Abstract
After obtaining complete remission of “major depression”, an attempt was undertaken to treat patient’s alcohol addiction (disaccustoming treatment) also with sertraline. Many authors regard sertraline is a drug significantly more effective in the treatment of major depression than fluoxetine. Sertraline is an extremely safe, well tolerated drug producing very little adverse effects. It is non-hepatotoxic, causes no overloading of the circulatory system and exerts very weak cholinolytic effect. Alcohol-addicted persons have usually many underlying somatic diseases. Therefore, for treatment of such patients low-toxic drugs producing very little adverse effects will be useful. Sertraline is definitely such a drug.

Introduction

In the group of persons who since recently6 have been observing alcohol abstinence, depressive disorders frequently develop. Not infrequently they include “major depression”. However, little is known6 as yet on the treatment of such type of persons.

Drugs with serotoninergic activity and particularly selective serotonin central reuptake inhibitors appear a very interesting and useful group of drugs that could find use in preventing recurrences or in reducing alcohol consumption. The premises for the use of serotoninergic drugs here, include: low activity of the serotoninergic system in a part of persons addicted to alcohol, and encouraging results of animal studies which have been confirmed by experiments by such authors as Baydens-Branchey L, Cloninger C, Gill K, Amit Z. The use of this group of drugs is connected usually with low risk of adverse effect development.1,5 These drugs demonstrate no cross-tolerance with alcohol, and interactions with alcohol are weak. The premises are present that the drugs from this group prevent or reverse certain consequences of alcohol intoxication which has been confirmed by such authors as Allen D, Lader M, Curran HV. As yet, such authors as, among others, Naranjo CA, George SR, Selleres EM conducted studies on the use of this group of drugs in treatment of alcohol addiction or limitation of its consequences. In these studies a positive effect was observed of the drugs from this group on the course of the addiction. This was expressed in increased number of days without alcohol drinking, drinking of lower alcohol volumes as compared with the pretreatment period and in earlier coming for professional help due to drinking. Generally good tolerance of the drugs was observed, mainly in low dosage intervals. The more the doses of drugs in this group were close to those used in the treatment of affective diseases, the poorer was the tolerance (nausea, vomiting, dyspeptic complaints, headache, delayed orgasm). This could result from impaired metabolism of drugs from this group in persons with alcohol-induced liver damage which was confirmed by studies of such authors as Kranzler HR, Bergstrom RF, van Harten J. Another possible mechanism causing good effects of this group of drugs in the treatment of alcohol addiction is the anticompulsive influence.^3,4 of these drugs on compulsive alcohol drinking.

Sertraline⁵ as a selective serotonin central reuptake inhibitor, that is a drug increasing serotoninergic transmission, proved more effective in “major depression” treatment than fluoxetine.^1,2

Case Report

Female patient aged 44 years never received any psychiatric nor disaccustoming treatment. The patient was born after normal pregnancy and labour. Her childhood was extremely bad. The patient’s mother was warm, affective, considerate, hard working, caring of her family. The father was alcohol-addicted. In alcoholic intoxication he used to painfully beat the patient’s mother, the patient and her younger sister and expelled all inhabitants from the apartment. Several times after alcohol he cut the patient’s veins. He never gave any money for keeping the family. The patient has a one-year younger sister. The patient’s mother is still alive, the father died four years ago. In primary school the patient, in spite of very bad family relations, learnt well. At the age of 16 years she left her home due to constant family rows and moved to another town. There at once she started to learn in a plastic arts secondary school from which she graduated with award being the best student in the whole school. Since her childhood she has demonstrated plastic, painting and sculpturing talents. Her economic situation made further education impossible, therefore, since obtaining of her secondary school certificate until now, she has been working as an aid in a painter’s study. She got married at the age of 25. Her marriage from the beginning until now has been unsuccessful. The patient has an “artist” nature. Her husband is very concrete, matter-of-fact, pragmatic and resolute. He completely misunderstands the patient’s emotions and feelings. He has no interests and hobbies. He is interested only in providing himself good food and comfortable night-sleep and this matters are most important for him. He is very reticent and unsociable. They have no children. The patient is gynaecologically healthy. Her husband’s sperm is completely inadequate for fertilization of the patient. In the patient’s family the father, apart from alcohol addiction had hidden schizophrenia. Possibly, the alcoholism of patient’s father was the consequence of schizophrenia. Besides that, in the patient’s family no mental diseases were present. The patient denied any head trauma and loss of consciousness. She had no major somatic diseases. The patient has been alcohol-addicted for 6-7 years. Possibly, the cause of patient’s alcoholism has been unsuccessful marriage, unsatisfied maternal instinct, very hard childhood.

