Alcohol-Induced Mood Disorder: Understanding Severity

Alcohol use disorder (AUD) is a prevalent condition that often co-occurs with other mental health disorders, including depressive disorders, bipolar disorder, anxiety disorders, and attention-deficit/hyperactivity disorder (ADHD). When AUD and mood disorders coexist, they can exacerbate each other, leading to increased severity and a poorer prognosis for both conditions. To determine the severity of alcohol-induced mood disorders, it is crucial to establish a timeline of symptoms and behaviours. This involves gathering information such as the age of onset of mood symptoms and alcohol use, the longest period of abstinence, the presence of mood symptoms during drinking and abstinence phases, and family history. By understanding the interplay between AUD and mood disorders, healthcare providers can make informed clinical decisions, refer patients to appropriate specialists, and improve treatment outcomes. Treatment approaches may include pharmacological interventions, behavioural therapy, or a combination of both, tailored to the specific needs of the patient and the severity of their conditions.

Timeline of symptoms and behaviours

A timeline of symptoms and behaviours is a key tool for diagnosing alcohol-induced mood disorders and determining the appropriate level of care. When patients who drink heavily report anxiety or mood symptoms, it is helpful to create a timeline to discern whether the symptoms are alcohol-induced or a separate, primary disorder. This can help set expectations and a treatment plan.

Sample queries to include in the timeline are:

• The age of onset of mood symptoms and the age of onset of alcohol use.
• The longest period of abstinence from alcohol and the presence or absence of mood symptoms during this period.
• Family history of mood disorders and alcohol use disorder.
• Changes in behaviour or emotional responses when drinking. For example, some people may experience feelings of euphoria or relaxation, while others may become aggressive or irritable.

In the case of depressive disorders, it is important to establish whether the symptoms are primary or induced by alcohol use. Alcohol-induced depressive disorder refers to a depressive-like syndrome (characterised by depressed mood or anhedonia) that occurs only during and shortly after alcohol intoxication or withdrawal, remits after 3 to 4 weeks of abstinence, and is associated with significant distress and impairment. If depressive symptoms are present during periods of abstinence, this may indicate a primary depressive disorder.

It is also worth noting that long-term exposure to alcohol against the backdrop of depressive or manic symptoms may lead to a more severe clinical course, with longer mood episodes, poorer cognitive function, and a higher risk of suicide.

Severity of alcohol use disorder (AUD)

Alcohol use disorder (AUD) is a prevalent psychiatric disorder that often co-occurs with depressive disorders and other mental health disorders. The severity of AUD can vary from mild to moderate to severe, and this determination is crucial for deciding the appropriate level of care.

Healthcare providers typically use the criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) to diagnose and assess the severity of AUD. According to the DSM-5, AUD is classified as:

• Mild: The individual's symptoms match two to three criteria.
• Moderate: The individual's symptoms match four to five criteria.
• Severe: The individual's symptoms match six or more criteria.

The specific symptoms and their impact on the individual's life will determine the severity of AUD. These symptoms can include cravings for alcohol, alcohol withdrawal symptoms, disturbances in appetite and sleep, psychomotor behaviours, energy levels, concentration, decision-making abilities, feelings of worthlessness or guilt, and thoughts of suicide. Additionally, AUD can lead to physical health issues such as alcohol-induced hepatitis, alcohol poisoning, cerebellar degeneration, cirrhosis of the liver, and delirium tremens.

The severity of AUD also influences the recommended treatment approach. For mild AUD, outpatient treatment options such as medication and behavioural therapy may be sufficient. For moderate to severe AUD, more intensive interventions may be necessary, including inpatient medical treatment or residential rehabilitation. It is important to closely monitor individuals with severe or moderate AUD who suddenly stop drinking, as they are at risk of developing delirium tremens (DT), a severe and potentially life-threatening form of alcohol withdrawal that can cause seizures and hallucinations.

Furthermore, the presence of co-occurring mental health disorders, such as depressive disorders or anxiety, can exacerbate the severity of AUD and worsen the prognosis. Treatment for co-occurring AUD and depressive disorders may include AUD medications (e.g., naltrexone), antidepressants, and behavioural therapy. However, the most effective approach is still unclear due to a lack of comparative trials.

Severity of co-occurring mental health disorders

The severity of both alcohol use disorder (AUD) and co-occurring mental health disorders determines the appropriate level of care. Patients with less severe AUD and mental health conditions may be treated in primary care, while those with more severe conditions may require care from a mental health or addiction specialist, or both.

When determining the severity of co-occurring mental health disorders, it is important to establish a timeline of symptoms and behaviours. This can help differentiate between alcohol-induced symptoms and those of a separate, primary condition. For example, in the case of anxiety, it is helpful to understand the ages of onset of anxiety symptoms and alcohol use, the longest period of abstinence, and the presence or absence of anxiety symptoms during phases of drinking and abstinence. The same approach can be applied to mood disorders, including major depressive disorder and bipolar disorder, which commonly co-occur with AUD.

