Depression and Substance Use Disorders

My childhood hero, Hall of Fame centerfielder for the New York Yankees Mickey Mantle, the brilliant entertainer Robin Williams, and astronaut Buzz Aldrin all suffered from depression and a substance use disorder (SUD). Sadly, Robin Williams’s life ended a few months ago when he committed suicide, the risk of which increases significantly with depression. And when a SUD is also involved, the risk is even greater. 

This combination of disorders is common among individuals in treatment. About one in three people with a SUD will experience a clinical depression during their lifetime. Studies show that individuals with a current or lifetime depression are two to seven times more likely to have a SUD. Studies also show high rates of depression among clients with SUD, especially women.  While depression is common with SUDs, it is also common with anxiety disorders, posttraumatic stress disorder (PTSD), eating disorders, personality disorders, nonsubstance addictions, and other disorders.

There are several depressive disorders in DSM-5, but the most common are major depression (single episode or recurrent), persistent depressive disorder (previously called dysthymia in DSM-IV), and substance or medication induced depressive disorder. Depressive disorders affect over 15 percent of the population with major depression being the most common. The groups with the highest rates of depression are American Indians and Alaskan Natives, women, and young adults between eighteen and twenty-five years of age.  

Depressive disorders are separated from bipolar disorders in DSM-5, but many people with bipolar illness experience depression. Common features across depressive disorders include:

• Feeling sad
• Feeling empty
• Irritable mood
• Feeling worthless
• Excessive guilt
• Hopelessness
• Sleep and/or appetite disturbance
• Low energy
• Agitation
• Retardation
• Diminished ability to think or concentrate
• Indecisiveness
• Recurrent thoughts of suicide  

Even with improvement, some clients have symptoms that persist and become chronic.

Over seven hundred behavioral health professionals who completed surveys identified depression and SUD to be an issue of high interest to them. I believe the reasons for this are the high rates of these disorders in behavioral health care settings; the increased risk for suicide associated with depression and SUDs; significant negative impacts across patients’ and families’ lives of these disorders; and each disorder affects the other as well as response to treatment or recovery.

The most common psychological treatments for depression are cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT). CBT is the most widely used therapy, and is effective with mild to moderate cases of depression. However, medicine can supplement therapy if sufficient relief is not achieved.

There are many medications for depression, but none appear to be superior. Medications are often used in conjunction with therapy or counseling. Electroconvulsive therapy is effective with severe cases of depression that do not respond to other treatments, or if medications cannot be taken. Light therapy is safe, effective, and well-tolerated with seasonal depressive disorder.    

Effective psychosocial treatments for SUDs include individual—CBT, individual drug counseling, Twelve Step facilitation, motivational incentives, and others—group, marital, and family therapies, as well as therapies that combine these approaches. In addition, there are FDA approved medications for opioid, alcohol, and nicotine dependence. Medications for opioid and alcohol dependence are usually used in combination with psychosocial treatments and mutual support programs.  

When possible, provide integrated care and address both disorders.  The initial focus is usually on stabilizing the client from acute symptoms of depression, facilitating abstinence from substance, and addressing problems that contribute to, or worsen, these disorders.  For those in psychiatric hospitals due to the severity of  depression, or in rehab due to an addiction, a key issue is linking the client with follow up care after discharge. Other ways to help include:

