Agents To Treat Psychiatric Disorders Concomitant To Alcoholism

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Alcoholism may be accompanied with various psychiatric problems including anxiety, depression, antisocial behavior, panic disorders, and phobias. Part of the problem in treatment is to determine if the psychiatric disorder developed before alcoholism (primary), or after (as a result of) alcoholism (secondary). Nevertheless, several studies have been conducted predominately with medications used to treat depression and anxiety.

Agents to Treat Alcoholics with Depression. Depression has been associated with alcoholism, especially with relapse to drinking. A frequent pharmacologic treatment of depression is with a group of medications called tricyclic Antidepressants (desipramine, imipramine, amitriptyline, and doxepin). Their efficacy in treating alcoholics with depression is, however, largely unknown. This is in part because of poor methodological studies. A recent study of desipramine was conducted on alcoholics with and without secondary depression (Mason & Kocsis, 1991). Preliminary findings showed that desipramine is effective in reducing depression in the depressed group and may also prolong the period of abstinence from alcohol in both depressed and nondepressed patients. Preliminary results of another study suggested that imipramine both improves mood and reduces drinking in alcoholics suffering from major (primary) depression.

In addition to the tricyclic antidepressants, the serotonin-uptake inhibitors are used to treat depression. One of these inhibitors, fluoxetine (Prozac), is widely used as an antidepressant. As discussed earlier, fluoxetine has been studied to see whether it attenuates drinking behavior in nonde-pressed alcoholics, but findings as of 1999 indicate that its usefulness is limited to alcoholics in the dual-diagnosis population.

Lithium, an effective medication for the treatment of manic-depressive disease, has also been studied as a pharmacologic agent in the treatment of alcoholic patients. In one multi-site clinical study of lithium in depressed and nondepressed alcoholics, lithium therapy was not effective in reducing the number of drinking days, improving abstinence, decreasing the number of alcohol-related hospitalizations, or reducing alcoholism dependence (Dorus et al., 1989). This investigation as well as other studies did not address the effectiveness of lithium in other types of psychiatric disorders that may respond—including hypomania (a mild degree of mania), bipolar manic-depressive illness, and other mood disorders. Studies of lithium in the 1990s concluded that it lacks efficacy in the treatment of alcoholism.

Agents to Treat Alcoholics with Anxiety Disorders. Recent studies have indicated that a sizeable proportion of individuals who abuse alcohol also suffer from anxiety disorders. Buspirone, an agent commonly used to treat anxiety, has shown potential in reducing alcohol consumption. As discussed earlier, buspirone acts as an agonist on the serotonin 5-HT1A receptors and also alters the dopamine and norepinephrine systems.

An attractive feature of buspirone is that its use does not lead to physical dependence on the drug, as with antianxiety drugs, particularly with Benzodiazepines. Furthermore, buspirone lacks side effects often found with anxiolytic medications. For example, buspirone lacks sedative, anti-convulsant, and muscle-relaxant properties, does not impair psychomotor, cognitive, or driving skills, and does not potentiate the depressant effects of alcohol.

Administration of buspirone to rats and monkeys has resulted in a decrease in alcohol intake (Litten & Allen, 1991). In humans, one study reported that buspirone diminished alcohol craving and reduced anxiety. Another study found buspirone to be more effective with alcoholics suffering from high anxiety than those with low levels of anxiety. A third study on more severe alcoholic patients found no effect. Thus, further research is needed before this drug's efficacy can be accurately evaluated.

In summary, the evidence indicates that effective treatment of a psychiatric disease may also be beneficial to the treatment of alcoholism, particularly in alcoholics with coexisting psychiatric disorders, but that psychoactive medications are not ''magic bullets'' for most alcoholics.

CONCLUSIONS

Development of new medications to decrease drinking, prevent relapse, and restore cognition may have a role in alcoholism treatment in the future—but as a part of treatment regimens— given with other nonpharmacological therapies. Advances in understanding the mechanisms responsible for alcohol craving, drinking behavior, cognition, and even some of the psychiatric disorders such as depression and anxiety disorders have not yet produced a medication that substantially improves abstinence rates. Some researchers have recommended a careful matching of subgroups of alcoholics to the medications that are presently available as a possible pharmacological treatment strategy.

Moreover, as of 2000, there is much that is still not known about the pharmacological treatment of alcoholism. The 1999 NIAAA report outlined three major areas of inquiry that need further research:

The optimal dosing strategy for anti-alcohol medications and the optimal duration of treatment.

The possible utility of combination therapies, either combinations of different medications or combinations of medication and psychotherapy.

The usefulness of specific pharmacotherapies for women; different ethnic and racial groups; adolescent and geriatric patients; and polydrug abusers.

(See also: Complications; Disease Concept of Alcoholism and Drug Abuse; Drug Interactions and

Alcohol; Drug Metabolism; Treatment, History of)

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Richard K. Fuller Raye Z. Litten Revised by Rebecca J. Frey

Cocaine, An Overview Cocaine abuse and dependence should be approached as chronic disorders that require long-term treatment. The clinical course of cocaine addiction is often progressive and generally marked by recidivism. Addiction to cocaine should be approached as a brain disease, and not a weakness to be viewed with judgmental overtones. In fact, cocaine produces a number of neuro-chemical alterations in the brain, especially in the reward centers of the midbrain and in the limbic system. When evaluating a patient for treatment, many factors must be taken into consideration. First, patients presenting for treatment often have complicating factors, such as coexisting psychiatric disorders, family problems, job jeopardy, and medical complications. These problems are often why the person is seeking treatment, and should be fully explored and linked to the addiction. Interpersonal and occupational dysfunction often results from cocaine becoming the addict's number one priority, taking precedence over family and financial responsibilities. Medical problems frequently result from cocaine's destructive action on the heart, brain, and kidneys, while co-occurring psychiatric disorders commonly include paranoia, depression, and anxiety. To a great extent, the presence of these disorders depends on the length of time the individual has been using cocaine, the dose of cocaine taken, and the route of administration. As individuals progressively lose control over cocaine intake, they become more likely to experience interpersonal, medical and psychiatric complications.

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