|Year : 2017 | Volume
| Issue : 1 | Page : 50-59
Co-occurring depression and alcohol-use disorders in South-East Asia: A narrative review
Yatan Pal Singh Balhara1, Prashant Gupta1, Deeksha Elwadhi2
1 National Drug Dependence Treatment Centre and Department of Psychiatry, All Institute of Medical Sciences, New Delhi, India
2 Hamdard Institute of Medical Sciences and Research, New Delhi, India
|Date of Web Publication||12-May-2017|
Yatan Pal Singh Balhara
National Drug Dependence Treatment Centre and Department of Psychiatry, All India Institute of Medical Sciences, New Delhi
Depression and alcohol-use disorders frequently co-occur and the presence of one augments the adverse consequences of the other. This article reviews and synthesizes the available literature on depression and alcohol-use disorders from the World Health Organization (WHO) South-East Asia Region, with respect to epidemiology, screening instruments, interventions and services, and policy. In common with other low- and middle-income settings, data from this region on co-occurring depression and alcohol-use disorders are scarce. The wide variations in language and cultural diversity within the countries of this region further make the identification and management of people with co-occurring depression and alcohol-use disorders a major challenge. A range of interventions for individuals with the two disorders have been studied. However, most of this work has been done in high-income countries, highlighting the need to explore the effectiveness and cost effectiveness of various pharmacological and non-pharmacological interventions in the WHO South-East Asia Region. Much of this region comprises low-resource settings, with a dearth of trained personnel and resources. Flexible transdiagnostic approaches, delivered by community health workers and integrated into primary health care may be a pragmatic approach. Such services should form part of strengthened national responses to alcohol-related public health problems across the region.
Keywords: alcohol, alcohol-use disorders, co-occurring disorders, depression, dual disorders, South-East Asia
|How to cite this article:|
Balhara YP, Gupta P, Elwadhi D. Co-occurring depression and alcohol-use disorders in South-East Asia: A narrative review. WHO South-East Asia J Public Health 2017;6:50-9
|How to cite this URL:|
Balhara YP, Gupta P, Elwadhi D. Co-occurring depression and alcohol-use disorders in South-East Asia: A narrative review. WHO South-East Asia J Public Health [serial online] 2017 [cited 2021 Apr 22];6:50-9. Available from: http://www.who-seajph.org/text.asp?2017/6/1/50/206166
| Background|| |
According to the Global Burden of Disease study 2015, the contribution of mental and substance-use disorders to global disability is enormous - 18.4% of the total years lived with disability (YLDs). Depressive disorders were the third-leading cause of disability in 2015, contributing about 6.86% of total YLDs, while alcohol-use disorders were ranked 28th, contributing a mean of 0.8% to the all-cause YLDs. Clinical experience, as well as published literature, indicates frequent co-occurrence of depression and alcohol-use disorders. The presence of either of the disorders is associated with a doubling of the risk of the other one. The lifetime prevalence of alcohol-use disorders in people with major depressive disorders has been reported to be as high 40%. Among people with alcohol-use disorders, the prevalence of depression has been reported to be as high as 35%. A meta-analysis of such studies reported a pooled comorbidity odds ratio of 2.42 (95% confidence interval [CI]: 2.22–2.64) for major depression and alcohol-use disorders. The two disorders are also thought to share a causal association, as the frequency of their co-occurrence is higher than might be expected by chance.,, Co-occurrence of these two disorders is also known to augment the adverse consequences of each individual disorder; for example, depression predicts poor treatment response and higher rates of relapse in alcohol-use disorders, while alcohol-use disorders are associated with higher rates of suicide among patients with depression.,
There is a high prevalence of both depression and alcohol-use disorders in low- and middle-income countries. Both cause significant distress to individuals and their families., There is a need to develop effective and comprehensive management options that target both depression and alcohol-use disorders and are well integrated within the health-care infrastructure of these countries. This article reviews the available evidence on co-occurring depression and alcohol-use disorders from the World Health Organization (WHO) South-East Asia Region.
| Methodology|| |
This narrative review focuses on the literature available from the Member States of the WHO South-East Asia Region. Three search engines were used for the review: PubMed, WHO online repository and Google Scholar. A PubMed search was conducted with the search terms “alcohol AND depression AND (SEAR OR south east Asia OR south Asia OR India OR Bangladesh OR Nepal OR Bhutan OR Myanmar OR Thailand OR Sri Lanka OR Maldives OR Indonesia OR Timor-Leste OR Korea)”, for relevant studies on epidemiology and screening and management strategies for co-occurring alcohol-use disorders and depression. Searches on the WHO online repository and Google Scholar were conducted to identify the relevant WHO publications or data provided by governments of countries of the South-East Asia Region. The keywords used were: “alcohol”, “depression”, “WHO”, “World Health Organization”, “SEAR”, “south east Asia”, “south Asia”, “Bangladesh”, “Bhutan”, “India”, “Indonesia”, “Korea”, “Maldives”, “Myanmar”, “Nepal”, “Sri Lanka”, “Thailand”, “Timor-Leste”, in various combinations. Back references from articles were accessed wherever deemed necessary. Studies on alcohol policy were searched through Google Scholar. The search terms used were: “alcohol”, “policy”, “legislation”, “SEAR”, “south east Asia”, “south Asia”, “Bangladesh”, “Bhutan”, “India”, “Indonesia”, “Korea”, “Maldives”, “Myanmar”, “Nepal”, “Sri Lanka”, “Thailand”, “Timor-Leste”, in various combinations. All relevant search results of iterations with the term “Korea” were individually sorted by the authors to include literature only from the Democratic People’s Republic of Korea, which is a Member State of the WHO South-East Asia Region. The abstracts and documents were examined by two authors (PG and DE) and all relevant resource material was selected. The review includes studies up to and including October 2016.
| Results|| |
While the highest levels of alcohol consumption per capita are found in high-income countries, the WHO South-East Asia Region has recorded one of the lowest levels of consumption (in 2010 - India: 2.5–4.9 L per capita; Bangladesh, Bhutan, Myanmar, Nepal: <2.5 L per capita). However, the disease burden per litre of alcohol consumed in low- and middle-income countries, such as all the Member States of the South-East Asia Region, is more than in high-income countries. Moreover, an increase in the alcohol consumption per capita has been noted from 2003–2005 to 2008–2010 in India (3.6 L to 4.3 L) and Sri Lanka (2.2 L to 3.7 L), the two countries that are home to the majority of the population of this region, and estimates project a further increase by 2025.
