Alcohol-Induced Psychotic Disorder and Depressive Disorder: a Dual Diagnosis Case Series Disorder: a Dual

Alcohol-induced psychotic disorder (AIPD) is a diagnosis in the ICD 10. Previous studies of AIPD do not appear to have reported the co-mor-bid presence of depressive disorder in either prevalence studies or treatment studies. Five cases are presented with a dual diagnosis of AIPD and depressive disorder. These cases were assessed using the Brief Psychiatric Rating Scale (BPRS), Hamilton Depression Rating Scale (HDRS), Clinical Global Impression Severity score (CGI-S), Clinical Global Impression Improvement score (CGI-I), Drug Attitude Inventory 10 (DAI 10), Short Assessment Personality-Abbreviated Scale (SAPAS) and Modified Sainsbury Tool. Antidepressants and antipsychotics were chosen based on drug attitude scores from DAI 10. Cases demonstrate inpatient and outpatient treatment with good treatment outcomes after six months. Three cases demonstrate suicide risk. The majority did not have a personality disorder. These cases highlight the importance of treating a depressive disorder in AIPD and of tailored medication treatments for poor medication compliance.


Case B.
A 60-year-old male who was in a long-term relationship with a diagnosis of alcohol dependency syndrome self-presented to the A&E. He was abstinent from alcohol for three years following completion of a 6-month residential alcohol detoxification and rehabilitation programme. His alcohol problem started from his teenage years. It never affected his ability to work, but it did cause his divorce. His son had an illicit drug addiction. There was no other family history of mental illness. He had started to consume 20 units per day for four weeks. He described persecutory delusions and persecutory auditory hallucinations which started when he resumed alcohol consumption. He thought that he might have a transistor implanted in his body causing him to hear voices. He barricaded his room because he felt people were after him and attempted to hang himself due to the distress. He described low mood, suicidal thoughts, agitation, poor concentration, disturbed sleep, poor appetite with weight loss. He had no previously treated mental illness. He stayed in the hospital for two weeks and was treated with fluoxetine and risperidone. While on the ward he attempted to cut his throat. He had a CGI-S: 6 Table).
R e s u l t s Five cases are presented with a diagnosis of alcoholinduced psychotic disorder and depressive episodes. These five cases demonstrate a degree of heterogeneity. All five cases are male. Four cases are above the age of 50. These cases support existing findings of AIPD in males of working age [15]. Four cases describe persecutory auditory hallucinations and persecutory delusions. One case describes visual hallucinations, which is supported by the literature [16]. Three cases demonstrated suicide risk, which is supported by the literature [5]. Three cases had inpatient treatments and were prescribed fluoxetine because of its long half-life to offset any missed doses due to non-compliance in the community [17]. Two of these 3 inpatient cases had low DAI 10 scores and were prescribed paliperidone depot medication in the community to help compliance with medication [18][19][20][21][22][23]. All 3 inpatient cases did not have any re-hospitalisations at one year follow-up. All cases at a review six months after admission reported improvement in symptoms as measured by CGI-I and selfreported compliance with medication. Four cases did not have a personality disorder.

D i s c u s s i o n
AIPD has a general population lifetime prevalence of 0.41%, or 4% for people with alcohol dependence syndrome. It is most common amongst men of working age [15]. AIPD is said to manifest immediately after the consumption of large amounts of alcohol. It may not be related to duration of alcohol dependence syndrome [15,24]. Symptoms may develop during alcohol intoxication or withdrawal or soon thereafter. The diagnosis cannot be made until clear consciousness is restored. AIPD is said to usually resolve within 18 to 35 days with antipsychotic and/or benzodiazepine treatment [25]. A minority of patients may have persistent symptoms for six months or more [26,27]. AIPD may end through alcohol abstinence alone and return soon after reinstatement of drinking [2, 3]. Antipsychotics are thought by some to be the treatment of choice [28,29], however, this is not supported by published randomised controlled trials. In the 1950s, three large-scale seminal studies followed patients with AIPD for 5-23 years in order to examine prognosis and diagnosis [26,27,30]. However, the presence of a depressive disorder was not described here. A two-part study by Glass 1989 did not include the impact of depressive disorders on AIPD either [2, 3]. Presence of depressive and anxiety symptoms were recognised in a later study, however the main emphasis of this study was to differentiate between AIPD and schizophrenia, and so depressive disorder was not diagnosed clearly [4].
These cases describe the comorbid presence of a depressive disorder and alcohol-induced psychotic disorder. These cases also show a degree of heterogeneity in age of onset, presentation, treatment compliance and suicide risk which can sometimes cause difficulty in clearly making diagnoses, which may have an impact on appropriate treatment. In particular, these cases highlight the need to be aware of diagnosing and treating depressive symptoms in alcohol-induced psychotic disorder.
Participants are likely to live in difficult social situations due to alcohol excess which would affect medication compliance [31]. Hence, compliance to treatment is important and should be a factor in the choice of medications. Medications with long half-lives were hypothesised to be a better choice in cases with low DAI 10 scores, to offset any missed doses due to non-compliance [18,19]. Hence, fluoxetine was chosen as the antidepressant in the inpatient cases because they had low DAI 10 scores and because of its long half-life [17]. Cases were also prescribed long-acting paliperidone depot because of its association with good medication compliance [21][22][23]. Inpatient cases were initially prescribed oral risperidone as a trial of medication compliance. If oral risperidone compliance was poor, they were switched to paliperidone depot. The patients who were prescribed paliperidone depot /oral risperidone and fluoxetine combination were also cases that required inpatient treatment which is a high level of intervention. This is consistent with the literature describing high re-hospitalisation rates in AIPD cases [32]. It would be hypothesised that non-compliance with alcohol abstinence and medications would be the cause for these high rates of re-hospitalisations. The 2 cases who were prescribed treatment other than paliperidone / risperidone and fluoxetine combination, were treated on an outpatient basis and had higher DAI-10 scores.
C o n c l u s i o n Treatment of AIPD should consider the presence of comorbid depressive disorder. Medication compliance should be taken account when delivering treatment interventions. Attention should be given to the fact that AIPD cases are associated with high re-hospitalisation rates and suicide risk [5,32]. Further robust studies are needed to describe optimum hospital and community treatment associated with AIPD.