The patient has on the average 3-4 times a month, 2-3 day series of alcoholic bouts. She used to drink usually great amounts of wine. She never gets completely drunk. After alcohol she is quiet, relaxed, slightly euphoric.

Dipsomania, schizophrenia and pscyhoses were excluded by psychiatric examination. No alcohol-induced psychoses develop in the patient as yet. In spite of her unsuccessful marriage she still lives with her husband. No family rows occur. Their sexual life is extremely bad. The husband treats the patient as an object serving for satisfying his animal sexual needs. The patient since many years has had one were affective partner in her work, whom she loves and who reciprocates her love and with whom she has had successful sexual life since many years.

The patient came to the author with the first episode of typical major depression. She was previously treated by another doctor with fluoxetine for four months completely without any therapeutic effect.

The psychiatric examination by the author revealed typical phase of major depression. The diagnosis was confirmed by tests according to the following scales:
- Hamilton scale
- Montgomery - Asberg scale
- DSM III and DSM IV scales
- Beck Depression Self - Assessment Inventory
- ICD - 10 scale

Analysing depression intensity it was found that this was a medium depression, according to psychiatric examination and ICD-10 scale. At the time of the first examination of the patient by the author, the patient was in a 10-day period of complete alcohol abstinence. The author at once withdrew fluoxetine and instituted individual psychotherapy and sertraline from low doses up to 75 mg daily. Complete remission of “major depression” was obtained. The author, after obtaining of complete remission, has maintained for a year constant treatment with sertraline in 50 mg daily dose in order to maintain alcohol abstinence and to treat patient’s alcohol addiction. This treatment has been supported by intensive individual psychotherapy of the patient. The patient has maintained complete alcohol abstinence.

Laboratory tests

- basic and detailed laboratory blood and urine analyses gave normal results. Only slightly abnormal liver function test results (alcoholism) were found, i.e. AspAT 58, bilirubin 2 mg%, AIAT 60, thymol test 5. After eight weeks of treatment with the oral drug Heparegan 100 mg tablets in 3 x 200 mg doses, the results of hepatic tests returned to normal,
- chest radiogram was normal,
- ECG record was normal
- EEG record was normal,
- eye fundus examination : normal,
- neurological examination: no focal and meningeal symptoms,
- physical examination: slightly yellow colour of the sclerae and soft palatine which regressed completely after treatment with Heparegen,
- cranial computed tomography; normal

Discussion

The author taking into account many factors mentioned in the introduction to the paper decided to treat “major depression” in the patient with sertraline. After obtaining complete remission of “major depression”, an attempt was undertaken to treat patient’s alcohol addiction (disaccustoming treatment) also with sertraline. The patient, being previously in “major depression” phase was ineffectively treated with fluoxetine. Fluoxetine was immediately discontinued in the patient and sertraline was instituted after 48 hour washout period. Many authors^1,2 regard sertraline as a drug significantly more effective in the treatment of major depression than fluoxetine. Some authors⁶ used sertraline in a group of patients with major depression who until recently observed alcohol abstinence. Sertraline was administered in 100 mg daily doses. The authors achieved “very significant improvement”. Other authors used sertraline in a group of alcohol-addicted persons⁵ with post-traumatic stress syndrome. The number of days increased during which the studied subjects observed abstinence and the average number of drinks consumed decreased. A part of patients reported observation of complete abstinence throughout the whole treatment period. The drug was well tolerated. Sertraline is an extremely safe,^1,5 well tolerated drug, producing very little adverse effects. It is non-hepatotoxic, causes no overloading of the circulatory system and exerts very weak cholinolytic effect. Alcohol-addicted persons have usually many underlying somatic diseases. Therefore, for treatment of such patients low-toxic drugs producing very little adverse effects will be useful. Sertraline is definitely such a drug.

References

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Professor Jan Krzysztof Podgorski, Department of Neurosurgery with Outpatient Clinic, Private Practice, Central University Teaching Hospital with Polyclinic, Armed Forces School of Medicine, Independent Public Health Care Institution.