Current Medical Treatments for Alcohol Abuse and Dependence

[Richard_smoker]

Treatment of alcohol abuse and dependence

Mark S Gold, MD & Mark D Aronson, MD

UpToDate performs a continuous review of over 350 journals and other resources. Updates are added as important new information is published. The literature review for version 14.1 is current through December 2005; this topic was last changed on December 6, 2005. The next version of UpToDate (14.2) will be released in June 2006.

INTRODUCTION — The role of the primary care physician in the care of the patient who abuses or is dependent on alcohol is to identify the problem, present the diagnosis, and participate in the initiation of treatment and continuum of care. The short-term goals for treatment include abstinence, attendance at Alcoholics Anonymous meetings or other related self-help and counseling programs for ninety days, and involvement in Employee Assistance Programs. Long-term goals include restoration of self-esteem, improvement in social and physical problems, and generally long-term abstinence from alcohol use.

Treatment not only works, but also saves money [1,2]. Detoxification alone is not adequate treatment; treatment requires time. Efficacy of treatments should be evaluated by objective testing of outcomes at one and five years [3].

Primary care physicians are uniquely placed to help with the problem of alcohol abuse and dependence [4]. Structured physician advice can substantially decrease the amount of alcohol consumed and decrease the number of episodes of binge drinking for up to 12 months [5]. Abstinence is critical for patients with alcoholic liver disease.

The primary care physician's role in the management of alcohol abuse and dependence is reviewed here. The screening and diagnosis of this disorder, including the use of specific questionnaires, are discussed in detail separately. The treatment of alcohol withdrawal syndromes is also discussed separately.


DEFINITIONS — Therapeutic options for patients who drink alcohol depend upon the degree of abuse. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) defines "at risk" (heavy) drinking (which suggests that the person is at risk for adverse consequences) as greater than 14 drinks per week or 4 drinks per occasion for men, and greater than 7 drinks per week or 3 drinks per occasion for women [6]. A standard drink contains approximately 0.5 ounces of alcohol as defined by Department of Health and Human Services and the United States Department of Agriculture [7]. This corresponds to 12 fl oz of regular beer, 5 fl oz of wine, and 1.5 fl oz of 80-proof distilled spirit. However, total consumption is not the only factor associated with adverse consequences; binge or high intensity drinking, for example, is linked to injuries, psychosocial problems, and negative consequences, especially in younger patients.

Alcohol dependence is defined by the DSM-IV as a maladaptive pattern of use associated with three or more of the Following[8]:

• Tolerance
• Withdrawal
• Substance taken in larger quantity than intended
• Persistent desire to cut down or control use
• Time is spent obtaining, using, or recovering from substance
• Social, occupational, or recreational tasks are sacrificed
• Use continues despite physical and psychological problems

PRESENTING THE DIAGNOSIS — Presenting the diagnosis to the patient is difficult and requires skill and practice. Patients tend to deny the problem and may be unwilling to participate in a meaningful discussion. A number of guidelines can be helpful:

·Take a family history, which includes alcohol abuse, dependence, consequences, Alcoholics Anonymous, and treatment.

·It is essential to use nonjudgmental language. Use of the term "disease" tends to reduce patient guilt. Making analogies to other chronic medical diseases such as hypertension or diabetes is also useful.

·The patient should be given specific facts from their history, physical examination, and laboratory data to demonstrate how problems with drinking are affecting their health and well being. At the same time, it is important to be hopeful, to emphasize your understanding of the positive aspects of drinking in their life, to avoid demoralizing the patient, and to avoid any negative attitude about alcohol problems.

·Family member involvement can be helpful during the initial presentation of the diagnosis, but the physician must be extremely careful.

·Physicians should be empathetic, but firm. It is important not to argue about labels or about patients' claims that they can periodically stop drinking.

