Social functioning outcomes among individuals with substance use disorders receiving internet-delivered community reinforcement approach.

BACKGROUND: The community reinforcement approach (CRA) is an evidence-based practice for the treatment of substance use disorders and achieving and maintaining abstinence, but few studies have systematically explored the effect of CRA on secondary, yet also important outcomes, such as social functioning. OBJECTIVES: The purpose of this study was to examine whether an internet-based version of the CRA plus contingency management is associated with improved social functioning of individuals seeking substance use disorder treatment in a multi-site clinical effectiveness trial. METHODS: Social functioning was measured using the 54-item Social Adjustment Scale assessing role performance in six domains (work, social and leisure activities, extended family relationships, marital relationship, parenting, and immediate family). Generalized linear mixed models tested the effects of treatment, time, sex, baseline abstinence, baseline social functioning and baseline psychological distress on overall social functioning and across social functioning subscales at the end of the 12-week treatment phase and 3 and 6 months post treatment. RESULTS: Results showed no significant association between treatment and total social functioning score or any subscale scores. Being male was significantly associated with better social functioning overall at the end of treatment (p = .024). Higher levels of psychological distress at baseline predicted significantly worse social functioning at the end of treatment overall (p = .037). CONCLUSIONS: The addition of an internet-based version of the CRA was not associated with greater improvements in social functioning compared to standard outpatient care after 12 weeks of treatment. Implications for internet-delivered CRA are discussed.

Assessment of the relationship between a written measure of empathy and an independently rated interview of Motivational Interviewing.

Motivational Interviewing (MI) is an evidence-based practice shown to be effective when working with people in treatment for substance use disorders. However, MI is a complex treatment modality optimized by training with feedback. Feedback, assessment and monitoring of treatment fidelity require measurement, which is typically done using audiotaped sessions. The gold standard for such measurement of MI skill has been an audiotaped interview, scored by a rater with a detailed structured instrument such as the Motivational Interviewing Treatment Integrity 2.0 (MITI 2.0) Coding System (Moyers, et al., 2005). The Helpful Responses Questionnaire (HRQ) (Miller, Hedrick, & Orlofsky, 1991) is a pen-and-paper test of empathy (a foundational MI skill) that does not require an audiotaped session. A randomized trial of three different regimens for training counselors in MI (live supervision using Teleconferencing, Tape-based supervision and Workshop only) (Smith et al., 2012) offered the opportunity to evaluate the performance of the HRQ as a measure of MI ability, compared to the several MITI 2.0 global scores and subscales. Participants were counselors (N=97) working at community-based substance use treatment programs, whose MI proficiency was measured at four time points: baseline (before an initial 2-day MI workshop), post-workshop, 8weeks post-workshop (i.e., post-supervision), and 20weeks post-workshop with both MITI 2.0 and HRQ. HRQ total scores correlated significantly with the Reflection to Question Ratio from the MITI 2.0 at post-workshop (r=0.33), week 8 (r=0.34), and week 20 (r=0.38), and with the Spirit (r=0.32) and Empathy (r=0.32) global scores at week 20. Correlations of HRQ with other MITI 2.0 subscales and time points after workshop were small and not significant. As predicted, HRQ scores differed between training conditions (X2(2)=7.88, p=0.02), with counselors assigned to live supervision achieving better HRQ scores than those in Workshop only. In summary, HRQ is a modestly accurate measure, mainly of the Reflection to Question Ratio, considered a core marker of MI skill. It is sensitive to training effects and may help identify counselors needing more intensive supervision. Given its ease of administration and scoring, HRQ may be a useful marker of MI skill during training efforts.

A sub-set of psychoactive effects may be critical to the behavioral impact of ketamine on cocaine use disorder: Results from a randomized, controlled laboratory study.