1. Assess depressed clients for SUDs and assess clients with SUDs for depression. A thorough evaluation determines diagnoses and can be used to develop an integrated treatment plan. Clinical interviews and pen and paper inventories (e.g., Beck Depression Inventory, Hamilton Rating Scale for Depression, Drug Abuse Screening Test, etc.) can help identify these problems and their severity. Be sure to assess for bipolar disorder if depression is the main mood disorder present.
2. Provide information and address questions related to either disorder. Clients benefit from understanding symptoms, how disorders interact, treatment options, and recovery programs. For example, maintenance treatment of recurrent major depression is different than that for a first episode of major depression. Alcohol or marijuana use raises the risk of relapse to cocaine.
3. Assess suicidality (intent, methods, reasons, protective factors). Most people who attempt or complete suicide are depressed. Risk factors include a recent loss (relationship, job, health), prior attempt or current plan, lack of support, inability to accept help, suicide by a significant other, and the burden of a chronic depression. You may reduce suicide if you help the client catch signs of psychiatric relapse early, discuss suicidal thoughts, feelings or plans, seek safety if there is an imminent risk of suicide, avoid substance use, have activities to calm or comfort self, review reasons for living, call a confidante, professional or crisis line, going to the ER or build on protective factors like spiritual beliefs, social support or meaning in life.  
4. Provide information and options for medications to clients with more severe forms of depression or dependence on opioids, alcohol or nicotine. Facilitate an evaluation with a physician, monitor adherence, and discuss the potential impact of substance use on medications as well as recovery. For clients with depression that is part of a bipolar disorder, lithium reduces the risk of suicide.
5. Address the SUD. Facilitate abstinence and monitor substance use since the efficacy of medications is affected by substances, which can lower the client’s motivation. Help clients understand and manage obsessions and cravings for substances, resist social pressures to use, manage feelings that could impact on relapse, establish and use a support network, and know the potential impact of depression on recovery from a SUD.
6. Promote recovery. For more severe depressions or addictions, recovery is a long-term process that requires commitment, hard work, and the use of skills to manage the challenges of recovery (e.g., refuting distorted thinking that contributes to depression, asking others for help or support).
7. Focus on managing emotions and moods. Clients benefit from learning to discriminate feelings of depression from a clinical disorder, especially in the early phases of recovery when depression is common. Some need help with anxiety, anger, boredom, grief, loneliness, guilt or shame. Inability to manage negative emotions is a cause of relapse to SUDs. Clients can also benefit from focusing on positive emotions such as gratitude, forgiveness, and love.   Using a daily log to rate depressive symptoms or other emotions helps the client increase awareness of moods and emotions, the context in which these occur, and what coping strategies are most effective. Clients with persistent mood symptoms that never totally remit can use a daily log to see improvements over time or identify any significant worsening of depressive symptoms.
8. Change inaccurate, faulty or “stinking” thinking. CBT and related interventions help clients understand and challenge distortions such as expecting the worse outcome, awfulizing or disqualifying the positive. Helping clients challenge addictive, also called “stinking,” thinking such as “I need alcohol or drugs to have fun,” “Recovery is a drag,” “I had a drink and blew my recovery so why even bother” can help sustain recovery.
9. Involve the family. Families or significant others can provide support, provide input to professionals, and help themselves through expression of their own needs. They may also get involved in treatment and/or recovery for themselves (e.g., Alanon, Naranon, NAMI groups) to learn ways to cope with the disorders and manage their own reactions.
10. Evaluate and enhance relationships. Helpful interventions include identifying and resolving interpersonal problems, improving social skills, addressing role transitions, and building a support network. Some clients need help learning how to ask others for help or support.
11. Facilitate lifestyle change. Participating in pleasurable activities, developing new leisure interests, using a daily or weekly plan, exercising regularly, meditating, and using relaxation techniques all can aid recovery. Some will need help with sleep, hygiene or money management—especially those with bipolar illness.
12. Facilitate involvement in mutual support programs. You can educate and provide options for mutual support programs (MSPs). While Twelve Step programs are the most widely available and used, some clients prefer other options, including online meetings. Explore common resistances to engaging in MSPs. When possible, link the client to specific groups or individuals in recovery who can facilitate their use of MSPs.
13. Address relapse and recurrence. Outcome studies show high rates of relapse to SUDs and recurrence of depression. For SUDs, the risk of relapse is higher during the initial ninety days of recovery and within the first year. About half of individuals with major depression will have a recurrence. Strategies to reduce relapse risk include monitoring and addressing adherence problems when they arise; identifying and managing high-risk factors and early signs of relapse; and preparing the client to take quick action should depression return or worsen or substances are used. Clients with more severe addictions and/or recurrent major depression benefit from long-term involvement in professional care and MSPs.
14. Address sleep problems. Some clients have difficulty falling or staying asleep or have early-morning awakening, any of which can adversely affect attention and concentration, cause fatigue, anxiety or irritability. Strategies to improve sleep include using relaxation or calming techniques prior to bedtime, reducing time in bed, getting up at the same time each day, not going to bed unless sleepy, not staying in bed for longer than a half-hour if one cannot sleep, changing thoughts and beliefs that contribute to difficulty sleeping, and not using alcohol or caffeine prior to going to bed. If these do not work, medications may help. Benzodiazepines are usually contraindicated for clients with SUDs due to their abuse potential.

• The combination of depression and a SUD often responds well to treatment, especially when it is integrated and focuses on recovery from both disorders.
• Clients may experience depression when they stop using substances. For many, this improves as sobriety progresses. For others, depression worsens after they stop substance use.
• Clinical attention needs to be paid to suicidality given the high rates of attempts and completions among depressed individuals.
• These disorders create distress and problems for families and significant others, yet many programs or clinicians do not include family and significant others in the treatment.

• If you work in a psychiatric setting, do you screen clients for substance use to determine if a problem exists and if so, do you focus on both disorders?
• If you work in an addiction setting, do you screen clients for clinical depression and if a problem is assessed, do you focus on both disorders?
• Given the risk of suicide, do you routinely assess suicidality with your clients?
• Do you address the impact of these disorders on the family, or work with clients to address family issues?