Dr Conor Farren's presentation the relationship between alcohol and mental health issues, including depression, in Ireland. Dr Farren is a Consultant Psychiatrist at St Patrick’s University Hospital and a Senior Clinical Lecturer at Trinity College Dublin. This presentation was given at Alcohol Action Ireland's conference, Facing 'The Fear': Alcohol and Mental Health in Ireland, on November 20, 2013.

1. Conor K Farren
Conorfarren.com
M.B., Ph.D., A.B.P.N. (Dipl.), F.R.C.P.I., M.R.C.Psych.
Trinity College Dublin
St Patrick’s University Hospital

2. Bacchus discovered the juice of the
grape and introduced it to mankind,
stilling thereby each grief that mortals
suffer from . . . sorrow's antidote.
Euripides, 407 BC, The Bacchae

9. Alcohol in Ireland
 4th highest in EU, 11.5 L/alc/adult/annum
 Highest binge drinking in Europe: 34%
 EU average: 10%
 Increased consumption by 17% in 1996-2005, tapered
since then.
 Increased alcohol related deaths to 1775 in 10 years:
100% increase
 Alcoholic liver disease: 147% increase in 10 years
 Alcohol related diseases/injuries: 90% increase in 10
years

10. Interaction between Mood and
Alcohol
 About 6% of the population suffers from alcohol
dependence (M>F), 7% from alcohol abuse, and
8% from heavy alcohol consumption.
 About 8% of the population currently suffer from
a depressive disorder. 1-2% suffer from a bipolar
disorder.
 Currently about 4% of the population suffer from
both an alcohol problem and a mood problem.

11. Mood Effects of Alcohol
 Intoxication:
 pleasant alteration in mood,
 diminution in anxiety symptoms.
 Depression caused by the alcohol:
 hours later,
 the next day,
 a few days later.
 For some alcoholics:
 a certain amount of alcohol to get depressed,
 only get depressed on one occasion out of 10 or 20,
 dependent upon the overall mood before drinking.
 Suicidal Ideas:
 Alcohol can bring them on,
 can make suicidal ideas more intense
 disinhibited enough to try suicide, wouldn’t while sober

12. Effect of abstinence
 At presentation, 40% of alcoholics have major depression;
50% have significant anxiety symptoms; 15% have manic
or elation symptoms
 After 4 weeks of sobriety, the incidence of depression
goes down to 10%, the incidence of anxiety goes down to
15% and the incidence of mania goes down to <5%.

13. Alcohol and Suicide
 25% of suicides solely attributable to alcohol
 Alcohol present in 58% of completed suicides in Ireland
(Bedford et al., 2007)
 International norm 38%
 93% of those under 30 years in Ireland
 Alcohol present in 41% of episodes of deliberate self harm

14. Alcohol Related Mortality Rate per 100,000
1970 - 2000
12
rates per 100,000
10
8
Suicide
6
Alcohol Consumption
4
2
0
1970
1975
1980
1985
1990
1995
2000

15. Reasons for depression in sobriety
 Alcohol withdrawal can produce significant anxiety
symptoms.
 Craving can present as depression.
 Coping with the effects of a long period of drinking –
financial, relationship, work problems.
 Immaturity of coping skills.

16. Anxiety and Alcohol




Social anxiety can lead to development of alcohol use disorder
Alcohol withdrawal is a significant cause of anxiety
Trying to deal with alcohol, trying to change, can cause anxiety.
Heavy drinkers often drink to overcome an underlying anxiety
 Generalised anxiety
 Panic disorder
 Phobia
 OCD
 Craving for alcohol can present as anxiety;
 Anxiety can cause craving.

18. The U Turn: Sections
 Why you need this book:

Self-understanding
 Negative emotions and how they hurt us:





Anger
Jealousy and envy
Depression: experience and escape
Fear and anxiety
Criticism and hatred

19. •The fundamentals of self-belief
Self belief and inferiority
Personality and projection
Talking and communication
•The importance of relationships
Intent
Power
•The reason for it all
Joy and purpose

20. The Dual Diagnosis Program at
St Patrick’s University Hospital.
 The program consists of:





Lectures, both general and specific for the program,
Video session, specific for the program
Individual therapy sessions
AA and Dual Recovery groups.
Group treatments:





Relapse prevention
Dual Diagnosis
1st Step
Recovery plan
Discussion Group
 Full time program consisting of 3 parts:
- Assessment with detoxification and mood stabilisation;
- Engagement with full or modified in patient program;
- Aftercare for up to 6 months post discharge.
Farren and McElroy, J Affect Disorder
2008, 106: 265-272

21. FIRESIDE
 Follow up.
 Interrelationship of diagnoses: can’t improve in
one without the other.
 Relapse Prevention.
 Education: Lectures, Videos, and Discussions.
 Stabilization of withdrawal and mood:
pharmacotherapy before and during program.
 Individuation of program. Flexibility for
retention proposes.
 Diagnostic equivalence. Both diagnoses
emphasised.
 Empowerment: Individual responsibility.
Farren and McElroy, J Affect Disorder
2008, 106: 265-272

