What approaches have you found most helpful for concurrent severe major depressive disorder and alcohol use disorder? 

I'm a strong believer in AA for alcoholics, to address the addiction and also the depression, as the social support offered there can be very helpful. A person agreeing to "work the steps" with a sponsor has more in-depth character restructuring and available support than most therapists can provide.

In addition, if someone wants to quit drinking, I offer antabuse. In addition to blocking alcohol metabolism, it works psychologically. If the person takes the pill in the morning, they don't have to struggle with temptation all day; they have made their decision for the day already. Many find this helpful.

Antidepressants can be helpful, but as long as someone is drinking, they are depressing themselves with the depressant called alcohol, so I...

I hate to sound flippant, but always the most helpful intervention is to listen, understand, and engage motivationally. We aren't going to be able to help if we don't deeply understand. We don't want to treat a PHQ-9 score or a response on an AUDIT-C. Try to understand the story of how depression became part of their life, what triggers it, and how it manifests. Understand the same about alcohol, in particular, what function it serves. (It is doing something that some part of the patient finds helpful, even if overall it's not a healthy thing.) Part of them may not want to change their use, so you're going to have employ your MI skills. (Want a free/cheap tool to hone your MI skills? https://www.wv-mi.com/mi-and-ai is an AI tool that create...

Depending upon what’s been tried already, I found TMS to be extremely helpful, i.e., greater than 75% of the time. It certainly addresses the severe major depressive diagnosis, but also has an improved effect on a patient’s desire to imbibe in addiction-type behavior. Also, having a good psychiatrist/addictionist who does eclectic psychotherapy could be life-saving for folks who suffer from the ravages of addiction behavior and other psychological disorders.

The question doesn't address whether the depression is refractory or the patient is suicidal, so taking the question at face value, I would say that it would be important to treat the depression with antidepressants (explaining to the patient the danger of excessive alcohol and antidepressant use and the depressing effect of alcohol and negative impact on judgement and potential suicidality) and to have the patient attend AA and an outpatient addiction program. For a very motivated patient, I have had 100% success with acamprosate (very motivated because of 3x/day dosing). Of course, psychotherapy and a positive relationship are essential. Involving family members (with the patient's consent, of course) can be very useful. And of course, if...

Starting natrexone even after a first visit can help engage people in treatment for their other conditions. AA is not sufficient or for everyone, despite its many benefits. Women in particular may find both the structure and the principle of "let go, let God" disempowering. Using medication to convince people that they can regain control of their drinking behavior, without having to commit to total permanent sobriety, can itself relieve depression. Attending to the problem of how change from drinking to not drinking may disrupt important relationships also has value. AA is a form of network transplant that not everyone needs...

As a psychiatrist & psychoanalyst, I have found that even someone attending AA, taking an SSRI, and seemingly participating in therapy enthusiastically...you can guess the rest is prevaricating about their drinking & only discovers when some disaster occurs! Maybe that's just the way it must first go with some highly bright folks until they're ready to work.