·The physician should point out that the type of alcohol consumed is unimportant since they can all be addictive. It is useful to explain the meaning of withdrawal symptoms and the impact the drug can have on the health of the patient, particularly in the long-term.

·Patients need to understand that alcohol abuse and dependence are chronic diseases that can relapse. If they have stopped drinking in the past, they should not consider the relapse as a sign that they have failed. All addictions tend to relapse and need to be viewed from a long-term perspective [9].

Once the disease has been presented, different patients will be at varying points of acceptance. Some will be ready to acknowledge their problem and move on to an intervention. They may be treated with a brief physician intervention, referral, and/or drug therapy. Others will be in denial and uninterested in behavioral change. Motivational enhancement therapy may be helpful in overcoming resistance.


MOTIVATIONAL ENHANCEMENT THERAPY — Motivational interviewing is a counseling technique for eliciting behavior change by helping the client explore and resolve ambivalence about change. It is client-centered and non-confrontational, avoiding judgments about behaviors and exhortations to modify unhealthy lifestyle issues [10]. The provider aims to:

·Seek to understand the client's frame of reference

·Express acceptance and affirmation

·Elicit and reinforce the client's own
self-motivational statements of problem recognition, concern, desire and intent to change, and ability to change

·Monitor the client's degree of readiness to change and ensure resistance is not generated by jumping ahead of the client

·Affirm the client's freedom of choice and self-regulation

Motivational enhancement therapy (MET) is a four-session, brief-contact intervention method involving comprehensive assessment of drinking and related behaviors and feedback [11]. Project MATCH demonstrated equivalent three year outcomes in a randomized trial of 1726 alcohol-abusers, comparing MET with cognitive behavioral therapy and 12 step facilitation therapy, both 12 weeks in duration [12].

BRIEF INTERVENTION— Primary care physicians may consider a brief intervention for patients who meet the criteria for at-risk drinking (see above) or in whom the physician feels problem drinking is developing, but who are not alcohol dependent. The brief intervention typically includes information about problems associated with drinking and advising patients to reduce their amount of drinking.

The efficacy of brief interventions has been illustrated in randomized, controlled clinical trials and meta-analyses [13-18]. One meta-analysis, for example, found that heavy drinkers who received a brief intervention were twice as likely to moderate their drinking at 6 to 12 months following the intervention [15]. In a second meta-analysis, a small to moderate treatment effect was observed after provider contacts; this effect was equivalent to a 10 to 20 percent increase in the number of patients achieving a favorable response [16]. This effect was seen even in patients who were not seeking treatment. Among studies that evaluated patients who were seeking help for alcohol problems, brief interventions did not differ from more extended treatment.

The duration of this effect and the necessary frequency of repeat sessions is not known. Nevertheless, at least one randomized trial found that a brief intervention in patients with problem drinking reduced alcohol consumption for up to 48 months [19]. In addition, a net benefit was seen when costs were analyzed from a societal perspective.

HOSPITALIZATION AND REFERRAL— Brief intervention is not useful for patients suffering from alcohol dependence. Once the diagnosis has been presented to these individuals and they decide to stop drinking, the physician must consider the following:

·Inpatient versus outpatient treatment
·Referral to alcoholics anonymous
·Pharmacotherapy to prevent relapse

Inpatient versus outpatient treatment— Patients with mild to moderate symptoms of alcohol withdrawal can be safely and effectively managed as outpatients [20]. Symptoms of minor withdrawal include tremulousness, mild anxiety, headache, diaphoresis, palpitations, anorexia, and gastrointestinal upset (show table 1). The severity of withdrawal may also be assessed using the Clinical Institute Withdrawal Assessment for Alcohol Scale [21].

Patients with more severe withdrawal symptoms should be hospitalized. Other indications for inpatient treatment include [22,23]:

·History of withdrawal seizures or complications
·Depression with suicidal ideation
·The presence of severe coexisting medical or psychiatric conditions
·Extremely unstable home situation
·Failure to respond to outpatient treatment

Inpatient detoxification may be cost-effective in a number of other patients as well, but this is often limited by insurance coverage.