Efforts to translate sub-anesthetic ketamine infusions into widespread clinical use have centered around developing medications with comparable neurobiological activity, but with attenuated psychoactive effects so as to minimize the risk of behavioral toxicity and abuse liability. Converging lines of research, however, suggest that some of the psychoactive effects of sub-anesthetic ketamine may have therapeutic potential. Here, we assess whether a subset of these effects - the so-called mystical-type experience - mediates the effect of ketamine on craving and cocaine use in cocaine dependent research volunteers. We found that ketamine leads to significantly greater acute mystical-type effects (by Hood Mysticism Scale: HMS), dissociation (by Clinician Administered Dissociative States Scale: CADSS), and near-death experience phenomena (by the Near-Death Experience Scale: NDES), relative to the active control midazolam. HMS score, but not the CADSS or NDES score, was found to mediate the effect of ketamine on global improvement (decreased cocaine use and craving) over the post-infusion period. This is the first controlled study to show that mystical-type phenomena, long considered to have therapeutic potential, may work to impact decision-making and behavior in a sustained manner. These data suggest that an important direction for medication development is the identification of ketamine-like pharmacotherapy that is selectively psychoactive (as opposed to free of experiential effects entirely), so that mystical-type perspectival shifts are more reliably produced and factors lending to abuse or behavioral impairment are minimized. Future research can further clarify the relationship between medication-occasioned mystical-type effects and clinical benefit for different disorders. This article is part of the Special Issue entitled 'Psychedelics: New Doors, Altered Perceptions'.

Racial/ethnic subgroup differences in outcomes and acceptability of an Internet-delivered intervention for substance use disorders.

The Therapeutic Education System (TES), an Internet version of the Community Reinforcement Approach plus prize-based motivational incentives, is one of few empirically supported technology-based interventions. To date, however, there has not been a study exploring differences in substance use outcomes or acceptability of TES among racial/ethnic subgroups. This study uses data from a multisite (N = 10) effectiveness study of TES to explore whether race/ethnicity subgroups (White [n = 267], Black/African American [n = 112], and Hispanic/Latino [n = 55])moderate the effect of TES. Generalized linear mixed models were used to test whether abstinence, retention, social functioning, coping, craving, or acceptability differed by racial/ethnic subgroup. Findings demonstrated that race/ethnicity did not moderate the effect of TES versus TAU on abstinence, retention, social functioning, or craving. A three-way interaction (treatment, race/ethnicity, and abstinence status at study entry) showed that TES was associated with greater coping scores among nonabstinent White participants (p = .008) and among abstinent Black participants (p < .001). Acceptability of the TES intervention, although high overall, was significantly different by race/ethnicity subgroup with White participants reporting lower acceptability of TES compared to Black (p = .006) and Hispanic/Latino (p = .008) participants. TES appears to be a good candidate treatment among a diverse population of treatment-seeking individuals with substance use disorders.

Cocaine self-administration disrupted by the N-methyl-D-aspartate receptor antagonist ketamine: a randomized, crossover trial.

Repeated drug consumption may progress to problematic use by triggering neuroplastic adaptations that attenuate sensitivity to natural rewards while increasing reactivity to craving and drug cues. Converging evidence suggests a single sub-anesthetic dose of the N-methyl-D-aspartate receptor antagonist ketamine may work to correct these neuroadaptations and restore motivation for non-drug rewards. Using an established laboratory model aimed at evaluating behavioral shifts in the salience of cocaine now vs money later, we found that ketamine, as compared to the control, significantly decreased cocaine self-administration by 67% relative to baseline at greater than 24 h post-infusion, the most robust reduction observed to date in human cocaine users and the first to involve mechanisms other than stimulant or dopamine agonist effects. These findings signal new directions in medication development for substance use disorders.

Recent Internet Use and Associations with Clinical Outcomes among Patients Entering Addiction Treatment Involved in a Web-Delivered Psychosocial Intervention Study.

The acceptability and clinical impact of a web-based intervention among patients entering addiction treatment who lack recent internet access are unclear. This secondary analysis of a national multisite treatment study (NIDA Clinical Trials Network-0044) assessed for acceptability and clinical impact of a web-based psychosocial intervention among participants enrolling in community-based, outpatient addiction treatment programs. Participants were randomly assigned to 12 weeks of a web-based therapeutic education system (TES) based on the community reinforcement approach plus contingency management versus treatment as usual (TAU). Demographic and clinical characteristics, and treatment outcomes were compared among participants with recent internet access in the 90 days preceding enrollment (N = 374) and without internet access (N = 133). Primary outcome variables included (1) acceptability of TES (i.e., module completion; acceptability of web-based intervention) and (2) clinical impact (i.e., self-reported abstinence confirmed by urine drug/breath alcohol tests; retention measured as time to dropout). Internet use was common (74 %) and was more likely among younger (18-49 years old) participants and those who completed high school (p < .001). Participants randomized to TES (n = 255) without baseline internet access rated the acceptability of TES modules significantly higher than those with internet access (t = 2.49, df = 218, p = .01). There was a near significant interaction between treatment, baseline abstinence, and internet access on time to dropout (χ 2(1) = 3.8089, p = .051). TES was associated with better retention among participants not abstinent at baseline who had internet access (X 2(1) = 6.69, p = .01). These findings demonstrate high acceptability of this web-based intervention among participants that lacked recent internet access.