The presence of depressive disorders should be carefully assessed, as they are complex and heterogeneous syndromes. Depressive disorders are characterised by a range of symptoms, including disrupted mood (e.g., low, numb, or irritable), cognitive symptoms (e.g., feelings of worthlessness, difficulty concentrating), and physical symptoms (e.g., fatigue, lack of energy). Alcohol-induced depressive disorder, in particular, is characterised by depressed mood or anhedonia that occurs during and shortly after alcohol intoxication or withdrawal, remitting after 3 to 4 weeks of abstinence. It is associated with significant distress and impairment.

Additionally, it is important to recognise that AUD can exacerbate the symptoms of co-occurring mental health disorders. For example, long-term exposure to alcohol in individuals with depressive or manic symptoms may lead to a more severe clinical course, with longer mood episodes, poorer cognitive function, and a higher risk of suicide. Similarly, AUD can worsen ADHD-related impairments, creating a cycle of increased drinking and worsening symptoms. Therefore, when assessing severity, it is crucial to consider the recency and severity of alcohol use, as well as the patient's psychosocial stressors.

Treatment response

Medication

Pharmacological treatments have demonstrated efficacy in treating co-occurring alcohol use disorder (AUD) and depressive disorders. Medications such as naltrexone, an AUD medication, and antidepressants have been supported by treatment studies for their effectiveness in addressing these co-occurring conditions. However, it is important to note that the lack of comparative trials makes it challenging to determine the most effective approach.

Behavioural Therapy

Behavioural therapy has been understudied in the population with co-occurring AUD and depressive disorders, despite its proven effectiveness in treating these disorders separately. The inclusion of behavioural therapy as part of the standard treatment may contribute to the modest treatment outcomes observed in some cases. Further research is needed to enhance our understanding of the heterogeneity of AUD and depressive disorders and to develop novel treatment approaches.

Timeline and Diagnosis

Creating a detailed timeline of an individual's symptoms and behaviours is crucial for differential diagnosis and guiding treatment. This involves gathering information such as the age of onset of mood disorder symptoms and alcohol use, the longest period of abstinence, the presence or absence of symptoms during phases of drinking and abstinence, and family history. This timeline helps differentiate between alcohol-induced mood disorders and primary mood disorders, which is essential for setting appropriate treatment expectations and plans.

Severity and Specialist Care

The severity of both AUD and the co-occurring mood disorder plays a significant role in determining the level of care required. Individuals with less severe AUD and mood disorders may receive treatment in primary care settings, while those with more severe conditions may need specialised care from mental health professionals, addiction specialists, or both. Bipolar disorder, for example, often requires referral to a specialist due to its high suicide risk.

Self-Management and Support

For individuals in recovery from alcohol-induced mood disorders, self-management strategies and support systems are crucial. This includes engaging in healthy activities such as exercise and meditation, establishing daily routines, and seeking out support groups or individuals who can provide emotional support and understanding during the recovery process.

Patient's needs and clinical resources

Patients' needs and clinical resources are key factors in determining the appropriate level of care for individuals with alcohol-induced mood disorders. The severity of the alcohol use disorder (AUD) and the co-occurring mood disorder dictates whether the patient can be treated in primary care or requires the expertise of a mental health or addiction specialist.

For patients with less severe AUD and mood disorders, primary care providers can play a crucial role in identifying and managing these conditions. They can refer patients to specialists when needed, improving treatment outcomes. A comprehensive patient assessment should be conducted, including a detailed history of alcohol use and mood symptoms, to establish a timeline of behaviours and symptoms. This information is vital for differential diagnosis and treatment planning.

When it comes to patients' needs, it is essential to address the unique challenges posed by co-occurring psychiatric disorders. The treatment priorities for patients with AUD and mood disorders may vary. In some cases, the emphasis may be primarily on the AUD component, while in other cases, the co-occurring mood disorder may take precedence. Alternatively, both conditions may be addressed simultaneously. The specific needs of each patient, such as the severity of their mood disorder, the impact of their alcohol use, and their individual psychosocial stressors, will guide the treatment approach.

Clinical resources available will also influence the treatment options. For example, patients may benefit from pharmacological treatments, such as AUD medications (e.g., naltrexone) and antidepressants, which have shown efficacy in treating co-occurring AUD and depressive disorders. However, the lack of comparative trials on effectiveness makes it challenging to determine the most suitable approach for each patient. Behavioural therapy is another treatment option with evidence supporting its effectiveness in treating depressive disorders and AUD separately. Additionally, patients in recovery can benefit from establishing daily routines, engaging in healthy activities like exercise and meditation, and seeking social support to help regulate their emotions and manage mood swings.

Frequently asked questions