HOW TO TREAT MENTAL DISORDERS DUE TO ALCOHOL 2025

HOW TO TREAT MENTAL DISORDERS DUE TO ALCOHOL 2025

GUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF COMMON MENTAL DISORDERS

(Enacted under Decision No. 2058/QĐ-BYT dated May 14, 2020, by the Minister of Health)

Article 7

MENTAL DISORDERS DUE TO ALCOHOL

CHIEF EDITOR

Associate Professor, PhD Nguyễn Trường Sơn

CO-EDITOR

Associate Professor, PhD Lương Ngọc Khuê

PhD Nguyễn Doãn Phương

CONTRIBUTING AUTHORS

PhD Trần Thị Hà An

MSc Trịnh Thị Vân Anh

PhD Vũ Thy Cầm

MSc Trần Mạnh Cường

PhD Nguyễn Văn Dũng

PhD Vương Ánh Dương

PhD Lê Thị Thu Hà

MSc Trần Thị Thu Hà

MSc Phạm Công Huân

MSc Đoàn Thị Huệ

Specialist Doctor II Nguyễn Thị Minh Hương

MSc Vũ Thị Lan

1. Nguyễn Phương Linh

Specialist Doctor II Nguyễn Thị Phương Loan

MSc Bùi Văn Lợi

MSc Nguyễn Thị Phương Mai

PhD Trần Nguyễn Ngọc

MSc Bùi Nguyễn Hồng Bảo Ngọc

MSc Trương Lê Vân Ngọc

MSc Bùi Văn San

PhD Dương Minh Tâm

MSc Phạm Xuân Thắng

MSc Lê Thị Phương Thảo

MSc Lê Công Thiện

MSc Vương Đình Thủy

Associate Professor, PhD Nguyễn Văn Tuấn

Specialist Doctor II Ngô Văn Tuất

MSc Đặng Thanh Tùng

MSc Vũ Sơn Tùng

MSc Cao Thị Ánh Tuyết

MSc Nguyễn Thị Ái Vân

Specialist Doctor II Hồ Thu Yến

MSc Nguyễn Hoàng Yến

CONTRIBUTORS TO EVALUATION AND FEEDBACK

Associate Professor, PhD Nguyễn Thanh Bình

PhD Vũ Thy Cầm

PhD Nguyễn Hữu Chiến

Specialist Doctor II Võ Thành Đông

PhD Lê Thị Thu Hà

Specialist Doctor II Đỗ Huy Hùng

PhD Nguyễn Mạnh Hùng

MSc Nguyễn Trọng Khoa

Specialist Doctor II Ngô Hùng Lâm

Associate Professor, PhD Phạm Văn Mạnh

Specialist Doctor II Trần Ngọc Nhân

PhD Dương Minh Tâm

MSc Đặng Duy Thanh

PhD Vương Văn Tịnh

Specialist Doctor II Lâm Tứ Trung

PhD Lại Đức Trường

PhD Cao Văn Tuân

Associate Professor, PhD Nguyễn Văn Tuấn

SECRETARIAT TEAM

MSc Đặng Thanh Tùng

MSc Trương Lê Vân Ngọc

BA Đỗ Thị Thư

Article 7

MENTAL DISORDERS DUE TO ALCOHOL

I. DEFINITION

Alcohol is a psychoactive substance, and alcohol-related mental disorders encompass a complex and diverse group of conditions that arise and develop in close association with alcohol dependence. Alcohol-induced psychosis results from the direct, prolonged impact of alcohol on the brain.

II. ETIOLOGY  

Several predisposing factors contribute to alcohol dependence: age, sociocultural influences, and genetic predisposition.

III. DIAGNOSIS  

1. Diagnosis of Alcohol Dependence

According to the International Classification of Diseases, 10th Revision (ICD-10, 1992), alcohol dependence is diagnosed when three or more of the following criteria occur concurrently for at least one month or, if present for less than one month, recur together over a 12-month period:  

– A strong desire or compulsion to consume alcohol;  

– Difficulty controlling alcohol use (onset, cessation, or quantity);  

– Physiological withdrawal state upon cessation or reduction of alcohol use;  

– Evidence of tolerance (e.g., increasing doses needed to alleviate withdrawal discomfort);  

– Progressive neglect of previous interests or pleasures;  

– Persistent alcohol use despite clear evidence of harmful consequences.  

Withdrawal Syndrome: A hallmark of dependence, this syndrome emerges upon abrupt cessation or reduction of alcohol intake. At least three of the following must be present:  

– Tremors (tongue, eyelids, outstretched hands);  

– Sweating;  

– Nausea or vomiting;  

– Tachycardia or hypertension;  

– Psychomotor agitation;  

– Headache;  

– Insomnia;  

– Malaise or fatigue;  

– Transient auditory, visual, or tactile hallucinations/illusions;  

– Grand mal seizures.  

Withdrawal duration varies from hours to days, depending on dependence severity.

