Treatment BY
AND
JON
of Depression A.
JAMES
The authors alcoholics imipramine decreased differences posttreatment medication thisfinding Inventory Inventory, assessment
SIIAW,
MI).,
in Alcoholics
PATRICK
A. ROBINSON,
DONLEY,
M.D.,
DONALD
THE HISTORY ofalcoholism is replete with the failure to define and identify an “alcoholic personality” profile, there is evidence that alcoholics exhibit some common characteristics. Therapists engaged in treating patients with alcohol problems frequently report that their patients are clinically depressed. A number of studies indicate the high frequency with which depression is present in alcoholics when measured by different psychodiagnostic methods ( 1 -6). The understanding of this dinical phenomenon has been hindered by marked individual differences in the alcoholic patients and by failure to use operational definitions of alcoholism and depression. Because of the clinically observed relationship between alcoholism and depression, there have been a number of studies exploring the use of antidepressants in the treatment of alcoholism (7-9). In a double-blind study comparing imipramine to placebo, with dropout rates as the outcome measure, Ditman(10) found no significant effect of the antidepressant. Kissin and Charnoff (9) tested antidepressants such as amitniptyline and isocarboxazide in a double-blind design and were unable to demonstrate that any drug was superior to placebo in producing abstinence for a six-month interval. In more recent studies, Kissin and Gross (4) discovered that a combination of chlordiazepoxide and imipramine was more effective than either drug alone or placebo. The present study further explores the relationship between alcoholism and depression, examining the ef-
Psychiatry and Neurology, ington, D.C. 20012. Dr.
The authors gratefully aro at the field site.
Clinic, Dr. Morgan is Chief, Psychiatry is Research Psychologist, Department
Walter Reed Army Medical Donley is Staff Psychiatrist,
Psychiatry and Neurology, waii. Address reprint requests
M.D.,
I).M.S.,
Tnipler General to Dr. Shaw.
acknowledge
the
Hospital,
assistance
of
Centet, WashDepartment of Honolulu,
of Ms.
Patricia
combiin a treat-
rates
METHOD
ALTHOUGH
Psychiatry Robinson
MORGAN,
fectiveness of the chlordiazepoxide-imipramine nation with depression and with dropout ment program.
compared two groups of depressed given either placebo or chlordiazepoxidein a double-blindstudy. Although depression in both groups. there were no significant between them on any ofthree pre- and measures. The Zung scale showed that decreased depression significantly; ho wever, was not supported by the Beck Depression or the Minnesota Multiphasic Personality indicating the necessityfor use of multiple instruments.
Dr. Shaw is Chief, Service, and Mr.
W.
MS.
HaFig-
The population for this study was 58 male patients seeking treatment in a multifaceted halfway house that included inpatient care for a period of no longer than two weeks and an outpatient program providing individual counseling, group counseling, chemotherapy, and strongly emphasizing Alcoholics Anonymous. It was the policy of the halfway house to administer disulfiram to every patient unless there were medical contraindications. Informed consent for the use of disulfiram was a condition for acceptance into this facility. The mean age of the population studied was 3 1 .6 years, with a range from 18 to 50 years. Forty-seven percent were married, 16 percent divorced, 36 percent single, and 3 percent
separated.