There is a dearth of epidemiological studies on co-occurring depression and alcohol-use disorders from the WHO South-East Asia Region (see [Table 1]).,,,,,,,,,,,,,,,,,,,,, This section compiles the studies available from countries of the region that have measured rates of depression and alcohol-use disorders in the same population, or looked at rates of co-occurrence among these two disorders, or looked into the association of one disorder with the other.
|Table 1: Epidemiological studies reporting the rates and associations of alcohol use and depression from the World Health Organization South-East Asia Region|
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Studies among a general adult population
The National Mental Health Survey of India, conducted in the general population in 12 Indian states (n = 34 802), reported the prevalence of depressive disorders as 2.7% and that of alcohol-use disorders (by use of the Mini International Neuropsychiatric Interview [MINI]) as 4.6%. Findings from the Thai National Mental Health Survey (n = 17 140) reported the prevalence of alcohol-use disorders (MINI) and major depression as 11.7% and 2.2% respectively. In the same survey, individuals with alcohol-use disorders were found to have significantly increased risk of depression. Another general-population-based survey from India (n = 3033) reported the prevalence of alcohol dependence (MINI) as 3.95% and depressive disorders as 14.82%. Jonas et al. (2014), in a community-based survey in India, found the rate of alcohol dependence (by use of the Alcohol Use Disorders Identification Test [AUDIT]) was 4.63%, and that of mild-to-moderate and major depression (by use of the Center for Epidemiologic Studies Depression Scale [CES-D]) was 39.6% and 13%, respectively.
Two general-population-based studies from India using AUDIT, from Chennai (n = 1053) and Madhya Pradesh (n = 3220), found an increased risk of depression among men who had alcohol-use disorders. The prevalence rates of alcohol-use disorders (hazardous drinking, harmful drinking, dependent drinking) differed between the studies, as did the cut-off scores for AUDIT.,
Studies among populations with alcohol-use disorders
In studies among populations of individuals with alcohol-use disorders, a high prevalence of depression was found among inpatient clients in de-addiction centres,,, attendees of Alcoholics Anonymous, female sex workers, army personnel with alcohol dependence, and other populations with alcohol-use disorders., These studies were conducted in India and Nepal, as well as in populations of Indian and African ancestry living in Trinidad and Tobago. Depressive disorders were commonly diagnosed co-occurring disorders among individuals with alcohol-use disorders seeking treatment from the national de-addiction centre in India.
Studies among populations at high risk of alcohol-use disorders and depression
One study conducted among men who have sex with men and transgender women reported a high prevalence of co-occurring depression and frequent alcohol use. Another study among female sex workers from India found a high likelihood of having depression among those who had consumed alcohol in the last 30 days. One study among 129 Indian IT professionals reported that subjects who were professionally stressed or were at risk of developing depression had a higher prevalence of harmful alcohol use. Another study in Thailand, among methamphetamine users or their sexual partners, found alcohol-use disorders were associated with high levels of depression in men. Moreover, in studies on people from Thailand or India, respectively, who attempted (n = 110) or died by suicide (n = 100), high rates of alcohol-use disorders were found, though only one of these studies commented upon the prevalence of depression among the subjects.
A secondary analysis of the Global School-Based Student Health Survey indicated that, among 13–15 year olds in Indonesia, Myanmar and Thailand, 2.5%, 3.0% and 23.9%, respectively, had experienced at least one episode of drunkenness in their lifetime. Also, 23.3%, 16.5% and 16.7% of students in Indonesia, Myanmar and Thailand, respectively, had experienced an episode of depression in the past 12 months.
Overall, only a few epidemiological studies have assessed the co-occurrence of depression and alcohol-use disorders in the WHO South-East Asia Region. Some of these have been compiled in previously published narrative reviews. Some suggest that there is an increased risk of depression among persons with alcohol-use disorders, the extent of which remains unclear. Also, none of the studies in the present review commented upon alcohol-use disorders in individuals with depression. A variety of measures for depression and alcohol-use disorders have been used in the studies; for example, harmful alcohol use has been variously measured as alcohol dependence, harmful or hazardous alcohol use, alcohol abuse, frequent alcohol use, or at least one episode of drunkenness in the lifetime. Even the same construct of dependence has been measured differently when using criteria from standard tools such as AUDIT, MINI and the International Statistical Classification of Diseases and Related Health Problems (ICD-10). Even for the same scale, different cut-off values have been used by different authors. Because of this, it is difficult to draw any conclusions based on the limited available literature, and the need for use of well-validated and standardized measuring instruments cannot be overstated.
Screening instruments for depression and alcohol-use disorders
A wide gap is apparent between mental health needs and service delivery in low- and middle-income countries. A considerable proportion of this can be attributed to the low rates of detection of mental disorders in these countries. Screening instruments that allow rapid assessment of a large number of subjects, with adequate sensitivity and specificity, and that could be administered by lay community health workers with some training, may help in bridging this gap.
A study from India assessed the applicability of five such screening instruments (the Patient Health Questionnaire [PHQ-9], the General Health Questionnaire [GHQ], the Self-Regulation Questionnaire [SRQ], and the Kessler Psychological Distress Scales [K10 and K6] for common mental disorders, including depression in primary care settings (n = 598). All five instruments showed moderate to high discrimination ability, moderate to high degrees of correlation with one another and good internal consistency, with the GHQ and SRQ showing the best results. The GHQ, SRQ and K6 have also been found to be useful in other low- and middle-income countries. A systematic review of studies from primary health-care settings in low- and middle-income countries (including four studies from India) found that brief screening instruments for depression (K6, K10, the Beck Depression Inventory-Short Form [BDI-SF], PHQ-9, the Edinburgh Postnatal Depression Scale [EPDS], the Clinical Interview Schedule-Revised [CIS-R], GHQ-12) are as accurate as the longer ones (CES-D, BDI, the Hopkins Symptom Checklist [HSCL-25]). A Thai version of the PHQ-9 has also been validated. The CES-D has been validated in older populations from the Democratic People’s Republic of Korea, Indonesia, Myanmar, Sri Lanka and Thailand.