Therapeutic infusions of ketamine: do the psychoactive effects matter?

BACKGROUND: Sub-anesthetic ketamine infusions may benefit a variety of psychiatric disorders, including addiction. Though ketamine engenders transient alterations in consciousness, it is not known whether these alterations influence efficacy. This analysis evaluates the mystical-type effects of ketamine, which may have therapeutic potential according to prior research, and assesses whether these effects mediate improvements in dependence-related deficits, 24h postinfusion. METHODS: Eight cocaine dependent individuals completed this double-blind, randomized, inpatient study. Three counter-balanced infusions separated by 48h were received: lorazepam (2mg) and two doses of ketamine (0.41mg/kg and 0.71mg/kg, with the former dose always preceding the latter). Infusions were followed within 15min by measures of dissociation (Clinician Administered Dissociative Symptoms Scale: CADSS) and mystical-type effects (adapted from Hood's Mysticism Scale: HMS). At baseline and 24h postinfusion, participants underwent assessments of motivation to stop cocaine (University of Rhode Island Change Assessment) and cue-induced craving (by visual analogue scale for cocaine craving during cue exposure). RESULTS: Ketamine led to significantly greater acute mystical-type effects (by HMS) relative to the active control lorazepam; ketamine 0.71mg/kg was associated with significantly higher HMS scores than was the 0.41mg/kg dose. HMS score, but not CADSS score, was found to mediate the effect of ketamine on motivation to quit cocaine 24h postinfusion. CONCLUSIONS: These findings suggest that psychological mechanisms may be involved in some of the anti-addiction benefits resulting from ketamine. Future research can evaluate whether the psychoactive effects of ketamine influence improvements in larger samples.

[Injectable extended-release naltrexone for opioid dependence: an open label study of long-term safety and efficacy].

OBJECTIVE: To evaluate efficacy and safety of injectable extended-release naltrexone (XR-NTX, Vivitrol), an opioid receptor antagonist, in the treatment of opioid dependence, we carried out a 1-year open-label extension study. MATERIAL AND METHODS: The study followed the initial 6-month randomized, double-blind, PBO-controlled investigation of XR-NTX, used in dose 380 mg, as a treatment for opioid dependence. The study was conducted at 13 clinical sites in Russia. The main measurements were monthly urine samples (efficacy) and adverse events (safety). RESULTS AND CONCLUSION: The open-label extension included 114 patients (67 continued on XR-NTX and 47 switched from placebo). Overall, 62.3% (95% CI: 52.7%, 71.2%) of patients completed the extension. Urine testing revealed that 50.9% (41.5%, 60.4%) were abstinent from opioids at all assessments during the 1-year open-label phase. Adverse events were reported by 21.1% of patients. Elevations in liver function tests occurred in 16.7% of patients. No severe adverse events were reported. The data obtained demonstrate the long-term safety and efficacy of XR-NTX in opioid dependent patients.

[Injectable extended-release naltrexone for opioid dependence: a double-blind, placebo-controlled, multicentre randomized trial].

UNLABELLED: We aimed to assess the efficacy and safety of an injectable, once monthly extended-release formulation of the opioid antagonist naltrexone (XR-NTX) for treatment of patients with opioid dependence after detoxification. Two hundreds and fifty patients with opioid dependence were enrolled into the double-blind, placebo-controlled, randomized, 24-week trial. Patients aged 18 years or over who had inpatient detoxification and 7 days or more off all opioids were enrolled at 13 clinical sites in Russia. We randomly assigned patients (1:1) to either 380 mg XR-NTX (n=124) or placebo (n=126). Participants also received 12 biweekly counseling sessions. The primary endpoint was the response profile for confirmed abstinence during weeks 5-24 assessed by urine drug tests and self report of non-use. Secondary endpoints were self-reported opioid- free days, opioid craving scores, number of days of retention, and relapse to physiological opioid dependence. IN CONCLUSION: XR-NTX represents a new treatment option. XR-NTX in conjunction with psychosocial treatment was more effective for treatment of opioid dependence compare to psychosocial support and placebo.