Alcoholics Anonymous— Referral to Alcoholics Anonymous (AA) appears to be cost-effective for alcohol-dependent patients. This was illustrated in a study of 200 patients who chose either to attend AA or to seek help from a professional outpatient alcoholism treatment provider [24]. Over the three-year course of the study, per-person treatment costs for the AA group were 45 percent ($1826) lower than costs for the outpatient treatment group. Outcomes for the two groups were similar.

In another report, men who were alcohol dependent were surveyed regarding their attendance at AA meetings during the first month after treatment [25].

Nonparticipants at AA consumed far more alcohol at the 48 week follow-up than moderate or occasional participants. Nonparticipants also had a lower rate of abstinence and spent more time in jail.

The physician can take an active role in the referral to AA by making the first call with the patient present, helping to locate meeting sites, and identifying times for the patient to attend. It is helpful to request that the patient provide feedback to the physician once they begin attending meetings. More information about AA can be found on their website, www.alcoholics-anonymous.org.
Involuntary or coerced treatment — Like other diseases, involuntary or coerced treatment for addiction can be effective. Our group and others have shown that involuntary and coerced treatment can work for alcohol dependent individuals [3,26].


PHARMACOTHERAPY — The role of pharmacotherapy is to reduce relapse in patients with alcohol dependence [27]. Pharmacologic therapy for alcoholism is limited when compared with the role of medicines in many other medical and psychiatric disorders; rather than pay for alcohol and get brain reward, the alcoholic pays for prescriptions and gets nothing. Nevertheless, medications may be useful in some individuals [28]. Three drugs, naltrexone, disulfiram, and acamprosate have been approved by the United States Food and Drug Administration for adjunctive therapy.

Naltrexone — Naltrexone is a pure opioid receptor antagonist that appears to modify the effects of alcohol by blunting its pleasurable effects and by reducing the craving [29]. In animals, naltrexone decreases both nucleus accumbens dopamine release after an alcohol challenge and dopamine release in anticipation of alcohol.

Naltrexone reduces relapse and number of drinking days as well as reducing craving without causing harm [30]. It increases control over alcohol urges and improves resistance to thoughts about drinking, making the therapeutic effects of cognitive behavioral therapy and naltrexone synergistic [31]. Treatment with naltrexone has made some relapsing and even chronic relapsing alcoholics more amenable to standard therapies such as Alcoholic Anonymous [32,33].

Oral — Several randomized, controlled trials and a meta-analysis have concluded that oral naltrexone treatment is effective in reducing alcohol consumption and relapse in alcoholics [31,34-40]. As examples:

·In a 12-week double-blind, placebo-controlled study of 70 alcohol-dependent men, relapse occurred in 23 and 54 percent of subjects receiving naltrexone and placebo, respectively [34]. The primary effect of naltrexone was seen in patients who drank any alcohol while attending outpatient treatment; 19 of the 20 placebo-treated patients (95 percent) relapsed after they sampled alcohol compared with 8 of 16 (50 percent) treated with naltrexone.

·In a second study, administration of 50 mg of naltrexone for 12 weeks as an adjunct to a comprehensive treatment program improved abstinence rates from approximately 25 percent for placebo to 50 percent for subjects treated with naltrexone [35]. Subjects who received naltrexone were less likely to drink heavily or to meet criteria for alcohol abuse or dependence at six months after cessation of therapy than those who received placebo. However, the effect of naltrexone on abstinence rates only persisted for the first month after cessation of the drug. Thus, some, but not all of the benefits of short-term naltrexone therapy persist after discontinuation of treatment.

In contrast, a study of 627 veterans (almost all men) found that naltrexone was of no benefit as measured by time to relapse, the percentage of days on which drinking occurred, or the number of drinks per drinking day [41]. These negative results, compared with the multiple previous positive studies, may reflect several characteristics of this VA population, including relatively older patients, longer time period of drinking, lower employment rate, and fewer stable family situations, all of which are negative predictors for successful alcoholism treatment.