Commonly used alcohol screening questionnaires,
AUDIT,,, and WHO-ASSIST (Alcohol, Smoking and Substance Involvement Screening Test), have been validated in some of the countries of the WHO South-East Asia Region. AUDIT is currently being adapted and translated into Hindi language in India. The CAGE questionnaire is another commonly used alcohol screening instrument that has been validated in high-income countries, while among countries of the WHO South-East Asia Region, the current review found just one study that validated the modified version of CAGE to include other drug use (CAGE-AID) in an Indian population, and another study in a Thai population that found high agreement between written and oral versions of the CAGE questionnaire.
The WHO mhGAP [mental health gap] intervention guide for mental, neurological and substance use disorders in non-specialized health settings provides a comprehensive tool for assessment, identification and management of mental health conditions, which can be administered by non-specialists. It includes flowchart-based modules for nine mental health conditions, including depression and alcohol-use disorders, and is meant for use in primary health-care settings for better integration of mental health with physical health conditions. Such primary care instruments are likely to be useful in low-and middle-income countries, including countries in the WHO South-East Asia Region. However, the modules do not address co-occurring depression and alcohol-use disorders specifically.
Interventions and services for alcohol-use disorders co-occurring with depression
A host of interventions have been studied among individuals with co-occurring depression and alcohol-use disorders. However, the majority of literature available on this topic is from high-income countries, with little evidence from the WHO South-East Asia Region.
Antidepressants: Meta-analyses have shown improved depression as well as alcohol outcomes with tricyclic antidepressants (imipramine, desipramine) and nefazodone., However, in the same studies, selective serotonin reuptake inhibitors (sertraline, fluoxetine, citalopram) were not found to be effective. None of the studies included in these meta-analyses was from the WHO South-East Asia Region. The guidelines on management of co-occurring depression and alcohol-use disorders from this region are also based primarily on evidence generated from the other regions.
No studies for antidepressant use in alcohol-use disorders were found from the WHO South-East Asia Region. Considering the cost-benefit ratio, some studies suggest that sertraline might be the best choice for moderate-to-severe depression, with a best balance between efficacy, acceptability and lower cost, which is quite important for low- and middle-income countries from this region. However, the WHO model list of essential medicines includes only fluoxetine and amitriptyline among the antidepressants, restricting the choice for antidepressant drugs of proven efficacy.
Anti-craving agents: Acamprosate and naltrexone are commonly used anti-craving agents, with proven efficacy for patients with alcohol-use disorders., However, their role in alcohol-use disorders co-occurring with depressive disorders is relatively less studied. A meta-analysis showed that acamprosate improved alcohol-use outcomes, but did not report the primary depression outcomes. Naltrexone has shown mixed findings in clinical trials in a population with co-occurring depression and alcohol-use disorders, with respect to both depression and alcohol outcomes.
No such studies from the South-East Asia Region were found. Acamprosate and naltrexone are not featured in the WHO model list of essential medicines, but they have been recommended by the mhGAP intervention guide.
Disulfiram: Disulfiram is an evidence-based deterrent therapy used in the management of alcohol-use disorders. The present review did not find any studies addressing its efficacy in patients with co-occurring depression. One randomized trial from India found significantly better alcohol outcomes in patients with alcohol dependence who received disulfiram after detoxification, compared to those receiving naltrexone (depression evaluation and outcomes not reported). Disulfram is not endorsed by the WHO model list of essential medicines, but has been recommended by the mhGAP intervention guide.
Brief intervention: A systematic review of psychological interventions in patients with alcohol misuse co-occurring with depression and anxiety showed that brief interventions improve both alcohol and depression outcomes, though longer interventions (cognitive behavioural therapy [CBT], motivational interviewing [MI], interpersonal therapy [IPT]) produced better results. A single randomized controlled trial was found from the WHO South-East Asia Region (India), which evaluated the efficacy of brief intervention for alcohol-use disorders in a community-based sample, with promising results, though the participants were not evaluated for depression. The mhGAP intervention guide has included brief interventions among the list of interventions for preventing harmful alcohol use.
Cognitive behavioural therapy: Various forms of CBT have been used in alcohol-use disorders and depression, including CBT (for depression), CBT + MI (integrated for alcohol-use disorders and depression), and group CBT, and have shown positive effects on both kinds of outcomes. CBT for depression alone has been shown to improve alcohol outcomes in patients with comorbidities., Integrated CBT, which includes interventions focused on both alcohol-use disorders and depression (usually CBT and MI), has also shown significant improvements in both measures,, which in some studies has been shown to be better than single-focused strategies.,
One such study from Thailand assessed the efficacy of a brief six-session course of CBT for depression among patients with co-occurring alcohol dependence and depression, and found significantly more improvement in depression scores in the CBT group than the group receiving treatment as usual. Studies on integrated CBT + MI were not available from the WHO South-East Asia Region.
Interpersonal therapy: IPT has shown improvements in both disorders in patients with co-occurring depressive disorders and alcohol-use disorders., However, there was no literature from the WHO South-East Asia Region regarding IPT.
Self-help groups: Higher attendance at Alcoholics Anonymous has been associated with better outcomes with respect to both alcohol-use disorders and depression among patients with co-occurring alcohol-use disorders and depression. There was no literature from the WHO South-East Asia Region regarding self-help groups. Self-help groups have been included in the recommendations of the mhGap intervention guide.
Transdiagnostic approach: Transdiagnostic interventions involve a set of common practice elements that can be delivered in varying combinations to address a range of problems. This approach allows for flexibility and adaptation, and treatment may be employed without specifying a disorder classification. Such an approach has been developed for low- and middle-income countries for delivery of community-based mental health treatments through lay counsellors. A randomized controlled trial for this approach (common elements treatment approach) among refugees from Myanmar (survivors of imprisonment, torture or related trauma) in Thailand showed significant improvements in depression, anxiety and post-traumatic stress scores in participants receiving the intervention, compared with waiting-list controls, though the effects for alcohol-use disorders were negligible.
Low- and middle-income countries in general have a shortfall of mental health specialists. Moreover, most of the qualified professionals in these countries are concentrated in the larger cities. Efforts towards inclusion of the vast majority of the rural population in the provision of treatment rest mostly with the primary health-care team. Thus, the efforts directed toward scaling-up the treatment services need to focus on ensuring the availability of facilities close to all communities. For this, lay community health workers may be trained to deliver health services through “task-shifting” or “task-sharing”. Task-shifting refers to delegating tasks to existing or new cadres with either less training or training that is narrowly tailored for the required services.