2. Diagnosis of Alcohol-Induced Psychosis  

Alcohol-induced psychosis is tightly linked to alcohol use, manifesting as emotional disturbances, behavioral changes, delusions, and hallucinations. Psychiatric symptoms typically resolve within 1-6 months of abstinence.  

2.1. Alcoholic Delirium (Delirium Tremens)  

A severe, acute psychotic state, typically occurring in chronic alcoholics during physical debilitation (e.g., infection, trauma) or after relative/total abstinence or excessive consumption.  

Clinical Features:  

– Prodromal Phase: Acute or gradual onset with fatigue, anorexia, sleep disturbances, and autonomic dysfunction. Emotional changes include panic and anxiety. Symptoms worsen toward evening, with possible visual illusions or flashbacks.  

– Full-Blown Phase: Delirious or confused consciousness; vivid illusions and hallucinations; severe tremors. Common features include delusions, agitation, insomnia, and disorientation to time and place (often distorted perception of surroundings). Consciousness impairment intensifies at night. Hallucinations (visual, auditory, tactile) and persecutory delusions predominate. Systemic symptoms include limb/tongue tremors, sweating, and mild fever. Symptoms typically resolve within one week.  

Differential Diagnosis: Non-alcoholic delirium, dementia, schizophrenia.

2.2. Alcoholic Hallucinosis  

A psychotic state due to chronic alcohol use.  

Clinical Features: Acute or gradual onset, often with delusions. Predominant hallucinations: auditory, visual, tactile.  

2.3. Alcoholic Delusional Disorder  

– Jealousy Delusions: Develop in chronic alcoholism, initially during intoxication, later becoming persistent and irrational. May co-occur with delusions of being followed or poisoned.  

– Persecutory Delusions: May accompany jealousy or surveillance delusions.  

Definitive Diagnosis: Psychosis emerges during or shortly after alcohol use (within 48 hours), with hallucinations/delusions predominant. Exclude combined intoxication/withdrawal or hallucinogen use. Do not diagnose if hallucinations/delusions predate alcohol abuse or persist unrelated to alcohol.  

Differential Diagnosis: Schizophrenia, delirium tremens.

2.4. Alcohol-Induced Depression  

Clinical Features: Atypical presentation with minimal/low mood stability, irritability, aggression, fatigue, anergia, loss of interest, and reduced activity. Insomnia and nightmares are common.  

Diagnostic Criteria: Symptoms onset within two weeks of alcohol use, persisting >48 hours but <6 months.  

Differential Diagnosis: Pre-existing depression unrelated to alcohol use.

2.5. Alcohol-Induced Amnestic Syndrome  

Clinical Features: A chronic organic brain disorder (e.g., Korsakoff psychosis) occurring in late-stage alcoholism.  

Differential Diagnosis: Non-alcoholic amnestic syndromes, other organic disorders causing memory impairment, depressive disorders.

2.6. Ancillary Testing  

– Hematology: Complete blood count (pre/post-treatment).  

– Biochemistry: Glucose, urea, creatinine, uric acid; creatine kinase (CK, pre/post-treatment, daily in first week if abnormal); electrolytes (pre/post-treatment, daily in first week if abnormal); liver function (GOT, GPT pre-treatment, at 1 and 2 weeks), GGT, protein, albumin, total/direct bilirubin, lipids (cholesterol, triglycerides, LDL, HDL).  

– Coagulation Profile, Urinalysis.  

– Alcohol Levels: Blood, breath.  

– Microbiology: HIV, HBsAg, anti-HCV, syphilis serology.  

– Imaging: Chest X-ray, abdominal ultrasound, gastric endoscopy.  

– Psychological Assessments: Pre/post-treatment: Depression (HDRS, Beck), anxiety (HARS, Zung), alcohol use disorder severity (AUDIT), withdrawal severity (CIWA), personality (EPI, MMPI), sleep (PSQI), cognition (MMSE), stress-anxiety-depression (DASS).  

– Functional Studies: ECG, EEG, cerebral blood flow, CT, MRI.  

– Daily testing for abnormalities as needed.

IV. TREATMENT  

1. Treatment Principles  

Comprehensive, aggressive, long-term management combining pharmacotherapy, psychotherapy, and community rehabilitation:  

– Pharmacotherapy:  

+ Withdrawal: Fluid/electrolyte replacement, high-dose B vitamins, sedatives, antipsychotics.  

+ Psychosis: Antipsychotics, sedatives, fluids, B vitamins.  

+ Depression: Antidepressants, fluids, B vitamins.  

– Psychotherapy: Individual, family, cognitive-behavioral therapy (CBT).  

– Community Rehabilitation: Social reintegration.  

– Treat co-occurring physical conditions (liver, gastric, respiratory diseases).

2. Treatment Framework  

– Detoxification and withdrawal management.  

– Aversion therapy (drug-induced alcohol aversion) and/or relapse prevention.  

– Antipsychotics for psychosis with delusions/hallucinations.  

– Antidepressants for depression.  

– Hepatoprotective agents (aminoleban, silymarin, boganic).  

– Neuroprotective/cognitive enhancers (piracetam, ginkgo biloba, choline alfoscerate, vinpocetine).

