W. Clay Jackson, MD, DipTh, discusses treatment approaches for patients with depression and substance use disorders, after his Psych Congress 2019 presentation "Clinical Challenges in MDD: Addressing the Needs of Patients with Comorbid Disorders" with Psych Congress cochairs Rakesh Jain, MD, MPH, and Charles Raison, MD.
Dr. Jackson is a Clinical Assistant Professor of Family Medicine and Psychiatry at the University of Tennessee College of Medicine in Memphis, maintains a private practice in family medicine, and directs the palliative medicine program at the West Cancer Center in Arlington, Tennessee.
Read the Transcript:
For our patients who have major depressive disorder and also suffer from substance use disorder, first of all, we need to make sure that we've established a strong therapeutic alliance, because those patients may be suffering from a dual stigma.
In our general population, there's a stigma of having mental illness and there's a stigma of having substance use disorder, and so, these patients may be reluctant to present for treatment. They may be discouraged about their response to therapy. Making sure that the patient understands that for him or for her we're there, and we want to help that patient get better, is critically important.
With respect to specific treatments that we might choose, there is some evidence, and it's a little bit mixed, with respect to how patients may respond.
For instance, when we talk about pharmacologic therapy that may help prevent relapse in alcohol use disorder or substance use disorder, there are some studies that are out there and some of them have positive findings and some don't.
For instance, in patients who have substance use disorder, the addition of escitalopram as an antidepressant to buprenorphine did not show an additional benefit in terms of preventing relapse, but in alcohol use disorder, when sertraline was used in combination with naltrexone, patients with alcohol use disorder did have a greater effect in terms of delaying relapse or preventing relapse.
It turns out that sertraline was helpful, naltrexone was helpful, but the combination was better than either treatment alone and better than placebo. That does show us that if we combine antidepressant therapy with pharmacotherapy for preventing relapse in alcohol use disorder that it can have additive effects.
There are some additional choices of how we may approach patients pharmacotherapeutically that can be evidence guided or evidence based, but for all patients, first of all, assuring that they have a strong therapeutic alliance is critical when we approach these patients as persons rather than a collection of diagnoses.