Fifty-two
were
on
active
duty
in the
United States Army and 6 were employed civilians. For the total sample, 52 percent had graduated from high school and 41 percent had attended college. The diagnosis of alcoholism was established in accordance with the recommendations of the National Council on Alcoholism (I 1). Only patients reporting at least one of the major obligatory criteria (physiological dependence, tolerance, or a major alcohol-associated illness) were included in the study. Depression was operationally defined by the depression scale of the Minnesota Multiphasic Personality Inventory (MMPI), Zung’s Self-Rating Depression Scale (12), and the Beck Depression Inventory (13). Upon admission to the treatment program, all patients were evaluated by one ofthe psychiatrists participating in the study. Psychological testing, including the three measures of depression, and a questionnaire designed to gather detailed data concerning drinking habits, demography, family relationships, and work adjustment were administered. All of the subjects had been detoxified before entering the study. Inclusion in the double-blind study required the patient’s informed consent, no medical contraindications to disulfiram (Antabuse), chlordiazepoxide (Libnium), or imipramine (Tofranil), and geographic proximity for follow-up evaluation (within 50 miles of the halfway house). Of the original 58 patients, 30 met the established criteria for inclusion in the doubleblind study. Fifteen patients received 40 mg af chlomdiazepoxide and 150 mg of imipramine daily for an average
Am
J Psychiatry
132:6,
June 1975
641
DEPRESSION
IN ALCOHOLICS
of 31 days; the remaining 15 patients received identical placebos on the same schedule. The patients were randomly assigned to the groups and neither patients nor treating psychiatrists were aware of whether active medication on placebo was being administered. The 28 patients who were not included in the double-blind study comprised the baseline group. All 58 patients were offered individual and group counseling and 250 mg pen day of disulfinam as part of the total halfway house program. A psychiatric nurse administered all psychopharmacologic agents. After approximately 30 days of treatment, both the active medication and the placebo groups were reevaluated, and repeated administrations of the MMPI depression scale, Beck Depression Inventory, and Zung’s Self-Rating Depression Scale were completed. Attendance records were maintained for all 58 patients in the study. Those individuals who did not maintain contact for five consecutive weeks following admission into the study were identified as dropouts.
FIGURE
1
Comparison inventory,
ofPreMMPJ
and Posttreatment Depression Scale,
642
Beck
Depression
132:6, June 1975
Depression Depression
Inventory
#{182}
101
Ativeroup
.--‘
I
Pl,neho
9-
Moderate
roup
depression
8
0 U 0)
5-
4.
3
(ii
None
I
or
minimal
depression
-
MMPI
A m J Psychiatry
on the Beck Self-Rating
Scale
RESULTS
The seriousness of the drinking problems in this sample is illustrated in that 57 percent reported a drinking problem in excess of 2 years and 10 percent reported a drinking problem in excess of 10 years. Sixty-four percent indicated that their drinking had increased in the 6 months before treatment, and 66 percent were daily drinkers. In terms of their alcoholic preferences, no one preferred wine, 41 percent preferred beer, 31 percent prefemned liquor, and 28 percent preferred liquor and been in approximately equal amounts. The physiological effects of the chronic drinking behavior in this group of 58 patients are illustrated by the large number of physiological problems they reported. Blackouts were very frequent in this sanple; only 16 of the 58 patients stated that they had never experienced blackouts and 22 percent reported having blackout episodes more than 10 times. Twenty-one percent of the group reported undergoing full-blown delirium tremens at least once and 2 patients had repeated episodes. Seventy-one percent described shakes following drinking; 50 percent noted gastrointestinal distress associated with drinking, and 9 percent admitted to either seizures or liven trouble. Depression, as defined by the Zung, MMPI, and the Beck scales, was present in 98 percent of the patients on at least one of the depression scales. Eighty-eight percent of the total sample scored two and 40 percent scored three standard deviations above the mean on the MMPI depression scale, indicating a significant degree of depression. According to the Beck Depression Inventory, 76 percent were rated at least mildly depressed and 15 percent were severely depressed. Eighty-four percent of our sample was clinically depressed according to Zung’s Self-Rating Depression Scale. Figure 1 illustrates the effectiveness of the chlordiazepoxide-imipramine combination compared to placebo. On initial testing, no significant differences were found
Scores and Zung
Depression
Si
ile
0
0 U 0)
2 SD jbove
nie,n
0
44.
Zun
Self-Patini
Depression
Sole
Depression
,‘
42-
‘‘ ,“
40M Id
38 0
360
34. Normal
32
-
0 I
Before
treatment TIME
After
treatment
OF TREATMENT
among the baseline group, the chlordiazepoxide-imipramine group, and the placebo group with any of the three measures of depression. As figure 1 shows, depression abated in both the active medication group and the placebo group over the treatment period. Retesting after ap-
SHAW,
proximately 30 days also revealed ences among groups. An analysis of the amount of from initial testing to 30 days into decrease in depression on all three
no
significant
differ-
change in depression treatment indicated a measures for the placebo group; however, this change was not significant. No significant differences in the amount ofchange in depression were noted in the active drug group for either the MMPI depression scale on the Beck Depression Inventory.
A statistically
however, Self-Rating
significant
decrease
in depression,
noted for the active drug group on Zung’s Depression Scale (p
AND
JON
of Depression A.
