Doctors urged to screen for alcoholism before prescribing antidepressants

New guidance to help family doctors detect and manage high-risk drinking addresses a crucial gap in knowledge among both patients and doctors, say its authors, who warn that a common practice to prescribe antidepressants can actually induce cravings for alcohol.

The advice is comprised of 15 recommendations on early detection of alcohol use disorder, withdrawal management, psychological interventions and community-based programs.

It urges routine screening for alcohol use and includes tips on what to avoid, such as prescribing antidepressants without ruling out problematic alcohol use first because selective serotonin reuptake inhibitors (SSRIs) can worsen alcoholism symptoms.

“A lot of Canadian doctors prescribe SSRIs,” said Jürgen Rehm, co-chair of the guideline writing committee.

“Unfortunately, all the literature is pretty clear that this is not good practice, whereas those medications that are specifically made for the treatment of alcohol use disorder are almost not used.”

Antipsychotic medications should also not be prescribed off-label to treat alcohol addiction and can exacerbate symptoms, Rehm said.

The guideline was published Monday in the Canadian Medical Association Journal, or CMAJ.

It was developed by the Canadian Research Initiative on Substance Misuse (CRISM) and the BC Centre on Substance Use (BCCSU), with input from a committee of 36 members across the country, including clinicians, academics and people who have experienced alcoholism or are struggling with it.

Rehm said committee members hope the guideline will be endorsed by medical associations across the country.

Rehm said screening would only take “half a minute.” Doctors are urged to ask patients how often in the past year they’ve had more than four drinks on one occasion if they’re female, or five drinks if they’re male.

Depending on alcohol use, physicians could advise patients on health risks, suggest ways to cut back or prescribe specific medications for alcohol use disorder. Patients may also be referred to treatment programs in or outside of hospital, based on whether they are at high or low risk of complications such as seizures.

Long-term treatment could also include cognitive behavioural or family-based therapy, peer groups or recovery programs.

Rehm said the treatment rate for alcohol use disorder in Canada is less than 10 per cent compared to an estimated 18 per cent in Britain, where a guideline for doctors was adopted in 2012. He’s not aware of any study that assesses whether more people have since been treated for alcohol use disorder.

In some provinces, less than two per cent of patients are prescribed medications, such as naltrexone or acamprosate, intended for use with alcohol use disorder and recommended in the guideline, said Rehm, also a senior scientist at the Centre for Addiction and Mental Health and a professor at the University of Toronto’s Dalla Lana School of Public Health.

Patients who report symptoms including depression or insomnia without disclosing alcohol overuse or being asked about it are often prescribed SSRIs, such as Prozac, said Rehm. He said doctors should screen for any connections to alcohol use because 18 per cent of Canadians aged 15 and older will meet the clinical criteria for an alcohol use disorder at some point in their lifetime.

Amanda Hintzen of Toronto said she went to a family doctor when she was “in a spiral” from drinking excessively every day.

“I said, ‘I’m an alcoholic. What can you do to help me?’ I left there with three different prescriptions,” she said, listing one for anxiety, another for insomnia and a third for high blood pressure.

Alcohol affects multiple organs, including the heart and is associated with raised blood pressure. It can also affect sleep, mood and anxiety.

When Hintzen asked for naltrexone by name, she was initially “deterred” from that option, she said of the drug commonly prescribed for patients with moderate to severe alcohol use disorder.

“At that point, I was more dependent on it to function,” she said of alcohol. “The shakes started in the morning.”

Hintzen said she paid for two private rehabilitation programs, the second time in January 2022 where she met many others who had been prescribed medication not intended to treat alcohol addiction.

“Everybody’s on antidepressants. Everyone’s on anti-anxiety medication,” she said.

Dr. Evan Wood, co-chair of the guideline writing committee and an addiction medicine specialist in Vancouver, said most people seeking support for excessive alcohol use do not get evidence-based treatment.

“The guideline really does speak to the failure of institutions to really effectively address the high level of morbidity and mortality in Canada from alcohol use disorder,” said Wood, adding there’s also a need to train more health-care providers.

Alcoholism could be the underlying cause of conditions such as depression, insomnia, anxiety and high blood pressure, but doctors must talk to their patients to find out, Wood said.

“If you don’t stop and talk to people about alcohol, you’ll end up treating their blood pressure with antihypertensive medicine when all they really need to do is cut back on their alcohol use.”

The guidance comes nine months after the Canadian Centre on Substance Use and Addiction (CCSA) released updated guidance that warns of escalating health risks associated with more than two standard drinks per week. Potential health harms include heart disease and cancer, including breast cancer in women.

Wood said the new guideline, funded by Health Canada, will be posted online and webinars will be offered to doctors.

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