit 6
Pregnancy