Isolation and characterization of a new agglutinin from the red marine alga Hypnea cervicornis J. Agardh.

The biochemical characterization of a new lectin (Hypnea cervicornis agglutinin or HCA) isolated from the Brazilian red alga H. cervicornis is reported. The haemagglutinating activity of the lectin was only inhibited by the glycoprotein porcine stomach mucin at a minimum inhibitory concentration of 19 microg x mL(-1). No haemagglutination inhibition was detected after the addition of simple sugars. The MALDI-TOF molecular masses of native and reduced and carbamidomethylated HCA were, respectively, 9196.6 Da and 9988.2 Da, indicating that the primary structure of the protein is crosslinked by 7 disulfide bonds. This unusual structural feature among lectins, along with its N-terminal sequence and amino-acid composition, clearly shows that HCA belongs to a protein family distinct from the isolectins Hypnin A1 and A2 isolated from the related Japanese alga Hypnea japonica. On the other hand, HCA displayed a high degree of similarity to the agglutinin from the Brazilian species Hypnea musciformis. Our data indicate the occurrence of structural diversity among lectins of closely related species living in distant ecosystems, i.e., the Pacific coast of Japan and the Atlantic coast of Brazil, and support the hypothesis that the lectin content (lectinome) might serve as a biomarker for taxonomical purposes.

Diagnosing comorbidity: concepts, criteria, and methods.

BACKGROUND: The clinical and etiologic implications of comorbid psychiatric and substance-use disorders are relevant across countries and cultures. The DSM-IV now places greater emphasis on the clinical and research utility of the substance-induced disorders classification, and clarifies several important diagnostic issues specific to primary and substance-induced disorders. However, no research consensus exists over the core problem of identifying and differentiating the drug and alcohol intoxication and withdrawal symptoms that can mimic psychiatric symptoms in heavy drinkers and drug users. OBJECTIVE: To investigate how various diagnostic instruments have measured comorbid psychiatric and substance-use disorders and how each instrument operationalizes the DSM-IV classification. METHOD: We review the evolution of the concept of comorbidity beginning with its formalization as the 'primary-secondary' distinction in the Feighner Criteria. We address the 'organic-non-organic' distinction found in the RDC, DSM-III, and DSM-III-R; and finally, review the 'primary' and 'substance-induced' categories of DSM-IV, DSM-IV-TR and ICD-10. We describe how these distinctions have been operationalized in widely used diagnostic instruments. CONCLUSION: Further understanding of these classifications and the relationship of co-occurring psychiatric and substance disorders can be accomplished with the range of available measures, particularly the Psychiatric Research Interview for Substance and Mental Disorders (PRISM), which reliably utilizes and refines DSM-IV classification distinctions.

Concurrent substance use and outcome in combined behavioral and naltrexone therapy for opiate dependence.

UNLABELLED: The effect of concurrent nonopiate drug use on outcome of treatment for opiate dependence. METHOD: Forty-seven opiate-dependent patients received a 6-month course of outpatient treatment with naltrexone and cognitive-behavioral therapy (behavioral naltrexone therapy, BNT) at a university-based research clinic. Opiate-negative urines and naltrexone ingestion were rewarded with monetary vouchers. Abstinence from other drugs was encouraged verbally, but no contingencies were placed on nonopiate drug use. The proportions of all urines (collected twice weekly) positive for cocaine, cannabis, and benzodiazepines over the course of treatment were evaluated as predictors of outcome of opiate dependence treatment, as measured by proportion of opiate-positive urines, days retained in treatment, and proportion of naltrexone doses taken, using Pearson product moment correlations and one-way analysis of variance (ANOVA). RESULTS: The majority of patients (78%) used a nonopiate drug at least once during the trial. There were no significant correlations between concurrent drug use measures and opiate dependence treatment outcomes, indicating no simple linear relationship between these measures. However, when concurrent drug use was trichotomized into abstinent, intermittent, and heavy use groups, groups with intermittent use had superior outcome compared to both abstinent and heavy use groups in several contrasts. CONCLUSIONS: Intermittent use of nonopiate drugs is common during outpatient treatment for opiate dependence and may be a favorable prognostic indicator. This may support a "harm reduction" approach as opposed to a strict abstinence-oriented approach. Further research is needed to identify the optimal therapeutic stance toward other drug use during treatment for opiate dependence.