The MANAS trial in India aimed to test the effectiveness of an intervention led by lay community health counsellors in primary care settings, to improve the outcomes of people with anxiety and depression. Overall, the trial found a beneficial effect of the intervention on recovery at 6 months. In a recent review focusing on the effectiveness of using lay community health workers in strategies for prevention of mental disorders in low- and middle-income countries, 15 studies were included, with four from South-East Asia (India,,, Bangladesh). This review provided evidence on the effectiveness of prevention interventions led by lay community health workers, although none of these addressed alcohol-use disorders. Lay community health workers have been reported to be cost effective and easily available, to have more understanding of the cultural contexts of their particular region, and to be able to take up several roles. This warrants a greater role of lay community health workers in the treatment strategies for the countries in the WHO South-East Asia Region. However, it is important to ensure that these workers do not become overburdened, as they already have an enormous workload. Adding more numbers to the existing cadre of these workers would help to address such concerns.
A stepped-care model has been studied in high-income countries and has shown modest efficacy in various mental disorders, although its use for people with co-occurring alcohol-use disorders and depression has not been studied. This model has been proposed for use in low- and middle-income countries. Each step represents an increased complexity of intervention, with a collaborative approach involving three key team members: lay health counsellor, primary care physician, and visiting psychiatrist (clinical specialist), with each playing their own designated role., When such approaches are integrated into the existing framework for other diseases such as HIV, tuberculosis etc., they are likely to lead to better integration of mental health care in primary care, thereby overcoming the stigma surrounding mental disorders and utilizing the existing infrastructure.
Alcohol policy: Indian and international perspective
Alcohol policy refers to the set of measures in a jurisdiction or society aimed at minimizing the health and social harms from alcohol consumption. Nine (Bhutan, Democratic People’s Republic of Korea, India, Indonesia, Maldives, Nepal, Sri Lanka, Timor-Leste) of the 11 countries in the WHO South-East Asia Region do not have any written national alcohol policies. The Global strategy to reduce harmful use of alcohol, proposed by WHO, has recommended five areas of action. These include leadership, awareness and commitment; drink-driving countermeasures; regulating availability; marketing restrictions; and reducing the negative consequences of drinking.
A substantial body of knowledge has accumulated on the feasibility, effectiveness and cost effectiveness of different policy options. Research findings indicate that population-based policy options, such as the use of taxation to regulate the demand for alcoholic beverages; restricting their availability and implementing bans on alcohol advertising; measures against drunk-driving, such as setting low limits (0.02% to 0.05%) for blood alcohol concentration and enforcing them by random breath testing, are effective in reducing alcohol consumption and alcohol-related harms., Harmful use of alcohol can also be reduced by screening for hazardous and harmful drinking, and providing brief interventions, counselling and pharmacotherapy, as appropriate., Most of this evidence comes from high-income countries, with very little evidence from low- and middle-income countries (including the WHO South-East Asia Region). One study from India found liquor taxation had favourable effects on consumption patterns, and the authors recommended keeping consumption of liquor legal (instead of prohibition) and that the pattern of taxation and pricing should be redesigned such that embedded seller incentives to promote sales volume are removed. Increasing the costs of liquor by 80–90% through excise taxes was projected to be a viable option to reduce alcohol consumption among rural youth in India. However, a potential confounder is the easy availability of home-brewed alcohol in India, which remains unaffected by taxation. Some policy-makers in the region have favoured prohibition or a blanket ban on alcohol products, such as in Maldives and certain states of India (e.g. Gujarat). Experience from other countries, including the United States of America, seems to offer limited support for prohibition. In India, Andhra Pradesh and Haryana repealed their alcohol prohibition laws in the 1990s, while Gujarat continues to have complete prohibition, in place since 1949, and the state of Bihar has adopted prohibition on alcohol in the recent past. The impact of the prohibition on alcohol across different states in India has not been studied systematically. One study from India estimated that the expected reduction in participation in alcohol consumption resulting from prohibition will at most be about 40% of what could be achieved with imposition of a minimum age limit for alcohol purchase of 21 years. Another study found that prohibition reduced the consumption of arrack (an indigenous distilled alcoholic drink), Indian-made foreign liquor (non-indigenous distilled liquor) and beer in the urban sector in India, but the effects on the rural sector were much lower. Moreover, it had no effect on the consumption of home-brewed alcohol. Also, spill-over effects of prohibition led to increased consumption of other substances like bidi and cigarettes. Mahal (2000) also reported that benefits are likely to be seen by increasing the minimum age for purchase of alcohol in states where it is 18 years, but there are hardly any gains from increasing the minimum age for purchase of alcohol beyond 21 years; this author therefore recommended setting the minimum age at 21 years rather than 25 years, which is the legal lower limit in certain regions of India.
All the aforementioned studies are limited by a host of methodological issues like small sample sizes, unaccounted confounders, lack of generalizability, etc. Moreover, it has been seen that similar policies might not ensure similar rates of alcohol consumption across different countries, as shown in a secondary data analysis of the Global School-Based Student Health Survey from 12 low- and middle-income countries, which noted that countries with similar legislation had strikingly different rates of alcohol use among adolescents. This was attributed to differential enforcement of laws, together with regional, religious and cultural considerations. Evaluation of policy outcomes is complex, and data on policy from India and other countries of the WHO South-East Asia Region are too scarce to be able to generate any credible conclusions about effective measures in a particular sociocultural environment.
To override this problem, WHO is actively involved in strengthening national responses to alcohol-related public health problems. The Global strategy to reduce harmful use of alcohol, an initiative by WHO, currently has involvement from 126 Member States, including some from the South-East Asia Region. WHO co-hosted a Global Alcohol Policy Conference, “From the Global alcohol strategy to national and local action”, held in Thailand in February 2012, which provided a global platform for information exchange, sharing experiences, building partnerships to raise awareness of public health problems attributable to alcohol, and advocating for implementation of the global strategy at all levels. WHO has also developed the Global Information System on Alcohol and Health (GISAH), a comprehensive internet-based information platform, to make up for the lack of monitoring systems for alcohol-related indicators in most low- and middle-income countries (including the WHO South-East Asia Region). The data generated from this platform are likely to guide policy-makers in designing effective alcohol-related policies and their proper implementation.
| Discussion|| |
The contribution of mental disorders and substance-use disorders to global disability is enormous. Frequent co-occurrence of depression and alcohol-use disorders is more than could be expected as a chance association. This co-occurrence is detrimental to the outcome for each disorder, with increased morbidity and disease burden, poor treatment response, high rates of relapse and higher suicide rates.
