What is the most appropriate next step in management for a 43-year-old female patient with a 12-month history of increased alcohol consumption, attention-deficit/hyperactivity disorder (ADHD), and recurrent major depressive disorder, currently treated with escitalopram (Selective Serotonin Reuptake Inhibitor (SSRI)) and atomoxetine?

From the Guidelines

The most appropriate next step in management for this 43-year-old female patient would be to address her alcohol use disorder while carefully managing her psychiatric comorbidities, and I recommend initiating naltrexone therapy (50mg daily) as pharmacotherapy for alcohol cravings, given its efficacy in reducing excessive drinking and recurrence rates, as supported by the study 1.

The patient's 12-month history of increased alcohol consumption, despite having attention-deficit/hyperactivity disorder (ADHD) and recurrent major depressive disorder, suggests the need for a comprehensive treatment approach that includes pharmacotherapy for alcohol use disorder.

• Naltrexone is a suitable option, as it decreases the concentration of dopamine in the brain and dampens activation of the reward pathway by alcohol, thereby decreasing excessive drinking and recurrence rates and increasing abstinence duration in patients with alcohol dependence, as noted in the study 1.
• The patient's current medications, escitalopram and atomoxetine, should be evaluated for potential interactions with alcohol and adjusted as necessary to ensure safety and efficacy.
• Cognitive behavioral therapy (CBT) or motivational interviewing may also be beneficial in addressing the patient's alcohol use disorder and psychiatric comorbidities, but naltrexone therapy is the most appropriate next step in management.
• It is essential to monitor the patient's liver function, mental health symptoms, and alcohol use patterns regularly throughout treatment, as naltrexone can cause toxic liver injury, and the patient's alcohol consumption may exacerbate underlying liver conditions.
• The study 1 highlights the importance of careful patient selection and monitoring when using naltrexone, particularly in patients with liver-function abnormalities or renal failure, but this patient's normal liver function tests and lack of renal failure make naltrexone a viable option.

From the Research

Patient Management

The patient presents with a 12-month history of increased alcohol consumption, attention-deficit/hyperactivity disorder (ADHD), and recurrent major depressive disorder. Considering the patient's history and current treatment with escitalopram and atomoxetine, the most appropriate next step in management would be:

• Cognitive Behavioral Therapy (CBT) as an adjunct to motivational interviewing, given its efficacy in treating substance use disorders and anxiety disorders 2, 3, 4, 5.

Rationale

• CBT has been shown to be effective in reducing substance use and improving treatment outcomes in patients with substance use disorders 3, 4.
• Motivational interviewing has been found to be a useful technique in promoting behavioral change and treatment adherence in patients with various health problems, including substance use disorders 6.
• The patient's history of ADHD and recurrent major depressive disorder suggests that CBT may be beneficial in addressing underlying cognitive and behavioral issues that may be contributing to her alcohol consumption.

Considerations

• The patient's current treatment with escitalopram and atomoxetine should be continued, and CBT should be used as an adjunct to her current treatment regimen.
• The patient's daughter's concerns about her drinking habits should be taken into consideration, and the patient should be encouraged to involve her daughter in her treatment plan if possible.
• Further evaluation and monitoring of the patient's alcohol consumption and mental health status should be conducted to assess the effectiveness of CBT and motivational interviewing in managing her condition 2, 4, 6.