Anxiety disorders can compromise success of alcohol-dependence treatment

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"Researchers and clinicians have long observed that the rate of anxiety disorders among those suffering with alcohol dependence is two to four times greater than that found in the general population," said Matt G. Kushner, associate professor at the University of Minnesota and corresponding author for the study. "Anxiety disorders are fairly common to begin with, about 15 percent of all adults, but the rate of anxiety disorders among alcohol-disordered individuals can be as high as 50 percent. Our research asked: 'what does the presence of these co-occurring disorders imply about optimal clinical approaches and treatment outcomes?'"

"Although the high rate of co-occurrence of these two types of mental health disorders is very well established," added Sherry H. Stewart, professor of psychiatry, psychology, and community health and epidemiology at Dalhousie University, "relatively little is known about the 'clinical significance' of this co-morbidity. For example, does having a co-morbid anxiety disorder influence a person's response to alcoholism treatment? More specifically, do those with a co-occurring anxiety disorder at the outset of alcoholism treatment fare worse in terms of increased risk for relapse to problematic alcohol use over time?"

Kushner and his colleagues examined the diagnostic status and daily drinking patterns of 82 (53 males, 29 females) individuals one week after they entered treatment for alcoholism, and again 120 days later (n=53).

Results indicate that screening for co-existing anxiety disorders in an alcoholism-treatment setting is clearly warranted.

"The key finding from our study is that having an anxiety disorder when starting treatment for alcohol dependence marks individuals at a significantly greater risk for relapse to drinking within four months," said Kushner. "This finding suggests that clinicians ought to provide additional resources for these patients during this 'high risk' period."

"Another very interesting finding was that different anxiety disorders predicted different aspects of alcohol relapse at alcoholism-treatment follow-up," said Stewart. "Having 'social phobia' - significant social fears and avoidance of social situations - at the outset of alcoholism treatment was the best predictor of a return to any drinking at treatment follow-up. Having 'panic disorder' - persistent 'panic attacks' or episodes of intense anxiety and arousal - at the outset of alcoholism treatment was the best predictor of a relapse to dependence at treatment follow-up. This pattern suggests that panic disorder is a risk factor for a major relapse, and social phobia a risk factor for a minor relapse, following alcoholism treatment."

"At a practical level," said Kushner, "our study tells clinicians that they should screen for co-occurring anxiety disorders, which is not typically done at this time, and that identifying these disorders, especially social phobia and panic disorder, should serve as a red flag for heightened relapse risk. In the past, many clinicians assumed that co-occurring anxiety problems were simply a product of excessive drinking and would 'take care of themselves' as soon as the drinking stopped. Our study, on the other hand, suggests that the chances that drinking will stop for as little as four months after treatment is severely undermined by the presence of an active anxiety disorder."

Stewart added that Kushner's findings also suggest that traditional alcoholism treatment is not particularly effective for those with co-occurring anxiety disorders. "It appears that we must develop new treatments, or modify existing treatments, to better serve those with co-occurring anxiety and alcohol use disorders," she said. "For example, integrated treatments that simultaneously address the anxiety symptoms, the problem drinking, and their inter-relations - that is, how the individual is using alcohol to self-medicate for their anxiety - might prove particularly effective for this type of patient. However," she added, "we cannot simply assume that such integrated treatments would be superior to existing alcoholism treatments in improving alcohol outcomes in co-morbid patients. This assumption would need to be tested rigorously."

Kushner agreed. "While seeming very logical based on our findings," he said, "this conclusion is not directly demonstrated by our study. That is, while we show that anxiety disorders mark a heightened risk for relapse to drinking following alcoholism treatment, it does not necessarily follow that treating the anxiety disorder would partially or wholly eliminate that risk."

Both Kushner and Stewart noted that the debate continues as to whether anxiety disorders in alcoholics are "independent disorders" or a consequence of their alcohol abuse/dependence, or for that matter, which comes first.

"The 'self-medication' hypothesis," said Kushner, "holds that alcohol is used deliberately as a means of managing anxiety symptoms. From this perspective, anxiety tends to cause alcohol problems to develop. However, things may be more complicated than this. For example, nearly one-third of our study subjects with both anxiety and alcohol disorder reported that the alcohol problems began first. Perhaps alcohol dependence and withdrawal can, themselves, either imitate or cause anxiety disorders via the neuro-chemical and environmental disruptions associated with alcohol addiction. Once this process occurs, an individual could begin to use alcohol to self-medicate the very anxiety symptoms that were caused by pathological drinking in the first place. This creates a vicious cycle, in which more drinking leads to greater anxiety, which, in turn, leads to more drinking. Once this vicious cycle is firmly in place, which disorder is operating as the cause' and which as the 'effect' becomes murky."

Dalhousie University