Epidemiological studies from the WHO South-East Asia Region focusing on co-occurring depression and alcohol-use disorders are few in number. Most of these are from India, followed by Thailand, Nepal, Myanmar and Indonesia. These studies do suggest that both depression and alcohol-use disorders each increase the risk of the other. However, there is limited evidence to comment on the extent or pattern of this association. Variations in the assessment instruments, cut-off points and diagnostic criteria applied also make it difficult to reach firm conclusions and make comparisons across the different studies. There is a need to generate meaningful data on the co-occurrence of depression and alcohol-use disorders from the Member States of the WHO South-East Asia Region.
Screening instruments are a promising tool to aid in the detection of mental disorders and alcohol-use disorders by lay community health workers in resource-poor settings like the nations of the WHO South-East Asia Region. However, lack of availability of these instruments in local language, along with wide regional variations in language and cultural factors, serve as an important barrier to effective screening and detection of this co-occurrence. Translation, adaptation and validation of the commonly used screening instruments in the local languages in the countries of this region can be a major impetus in the early detection and referral of such patients.This review did not find any studies from Member States of the WHO South-East Asia Region addressing the effectiveness of pharmacological interventions available for depression and alcohol-use disorders. The WHO model list of essential medicines does not include the anti-craving and deterrent agents that are used as the first line of pharmacological intervention worldwide. This could be detrimental to the availability of these medicines in the WHO South-East Asia Region.
There is limited evidence from Member States of the WHO South-East Asia Region on non-pharmacological interventions for co-occurring depression and alcohol-use disorders, with only one study assessing brief intervention and another evaluating CBT.
The current review has certain limitations. It has not followed the rigour of a full systematic review and some relevant published studies might have been missed, as the search was limited to three electronic database, i.e. PubMed, WHO online repository and Google Scholar. Also, only English-language publications were included in the review.
Most of the countries of the WHO South-East Asia Region are low-resource settings with significant burden due to depression and alcohol-use disorders. There is a need to explore the effectiveness and cost effectiveness of various pharmacological and non-pharmacological interventions across the region. Also, the interventions for co-occurring depression and alcohol-use disorders need to be integrated into the existing health-care system at various levels of care. Finally, the countries in the region should formulate evidence-supported policy and a legislative framework to address alcohol-use disorders.
Source of support: Nil.
Conflict of interest: None declared.
Authorship: YPSB was involved in conceptualization, preparing the outline, reviewing the initial draft, editing and approval of final draft. PG and DE were involved in the literature search, literature review, preparation of the first draft and approval of the final draft.
| References|| |
GBD 2015 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388:1545–602. doi:10.1016/S0140–6736(16)31678–6.
Boden JM, Fergusson DM. Alcohol and depression. Addiction. 2011;106(5):906–14. doi:10.1111/j.1360–0443.2010.03351.x.
Lai HM, Cleary M, Sitharthan T, Hunt GE. Prevalence of comorbid substance use, anxiety and mood disorders in epidemiological surveys, 1990–2014: a systematic review and meta-analysis. Drug Alcohol Depend. 2015;154:1–13. doi:10.1016/j. drugalcdep.2015.05.031.
Lyons MJ, Schultz M, Neale M, Brady K, Eisen S, Toomey R et al. Specificity of familial vulnerability for alcoholism versus major depression in men. J Nerv Ment Dis. 2006;194(11):809–17. doi:10.1097/01.nmd.0000244480.78431.49.
Kuo PH, Gardner CO, Kendler KS, Prescott CA. The temporal relationship of the onsets of alcohol dependence and major depression: using a genetically informative study design. Psychol Med. 2006;36(8):1153–62. doi:10.1017/S0033291706007860.
Fergusson DM, Boden JM, Horwood LJ. Tests of causal links between alcohol abuse or dependence and major depression. Arch Gen Psychiatry. 2009;66(3):260–6. doi:10.1001/archgenpsychiatry.2008.543.
Hawton K, Casañas I Comabella C, Haw C, Saunders K. Risk factors for suicide in individuals with depression: a systematic review. J Affect Disord. 2013;147(1–3):17–28. doi:10.1016/j.jad.2013.01.004.
Suter M, Strik W, Moggi F. Depressive symptoms as a predictor of alcohol relapse after residential treatment programs for alcohol use disorder. J Subst Abuse Treat. 2011;41(3):225–32. doi:10.1016/j. jsat.2011.03.005.
de Silva V, Samarasinghe D, Hanwella R. Association between concurrent alcohol and tobacco use and poverty. Drug Alcohol Rev. 2011;30(1):69–73. doi:10.1111/j.1465–3362.2010.00202.x.
Suttajit S, Kittirattanapaiboon P, Junsirimongkol B, Likhitsathian S, Srisurapanont M. Risks of major depressive disorder and anxiety disorders among Thais with alcohol use disorders and illicit drug use: findings from the 2008 Thai National Mental Health survey. Addict Behav. 2012;37(12):1395–9. doi:10.1016/j.addbeh.2012.06.014.
Sathyanarayana Rao TS, Darshan MS, Tandon A, Raman R, Karthik KN, Saraswathi N et al. Suttur study: an epidemiological study of psychiatric disorders in south Indian rural population. Indian J Psychiatry. 2014;56(3):238–45. doi:10.4103/0019–5545.140618.
Jonas JB, Nangia V, Rietschel M, Paul T, B ehere P, Panda-Jonas S. Prevalence of depression, suicidal ideation, alcohol intake and nicotine consumption in rural Central India. The Central India Eye and Medical Study. PloS One. 2014;19;9(11):e113550. doi:10.1371/journal.pone.0113550.
Gupta A, Priya B, Williams J, Sharma M, Gupta R, Jha DK et al. Intra-household evaluations of alcohol abuse in men with depression and suicide in women: a cross-sectional community-based study in Chennai, India. BMC Public Health. 2015;15:636. doi:10.1186/s12889–015-1864–5.
