Skip to main content

Main menu

  • Home
  • COVID-19
    • Articles & podcasts
    • Blog posts
    • Collection
    • News
  • Content
    • Current issue
    • Past issues
    • Early releases
    • Collections
    • Sections
    • Blog
    • Infographics & illustrations
    • Podcasts
    • Classified ads
  • Authors
    • Overview for authors
    • Submission guidelines
    • Submit a manuscript
    • Forms
    • Editorial process
    • Editorial policies
    • Peer review process
    • Publication fees
    • Reprint requests
  • CMA Members
    • Overview for members
    • Earn CPD Credits
    • Print copies of CMAJ
    • Career Ad Discount
  • Subscribers
    • General information
    • View prices
  • Alerts
    • Email alerts
    • RSS
  • JAMC
    • À propos
    • Numéro en cours
    • Archives
    • Sections
    • Abonnement
    • Alertes
  • CMAJ JOURNALS
    • CMAJ Open
    • CJS
    • JAMC
    • JPN

User menu

Search

  • Advanced search
CMAJ
  • CMAJ JOURNALS
    • CMAJ Open
    • CJS
    • JAMC
    • JPN
CMAJ

Advanced Search

  • Home
  • COVID-19
    • Articles & podcasts
    • Blog posts
    • Collection
    • News
  • Content
    • Current issue
    • Past issues
    • Early releases
    • Collections
    • Sections
    • Blog
    • Infographics & illustrations
    • Podcasts
    • Classified ads
  • Authors
    • Overview for authors
    • Submission guidelines
    • Submit a manuscript
    • Forms
    • Editorial process
    • Editorial policies
    • Peer review process
    • Publication fees
    • Reprint requests
  • CMA Members
    • Overview for members
    • Earn CPD Credits
    • Print copies of CMAJ
    • Career Ad Discount
  • Subscribers
    • General information
    • View prices
  • Alerts
    • Email alerts
    • RSS
  • JAMC
    • À propos
    • Numéro en cours
    • Archives
    • Sections
    • Abonnement
    • Alertes
  • Visit CMAJ on Facebook
  • Follow CMAJ on Twitter
  • Follow CMAJ on Pinterest
  • Follow CMAJ on Youtube
  • Follow CMAJ on Instagram
Practice

A 35-year-old woman with low mood and concerns about her alcohol use

Andriy V. Samokhvalov and Bernard Le Foll
CMAJ February 27, 2017 189 (8) E317-E318; DOI: https://doi.org/10.1503/cmaj.160132
Andriy V. Samokhvalov
Addictions Division (Samokhvalov, Le Foll); Institute for Mental Health Policy Research (Samokhvalov); Translational Addiction Research Laboratory and Campbell Family Mental Health Research Institute (Le Foll), Centre for Addiction and Mental Health; Department of Psychiatry (Samokhvalov), Faculty of Medicine; Institute of Medical Science (Samokhvalov, Le Foll); Departments of Pharmacology and Toxicology, and Family and Community Medicine (Le Foll), University of Toronto, Toronto, Ont.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • For correspondence: Andriy.Samokhvalov@camh.ca
Bernard Le Foll
Addictions Division (Samokhvalov, Le Foll); Institute for Mental Health Policy Research (Samokhvalov); Translational Addiction Research Laboratory and Campbell Family Mental Health Research Institute (Le Foll), Centre for Addiction and Mental Health; Department of Psychiatry (Samokhvalov), Faculty of Medicine; Institute of Medical Science (Samokhvalov, Le Foll); Departments of Pharmacology and Toxicology, and Family and Community Medicine (Le Foll), University of Toronto, Toronto, Ont.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Tables
  • Related Content
  • Responses
  • Metrics
  • PDF
Loading

A 35-year-old single woman with no history of mental disorders presents to a family physician with concerns about her alcohol use and emotional problems. She was referred from the emergency department. She drinks one to two bottles of wine almost every night and notices that she has to drink substantially more to achieve the same effect. She was unsuccessful in previous attempts to reduce her drinking; she could abstain for a week but relapsed because of cravings (i.e., strong urges to drink that she had multiple times a day) and her inability to control the amounts of alcohol she consumed. Drinking has affected her relationships and social life — she left a long-term relationship and has become more isolated as her friends have commented on her excessive drinking and associated erratic behaviour. Each morning, she is nauseated, has headaches and cannot focus on her work as a retail manager. She has had to call in sick on several occasions. She often feels tired, wakes up several times a night and does not feel rested in the morning. She has low appetite, has lost weight, and feels sad, isolated and worthless most of the time.

Physical examination does not show any concerning abnormalities. Bloodwork done in the emergency department showed moderately elevated serum levels of γ-glutamyltransferase, aspartate transaminase and alanine transaminase, and a larger mean corpuscular volume.

What diagnoses should be considered?