JAMES
The authors alcoholics imipramine decreased differences posttreatment medication thisfinding Inventory Inventory, assessment
SIIAW,
MI).,
in Alcoholics
PATRICK
A. ROBINSON,
DONLEY,
M.D.,
DONALD
THE HISTORY ofalcoholism is replete with the failure to define and identify an “alcoholic personality” profile, there is evidence that alcoholics exhibit some common characteristics. Therapists engaged in treating patients with alcohol problems frequently report that their patients are clinically depressed. A number of studies indicate the high frequency with which depression is present in alcoholics when measured by different psychodiagnostic methods ( 1 -6). The understanding of this dinical phenomenon has been hindered by marked individual differences in the alcoholic patients and by failure to use operational definitions of alcoholism and depression. Because of the clinically observed relationship between alcoholism and depression, there have been a number of studies exploring the use of antidepressants in the treatment of alcoholism (7-9). In a double-blind study comparing imipramine to placebo, with dropout rates as the outcome measure, Ditman(10) found no significant effect of the antidepressant. Kissin and Charnoff (9) tested antidepressants such as amitniptyline and isocarboxazide in a double-blind design and were unable to demonstrate that any drug was superior to placebo in producing abstinence for a six-month interval. In more recent studies, Kissin and Gross (4) discovered that a combination of chlordiazepoxide and imipramine was more effective than either drug alone or placebo. The present study further explores the relationship between alcoholism and depression, examining the ef-
Psychiatry and Neurology, ington, D.C. 20012. Dr.
The authors gratefully aro at the field site.
Clinic, Dr. Morgan is Chief, Psychiatry is Research Psychologist, Department
Walter Reed Army Medical Donley is Staff Psychiatrist,
Psychiatry and Neurology, waii. Address reprint requests
M.D.,
I).M.S.,
Tnipler General to Dr. Shaw.
acknowledge
the
Hospital,
assistance
of
Centet, WashDepartment of Honolulu,
of Ms.
Patricia
combiin a treat-
rates
METHOD
ALTHOUGH
Psychiatry Robinson
MORGAN,
fectiveness of the chlordiazepoxide-imipramine nation with depression and with dropout ment program.
compared two groups of depressed given either placebo or chlordiazepoxidein a double-blindstudy. Although depression in both groups. there were no significant between them on any ofthree pre- and measures. The Zung scale showed that decreased depression significantly; ho wever, was not supported by the Beck Depression or the Minnesota Multiphasic Personality indicating the necessityfor use of multiple instruments.
Dr. Shaw is Chief, Service, and Mr.
W.
MS.
HaFig-
The population for this study was 58 male patients seeking treatment in a multifaceted halfway house that included inpatient care for a period of no longer than two weeks and an outpatient program providing individual counseling, group counseling, chemotherapy, and strongly emphasizing Alcoholics Anonymous. It was the policy of the halfway house to administer disulfiram to every patient unless there were medical contraindications. Informed consent for the use of disulfiram was a condition for acceptance into this facility. The mean age of the population studied was 3 1 .6 years, with a range from 18 to 50 years. Forty-seven percent were married, 16 percent divorced, 36 percent single, and 3 percent
separated.
