so let's move on to the next section psychiatric comorbidities with alcohol use disorder problems and management so both mood and anxiety disorders are frequently co-occur with substance use disorders and data from the knee start study that i mentioned at the beginning of this talk as many as 40 percent of individuals with alkaloids disorder had a current mood disorder and then 30 with a current anxiety disorder i'll just point out that the relationship between negative affect or the psychiatric diagnoses like mood and anxiety disorders and alcohol is a complicated bi-directional relationship so on the one hand alcohol use disorder or alcohol use can worsen depression alcohol on itself independently can worsen mood and sort of contribute to the development of depressive disorder or anxiety disorders later alcohol is a depressant so it can worsen depression on its own it can actually prolong the course of depression but the converse could be true somebody who's depressed might use alcohol to self-medicate to feel better depression can actually make it more difficult to use to maintain abstinence and so depression on its own might contribute to somebody picking up a drink in the first place or making the alcohol worse on the other hand both of these things could be stemming from some shared vulnerability early life childhood adversities for example or genetic predispositions or it could be that these are common diagnoses and they just happen to occur by chance it's really important in my mind to avoid any simplistic explanations of this dual diagnosis to simply categorize this comorbidity as self-medication or that mood symptoms are always a result of substance use i really believe it's a complicated sort of bi-directional and multi-directional relationship regardless of what the relationship is the presence of this comorbidity often makes treatment challenging because even if both are treated having both disorders actually likely means that the treatment outcomes won't be as good with individual the independent diagnoses alone another complicating factor of this comorbidity is that symptoms of major depression and anxiety can mimic those of alcoholic disorder and vice versa therefore it becomes important to discern if there is an independent mood or anxiety disorder as opposed to disorders that are a substance induced so there are several ways to distinguish these one is the order in which they appear if the most symptoms predate alcohol use then a primary mood disorder in addition to an alkaloid disorder may be likely a strong family history of the disorders whether it's mood disorder or anxiety disorder actually might give you stronger justification to diagnose a primary mood or anxiety disorder of note anxiety disorders more often than not predate the development of substance disorder and therefore may actually might play a greater ideological role for many patients this actually becomes even more strong of a predictor so early life trauma and traumatic experiences actually may play a substantial ideological role the development of substance use disorder later in life the next thing to assess in the history is the presence of mood or anxiety symptoms during sustained periods of abstinence if they are largely absent during periods of abstinence the person reports really minimal mood or anxiety symptoms or that those symptoms remitted pretty rapidly over the course of several weeks then actually perhaps in a diagnosis of a substance induced disorder may be more likely now distinguishing these can be important because a presence of a primary mood anxiety disorder generally means that you really want to target that disorder independently you might have to actually target the depression or anxiety and not just target the alcohol the reduction in alcohol use or substance use generally may not actually reduce the anxiety or mood symptoms now on the contrary if the evidence applied strongly to a substance induced disorder then it's reasonable to actually really focus on cessation of alkalis or dramatic reduction and to see where the mood symptoms go then they actually may not need any targeted interventions for the mood anxiety disorders a reasonable sort of course to take is to first target the alcohol use really aggressively and then only treat the mood disorder if it actually turns out that it may be an independent disorder in reality many individuals who are diagnosed with a substance inducement disorder or anxiety disorder turn out eventually to be diagnosed with a primary mood disorder anyway and therefore the clinicians should sure on the side of treating the mood disorder as if they were independent unless you have strong evidence to support that it's a you know likely to be a substance induced disorder now antidepressants which are commonly used for both mood and anxiety disorders exert only a mild level benefit for those who have a concurrent substance use disorder and mood disorder it has mild effect on substance use and a little bit better on depression so because of this the current recommendation again is to really offer evidence-based sacrificial treatments for those with mild moderate level of depression in a comorbid substance use and to see where the depression goes you do the best you can to reduce that cut back you know attain abstinence if you can and then see where the mood symptoms go but offer evidence-based psychosocial treatments to support it cbt for example but if the depression is severe or the depression doesn't get better during that time then a much more early introduction of medication treatment to adjusted depression may be warranted like antidepressants now this raises a question of whether antidepressants and medications for ocular disorder really should be combined for those with comorbid depression and alcohol so there's actually one trial that enrolled individuals with both major depressive disorder and alkaloids disorder and those patients were randomized to receive placebo sertaline naltrexone or naltrexone and sertraline and the results really showed that 170 individuals with randomized to these four groups results really indicated that the combination treatment outperformed monotherapy of either really suggesting that if you really have an independent mood disorder and alcohol use disorder then initiation of concurrent treatment may actually be not a bad idea if you're pretty confident this is an independent mood disorder and the symptoms are severe enough initiating both treatment to target both actually may lead to better outcomes than a sequential treatment approach now really the evidence base is only on circling and other ssris and medications that have been tried are fluoxetine and tricyclics but really this certainly has the most evidence based and therefore is the one that's recommended and whether to really start this both at the same time or not really sometimes comes down to patient preferences while it may hinge on the severity of the mood symptoms at the time that you're evaluating the patient if it's still mild to moderate then it's not unreasonable to start naltrexone and provide psychosocial therapy and then only add antidepressants if the symptoms don't remain or if they continue to be severe or patient preference or they start out severe then i think in that situation i would strongly recommend the simultaneous initiation of both of course in pharmacotherapy we try to avoid starting two medications at the same time because of confusions around tolerability which is causing side effects but if the symptoms are severe enough and especially if they have a prior history of tolerating it for example then i would probably encourage initiation of both now in terms of comorbid anxiety disorders i mentioned earlier gabapentin can be used and so here's an example where gap pendant may be a good medication to do dual duty to address both the anxiety disorder and the alcohol and there's actually quite a bit of data for social phobia panic disorder and certain anxiety related to surgery for gabapentin and so it may be a reasonable thing to combine when we're treating alcohol and anxiety now benzodiazepines i've talked about using them for withdrawal management by using benzodiazepines to treat things like insomnia or anxiety in individuals with alcohol disorder would be relatively contraindicated this would not be recommended there's a greater likelihood for misuse of benzos and therefore unless there's a very targeted reason for using them in the very short term benzodiazepines would not be your first line treatment for concurrent anxiety or insomnia and patients with alcoholic disorder you would want to use things like tracezone other anti-convulsants ramelteon for example even quetiapine if needed and lifestyle modifications would be recommended so key points here depression and anxiety disorders are frequently co-occur with alcohol disorder and clinicians should assess whether the mood or anxiety symptoms represent an independent disorder or a substance-induced disorder now treatment of depression should be initiated alongside tremendous disorder but it's reasonable to start with psychosocial treatment first unless the depression is severe or there's patient preference or mood symptoms don't remit in which case medication treatment like antidepressants is warranted