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


A simple guide to assessing severity of withdrawal and estimating dose regimes using diazepam ... Diazepam regime (example) Can be modified according to ... – PowerPoint PPT presentation

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

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

  • 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

(No Transcript)
Patterns of use, metabolism and blood alcohol
Concentration of alcohol in the blood after 6
units of alcohol (48mg of alcohol)
blood alcohol (MG/100ML)
Rate of decrease of concentration of alcohol in
the blood in heavy, social naïve drinkers
Heavy drinker
Social drinker
Naïve drinker
5 hours
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)
Risk factors for alcohol use disorders
  • Genetic
  • Personal risk vs protective factors
  • Psychological vulnerability, trauma, abuse
  • Psychiatric illness
  • Occupation
  • Availability
  • Experience
  • Community
  • Culture

Alcohol related presentations in primary care
  • Hypertension
  • Fatigue/ insomnia
  • Nausea/ indigestion/ diarrhoea/ reflux/
  • 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

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

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
  • Have people Annoyed you by criticising your
  • Have you ever felt bad or Guilty about your
  • Have you ever had a drink first thing in the
    morning to steady your nerves or to get rid of a
    hangover (Eye opener)?

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

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
  • (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)

Assessing alcohol use
Consumption amount x frequency x duration
Other substance use?
A typical day
  • What time do they wake up? When? Why? How do
    they feel?
  • (low mood, responsibility, withdrawal,
  • 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

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

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

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?

  • 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

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

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

Progress of untreated withdrawal
Planning for withdrawal
  • Timing, what support is available?
  • Relief drinking drives continued use in some
  • Fear of withdrawal may prevent a person trying to
    stop drinking
  • Predicted severity determines best location for
    undertaking withdrawal
  • Contraindications for out patient detox

Range of detoxification intervention
GP/ Shared care
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
A simple guide to assessing severity of
withdrawal and estimating dose regimes using
  • 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

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)

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?

The relationship between alcohol use and mental
  • 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

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
  • Higher rates of disability and health service
    utilisation in those with both an alcohol use
    disorder and a co morbid mental disorder

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
  • M gt F
  • Limited follow up (12 weeks typical)
  • Many are dealt with in primary care
  • Many undetected

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
  • Depression ? poor prognosis for achieving
  • from alcohol
  • Active alcohol dependence ? poor prognosis for
  • remission for depression
  • Reasons for co morbidity.not mutually exclusive

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

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 -

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
  • Abstinence periods, relapse triggers
  • Retrospective patient information problemsrecall
    bias, cognitive impairment
  • Collateral informants
  • Assessment of risk and risk factors

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

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 


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

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
Monitor response and document treatment
progression in notes for future reference.
In case of relapse consider alcohol specific
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

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

Timing the commencement of treatment in the
alcohol dependent patient
  • GPs are often faced with apparently depressed
  • seeking treatment for depression
  • Commencing anti depressant treatment in a
    current drinker
  • may be problematic- both in terms of making an
  • 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

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

Newer agents in the management of alcohol
  • 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

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
The use of psychological therapies
  • Psychological treatments for depression (CBT)
    are effective in both improving depression and
    in reducing alcohol consumption (Brown et al
  • 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
  • Family involvement ideal

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

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

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

PTSD and alcohol
  • PTSD-adaptive hyper-vigilance through
    sensitisation of CRF/NA systems augment stress
  • 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

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

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
  • Manic episodes associated with alcohol
    consumption can be staggering
  • Mood stabilisers may have a dual role

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

  • 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
  • Monitor with it serial liver function tests
  • Review and reassess at regular intervals

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
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