Rathod SD, Nadkarni A, Bhana A, Shidhaye R. Epidemiological features of alcohol use in rural India: a population-based cross-sectional study. BMJ Open. 2015;5(12):e009802. doi:10.1136/bmjopen-2015–009802.
Sau M, Mukherjee A, Manna N, Sanyal S. Sociodemographic and substance use correlates of repeated relapse among patients presenting for relapse treatment at an addiction treatment center in Kolkata, India. Afr Health Sci. 2013;13(3):791–9. doi:10.4314/ahs. v13i3.39.
Khalid A, Kunwar AR, Rajbhandari KC, Sharma VD, Regmi SK. A study of prevalence and comorbidity of depression in alcohol dependence. Indian J Psychiatry. 2000;42(4):434–8.
Neupane SP, Bramness JG. Prevalence and correlates of major depression among Nepalese patients in treatment for alcohol-use disorders. Drug Alcohol Rev. 2013;32(2):170–7. doi:10.1111/j.1465–3362.2012.00487.x.
Saxena PP, Mital AK. Predictive value of depression and social support with respect to alcohol abstinence. Indian J Psychol Med. 2011;33(2):115–8. doi:10.4103/0253–7176.92050.
Pandiyan K, Chandrasekhar H, Madhusudhan S. Psychological morbidity among female commercial sex workers with alcohol and drug abuse. Indian J Psychiatry. 2012;54(4):349–51. doi:10.4103/0019–5545.104822.
Raju M, Chaudhury S, Sudarsanan S, Salujha SK, Srivastava K. Trends and issues in relation to alcohol dependence in the armed forces. Med J Armed Forces India. 2002;58(2):143–8. doi:10.1016/S0377–1237(02)80049–1.
Shafe S, Gilder DA, Montane-Jaime LK, Josephs R, Moore S, Crooks H et al. Co-morbidity of alcohol dependence and select affective and anxiety disorders among individuals of East Indian and African ancestry in Trinidad and Tobago. West Indian Med J. 2009;58(2):164–72.
Pradhan SN, Adhikary SR, Sharma SC. A prospective study of comorbidity of alcohol and depression. Kathmandu Univ Med J (KUMJ). 2008;6(23):340–5. doi:10.3126/kumj.v6i3.1709.
Balhara YPS, Sarkar S, Bera SC, Gupta R, Chawla N, Lal R. Who seeks treatment for dual disorders? Observations from a dual disorder clinic at the national drug dependence treatment centre in India over a 12 year period. Int J High Risk Behav Addict. 2016;epub 26 September. doi:10.5812/ijhrba.32501.
Chakrapani V, Newman PA, Shunmugam M, Logie CH, Samuel M. Syndemics of depression, alcohol use, and victimisation, and their association with HIV-related sexual risk among men who have sex with men and transgender women in India. Glob Public Health. 2015;12:1–16. doi:10.1080/17441692.2015.1091024.
Patel SK, Saggurti N, Pachauri S, Prabhakar P. Correlates of mental depression among female sex workers in Southern India. Asia Pac J Public Health. 2015;27(8):809–19. doi:10.1177/1010539515601480.
Darshan MS, Raman R, Rao TS, Ram D, Annigeri B. A study on professional stress, depression and alcohol use among Indian IT professionals. Indian J Psychiatry. 2013;55(1):63–9. doi:10.4103/0019–5545.105512.
Celentano DD, Aramrattana A, Sutcliffe CG, Sirirojn B, Quan VM, Taechareonkul S et al. Associations of substance abuse and sexual risks with self-reported depressive symptoms in young adults in northern Thailand. J Addict Med. 2008;2(2):66–73. doi:10.1097/ADM.0b013e31816c60c1.
Suppapitiporn S. Comorbidity of alcohol dependence in suicidal depressed patients. J Med Assoc Thai. 2005;88 Suppl. 4.:S195–9.
Srivastava A. Psychological attributes and socio-demographic profile of hundred completed suicide victims in the state of Goa, India. Indian J Psychiatry. 2013;55(3):268–72. doi:10.4103/0019–5545.117147.
Balogun O, Koyanagi A, Stickley A, Gilmour S, Shibuya K. Alcohol consumption and psychological distress in adolescents: a multi-country study. J Adolesc Health. 2014;54(2):228–34. doi:10.1016/j. jadohealth.2013.07.034.
Singh S, Balhara YS. A review of Indian research on co-occurring psychiatric disorders and alcohol use disorders. Indian J Psychol Med. 2016; 8:10–19. doi:10.4103/0253–7176.175089.
Patel V, Araya R, Chowdhary N, King M, Kirkwood B, Nayak S et al. Detecting common mental disorders in primary care in India: a comparison of five screening questionnaires. Psychol Med. 2008;38(2):221–8. doi:10.1017/S0033291707002334.
Patel V, Simon G, Chowdhary N, Kaaya S, Araya R. Packages of care for depression in low- and middle-income countries. PloS Med. 2009;6(10):e1000159. doi:10.1371/journal.pmed.1000159.
Akena D, Joska J, Obuku EA, Amos T, Musisi S, Stein DJ. Comparing the accuracy of brief versus long depression screening instruments which have been validated in low and middle income countries: a systematic review. BMC Psychiatry. 2012;12:187. doi:10.1186/1471–244X-12–187.
Lotrakul M, Sumrithe S, Saipanish R. Reliability and validity of the Thai version of the PHQ-9. BMC Psychiatry. 2008;8:46. doi:10.1186/1471–244X-8–46.
Mackinnon A, McCallum J, Andrews G, Anderson I. The Center for Epidemiological Studies Depression Scale in older community samples in Indonesia, North Korea, Myanmar, Sri Lanka, and Thailand. J Gerontol B Psychol Sci Soc Sci. 1998;53(6):P343–52. doi:10.1093/geronb/53B.6.P343.
Pal HR, Jena R, Yadav D. Validation of the Alcohol Use Disorders Identification Test (AUDIT) in urban community outreach and de-addiction center samples in north India. J Stud Alcohol. 2004;65(6):794–800. doi:10.15288/jsa.2004.65.794.
