Sign in to follow this  
Followers 0
Gurpal

PMPs Extravaganza: Alcohol problems

12 posts in this topic

You are assessing a 39 year old publican who presents with depressive symptoms and panic attacks. He tells you he is drinking to excess. What are the dangers of him stopping drinking alcohol immediately? Are there any problems in treating his mood and anxiety symptoms with an SSRI? How will you assess him for suitability for an alcohol detoxification programme? What types of medication are used in the treatment of alcohol dependency?

Share this post


Link to post
Share on other sites

If he stops immediately then he will most likely develop withdrawal symptoms tremor, sweating, possible hallucinations - visual/kinaesthetic, DT, and if severe convulsions which may be life threatening.

Tx with SSRI would be inadvisable. You would be tx for a depressive disorder. However in ICD-10 it clearly stipulates that an alcohol abuse disorder should be excluded before diagnosing a depressive disorder. Therefore you shouldn't treat for a mood disorder until this gentleman has been free from alcohol for a few weeks. There may be problems with compliance if he is so intoxicated he forgets to take it, or else he may take an intoxicated impulsive overdose etc.

Anxiety sx may be secondary to alcohol abuse and the same arguments would apply.

In assessing for a detoxication programme his commitment to such a programme needs to be assessed. He should have insight into his alcohol problem and be ready to comply fully with a programme

In tx of alcohol dependency one would use chlordiazepoxide reducing regime tailored to the patient's weight/height, level of alcohol use and period of alcohol use. One can also use acamprosate although i am not sure if it has been shown to have much efficacy. I cannot think of any others at the moment.

Share this post


Link to post
Share on other sites

I am sure that some one can be depressed and also have alcohol problems and it is quite a chicken and egg situation ,rather than trying to get a person alcohol free for a few weeks before starting anti depressant medication ,if we are able to assess his level of drinking and start him on a regimen for his alcohol problem and also start antidepressant medication ,we should be cautious in the use of medication and also explain to the patient the combined effects of drugs {ssri's}and alcohol .the question should be addressed and we dont in practice giving anti depreesants to people who drink and the amount of alcohol he drinks and the previous pattern and the consequences of him stopping himself and the kind of withdrawals he suffered and the kid of community support would help in planning the management for his detox community detox should be avoided if he has had fits in the past and the likeliyhood that he has had 2 failures of community detox should make us think of an inpatient detox

Share this post


Link to post
Share on other sites

The focus of this vignette is on

1]Alcohol withdrawal symptoms

2]SSRI induced anxiety

3]Motivation for change

4]Meds for Alcohol dependency

1]Stopping alcohol suddenly would not be advisable and may lead to withdrawal symptoms like increased anxiety, tremors etc, DT or withdrawal seizures.

2]Starting SSRIs would increase his anxiety further

3]Suitability for detox would depend on his motivation and willingness to stop alcohol. Depending on the duration,severity and risk I would have to decide about inpatient or outpatient detox

4]Meds for detox are reducing regimen of Chlordiazepoxide or diazepam if sensitive to Chlordiazepoxide. Thiamine supplementation is also needed. Detox is started if score is more than 10 on CIWA-Ar scale  

Share this post


Link to post
Share on other sites

Very well Nutty professor (bTW, Welcome to the forum).. I agree with all the above except I think it's a risky answer in exam to combine alcohol with antidepressant: remember: keep safe! Too many interactions and OD risks. I think it's best to first try obtain alcohol free period. I think engaging CMHT and Drug councelling services should be paramount.

Acamprosate is NOT used in alcohol withdrawal but in the maintainance stage.

8)

Share this post


Link to post
Share on other sites

i got asked this in my part 2 viva - luckily there is a good series in advances on alcohol/depression, alcohol/anxiety etc. Goes through management so there is a whole review on managing depression in alcohol misuse.

Che ;)

Share this post


Link to post
Share on other sites

1)oops, if he stops drinking suddenly, risk of severe withdrawal symptoms and even more worrying is DT. :-[

2)his motivation for detox programme is the key to starting one and the mainstay will be chlordiazepoxide. thiamine, ascorbic acid are supplements in it and PRN Diazepam.

3)Disulfiram is antabuse and acamprosate are used in relapse prevention. disulfiram will give the flushing and ill side effects when alcohol is comsumed and acamprosate(666mg)is for craving.

4)and all the symptoms he is complaining have to be assessed after his alcohol detox is complete as my senior colleagues have pointed out,it shall be a dangerous idea to commit in the exams that antidepressants can be started whilst detoxing. :)

Share this post


Link to post
Share on other sites

'However, acamprosate blocks increased glutamate in withdrawal and is neuroprotective. Acamprosate should be started with detoxification if it is intended for use afterwards.'

Puri & Hall, 2 Edition, p 348

Good luck to Parts 1 and 2 people this week.

Share this post


Link to post
Share on other sites

I personally know someone who has failed solely because he mentioned that he would not start antidepressant instantly rather wait until sobriety. Strange but true!

Share this post


Link to post
Share on other sites

As this is a very common scenario and different expert opinions can be arised.

Can it be safer to talk about like this:

(Reference: Oxford Handbook P. 528)

A. Basic facts (need not to voice it out)

- 2-way relationship between depression and alcoholism

- Alcohol damages LFT, and antidepressants uses Liver enzyme to metabolizee (risk of increasing serotonin syndrome due to increase serum level)

- Initial use of SSRI increases irritabiliity and suicidal risk

B. Risk identification (apart from other co-morbid Hx / general background)

- Depression: Hx, severity, suicidal, hx of prev. suicide / violence

- Alcohol: dependence / harmful use / misuse / withdrawal, phase of motivation, hx of forensic / violence related to alcohol

C. Consideration

- Outpatient

* Discuss and advise patient + relatives to try detox first (home / in-patient)

- If agreed, reassess mood after 4-weeks then see need to treat residual syndrome

**If patient is not motivated to quit

- Continue follow-up with multidisciplinary input (alcohol team? CP, CMHT) to motivate and monitoring symptoms

- If patient had hx of depression before alcohol, and now already on antidepressants, discuss pros and cons and

1. keep on antidepressant if not contraindicated

2. consult second opinion if feel uncomfortable!

- If mood symptoms is severe with risk, suggest in-patient

Respect patient's wish and document fully, explain the pros and cons of giving antidepressant without stopping alcohol, keep patient motivated at follow-ups.

- Inpatient: informal / section; emergency Rx for DT/encephalopathy/depressive stupor (IVF) first; start in-patient detox within 1-2 weeks,

- consider ECT if depression is deliberating and after consult patient/relative/senior

*** Antidepressant: if hx of depression presents before alcoholism, more likely that you can consider to RESUME antidepressant (after LFT checked)

If not, consider wait after detox to start antidepressant.

MENTION that you would discuss with patient/relative/senior for that.

Share this post


Link to post
Share on other sites

hey just a minor point which everyone missed in their excellent answers

he is a publican and hence will be difficult for him to stay away from alcohol...

will need change in profession :lol:

Share this post


Link to post
Share on other sites
Sign in to follow this  
Followers 0