Treatment of Comorbid Alcohol Use Disorder and Major Depressive Disorder

As the co-chairs of the 2023 Canadian Research Initiative in Substance Use Matters (CRISM) guideline on high-risk drinking and alcohol use disorder (AUD), we read the recent position statement by Primeau et al. with interest. ¹ We note that when put alongside earlier work by several of the same authors, the new statement is remarkably similar. Specifically, the position statement's description of the benefits of antidepressants, the importance of integrated care, the description of relevant Cochrane reviews, and the potential value of combining antidepressants with AUD treatment is nearly identical in both argument and, in a number of cases, uses almost the exact language as an earlier critique by Bahji et al. ² With humility, we note this since what is entirely absent from the more recent position statement and other recent works is the alternative perspective provided in our response to the original critique of Bahji et al. ³

Of course, we acknowledge that there can be more than one way to interpret a complex evidence-base and that some might view the literature in this area as conflicting.^2,3 When a literature base is complex and clinical views may differ, we believe critical appraisal and ongoing research are the optimal path forward and are committed to taking this approach. Efforts that may help reconcile differing viewpoints should involve ongoing objective review of the evidence from an evidence-based medicine perspective. ⁴ We encourage the authors of the position statement to engage in activities that might help resolve the question from this perspective, including re-appraising their own work.^4,5 Additionally, unanswered questions remain that may well be answered by critical appraisal from other perspectives including searching for unpublished randomized controlled trials and updating meta-analyses where possible, exploring for outcome reporting bias (e.g., where registered primary outcomes differ from published reports), and assessing past reviews for related biases using validated tools.

While most antidepressant prescribing occurs in primary care and the CRISM guideline was geared toward primary care providers, we also wish to stress that the CRISM guideline does not preclude antidepressant prescribing for those with AUD. Indeed, it specifically encourages referral to specialists with appropriate expertise for assessment and evidence-based treatment for patients with severe concurrent mental health challenges. Regardless of one's position on the safety of antidepressant prescribing in the AUD context, we acknowledge all parties are seeking to optimize patient care and hope that the above approach may help with consensus building.