Thus, the optimal use of naltrexone may require better definition of the patient populations most likely to benefit. As an example, the efficacy of naltrexone may be most pronounced in patients with a positive family history of alcohol dependence [42]. One study suggests that therapeutic response to naltrexone may be predicted by serum 6-beta-naltrexol concentrations [43]. A long-acting depot form of naltrexone is currently under investigation.

The most common side effect of naltrexone is nausea. Other less common adverse effects include headache, arthralgias, anxiety, and sedation. The drug will cause opioid withdrawal; thus, it should not be used until the patient is opioid free for 7 to 10 days. Studies in the 1970s employing high doses of naltrexone found that it can cause hepatocellular injury; it should not be administered to patients with acute hepatitis or liver failure. In doses greater than 50 mg, naltrexone can cause liver toxicity, so liver function tests should be monitored.

Naltrexone should only be given as an adjunct to a comprehensive treatment plan [44]; it will not sustain abstinence when used alone, particularly after it is discontinued [45]. Naltrexone, 50 mg daily, decreases relapse rates when added to all types of treatment programs, and even reduces alcohol consumption in healthy volunteers, social drinkers, and other drinkers who do not meet the criteria for alcohol dependence [46]. Higher doses of naltrexone may become standard in the future. An expert panel selected a dose of 100 mg daily for evaluation in the multicenter NIAAA-sponsored COMBINE study that is currently underway [47].

While long-term benefits appear to diminish, patients treated in double-blind studies with naltrexone continue to have higher abstinence rates after one year compared with placebo-treated patients. Maintenance of the reduction in heavy drinking may be enhanced after short-term therapy by targeted medication use (eg, taking the drug only when craving alcohol) [39].

Intramuscular — A long-acting depot form of naltrexone that can be injected monthly is also under evaluation. A six month multicenter trial randomly assigned 627 actively-drinking alcohol-dependent adults to monthly injections with naltrexone 380 mg, naltrexone 190 mg, or placebo [48]. The primary outcome of the rate of heavy drinking days (five or more drinks for men; four or more drinks for women) was less common in patients receiving high or low dose naltrexone than placebo (hazard ratio 0.75 [95% CI 0.60-0.94] and 0.83 [95% CI 0.68-1.02], respectively). However, the median number of heavy drinking days decreased substantially even in the placebo group (from approximately 19 to approximately 6 days per month). Side effects (mainly nausea, headaches, and injection site reactions) lead to treatment discontinuation more frequently with high dose naltrexone than with low dose naltrexone or placebo (14.1 versus 6.7 and 6.7 percent, respectively). One case of interstitial pneumonia and one case of eosinophilic pneumonia occurred in patients receiving high dose naltrexone. Naltrexone did not appear to be associated with an increased risk of elevated aminotransferase levels.
Depot naltrexone is not currently available in the United States. All pharmacologic treatments for alcohol dependence are only effective if taken. This formulation of naltrexone may have a role in the treatment of alcoholism, particularly in patients who have court mandated treatment or difficulty with adherence, and resistance to motivational and other therapeutic approaches. However further prospective and long-term research comparing depot naltrexone to oral naltrexone, acamprosate, and Alcoholics Anonymous is needed to better demonstrate safety and efficacy before it can be recommended for routine therapy. Adherence for repeated injections may be a problem given a relatively high rate of side effects.