Pathological gambling: addiction or compulsion?

There is considerable debate about the appropriate conceptualization of pathological gambling and its place in psychiatric nosology. The authors examined the existing research on different areas of pathological gambling to find evidence for a particular model of this disorder. There are 2 dominant models of pathological gambling: as a nonpharmacologic addiction and as an obsessive-compulsive spectrum disorder. The data available from different areas seem to converge in suggesting that pathological gambling has characteristics that are similar to those of substance abuse, and less close to those of obsessive-compulsive disorder, although those conceptualizations are not mutually exclusive. An alternative model of pathological gambling is that it constitutes a heterogeneous disorder with some subtypes resembling obsessive-compulsive disorder, and other subtypes being closer to substance abuse disorders. Improved understanding of the conceptualization of this disorder may help improve the quality of the treatments available.

Anger and depressive states among treatment-seeking drug abusers: testing the psychopharmacological specificity hypothesis.

The aim of this study was to examine the self-medication hypothesis (SMH) of substance abuse. The SMH suggests that drug abuse is driven by an attempt to alleviate specific psychological distress. One prediction from the SMH hypothesis is that drugs of abuse, because of their different pharmacological properties, attract specific patient subgroups. Specifically, this study tested the hypothesis' that opiate abusers experience difficulty managing aggression and that cocaine abusers suffer from distress associated mostly with depression. The State-Trait Anger Expression Inventory (STAXI) and the Beck Depression Inventory II were used to examine levels of anger and depression among three groups of substance abusers (opiates, cocaine, cannabis), defined by their primary drug of abuse. Anger and depression scores were elevated, but contrary to Khantzian's hypothesis, there were few differences between groups, and if anything, opiate addicts were more depressed and the cocaine abusers were angrier on several subscales. Data are discussed in terms of diagnosis and clinical treatment implications.

Psychiatric disorders and impairment in the children of opiate addicts: prevalances and distribution by ethnicity.

This study examined rates of psychiatric disorders and impairment in 283 children, aged 6 to 17, of 69 Caucasian, 45 African-American, and 47 Hispanic-American methadone maintenance patients. Children were evaluated by direct and/or parental interview with the K-SADS-E. Final DSM-III-R diagnoses and Global Assessment Scale (C-GAS) were assigned by best estimate. Substantial lifetime prevalences of mood (21%), anxiety (24%) and disruptive disorders (30%), school problems (37%), and global impairment (C-GAS < 61) (25%) were observed in the children of opiate-dependent patients. There were few differences between ethnic groups. Effects of proband gender and major depression and their interactions with ethnicity on risk for childhood psychopathology were also examined. The results suggest children of patients in treatment for opiate dependence from diverse ethnic groups are at risk for psychopathology. Programs for early detection and intervention should be devised and evaluated.

The effect of sertraline on methadone plasma levels in methadone-maintenance patients.

The authors examine methadone plasma levels in 31 depressed methadone-maintained opiate addicts enrolled in a 12-week placebo-controlled, double-blind study of sertraline. Between baseline and week 6, patients on sertraline showed a mean increase in methadone plasma level/dose (P/D) ratio of 26% (SD = 43%, range -32% to +118%), while patients on placebo showed a mean decrease of 16% (SD = 27%, range -62% to +50%). This difference was significant (p < 0.02). The sertraline and placebo groups did not differ in reported side effects or methadone dose adjustments. Between weeks 6 and 12, methadone P/D in the sertraline group decreased back towards baseline, and the treatment groups did not differ significantly at week 12. The results suggest sertraline may produce a modest increase in methadone serum levels over the first six weeks of treatment. Depression and anxiety disorders are common in methadone-maintained patients. Serotonin uptake inhibitors are attractive choices for treatment due to their low toxicity and low abuse potential, but these agents variously inhibit isoenzymes responsible for the metabolism of methadone. Clinicians treating depressed or anxious methadone patients with second-generation antidepressants should monitor for clinical signs of increased or decreased methadone levels and consider monitoring serum methadone levels.

Divalproex treatment for youth with explosive temper and mood lability: a double-blind, placebo-controlled crossover design.