The patient meets six diagnostic criteria for alcohol use disorder:1 increased tolerance; inability to cut down drinking; cravings; failure to fulfill major role obligations; alcohol affecting health, personal life and work; and spending substantial time consuming alcohol and recovering from its effects. The extent of her symptoms and effect on function are consistent with a diagnosis of alchohol use disorder. Her mood disturbances qualify her for a major depressive episode — she feels depressed, tired and worthless most of the time, and there are changes in sleep and appetite.1 However, given that this may be alcohol-induced, the diagnosis would require reassessment after a period of abstinence.2,3 Appendix 1 (available at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.160132/-/DC1) contains a diagnostic checklist.

Does the patient require admission to hospital or medication for alcohol withdrawal?

A careful assessment of alcohol use history, drinking patterns and symptoms of alcohol withdrawal are very informative in making decisions about managing alcohol withdrawal. Alcohol withdrawal can be masked when patients drink daily. Because this patient was able to abstain recently without substantial withdrawal suggests that no medication for alcohol withdrawal (e.g., benzodiazepines) is required (e.g., for more information on managing alcohol withdrawal, https://porticonetwork.ca/web/alcohol-toolkit/treatment/alcohol-withdrawal).

Does the patient require any investigations?

Although the diagnosis of alcohol use disorder is made primarily on self-reported symptoms, any assessment should include specific laboratory tests such as complete blood cell count and serum levels of γ-glutamyltransferase, alanine transaminase and aspartate transaminase4 to determine the impact of alcohol use and to guide pharmacotherapy (e.g., naltrexone would be contraindicated if serum levels of transaminases were higher than three to five times the upper limit). Because the patient had these done recently in the emergency department, they do not need to be repeated at this time.

Although there are newer biomarkers, such as carbohydrate-deficient transferrin, none are currently used in regular clinical practice.

What should the treatment plan include?

The first step is clarifying the goal of treatment with the patient. Although abstinence has been promoted classically, reduction of alcohol consumption has also shown to be beneficial.5 Abstinence is easy to monitor but may be difficult to maintain. Recognizing the patient’s goal is important in strengthening the therapeutic relationship. A motivational approach can be helpful to guide the patient toward the optimal treatment regimen.5 A stepped-care approach that includes support groups has been shown to be effective.6

A discussion of the physician’s duty to report medical conditions that interfere with driving abilities should be part of the plan. Patients who have children in their care should prompt a risk assessment and involvement of the Children’s Aid Society if necessary. Thiamine should be prescribed to supplement depletion in severe cases (e.g., patients who are malnourished, those with liver disease and/or requiring medical withdrawal management). The usual dosage would be 100 mg three times a day (orally) for one month, but it should be started parenterally in the most severe cases (refer to the National Institute for Health and Care Excellence (NICE) guideline for a list of criteria).6,7

Medications approved by Health Canada (naltrexone, acamprosate and disulfiram) should be offered to all patients with alcohol use disorder as first-line therapies. Second-line therapies would comprise other medications that have shown utility in clinical trials, such as topiramate or gabapentin.2,8,9

If mood does not improve after four to six weeks, the Canadian Network for Mood and Anxiety Treatments task force guideline and other experts recommend the addition of an antidepressant to the treatment plan.2,3 Specifically, sertraline was shown to be an effective addition to naltrexone in a randomized controlled trial that examined the management of relapse in patients with alcohol dependence and depression.10 The available evidence (from systematic reviews and clinical trials) suggests that pharmacotherapy should be supported by psychotherapy and psycho-education to increase compliance and effectiveness.11

Case resolution

The patient set a goal to reduce the amount of alcohol she consumed. She was prescribed naltrexone and provided supportive counselling. She reduced her alcohol consumption to one or two glasses of wine twice a week. Her mood did not improve substantially during the first six weeks of monotherapy with naltrexone (50 mg orally, taken once a day) but improved when sertraline was added at a dosage gradually increased to 150 mg daily. After four months of treatment with naltrexone, the patient’s cravings for alcohol were under control, and the treatment was stopped. She continued to take sertraline to maintain a stable mood.

Footnotes

  • Competing interests: Bernard Le Foll has received nonfinancial support from GW Pharma, a grant from Bioprojet Pharma and consultant fees from Ethypharm and Lundbeck. No other competing interests were declared. This article was solicited and has been peer reviewed.

  • The clinical scenario is fictional.

  • Contributors: Both authors contributed equally to the conception, design, drafting and revision of the manuscript. Both authors approved the final version to be published and agreed to be accountable for all aspects of the work.