Nalmefene — Nalmefene, a newer opioid antagonist, has been successfully used in some alcohol-dependent patients and may have some advantages over naltrexone, including no dose-dependent association with liver toxicity and more effective binding to central opiate receptors that are thought to reinforce drinking [49]. In a double-blind, placebo controlled study, 105 outpatient volunteers with alcohol dependence were randomly assigned to nalmefene 10 mg twice daily or 40 mg twice daily, or placebo [50]. All patients had weekly cognitive behavioral therapy during the course of the study. Both doses of nalmefene were similarly effective. The odds ratio of relapsing to heavy drinking was 2.4 times greater with placebo than with nalmefene (95% CI 1.05-5.59). Patients treated with nalmefene also had fewer subsequent relapses (16 versus 34 percent, P<.03) than the placebo group.

This study is somewhat limited by the small sample size and relatively short duration of follow-up (12 weeks). Nevertheless, these findings support the importance of opioid systems in relapse and suggest that nalmefene may become an important drug for the treatment of alcohol dependence. Nalmefene is not yet approved by the United States Food and Drug Administration for this purpose.

Disulfiram — Disulfiram (Antabuse) acts as a deterrent to drinking by causing painful symptoms if alcohol is consumed. The drug inhibits the activity of acetaldehyde dehydrogenase (ALDH) and, after alcohol ingestion, results in plasma acetaldehyde concentrations 5 to 10 times that seen in the absence of disulfiram. The accumulation of acetaldehyde leads to facial flushing, tachycardia, hypotension, dyspnea, nausea, vomiting, headache, blurred vision, vertigo, and anxiety within 15 to 30 minutes of alcohol ingestion. The syndrome lasts for several hours and the inhibitory activity lasts for several days.

Results with disulfiram have been mixed. In one randomized, partially-blinded study of 126 patients, administration of 200 mg of disulfiram daily increased the number of abstinent days compared with subjects receiving vitamin C (100 versus 69) and reduced the mean weekly alcohol consumption [51]. In a second controlled, blinded study of 605 men, treatment with 250 mg of disulfiram was again associated with a decrease in the number of drinking days compared with placebo [52]. However, there were no differences among the groups in total abstinence, time to first drink, employment, or social stability. Compliance is the greatest predictor of outcome [30], and monitoring for compliance may increase efficacy.

Disulfiram therapy can be hazardous if the patient is not fully aware of the consequences of alcohol ingestion; even alcohol in sauces and cough syrups may trigger a violent reaction [53]. This problem, combined with its limited efficacy and potential to cause hepatotoxicity, have reduced its use. Nevertheless, it may be effective for certain individuals as an adjunct to an outpatient treatment program. Disulfiram increases drug levels of phenytoin, isoniazid, and anticoagulants. It can also cause hepatitis, so liver function tests should be monitored.

Acamprosate — Acamprosate calcium acetyl homotaurinate is a synthetic derivative of homotaurine, a structural analog of gamma-aminobutyric acid (GABA), which can reduce the relapse rate of alcohol dependent individuals. As an example, a controlled study randomly assigned 448 patients with chronic or episodic alcohol dependence to acamprosate or placebo for one year; the incidence of continuous abstinence was higher with acamprosate (18 versus 7 percent with placebo) [54]. The mean cumulative abstinence duration was also significantly greater in the acamprosate group (139 versus 103 days).

A meta-analysis that compared acamprosate to naltrexone showed that these treatments had a comparable effect on abstinence and reduced frequency of drinking [38]. Naltrexone appears to be effective in reducing heavy drinking, but there are not enough data available about acamprosate on this measure.

There is good evidence that acamprosate is well tolerated and enhances abstinence as well as reducing drinking days in dependent patients [30]. Investigational new drug studies in the United States suggest that results are enhanced with a 2.0 g dose of acamprosate compared with a 1.3 g dose.

In 2004, the US Food and Drug Administration (FDA) approved acamprosate for relapse prevention in patients who have already stopped drinking. The prescribing information recommends starting acamprosate as soon as possible after abstinence at a dose of 666 mg three times daily, and that it be continued through relapses [55].

The optimal duration of therapy with acamprosate has not been established. One review suggested a minimum of six months of therapy, and that twelve months would be preferable [56].

