A combination of medical treatment (naltrexone, acamprosate or disulfiram) and CBT as treatment for alcohol dependence was associated with a reduction of patients' symptoms of depression and improvement in their QL. During the follow-up period, the average alcohol consumption in all groups (accessible to follow-up) remained significantly below baseline. In addition, allocation to disulfiram was associated with cessation of smoking.
There were no differences between the medication groups on improved QL or depression—this could be related to the use of CBT and antidepressant medication.
Before the end of the study period (treatment Week 52), 51.8% of patients dropped out. The most common reason for premature discontinuation was poor compliance or change of study medication (six patients) (Laaksonen et al., 2008a,b). A higher risk of dropping out was related to younger age, symptoms of pain at study baseline and poor compliance in maintaining the drinking diary during the therapy. For patients who stayed in the study, a significant reduction in drinking was observed. In addition, treatment impacted on their QL by reducing pain, improving sleep and mood and increasing their ability to act.
It has been shown that people suffering from anxiety, depression and also insomnia are four more times at risk of developing alcohol problems than patients who suffer from anxiety and depression but manage to sleep well (Crum et al., 2004). Thus, sleeping problems should be addressed promptly and taken seriously when treating patients with alcohol problems. In our study, a reduction in symptoms of sleep and depression was observed with all medication groups, with no significant difference between groups. This would suggest that the benefit of acamprosate on sleep reported byPerney et al. (2012) might have reflected reduced drinking rather than a specific effect of acamprosate on sleep.
Twenty-three percent of patients had medication for depression at the beginning of our study, and 34–47% of the patients had either moderate or severe symptoms of depression when assessed at their first visit. The percentage of patients with depression dropped to 20% in the first 6 weeks. The BDI and DEPS tests are screening tools for depression used by health-care professionals. The sensitivity of the DEPS test is 74% and its specificity is 85% (Salokangas et al., 1995), while the sensitivity and specificity of the BDI test are 81 and 90%, respectively (Beck and Steer, 1984). However, it should be noted that both of the tests are subjective and therefore cannot be used to draw concrete conclusions regarding the participants' level of clinical depression. Nonetheless, screening can be helpful when forming a diagnosis and/or with follow-up appointments (Paykel and Priest, 1992). There is no consensus regarding the use and timing of depression medication with depressed alcohol-dependent patients. If depression remains after alcohol consumption has been reduced to a moderate consumption level, medical treatment of depression should be started. A German study of alcohol-dependent patients in a psychiatric department (n = 100) concluded that severe trait anxiety persisting after 3 weeks of abstinence, co-morbid depressive and/or anxiety disorders, and combinations of these represent the greatest risks of relapse and therefore suggests a need for treatment (Driessen et al., 2001). Even mild to moderate depression symptoms at 3 months post-treatment are associated with a large relapse risk (Curran et al., 2000). People who suffer from both a depressive disorder and alcoholism are at great risk of chronic impairment, persistent symptomatic misery and premature death. Untreated alcoholism intensifies depressive states, decreases responsiveness to conventional therapies and increases the likelihood of suicide, suicide attempts and other self-destructive behavior. The availability of effective treatments provides further impetus for health-care professionals to improve their recognition of co-morbid alcoholism and depressive disorders (Thase et al., 2001).
One of the findings of this study was that patients who received disulfiram were more successful at quitting smoking than the patients in the naltrexone and the acamprosate groups. The relationship between smoking and treatment was analyzed post hoc. This finding is important because together, tobacco and alcohol cause about 40 times the total number of deaths of all illegal drugs combined (O'Dowd, 2006). However, the successful attempt to quit smoking improves treatment results of alcohol dependency (Baltieri et al., 2009). Concurrent alcohol and smoking treatment should focus on enhancing abstinence self-efficacy, positive mood and the curbing of urges in order to offset lapse risk (Holt et al., 2012), and CBT is a promising treatment tool, at least in the case of short-term smoking outcomes (Mueller et al., 2012). One can speculate that disulfiram's influence on quitting smoking might be disulfiram's inhibition of dopamine beta hydroxylase (Musacchio et al., 1966). Alcohol-dependent patients who wish to stop drinking and smoking simultaneously or sequentially may profit especially from disulfiram. To our knowledge, there are no previous studies about the effect of disulfiram on smoking. The interrelationships between disulfiram, drinking, smoking and craving would be worth further study.
This study has some limitations. We did not analyze the difference between patients taking depression medicine and those not taking them, and patients were not examined and diagnosed according to psychiatric criteria. Furthermore, it is unclear whether the improved QL was related to decreased craving causing a reduction in depression, or whether it was a direct result of less drinking. Finally, patients' smoking behavior was assessed by asking whether the patient smoked or not, instead of using validated instruments.
As well as those limitations, our study has several strengths, including a fairly large sample size consisting of 243 subjects who voluntarily sought help for their alcohol problems and a long study and follow-up period lasting 2.5 years in total. So far, only a few controlled, randomized studies have compared the effectiveness of naltrexone, acamprosate and disulfiram. Further randomized research in this field is needed because QL and smoking are tightly connected with alcohol consumption. Since the original article was published, we have not found any other randomized studies that have addressed QL, depression, alcohol dependence and CBT together. The results of this study support the recommendations of the National Institute for Health and Clinical Excellence (NICE) of England regarding the use of cognitive behavioral therapies and cost-effective medication for the treatment of harmful drinking and alcohol dependence (Pilling et al., 2011). Furthermore, this study revealed new information about the possibility of using CBT and disulfiram as treatments for quitting smoking.
Assessing the QL among alcohol-dependent patients is a valuable measure of their clinical status and may be more relevant than measures of alcohol consumption or liver toxicity tests. It may also help to identify predictors of relapse and issues of major concern to the individual patient (Peters et al., 2003). Acknowledging the high risk of relapse for patients who suffer from a comorbid alcohol problem and a mood disorder, symptoms of depression, insomnia and anxiety should also be assessed and included as part of treatments for alcohol use disorders. Furthermore, patients who smoke may need special attention such as motivational support to reduce their drinking and smoking. The results of this study also indicate that, due to alcohol dependence, patients often have high resistance to changing their problematic behaviors, so the treatment period should be long enough to achieve more permanent results.