3. Specific Treatments  

3.1. Alcohol Withdrawal Syndrome  

– Requires inpatient treatment.  

– Sedatives: Benzodiazepines (e.g., diazepam 10-30 mg/day, oral/IM/IV).  

– Antipsychotics (if delusions/hallucinations/behavioral disturbance): 1-3 agents (prefer monotherapy, switch or combine up to 3 if ineffective):  

+ Typical: Haloperidol (1.5 mg, 5 mg tabs; 5 mg vials; 5-30 mg/24h).  

+ Atypical: Risperidone (1-2 mg tabs; 1-12 mg/24h), Olanzapine (5-10 mg tabs; 5-60 mg/24h), Quetiapine (50-300 mg tabs; 600-800 mg/day), Clozapine (25-100 mg tabs; 50-800 mg/24h), Aripiprazole (5-30 mg tabs; 10-30 mg/day).  

– Fluid/Electrolyte Replacement: Ringer’s lactate, 0.9% NaCl, 5% glucose (2-4 L/day IV; oral rehydration with Oresol).  

– Vitamins: High-dose B1 (1 g/day IV), B6, B12.  

– Hepatic Support: Aminoleban, silymarin, boganic, branched-chain amino acids.  

– Nutrition: IV or oral supplementation.  

– Cognitive Enhancers, Psychotherapy, Physical/Occupational Therapy.  

– Outpatient Phase: Disulfiram (125-250 mg/day), Naltrexone (25-50 mg/day).

3.2. Delirium Tremens in Withdrawal  

– Sedatives: Diazepam (10-30 mg/day, oral/IM/IV).  

– Antipsychotics: As above (1-3 agents).  

– Fluids, Vitamins, Hepatic Support, Nutrition: As above.  

– Severe Cases: Intensive care unit transfer for aggressive resuscitation.  

– Psychotherapy, Physical/Occupational Therapy.

3.3. Alcohol-Induced Psychosis  

– Antipsychotics: 1-3 agents:  

+ Typical: Haloperidol (5-30 mg/24h), Chlorpromazine (25 mg tabs/vials; 50-250 mg/24h), Levomepromazine (25 mg tabs; 25-500 mg/24h), Thioridazine (50 mg tabs; 100-300 mg/24h).  

+ Atypical: Risperidone (1-12 mg/24h), Olanzapine (5-60 mg/24h), Amisulpride (50-400 mg tabs; 200-800 mg/24h), Clozapine (50-800 mg/24h), Quetiapine (600-800 mg/day), Aripiprazole (10-30 mg/day).  

– Anxiolytics: Benzodiazepines (5-30 mg/day, e.g., lorazepam, bromazepam), non-benzodiazepines (etifoxine 50-200 mg/day, passionflower extract).  

– Fluids, Vitamins, Hepatic Support, Nutrition: As above (1-3 L/day fluids).  

– Sleep Aids: Zopiclone (3.75-15 mg/day), melatonin.  

– Psychotherapy, Physical/Occupational Therapy, Relapse Prevention: Disulfiram (125-250 mg/day), Naltrexone (25-50 mg/day).

3.4. Alcohol-Induced Depression  

– Antidepressants: 1-3 agents:  

+ SSRIs: Fluoxetine (10-40 mg/day), Paroxetine (20-60 mg/day), Sertraline (50-200 mg/day), Fluvoxamine (100-300 mg/day), Escitalopram (10-20 mg/day), Citalopram (10-60 mg/day).  

+ Dual-Acting: Venlafaxine (75-225 mg/day), Mirtazapine (30-60 mg/day).  

+ Tricyclics: Amitriptyline (50-100 mg/day), Clomipramine (50-75 mg/day), Imipramine (10-150 mg/day).  

+ Other: Tianeptine (12.5-50 mg/day).  

– Combine with antipsychotics or anxiolytics (benzodiazepines/non-benzodiazepines) if needed.  

– Fluids, Vitamins, Hepatic Support, Nutrition, Cognitive Enhancers: As above (1-3 L/day fluids).  

– Psychotherapy: Individual, family, motivational, CBT.  

– Community Rehabilitation: Social reintegration, occupational therapy.  

– Diet: IV fluids if unable to eat; oral diet rich in nutrients, easily digestible, balanced across four food groups.  

– Treat comorbidities.

V. PROGNOSIS AND COMPLICATIONS  

Alcohol dependence is a chronic, progressive disorder requiring long-term treatment with family, institutional, and community involvement. It often leads to personality changes, psychiatric disorders, and physical health consequences.

VI. PREVENTION  

1. Preventing Alcohol Dependence  

– Educate communities on alcohol’s physical, mental, and social harms.  

– Enforce strict regulations on alcohol production, distribution, and use.  

– Target high-risk groups: families with alcoholics, individuals in crisis, psychiatric patients.

2. Preventing Alcohol-Induced Psychosis  

– Aggressively treat alcohol abuse/dependence and prevent relapse.  

– Manage co-occurring physical disorders and enhance B vitamin intake.

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