Topiramate — Topiramate has been evaluated in a single randomized trial of 150 people with alcohol dependence [57,58]. The 55 people who completed the 12-week study and received topiramate, compared with the 48 people who completed the study and received placebo, showed a significant improvement in drinks per day (6.24 versus 3.36 fewer drinks), drinks in a drinking day (6.24 versus 3.14 fewer drinks), percentage of days with heavy drinking (absolute decrease of 60.3 versus 32.7 percent), and percentage of days with abstinence (absolute increase of 44.2 versus 18 percent). Plasma gamma-glutamyl transferase (GGT) concentrations, an objective marker for alcohol ingestion, were reduced more in the topiramate group than in the placebo group. There were more adverse events in the topiramate group, but no serious adverse events. Significant weight change was seen with topiramate (1.4 kg loss versus 0.61 kg gain with placebo) that the authors attribute to decreased intake of calories from alcohol; however, weight loss has been seen in studies of topiramate for other conditions such as bulimia nervosa.

Although these results appear promising, the study had limitations. It was relatively brief compared with many other addiction outcomes studies, following patients for only 12 weeks, and the large number of patients not assessed at the end of the 12 weeks (27 percent of those taking topiramate and 36 percent of those taking placebo) limits the strength of the evidence. Direct measures of alcohol and drug ingestion by routine alcohol breath tests and urine drug screens showed no difference between the topiramate and placebo groups.

Like some studies of acamprosate and naltrexone, this trial did not require abstinence prior to entry and so looked at abstinence initiation rather than relapse prevention [59].
Combination therapy— A randomized controlled trial of 160 alcoholics after detoxification found the combination of naltrexone and acamprosate to be significantly more efficacious in preventing relapse at 12 weeks than acamprosate alone [60]. Although not statistically significant, the combination also showed a trend toward reducing relapse compared with naltrexone alone.

Other drugs— A number of other drugs have been associated with significantly reduced alcoholic consumption, including GABA-b agonists such as baclofen [61], and the selective serotonin reuptake inhibitors (SSRIs) and St. John's wort [62]. Serotonergic agents, lithium, and St. John's wort have minimal efficacy in the treatment of alcohol dependence [30], but can modify drinking behavior, suggesting a role for serotonin in alcohol-related behaviors [63].

The selective serotonin receptor antagonist ondansetron has shown promise in patients with early onset alcoholism (eg, onset at age 25 or younger), a group that differs from later onset alcoholics by its association with greater serotonergic abnormality and antisocial behaviors [64]. In one double-blind, randomized, placebo-controlled study, treatment with ondansetron at a dose of 4 mcg/kg twice daily was superior to placebo in terms of the proportion of abstinent days and the number of drinks per day in this early onset subgroup; the results of treatment in later onset alcoholics did not differ from placebo [64]. Further study is necessary before recommendations can be made regarding use of this drug.

Treatment during pregnancy — Maternal alcohol abuse can be harmful to a developing fetus. There are very limited data on the efficacy and safety of pharmacologic therapies for alcohol abuse in pregnant women. Potential issues with medications used for the treatment of alcohol abuse include the following [65]:

·Disulfiram could theoretically cause harm to the developing fetus by increasing levels of acetaldehyde.

·Naltrexone may have had effects on the behavior of offspring in animal studies.

·There are little or no data on the safety of acamprosate in pregnancy.

The use of pharmacotherapy for the management of alcohol withdrawal in pregnant women is discussed separately.

The decision to use pharmacologic therapies in pregnancy must weigh the potential risks to the mother and the fetus from alcohol consumption against the potential risks to the fetus from pharmacotherapy. Ideally, pregnant women with substance abuse disorders should be managed by specialists.


Summary — Current evidence suggests:
·Naltrexone reduces the risk of relapse to heavy drinking and the frequency of drinking compared with placebo, but does not substantially improve abstinence (avoidance of all drinking) [66].