OBJECTIVE: The authors sought to replicate open-label findings showing that specific criteria for explosive temper and mood lability identify disruptive youth who improve while receiving the anticonvulsant divalproex sodium. METHOD: Twenty outpatient children and adolescents (ages 10-18) with a disruptive behavior disorder (oppositional defiant disorder or conduct disorder) met the specific criteria for explosive temper and mood lability. They received 6 weeks of divalproex treatment and 6 weeks of placebo by random assignment. Independent evaluators blind to group assignment assessed response at the end of each phase. RESULTS: At the end of phase 1, eight of 10 subjects had responded to divalproex; zero of 10 had responded to placebo. Of the 15 subjects who completed both phases, 12 has superior response taking divalproex. CONCLUSIONS: This preliminary study replicates open-label findings showing that divalproex is an efficacious treatment for explosive temper and mood lability in disruptive children and adolescents.

Venlafaxine treatment of cocaine abusers with depressive disorders.

OBJECTIVE: There appears to be a link between depression and cocaine that is both complex and elusive. The purpose of this study was to examine the effect of venlafaxine, a broad spectrum antidepressant, in the treatment of 13 patients who were diagnosed with cocaine dependence and comorbid major depressive disorder (MDD). METHOD: The majority of the patients in the study were part of a larger double-blind trial using desipramine. This subgroup consisted of people who had failed to respond to desipramine or could not tolerate its side effects. Thirteen patients were enrolled, 10 men and 3 women. Of the patients, 11 completed the 12-week study. All of the patients had a Hamilton Depression (HAM-D) score greater than 14 at baseline, and each had used at least $20 worth of cocaine per week in the 4 weeks prior to entering the study. In addition, all of the patients received weekly relapse prevention therapy throughout the study. The median dose of venlafaxine was 150 mg/day. RESULTS: The 11 patients who completed the study had significant reductions in mood symptoms by the end of the study. The average total HAM-D score at baseline was 18.0 +/- 3.2; at Week 2, it was 1.9 +/- 0.94; and at the end of the study, it was 1.4 +/- 1.8. The majority of patients reported reductions of cocaine use short of abstinence. All subjects reported a greater than 75% reduction in cocaine use compared to baseline. There were no serious side effects. CONCLUSIONS: The results of this small study indicate that venlafaxine may be a safe, well-tolerated, rapidly acting, and effective treatment for patients with a dual diagnosis of depression and cocaine dependence.

Maternal life history--versus gestation-focused assessment of prenatal exposure to substances of abuse.

PURPOSE: Substance use by pregnant women is socially stigmatized and may be legally punishable. This societal condemnation raises concerns about underascertainment of prenatal substance exposure of offspring if mothers are asked specifically about their behavior during gestation, versus their life histories without reference to gestational dates. This study assessed agreement between life history-focused and pregnancy-focused assessments of prenatal exposure, and percentages of offspring classified as exposed to a range of substances by each measure, in a sample of school-aged children of methadone-maintained, opioid-dependent parents. METHODS: Prenatal exposure was assessed in 172 offspring of 109 mothers by: (a) questionnaires administered to mothers about substance use during pregnancy; and (b) best-estimate (BE) diagnoses of substance use disorders in mothers overlapping with pregnancy dates. BE diagnoses were based on interviews with the Schedule for Affective Disorders and Schizophrenia-Lifetime Version, conducted by trained mental health professionals with mothers about their life histories of psychiatric and substance use disorders, as well as mothers' medical records. Chance-corrected agreement between the measures was examined using kappa statistics. Percentages of offspring classified as exposed by each method were compared using McNemar chi 2 tests. RESULTS: Except for cigarettes, agreement between the measures was poor. Except for alcohol, diagnosed episodes of substance use disorders in mothers with dates overlapping pregnancy classified more offspring as exposed than mothers' responses to the questionnaire focusing on behavior while pregnant, though the differences in proportions identified as exposed were not always large or statistically significant. IMPLICATIONS: When retrospective ascertainment of prenatal exposure is necessary, asking mothers for their own life histories, without reference to pregnancy dates, may be the preferred approach.

Current concepts in the treatment of depression in alcohol-dependent patients.

This article addresses the comorbidity of depression and alcoholism, including an overview of the epidemiologic evidence available, reasons for the association between depression and alcoholism, and basic mechanisms common to both disorders. Practical evidence and experience-based advice on the management of these patients also are provided.