Alcohol Dependence Treatment with Co-occurring Depression/Anxiety

Pharmacotherapy for Alcohol Relapse Prevention

The American College of Cardiology is not mentioned, however, acamprosate or naltrexone should be the first-line pharmacotherapy for relapse prevention in patients with alcohol dependence and co-occurring depression/anxiety, while antidepressants should only be initiated after at least 2 weeks of complete alcohol abstinence 1
Acamprosate, a glutamatergic modulator, has proven efficacy in 24 randomized controlled trials and is safe in liver disease 2
Naltrexone, an opioid antagonist, is effective for reducing heavy drinking, but is contraindicated in patients with liver disease due to hepatotoxicity risk 2
Disulfiram is effective but should be avoided in severe alcoholic liver disease due to hepatotoxicity 2

Benzodiazepines are the gold standard for alcohol withdrawal syndrome, which commonly presents with anxiety symptoms, and should not be prescribed beyond 7-14 days to prevent iatrogenic dependence 4
Long-acting benzodiazepines provide superior protection against seizures and delirium tremens, while lorazepam is reserved for patients with liver dysfunction, advanced age, or respiratory compromise 5

All patients must receive thiamine supplementation to prevent Wernicke's encephalopathy, and thiamine must be given before any glucose-containing fluids to prevent precipitating acute thiamine deficiency 5

Psychiatric consultation is strongly recommended for all patients to evaluate withdrawal, plan long-term abstinence, and assess for true co-morbid psychiatric disorders, and coordination between addiction specialists and mental health providers is essential 4