22. Demographics
Depression
(N=101) (M= 54, F=47)
Bipolar
(N=88) (M=43, F=45)
Age
44.7
41.6
Education
14.0
13.7
Length of stay
37.1 **
46.5 **
Previous admissions
1*
1.7 *
F. Hx of alcohol abuse
59.4%
67%
F. Hx of psychiatric disorder
49.5%**
69.3%**
Suicide attempt
29.7%
34.1%
Illegal drug use
23.8%
34.1%
Prescription drug abuse
24.8%
29.5%
* p<0.05
** p<0.01

23. Mood Disorder Symptoms
Depression - BDI
30
25
20
15
10
5
0
ar
ye
2
on
th
6
m
ge
ha
r
D
isc
Ba
se
l
in
e
Depression
BPAD
Farren CK, Snee L , McElroy S:
J Stud Alcohol Drugs,
2011, 72: 872-880

24. Mood Disorder Symptoms
Anxiety - BAI
30
25
20
15
10
5
0
r
ye
a
2
on
th
6
m
ge
ha
r
D
isc
Ba
se
l
in
e
Depression
BPAD

25. Drinking Outcomes:
Self Report
Drinking Days
Units per Drinking Day
45
40
35
30
25
20
15
10
5
0
Depression
BPAD
14
12
10
8
6
4
2
0
Depression
BPAD
Baseline
Baseline 6 months 1 Year
2 Year
6
1 Year
Months
2 year

26. Drinking Outcomes
Depre ssion
Base
3 mths
Bipolar
6mths
2 years
Baseline 3 mths
6 mths
2 years
No. drink
days
40.96
5.46
37.39
6.32
Units per
day
11.55
3.92
12.28
6.68
Abstinent
0%
57.3 %
0%
70.3%
50.7%
60.2%
49.3%
53.7 %

27. Predictive Relapse Factors at 3 Months.
B
S.E
Exp (B)
95%C.I for EXP(B)
Lower-upper
Sig.
Organised aftercare on discharge
2.200
.466
.111
.045-.277
<.01
BAI on admission
-.040
.020
.961
.924-.998
<.05.
.062
.030
1.064
1.001-1.128
<.05
Family psych history
-.660
.418
.517
.228-1.172
N.S
BDI score at admission
-.040
.026
.961
.910-1.022
N.S
Unemployed
2.241
1.718
.106
.004-3.620
N.S
Audit score at admission
Farren and McElroy,
Alcohol and Alcoholism,
2010, 45 (6): 527-533.

28. Predictive Relapse Factors at 6 Months.
B
Organised aftercare on
discharge
BAI on admission
Audit score on admission
Family psychiatric history
BDI score Discharge
OCDS score on admission
DAST score on admission
Drug History
S.E
Exp (B)
95%C.I for EXP(B)
Lower-upper
Sig.
1.766
.459
.171
.070-.421
<.01
-.010
.017
.990
.958-1.02
N.S
.060
.030
1.06
1.01-1.13
<.05
-.813
.414
.444
.197-1.00
<.05
.036
.027
1.04
.984-1.09
N.S
-.040
.031
.961
.903-1.02
N.S
-.061
.053
.941
.848-1.04
1.417
.653
4.13
1.15-14.8
N.S
<.05
Farren and McElroy,
Alcohol and Alcoholism,
2010, 45 (6): 527-533.

29. 5-year follow up of AUD with
Affective Disorder
Total Sample
Baseline
n = 205
3 months
n = 196
6 months
n = 155
2 years
n = 144
5 years
n =114
% abstinent
–
66.3%
55.2%
45.1%
51.8%
No. of drink days
39
3.5
7.9
7.6
10.9
12.1
22.2
3
–
3.8
–
5.3
7
5.7
5.5
28.8%
25.5%
–
–
–
7%
2.8%
1.8%
3.5%
Variable
Units per day
AUDIT
Illegal drug use
Pres. misuse
Of those who
% Light
Drinkers
were non-
abstinent at
3 months
93.8 %
5 years
Light Drinkers
Abstinence
53.6%
39.3%
Farren, Murphy and McElroy,
Alcoholism: Clinical and Experimental Research:
In Press

30. Supportive Text Messaging For Depression And Comorbid
Alcohol Use Disorder:
Single-blind Randomised Trial
 Mobile phone text message technology has the potential to improve
outcomes for patients with depression and co-morbid
Alcohol Use Disorder (AUD).
Aims
 To perform a randomised rater-blinded trial to explore the effects of
supportive text messages on mood and abstinence outcomes for patients
with depression and co-morbid AUD.
Agyapong V, Ahern S, McLoughlin D, Farren CK
J Affect Disorder, 2012

31. Methods
Participants (n=54) with a DSM IV diagnosis of unipolar depression and
AUD
Completion of the in-patient dual diagnosis treatment programme
Randomised to receive twice daily supportive text messages (n = 26) or a
fortnightly thank you text message (n = 28) for three months.
Primary outcome measures were :
Beck’s Depression Inventory (BDI-II) scores and
Cumulative Abstinence Duration (CAD) in days at three months.
Trial registration: NCT0137868.