De Silva P, Jayawardana P, Pathmeswaran A. Concurrent validity of the alcohol use disorders identification test (AUDIT). Alcohol Alcohol. 2008;43(1):49–50. doi:10.1093/alcalc/agm061.
Lapham SC, Skipper BJ, Brown P, Chadbunchachai W, Suriyawongpaisal P, Paisarnsilp S. Prevalence of alcohol problems among emergency room patients in Thailand. Addiction. 1998;93(8):1231–9. doi:10.1046/j.1360–0443.1998.938123111.x.
Pradhan B, Chappuis F, Baral D, Karki P, Rijal S, Hadengue A et al. The alcohol use disorders identification test (AUDIT): validation of a Nepali version for the detection of alcohol use disorders and hazardous drinking in medical settings. Subst Abuse Treat Prev Policy. 2012;7:42. doi:10.1186/1747–597X-7–42.
WHO ASSIST Working Group. The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST): development, reliability and feasibility. Addiction. 2002;97(9):1183–94.
Balhara YS, Dayal P. Development of Hindi version of alcohol use disorder identification test (AUDIT): an update. Indian J Psychol Med. 2016;38:85–6. doi:10.4103/0253–7176.175138.
Basu D, Ghosh A, Hazari N, Parakh P. Use of Family CAGE-AID questionnaire to screen the family members for diagnosis of substance dependence. Indian J Med Res. 2016;143(6):722–730. doi:10.4103/0971–5916.191931.
Ratta-Apha W, Sitdhiraksa N, Pariwatcharakul P, Saisavoey N, Limsricharoen K, Thongchot L et al. Under-recognized alcohol-related disorders in psychiatric outpatient unit. J Med Assoc Thai. 2014;97(4):439–46.
Iovieno N, Tedeschini E, Bentley KH, Evins AE, Papakostas GI. Antidepressants for major depressive disorder and dysthymic disorder in patients with comorbid alcohol use disorders: a meta-analysis of placebo-controlled randomized trials. J Clin Psychiatry. 2011;72(8):1144–51. doi:10.4088/JCP.10m06217.
Nunes EV, Levin FR. Treatment of depression in patients with alcohol or other drug dependence: a meta-analysis. JAMA. 2004;291(15):1887–96. doi:10.1001/jama.291.15.1887.
Basu D, Dalal PK, Balhara YPS, editors. Clinical practice guidelines on newer and emerging addictive disorders in India. Haryana: Indian Psychiatric Society; 2016.
de Jesus Mari J, Tófoli LF, Noto C, Li LM, Diehl A, Claudino AM et al. Pharmacological and psychosocial management of mental, neurological and substance use disorders in low- and middle-income countries: issues and current strategies. Drugs. 2013;73(14):1549–68. doi:10.1007/s40265–013-0113–4.
Srisurapanont M, Jarusuraisin N. Naltrexone for the treatment of alcoholism: a meta-analysis of randomized controlled trials. Int J Neuropsychopharmacol. 2005;8(2):267–80. doi:10.1017/S1461145704004997.
Rösner S, Leucht S, Lehert P, Soyka M. Acamprosate supports abstinence, naltrexone prevents excessive drinking: evidence from a meta-analysis with unreported outcomes. J Psychopharmacol. 2008;22(1):11–23. doi:10.1177/0269881107078308.
Lejoyeux M, Lehert P. Alcohol-use disorders and depression: results from individual patient data meta-analysis of the acamprosate-controlled studies. Alcohol Alcohol. 2011;46(1):61–7. doi:10.1093/alcalc/agq077.
Oslin DW. Treatment of late-life depression complicated by alcohol dependence. Am J Geriatr Psychiatry. 2005;13(6):491–500. doi:10.1176/appi.ajgp.13.6.491.
Laaksonen E, Koski-Jännes A, Salaspuro M, Ahtinen H, Alho H. A randomized, multicentre, open-label, comparative trial of disulfiram, naltrexone and acamprosate in the treatment of alcohol dependence. Alcohol Alcohol. 2008;43(1):53–61. doi:10.1093/alcalc/agm136.
De Sousa A, De Sousa A. A one-year pragmatic trial of naltrexone vs disulfiram in the treatment of alcohol dependence. Alcohol Alcohol. 2004;39(6):528–31. doi:10.1093/alcalc/agh104.
Baker AL, Thornton LK, Hiles S, Hides L, Lubman DI. Psychological interventions for alcohol misuse among people with co-occurring depression or anxiety disorders: a systematic review. J Affect Disord. 2012;139(3):217–29. doi:10.1016/j.jad.2011.08.004.
Pal HR, Yadav D, Mehta S, Mohan I. A comparison of brief intervention versus simple advice for alcohol use disorders in a North India community-based sample followed for 3 months. Alcohol Alcohol. 2007;42(4):328–32. doi:10.1093/alcalc/agm009.
Brown RA, Evans DM, Miller IW, Burgess ES, Mueller TI. Cognitive-behavioral treatment for depression in alcoholism. J Consult Clin Psychol. 1997;65(5):715–26.
Kalapatapu RK, Ho J, Cai X, Vinogradov S, Batki SL, Mohr DC.Cognitive-behavioral therapy in depressed primary care patients with co-occurring problematic alcohol use: effect of telephone-administered vs. face-to-face treatment-a secondary analysis. J Psychoactive Drugs. 2014;46(2):85–92. doi:10.1080/02791072.2013 .876521.
Riper H, Andersson G, Hunter SB, de Wit J, Berking M, Cuijpers P. Treatment of comorbid alcohol use disorders and depression with cognitive-behavioural therapy and motivational interviewing: a meta-analysis. Addiction. 2014;109(3):394–406. doi:10.1111/add.12441.
Brown SA, Glasner-Edwards SV, Tate SR, McQuaid JR, Chalekian J, Granholm E. Integrated cognitive behavioral therapy versus twelve-step facilitation therapy for substance-dependent adults with depressive disorders. J Psychoactive Drugs. 2006;38(4):449–60. doi:10.1080/02791072.2006.10400584.
Baker AL, Kavanagh DJ, Kay-Lambkin FJ, Hunt SA, Lewin TJ, Carr VJ et al. Randomized controlled trial of cognitive-behavioural therapy for coexisting depression and alcohol problems: short-term outcome. Addiction. 2010;105(1):87–99. doi:10.1111/j.1360–0443.2009.02757.x.