References

  1. ↵
    American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington (VA): American Psychiatric Association Publishing; 2013.
  2. ↵
    1. Beaulieu S,
    2. Saury S,
    3. Sareen J,
    4. et al
    .; Canadian Network for Mood and Anxiety Treatments (CANMAT) Task Force. The Canadian Network for Mood and Anxiety Treatments (CANMAT) task force recommendations for the management of patients with mood disorders and comorbid substance use disorders. Ann Clin Psychiatry 2012;24:38–55.
    OpenUrlPubMed
  3. ↵
    1. Nunes EV,
    2. Levin FR
    . Treatment of co-occurring depression and substance dependence: using meta-analysis to guide clinical recommendations. Psychiatr Ann 2008;38:nihpa128505.
  4. ↵
    1. Allen JP
    . Use of biomarkers of heavy drinking in health care practice. Mil Med 2003;168:364–7.
    OpenUrlPubMed
  5. ↵
    1. Marlatt GA,
    2. Witkiewitz K
    . Harm reduction approaches to alcohol use: health promotion, prevention, and treatment. Addict Behav 2002;27:867–86.
    OpenUrlCrossRefPubMed
  6. ↵
    Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence. London: National Institute for Health and Care Excellence; 2011. Available: https://nice.org.uk/guidance/cg115 (accessed 2017 Feb. 9).
  7. ↵
    1. Bower P,
    2. Gilbody S
    . Stepped care in psychological therapies: access, effectiveness and efficiency. Narrative literature review. Br J Psychiatry 2005;186:11–7.
    OpenUrlAbstract/FREE Full Text
  8. ↵
    1. Rolland B,
    2. Paille F,
    3. Gillet C,
    4. et al
    . Pharmacotherapy for alcohol dependence: the 2015 recommendations of the French Alcohol Society, issued in partnership with the European Federation of Addiction Societies. CNS Neurosci Ther 2016;22:25–37.
    OpenUrlCrossRefPubMed
  9. ↵
    1. Jonas DE,
    2. Amick HR,
    3. Feltner C,
    4. et al
    . Pharmacotherapy for adults with alcohol-use disorders in outpatient settings: executive summary. Rockville (MD): Agency for Healthcare Research and Quality; 2014.
  10. ↵
    1. Pettinati HM,
    2. Oslin DW,
    3. Kampman KM,
    4. et al
    . A double-blind, placebo-controlled trial combining sertraline and naltrexone for treating co-occurring depression and alcohol dependence. Am J Psychiatry 2010;167:668–75.
    OpenUrlCrossRefPubMed
  11. ↵
    1. Willenbring ML,
    2. Massey SH,
    3. Gardner MB
    . Helping patients who drink too much: an evidence-based guide for primary care clinicians. Am Fam Physician 2009; 80:44–50.
    OpenUrlPubMed
PreviousNext
Back to top

In this issue

Canadian Medical Association Journal: 189 (8)
CMAJ
Vol. 189, Issue 8
27 Feb 2017
  • Table of Contents
  • Index by author

Article tools

Respond to this article
Print
Download PDF
Article Alerts
To sign up for email alerts or to access your current email alerts, enter your email address below:
Email Article

Thank you for your interest in spreading the word on CMAJ.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
A 35-year-old woman with low mood and concerns about her alcohol use
(Your Name) has sent you a message from CMAJ
(Your Name) thought you would like to see the CMAJ web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
A 35-year-old woman with low mood and concerns about her alcohol use
Andriy V. Samokhvalov, Bernard Le Foll
CMAJ Feb 2017, 189 (8) E317-E318; DOI: 10.1503/cmaj.160132

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
‍ Request Permissions
Share
A 35-year-old woman with low mood and concerns about her alcohol use
Andriy V. Samokhvalov, Bernard Le Foll
CMAJ Feb 2017, 189 (8) E317-E318; DOI: 10.1503/cmaj.160132
Digg logo Reddit logo Twitter logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Jump to section

  • Article
    • What diagnoses should be considered?
    • Does the patient require admission to hospital or medication for alcohol withdrawal?
    • Does the patient require any investigations?
    • What should the treatment plan include?
    • Case resolution
    • Footnotes
    • References
  • Figures & Tables
  • Related Content
  • Responses
  • Metrics
  • PDF

Related Articles

  • What role does humanity play in assessing and treating alcohol use disorder?
  • PubMed
  • Google Scholar

Cited By...

  • What role does humanity play in assessing and treating alcohol use disorder?
  • Google Scholar

More in this TOC Section

  • Azathioprine-induced severe anemia potentiated by the concurrent use of allopurinol
  • Schwannoma of the tongue
  • “Superscan” in diffusion-weighted imaging with background body suppression magnetic resonance imaging
Show more Practice

Similar Articles

Content

  • Current issue
  • Past issues
  • Collections
  • Sections
  • Blog
  • Podcasts
  • Alerts
  • RSS
  • Early releases

Information for

  • Advertisers
  • Authors
  • Reviewers
  • CMA Members
  • Media
  • Reprint requests
  • Subscribers

About

  • General Information
  • Journal staff
  • Editorial Board
  • Governance Council
  • Journal Oversight
  • Careers
  • Contact
  • Copyright and Permissions

Copyright 2021, Joule Inc. or its licensors. All rights reserved. ISSN 1488-2329 (e) 0820-3946 (p)

All editorial matter in CMAJ represents the opinions of the authors and not necessarily those of the Canadian Medical Association or its subsidiaries.

Powered by HighWire