32. Sample Messages
 Monitor changes in your mood; develop a list of personal
warning signs
 If you are having a good day, share your joy with others. If you
are having a bad day, share it with others and accept their help.
 Stick to your treatment plan; take your medication as prescribed
and keep your appointments.
 Keep Sobriety as a number one priority and you will reach your
goals.
 Make a list of 5 people you can call if you are craving. Make sure
you carry their numbers with you all the time.
 AA meetings are crucial; attend regularly; if you don’t like a
particular AA meeting, shop around until you find one that suits
you.

33. Primary Outcomes
Measure
Baseline
Post-treatment
p-value
Text
message
group
Beck’s Depression
Inventory-II
Cumulative
Abstinence Duration
Control
group
Text
message
group
Control
group
31.58
31.99
8.6 *
16.6
0.003
88.3
79.3*
0.08

34. Secondary Outcomes
Measure
Baseline
Text
Control
message group
group
Post-treatment
Text
Control
message
group
group
p-value
48.2
48.6
89.8*
76.1
0.001
OCDS
26.0
23.7
8.4
6.8
0.40
Alcohol Self Efficacy Scale
38.9
43.9
79.5 *
72.3
0.09
20 %
16 %
0.12
43.0
30.4
0.49
1.13
6.9
0.10
GAF Scale
Proportion continuously
Abstinent
Days to first drink
Units alcohol per
day
25.0
20.7

35. Conor K Farren,
Jennie Milnes, Kathryn Lambe, Sinead Ahern

36. The Setting
 Inpatient 4-week rehabilitation programme, based at
St Patrick’s University Hospital.
 Patients were recruited from the inpatient group,
following detoxification and initiation onto the
Alcohol and Chemical Dependence Programme.
 The programme consists of education groups,
individual therapy sessions, self help groups, plus
educational lectures.
 A comparison group of cognitive computer exercises
was used as a placebo, for a similar number of sessions.
This consisted of basic mental arithmetic exercises.

37. The Therapy
 5 X 50 minute therapy sessions were developed using
the CBT manual for Project MATCH as a basis.
 Topics covered include:
 an interactive exploration of emotions relating to




triggers for drinking episodes;
inaccurate thinking associated with AUD;
feelings around alcohol use, and the development of
strategies to deal with distressing feelings;
education about relapse, prevention strategies;
craving induction and craving reduction strategies

38.  Each session had an appropriate case history presented to
the patient, based upon their original allocation to a
personal drinking pattern.
 At the end of each session, the patient was given
standardised feedback via computer about their answers to
questions,
 Also given specific therapeutic instructions via computer
regarding what would be helpful for their recovery.
 Both groups were followed for 3 months after discharge,
with measurement of drinking outcomes.

39. Typical CCBT Programme Screens
Types of Drinkers: Reasons for Drinking
90
80
Social
Drinker
Interpersonal
Conflict
70
60
50
40
30
20
10
0
Testing
Personal Emotional Drinker
Control Drinker

40. FIGURE 1
APPROACHED
(n = 102)
Ineligible (n = 22)
Declined (n = 25)
RANDOMISED
(n = 55)
INTERVENTION
(n = 31)
EXCLUDED FROM ANALYSIS (n = 11)
Did not complete protocol
Discharged AMA (n = 2)
Early discharge (n = 2)
60% completion of protocol (n = 1)
Computer issues (n = 3)
Withdrawal from study
Withdrew (n = 1)
Insufficient information for analysis (n = 2)
INCLUDED IN
ANALYSIS
(n = 20)
CONTROL
(n = 24)
EXCLUDED FROM ANALYSIS (n = 9)
Did not complete protocol
Withdrew (n = 3)
Early discharge (n = 2)
Computer issues (n = 1)
Ineligible
Depression diagnosis (n =1)
Change of Tx programme (n =2)
INCLUDED IN
ANALYSIS
(n = 15)
)

41. No. of Drinking Days
70
60.63
60
51.27
Days
50
40
Baseline
30
3 months
20
10
8.56
3
0
CCBT group
Control group

42. Units per Drinking Day
30
25
24.34
23.08
Units
20
Baseline
15
3 months
10
5.94
5
0
CCBT group
4.79
Control group

43. Alcohol Misuse and Diabetes
 Alcohol Misuse is the Diabetes of Psychiatry
 They are both your “Friends for Life”
 They are managed not cured.
 They should be managed under 3 headings:
Diabetes
Complications
Oral Meds: Antabuse, Anti-craving
Anti-craving Injection
Diet
Recovery Activity: e.g. AA
Exercise
Behavioral
Oral Meds
Insulin Injection
Medical
Alcohol Misuse
Avoidance of Risk: e.g. Pubs
CV Disease
Anxiety
PV Disease
Depression
Diabetic coma
Bipolar Disorder