Fifty-two
were
on
active
duty
in the
United States Army and 6 were employed civilians. For the total sample, 52 percent had graduated from high school and 41 percent had attended college. The diagnosis of alcoholism was established in accordance with the recommendations of the National Council on Alcoholism (I 1). Only patients reporting at least one of the major obligatory criteria (physiological dependence, tolerance, or a major alcohol-associated illness) were included in the study. Depression was operationally defined by the depression scale of the Minnesota Multiphasic Personality Inventory (MMPI), Zung’s Self-Rating Depression Scale (12), and the Beck Depression Inventory (13). Upon admission to the treatment program, all patients were evaluated by one ofthe psychiatrists participating in the study. Psychological testing, including the three measures of depression, and a questionnaire designed to gather detailed data concerning drinking habits, demography, family relationships, and work adjustment were administered. All of the subjects had been detoxified before entering the study. Inclusion in the double-blind study required the patient’s informed consent, no medical contraindications to disulfiram (Antabuse), chlordiazepoxide (Libnium), or imipramine (Tofranil), and geographic proximity for follow-up evaluation (within 50 miles of the halfway house). Of the original 58 patients, 30 met the established criteria for inclusion in the doubleblind study. Fifteen patients received 40 mg af chlomdiazepoxide and 150 mg of imipramine daily for an average
Am
J Psychiatry
132:6,
June 1975
641
DEPRESSION
IN ALCOHOLICS
of 31 days; the remaining 15 patients received identical placebos on the same schedule. The patients were randomly assigned to the groups and neither patients nor treating psychiatrists were aware of whether active medication on placebo was being administered. The 28 patients who were not included in the double-blind study comprised the baseline group. All 58 patients were offered individual and group counseling and 250 mg pen day of disulfinam as part of the total halfway house program. A psychiatric nurse administered all psychopharmacologic agents. After approximately 30 days of treatment, both the active medication and the placebo groups were reevaluated, and repeated administrations of the MMPI depression scale, Beck Depression Inventory, and Zung’s Self-Rating Depression Scale were completed. Attendance records were maintained for all 58 patients in the study. Those individuals who did not maintain contact for five consecutive weeks following admission into the study were identified as dropouts.
FIGURE
1
Comparison inventory,
ofPreMMPJ
and Posttreatment Depression Scale,
642
Beck
Depression
132:6, June 1975
Depression Depression
Inventory
#{182}
101
Ativeroup
.--‘
I
Pl,neho
9-
Moderate
roup
depression
8
0 U 0)
5-
4.
3
(ii
None
I
or
minimal
depression
-
MMPI
A m J Psychiatry
on the Beck Self-Rating
Scale
RESULTS
The seriousness of the drinking problems in this sample is illustrated in that 57 percent reported a drinking problem in excess of 2 years and 10 percent reported a drinking problem in excess of 10 years. Sixty-four percent indicated that their drinking had increased in the 6 months before treatment, and 66 percent were daily drinkers. In terms of their alcoholic preferences, no one preferred wine, 41 percent preferred beer, 31 percent prefemned liquor, and 28 percent preferred liquor and been in approximately equal amounts. The physiological effects of the chronic drinking behavior in this group of 58 patients are illustrated by the large number of physiological problems they reported. Blackouts were very frequent in this sanple; only 16 of the 58 patients stated that they had never experienced blackouts and 22 percent reported having blackout episodes more than 10 times. Twenty-one percent of the group reported undergoing full-blown delirium tremens at least once and 2 patients had repeated episodes. Seventy-one percent described shakes following drinking; 50 percent noted gastrointestinal distress associated with drinking, and 9 percent admitted to either seizures or liven trouble. Depression, as defined by the Zung, MMPI, and the Beck scales, was present in 98 percent of the patients on at least one of the depression scales. Eighty-eight percent of the total sample scored two and 40 percent scored three standard deviations above the mean on the MMPI depression scale, indicating a significant degree of depression. According to the Beck Depression Inventory, 76 percent were rated at least mildly depressed and 15 percent were severely depressed. Eighty-four percent of our sample was clinically depressed according to Zung’s Self-Rating Depression Scale. Figure 1 illustrates the effectiveness of the chlordiazepoxide-imipramine combination compared to placebo. On initial testing, no significant differences were found
Scores and Zung
Depression
Si
ile
0
0 U 0)
2 SD jbove
nie,n
0
44.
Zun
Self-Patini
Depression
Sole
Depression
,‘
42-
‘‘ ,“
40M Id
38 0
360
34. Normal
32
-
0 I
Before
treatment TIME
After
treatment
OF TREATMENT
among the baseline group, the chlordiazepoxide-imipramine group, and the placebo group with any of the three measures of depression. As figure 1 shows, depression abated in both the active medication group and the placebo group over the treatment period. Retesting after ap-
SHAW,
proximately 30 days also revealed ences among groups. An analysis of the amount of from initial testing to 30 days into decrease in depression on all three
no
significant
differ-
change in depression treatment indicated a measures for the placebo group; however, this change was not significant. No significant differences in the amount ofchange in depression were noted in the active drug group for either the MMPI depression scale on the Beck Depression Inventory.
A statistically
however, Self-Rating
significant
decrease
in depression,
noted for the active drug group on Zung’s Depression Scale (p
