Alcohol and Alcoholism Vol. 34, No. 6, pp. 916-917, 1999
© 1999 Medical Council on Alcoholism
Letters to the Editors
SECONDARY DEPRESSION IN WEANED ALCOHOLICS: IMPLICATIONS OF LESCH'S TYPOLOGY OF CHRONIC ALCOHOLISM
Clinic of Psychiatry, University Hospital Eppendorf, Martinistr. 52, D-20246 Hamburg and
1 Clinic of Psychiatry, University of Erlangen–Nueremberg, Schwabachanlage 6–10, 91054 Erlangen, Germany
Received 9 February 1999; first review notified 19 April 1999; accepted 5 May 1999
Schuckit (1983) described two types of alcohol-related depression: (1) the common type, in which secondary depression disappears without treatment within the first few weeks of abstinence; (2) a less frequent type, primary depression, requiring specific treatment. It is difficult to anticipate whether an alcoholic patient needs antidepressive treatment or whether depression will remit spontaneously. A potential guide to differentiate depressed alcoholic patients who might need specific treatment for depression could be the typology of Lesch et al. (1990). Based on the course of the illness, Lesch established four subtypes of alcoholism, taking into account social, psychic and somatic factors: (1) Type 1 is characterized by early withdrawal symptoms and frequent alcohol-related psychoses and convulsions; (2) Type 2 exhibits pre-morbid conflicts and anxiety; (3) Type 3 emerges from a permissive alcoholic milieu and shows pre-alcoholic mood changes; (3) Type 4 has pre-morbid cerebral injuries and serious social problems.
We studied depressive syndromes in a consecutive series of 36 (of 45 screened) male inpatients in a closed detoxification ward for 5 weeks, during which abstinence was monitored by alcohol and drug screening. All were primary alcoholics according to Schuckit (1985), namely, no other psychiatric illness was present at the time when alcohol abuse began or earlier. Alcohol dependence was diagnosed according to ICD-10 and DSM-III-R (integrative check-list, The Plinius Maior Society, 1994) with a minimum of five positive items (mean ± SD: 8.2 ± 1.8). Exclusion criteria were: any psychiatric co-morbidity, a positive drug screening for benzodiazepines, barbiturates, opiates, amphetamines or cannabinoids at onset or at weekly urine checks; any psychopharmacological treatment during the study, except clormethiazole up to 10 days after admission; relapse into alcohol intake. The patients were aged between 25 and 52 (mean 36.8 ± 6.8) years. The mean weight was 77.2 (± 12.2) kg. The mean age of first alcohol-related problems was 23.3 ± 8.1 years. Three and 5 weeks after admission, an independent interviewer completed the 21-item Hamilton Rating Scale for Depression (Ham-D; Hamilton 1960). Patients were typed on admission according to Lesch's method.
The study protocol was approved by the Ethics Committee for human experiments, and written informed consent was given by each participant. For the statistical analysis, one-way analysis variance (ANOVA) with correction of the 
-error by the Tukey HSD-test and Student's t-test were used.
As shown in Fig. 1
, after 3 weeks, the Ham-D score differed significantly (F = 8.3; P < 0.001) between Lesch's four subtypes. Type 3 (n = 10; Ham-D: 15.3 ± 4.7) scored significantly higher than Type 1 (n = 9; Ham-D: 5.4 ± 4.1) and Type 4 (n = 7; Ham-D: 7.3 ± 3.0). After 5 weeks, nine patients had discontinued therapy and dropped out of the study. Ham-D scores of the 27 remaining subjects were still elevated significantly in Lesch Type 3 (n = 7; Ham-D: 14.9 ± 9.2, F = 4.1; P < 0.05), whereas in Type 1 (n = 5; Ham-D: 4.4 ± 3.0) and Type 4 (n = 6; Ham-D: 4.7 ± 2.7) scores remained low. In Type 2, a significant decline in scores was observed (n = 10; Ham-D: 10.5 ± 5.7 to n = 9; 6.3 ± 6.4, P < 0.03). The stability of depressive symptoms in Type 3 could indicate, according to Lesch et al. (1988), the primary psychic susceptibility of this group. It is important to note that a bias for self-rating evidence is not the case here. Secondary alcoholics according to Schuckit (1985), who received psychiatric treatment for depressive syndromes, anxiety disorders, etc., before onset of their chronic alcoholism, or by whom such pre-alcoholic episodes could be anamnestically traced, as well as alcoholics with a co-morbidity of an affective disorder were excluded from the study. Primary alcoholics were typed as Lesch's Type 3 when they described drinking alcohol especially as compensation for lethargy, sleep disorders and lack of motivation, and gave a history of intervals of moderate or no alcohol consumption (Lesch et al., 1990). Typing the patients of our sample according to Cloninger et al. (1981) revealed no significant group difference in Ham-D scores.
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Conclusion
Amongst the group of primary alcoholics with secondary depression an alcoholic subgroup (Lesch's Type 3) is present that shows a stable depressive syndrome despite continuing abstinence. The course of depressive symptoms taken by this group significantly differs from other Types of alcoholics (Lesch et al., 1988). Lesch's Type 3 alcoholics who are depresssed may merit treatment with antidepressants. These preliminary observations regarding the course of depression in Lesch's Type 3 and also Type 2, and the impact on possible therapeutic consequences, need further investigation on a larger sample.
FOOTNOTES
* Author to whom correspondence should be addressed. 
REFERENCES
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Lesch, O. M., Dietzel, M., Musalek, M., Walter, H. and Zeiler, K. (1988) The course of alcoholism. Long-term prognosis in different Types. Forensic Science International 36, 121–138.[Web of Science][Medline]
Lesch, O. M., Kefer, J., Lentner, S., Mader, R., Marx, B., Musalek, M., Nimmerrichter, A., Reinsberger, H., Puchinger, H., Rustembegovic, A., Walter, H. and Zach, E. (1990) Diagnosis of chronic alcoholism — classificatory problems. Psychopathology 23, 88–96.[Web of Science][Medline]
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