The results of a Cochrane review, which explored the efficacy of pharmacotherapy as a treatment for anxiety in the presence of comorbid alcohol disorders
Citation: Phillips P (2016) Pharmacotherapy: anxiety and comorbid alcohol use. Nursing Times; 112: 11, 24.
Author: Patrick Phillips is research associate, School of Health and Related Research, the University of Sheffield, and is a member of the Cochrane Nursing Care Field.
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Anxiety is a common and debilitating condition; furthermore, people with diagnoses such as generalised anxiety disorder (GAD), post-traumatic stress disorder and social anxiety disorder (SAD) have an elevated risk of developing comorbid alcohol use problems.
Comorbid anxiety and alcohol use disorders are associated with worsened symptoms, high rates of relapse and increased use of mental health services. Techniques such as cognitive behavioural therapy are the first-line treatment but there is little evidence of the effectiveness of these approaches, leading to suggestions that pharmacotherapy should be considered as an alternative or complementary treatment.
This Cochrane review (Ipser et al, 2015) assessed the effects of pharmacotherapy for treating anxiety in people with comorbid alcohol-use disorders.
It aimed to estimate the overall effects of medication in improving treatment response and reducing symptom severity, and to establish whether certain medications are more or less effective and tolerable than others.
Comprehensive electronic database searches were conducted to January 2014; additionally, reference list searches were conducted and correspondence with key researchers was used to identify published and unpublished trials.
Participants were people diagnosed with alcohol dependence or misuse, as well as an anxiety disorder. Interventions included drugs administered to treat the anxiety disorder and primary outcome measures were:
- Treatment response measured by the clinician using the clinical global impressions (CGI) scale;
- Reduction of symptom severity measured using a validated tool;
- Acceptability of medication (measured by withdrawal from the study).
The included studies were small and of generally low quality.
Five studies (n=290) were included in the review; all participants had a diagnosed alcohol disorder and anxiety.
Two studies (n=57) assessed treatment response using the CGI scale, both were comparisons of paroxetine versus placebo in patients with SAD.
A meta-analysis suggested twice as many patients responded to treatment with paroxetine than placebo.
All the included studies assessed reduction in symptom severity by using a variety of validated measures; no evidence of a statistically significant effect of paroxetine versus placebo, sertraline versus placebo or paroxetine versus desipramine was found. A single-study comparison of busiprone versus placebo found evidence of a statistically significant treatment effect.
There was no evidence of increased dropout rates as a result of adverse events in treatment arms of any of the studies. This suggested the acceptability of pharmacotherapy as an intervention in this patient group
Insufficient evidence is available to reach firm conclusions on the effectiveness of pharmacotherapy as a treatment for anxiety in the presence of comorbid alcohol disorders. There is a small amount of evidence that patients with SAD respond to treatment with paroxetine and limited evidence of a reduction in anxiety levels in patients with GAD treated with busiprone. Additionally, there is evidence that treatment medications were well tolerated.
However, all of the available evidence is from small studies which the review’s authors grade as of very low overall quality. This suggests that large, rigorously conducted, multi-centre randomised controlled trials are needed to help establish an evidence base for the tolerability and efficacy of pharmacotherapy, with a particular focus on identifying specific patient groups that might benefit from treatment.
Implications for practice
The lack of available evidence means that any recommendations for practice are tentative; medication remains one potential approach to the treatment of anxiety in the presence of comorbid alcohol use. The review authors suggest that treatment for anxiety may be facilitated by combined interventions that target alcohol use alongside anxiety. The implications for nurses involved in the care of patients with either anxiety or alcohol-use disorders is that a comprehensive assessment is indicated before and during treatment, paying attention to the possible presence, and likely effects on treatment, of comorbid anxiety or alcohol use.
Ipser JC et al (2015) Pharmacotherapy for anxiety and comorbid alcohol use disorders. Cochrane Database of Systematic Reviews, Issue 1. Art. No.: CD007505. DOI: 10.1002/14651858.CD007505.pub2