·Acamprosate reduces the frequency of drinking, and appears to be safe and effective in reducing relapses among alcoholics [67]. Acamprosate can be used instead of benzodiazepines for detoxification and continued use reduces the frequency of drinking alcohol [66].

·Naltrexone and acamprosate may be utilized together both for detoxification and then to enhance abstinence and reduce relapse [66].

·Use of disulfiram is less clearly supported by the literature [66]. There is some evidence that the frequency of drinking is reduced, but minimal evidence of improvement in abstinence rates.

·Ondansetron may prove to be useful in patients with early onset alcohol problems [66].

Studies also indicate possible roles for nalmefene [50] and topiramate [57] in the treatment of alcoholism.
COMORBID CONDITIONS— Physicians should look for and treat comorbid disorders such as cigarette smoking, anxiety, and depression, among others.

Cigarette smoking — As many as 80 percent of people with alcohol problems smoke, and 30 percent of smokers have alcohol problems [32]. In one report, patients previously treated for alcohol abuse and dependence had an increased cumulative mortality that was due more to tobacco-related than to alcohol-related causes [68].

Cigarettes and alcohol interact to cause certain malignancies such as head and neck cancer. The association between alcoholism and smoking may be related to a common genetic vulnerability to nicotine and alcohol dependence [69]. Often cigarette smokers may drink for the sedating effect of alcohol, and drinkers smoke to enhance the effect of alcohol.

Anxiety — Higher levels of anxiety may be associated with increasing alcohol use [70]. Alcohol withdrawal causes many of the signs and symptoms of anxiety and can fool an expert into thinking that the alcoholic has panic attacks. Patients with social and other phobias may choose alcohol as a form of self-medication, making them especially vulnerable to abuse and dependence.

Depression and suicide— There is a high incidence of comorbid affective disorders among patients with alcohol problems [71]. The significance of this association is illustrated by the high rate of suicide among patients who abuse alcohol as shown by the following:

·The United States Surgeon General reported in 1992 that 70 percent of attempted suicides by college students involved the frequent use of alcohol [72].

·In a study of completed suicides in Georgia, almost 42 percent of white teenage victims used alcohol [73].

·Alcohol use appears to increase the likelihood of acting on a suicidal impulse [74,75].

·Lifetime suicide risk among alcohol dependent individuals is estimated to be 10 percent (five to ten times greater than the general population) [76].

·Approximately 15 to 20 percent of alcohol dependent individuals will attempt suicide at some point, and among those who do attempt suicide 15 to 20 percent will attempt suicide again in the next five years [76].

The relationship between depression and alcohol use is further illustrated by the following:

·In addition to improving depressive symptoms, treating depression secondary to alcoholism may reduce the risk of drinking relapse in some patients [77,78].

·Having a major depressive disorder (MDD) decreases the likelihood of remission of substance abuse and increases the likelihood of relapse [79].

·A study of 6050 people found that former drinkers with a past history of alcohol dependence had four times the risk of developing a MDD compared with former drinkers without such a history [80].

·A systematic review found median current and lifetime prevalances of alcohol problems in patients with depression of 16 and 30 percent, respectively [81].

Other disorders

·Alcohol abusers and dependents and their children are at increased risk of developing eating disorders, especially obesity or binge or addictive overeating.
The process of alcohol detoxification and abstinence is often accompanied by overeating; sometimes food becomes a replacement for alcohol.

-Hope this was helpful... just a word for those actually considering any of these treatments for yourself or your family or friends, the article doesn't mention it, but Topiramate also causes a significant amount of weight-loss in the users... of course, the drug is not--and probably never will be--marketed for non-obese weight-loss, but many patients, especially women, have fallen in love with this treatment (for migraines, seizures, alcoholism, etc.) because its side effects include weight-loss.
-Dick

Reputation Comments on this post:

Good summay of alcohol abuse/dependence/treatment, even if 3 years old.