Baker AL, Kavanagh DJ, Kay-Lambkin FJ, Hunt SA, Lewin TJ, Carr VJ et al. Randomized controlled trial of MICBT for co-existing alcohol misuse and depression: outcomes to 36-months. J Subst Abuse Treat. 2014;46(3):281–90. doi:10.1016/j.jsat.2013.10.001.
Thapinta D, Skulphan S, Kittrattanapaiboon P. Brief cognitive behavioural therapy for depression among patients with alcohol dependence in Thailand. Issues Ment Health Nurs. 2014;35(9):689–93. doi:10.3109/01612840.2014.917751.
Gamble SA, Talbot NL, Cashman-Brown SM, He H, Poleshuck EL, Connors GJ et al. A pilot study of interpersonal psychotherapy for alcohol-dependent women with co-occurring major depression. Subst Abus. 2013;34(3):233–41. doi:10.1080/08897077.2012.746950.
Markowitz JC, Kocsis JH, Christos P, Bleiberg K, Carlin A. Pilot study of interpersonal psychotherapy versus supportive psychotherapy for dysthymic patients with secondary alcohol abuse or dependence. J Nerv Ment Dis. 2008;196(6):468–74. doi:10.1097/NMD.0b013e31817738f1.
Kelly JF, Stout RL, Magill M, Tonigan JS, Pagano ME. Mechanisms of behaviour change in alcoholics anonymous: does Alcoholics Anonymous lead to better alcohol use outcomes by reducing depression symptoms? Addiction. 2010;105(4):626–36. doi:10.1111/j.1360–0443.2009.02820.x.
Murray LK, Dorsey S, Haroz E, Lee C, Alsiary MM, Haydary A et al. A common elements treatment approach for adult mental health problems in low- and middle-income countries. Cogn Behav Pract. 2014;21(2):111–123. doi:10.1016/j.cbpra.2013.06.005.
Bolton P, Lee C, Haroz EE, Murray L, Dorsey S, Robinson C et al. A transdiagnostic community-based mental health treatment for comorbid disorders: development and outcomes of a randomized controlled trial among Burmese refugees in Thailand. PloS Med. 2014;11(11):e1001757. doi:10.1371/journal.pmed.1001757.
Fulton BD, Scheffler RM, Sparkes SP, Auh EY, Vujicic M, Soucat A. Health workforce skill mix and task shifting in low income countries: a review of recent evidence. Hum Resour Health. 2011;9:1. doi:10.1186/1478–4491-9–1.
Patel V, Weiss HA, Chowdhary N, Naik S, Pednekar S, Chatterjee S et al. Effectiveness of an intervention led by lay health counsellors for depressive and anxiety disorders in primary care in Goa, India (MANAS): a cluster randomised controlled trial. Lancet. 2010;376(9758):2086–95. doi:10.1016/S0140–6736(10)61508–5.
Mutamba BB, van Ginneken N, Smith Paintain L, Wandiembe S, Schellenberg D. Roles and effectiveness of lay community health workers in the prevention of mental, neurological and substance use disorders in low and middle income countries: a systematic review. BMC Health Serv Res. 2013;13:412. doi:10.1186/1472–6963-13–412.
Vijayakumar L, Kumar MS. Trained volunteer-delivered mental health support to those bereaved by Asian tsunami - an evaluation. Int J Soc Psychiatry. 2008;54(4):293–302. doi:10.1177/0020764008090283.
Tripathy P, Nair N, Barnett S, Mahapatra R, Borghi J, Rath S et al. Effect of a participatory intervention with women’s groups on birth outcomes and maternal depression in Jharkhand and Orissa, India: a cluster-randomised controlled trial. Lancet. 2010;375(9721):1182–92. doi:10.1016/S0140–6736(09)62042–0.
Dias A, Dewey ME, D’Souza J, Dhume R, Motghare DD, Shaji KS et al. The effectiveness of a home care program for supporting caregivers of persons with dementia in developing countries: a randomised controlled trial from Goa, India. PloS One. 2008;3(6): e2333. doi:10.1371/journal.pone.0002333.
Hamadani JD, Huda SN, Khatun F, Grantham-McGregor SM. Psychosocial stimulation improves the development of undernourished children in rural Bangladesh. J Nutr. 2006;136(10):2645–52.
Prince M, Patel V, Saxena S, Maj M, Maselko J, Phillips MR, Rahman A. No health without mental health. Lancet. 2007;370(9590):859–77.
Alcohol and Public Policy Group. Alcohol: no ordinary commodity -a summary of the second edition. Addiction. 2010;105(5):769–79. doi:10.1111/j.1360–0443.2010.02945.x.
Wagenaar AC, Salois MJ, Komro KA. Effects of beverage alcohol price and tax levels on drinking: a meta-analysis of 1003 estimates from 112 studies. Addiction. 2009;104(2):179–90. doi:10.1111/j.1360–0443.2008.02438.x.
Anderson P, Chisholm D, Fuhr DC. Effectiveness and cost-effectiveness of policies and programmes to reduce the harm caused by alcohol. Lancet. 2009;373(9682):2234–46. doi:10.1016/S0140- 6736(09)60744–3.
Rajaraman I. Impact of liquor taxation on consumption patterns in India. Journal of Policy Modelling. 2007;29:195–207. doi:10.1016/j. jpolmod.2007.01.001
Mahal A. What works in alcohol policy? Evidence from rural India. Economic and Political Weekly. 2000;35(45):3959–68. doi:10.2307/4409926.
Benegal V. India: alcohol and public health. Addiction. 2005;100(8):1051–6. doi:10.1111/j.1360–0443.2005.01176.x.
Global strategy to reduce harmful use of alcohol. Report on the WHO regional technical consultation 24–26 February 2009, Nonthaburi, Thailand. Convened by the WHO Regional Office for South-East Asia and WHO headquarters. Co-sponsored by Ministry of Public Health, Government of Thailand. New Delhi: World Health Organization Regional Office for South-East Asia; 2009 (http://www. who.int/substance abuse/msbsearalcconsult.pdf?ua=1
, accessed 8 December 2016).
World Health Organization. Global Health Observatory (GHO) data. Global Information System on Alcohol and Health (http://www.who.int/gho/alcohol/en/
, accessed 8 December 2016).