We all have times in our lives when we feel down in the dumps. Sadness is a normal part of the human experience. Feelings of apathy and pessimism strike even the most energetic and optimistic among us. For most people, these negative emotions are relatively short-lived. We shake them off and get on with life. For some individuals, however, these negative feelings persist. Rather than lasting for a few hours or a few days, they continue for weeks, months, or even years. When the person’s ability to carry out daily tasks or their ability to meet work, family, or social obligations is also impaired, it’s a sign of depression.
Depression can affect anyone, regardless of race, gender, age, or socioeconomic status. Children, teens, and the elderly battle depression. Celebrities at the peak of their career, star athletes, and those who appear to live charmed lives are not immune.
Unfortunately, like other psychiatric disorders, depression can make an individual more vulnerable to developing an alcohol or substance use disorder. Alcohol and drugs are often used to self-medicate, providing at least short-term relief from the dark cloud of depression. That being said, it’s not always the depression that comes first. For some, depression is the result of substance abuse and addiction. Regardless of which comes first, co-occurring or comorbid depression and substance use disorder (SUD) can be difficult to treat.
What is Depression?
Depression is a mood disorder that negatively affects a person’s thoughts, emotions, and behavior. It’s one of the most common psychiatric disorders known. Symptoms of depression can range from mild to severe. Depression can make it difficult to impossible to get through the day. Most cases of depression are treatable with therapy or a combination of therapy and medication. Sadly, some people never seek treatment. Left untreated, the symptoms of depression may last for months or even years. Statistics show that approximately 85% of those who have one episode of depression will have future episodes.
Different Types of Depression
Quite often, when people talk about depression, they’re referring to major depressive disorder.
However, the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-V), the go-to manual for the diagnosis of mental health disorders, identifies several different types of depression:
- Major depressive disorder (also called major depression). This is what most people are talking about when they say “depression.”
- Persistent depressive disorder (formerly called dysthymic disorder). This consists of a low-grade chronic depression lasting at least 2 years in adults.
- Substance-induced mood disorder. In this type of depression, symptoms are caused by a substance or medication such as alcohol, benzodiazepines, or opioid pain medication.
- Seasonal affective disorder (SAD). In this type of depression, symptoms occur seasonally, typically during the winter months.
- Premenstrual dysphoric disorder (PMDD). These depressive symptoms are specific to premenstrual syndrome.
- Peripartum depression. This type of depression occurs during pregnancy or following childbirth.
- Bipolar disorder. This disorder includes depressive episodes that alternate with manic or hypomanic episodes.
- Adjustment disorder with depressed mood. Also known as situational depression, depressive symptoms are triggered by a specific life event or trauma.
- Psychotic depression. This is major depressive disorder (see above) with psychotic symptoms.
Symptoms of Depression
Symptoms of depression vary from one person to the next. The most common symptoms include:
- Persistent feelings of sadness
- Frequent crying or tearfulness
- A sense of hopelessness
- Excessive guilt
- Feelings of worthlessness
- Restlessness or agitation
- Low energy levels
- Increased isolation and/or withdrawal from family and friends
- Changes in appetite or weight
- Sleep disturbances, particularly waking up early or difficulty getting out of bed at all
- Difficulty concentrating
- Difficulty making decisions, even those that are small or simple
- Loss of interest in hobbies and activities that used to enjoyable
- Physical complaints (e.g. aches or pains that have no identifiable medical cause)
- Frequent thoughts of death
- Suicidal thoughts, ideation, or attempts
Disorders that often Co-Occur with Depression
It’s not uncommon for individuals who struggle with depression to have one or more other mental health disorders as well. Some of the most common co-occurring disorders include:
- Alcohol or substance use disorders
- Anxiety disorders, particularly social phobia, panic disorder, and generalized anxiety disorder
- Borderline personality disorder
- Eating disorders
- Obsessive-compulsive disorder
- Posttraumatic stress disorder
Here are a few statistics regarding the prevalence of depression:
- Women experience depression at nearly twice the rate of men
- Over 8% of American adults (20 years and older) experienced a depressive episode, during a two-week period, between 2013 and 2016
- Rates of depression in American adults have remained fairly stable over the past decade
- Depression is the number one cause of disability throughout the world
Challenges of Comorbid Depression and SUD
Depression by itself can create many problems in a person’s life – relationships suffer, job performance diminishes, and financial problems begin to snowball. Financial problems may be due to decreased work hours caused by frequent absences, difficulties finding or keeping a job, or treatment costs either not covered by existing insurance or when there’s no insurance at all. When addiction is also part of the picture these problems are inevitably magnified, and a person’s life can quickly spiral out of control. Legal problems and mounting legal expenses (e.g. due to a DUI or other substance-related criminal charges, such as possession or theft) can create further financial, emotional, and relationship strain.
To make matters even worse, both disorders still have stigma attached to them.
One of the greatest challenges of comorbid depression and SUD, however, is an increased risk for suicide. Suicidal ideation is a common symptom of depression. While many individuals with depression never act on their suicidal thoughts, a significant percentage attempt to commit suicide. When substance use is part of the picture – particularly alcohol – the risk of suicide is especially high. Alcohol has a disinhibiting effect, meaning the usual self-restraints that may keep an individual from acting on his or her suicidal thoughts when sober are weakened significantly when intoxicated.
Individuals with comorbid depression and SUD, who have a history of suicide attempts or who are struggling with suicidal thoughts, may need a period of inpatient treatment in order to help ensure their safety. It’s vital that suicide history and suicidal ideation be assessed at the beginning of treatment, and closely monitored and addressed as warranted throughout the course of treatment
The Connection Between Depression, Substance Use Disorder, and Addiction
As mentioned earlier in the article, some individuals who struggle with depression turn to alcohol or drugs to self-medicate their symptoms. Stimulants such as methamphetamine, cocaine, and medications prescribed for ADHD (e.g. Adderall) can boost low energy levels. Alcohol, marijuana, and sedating drugs, such as benzodiazepines or opioids, can provide a temporary escape from painful emotions and negative thoughts.
Unfortunately, each time the substance brings any kind of relief, it reinforces the desire to use that substance again. And again. Over time, this leads to an increased tolerance for the substance and can result in dependence or the development of an alcohol or substance use disorder. Also, when individuals come down from some substances, particularly stimulants, the depressive symptoms seem more pronounced. This can make the desire to use even greater.
Sometimes depression is a physiological result of excessive, prolonged substance use. For example, studies have shown that alcohol dependence can cause lower levels of serotonin. Serotonin is a neurotransmitter that helps regulate mood. Dopamine, a neurotransmitter that helps regulate emotions, is altered by cocaine and other substances.
Depression can also be triggered by the situational problems caused by substance use disorder. When an individual’s substance use starts creating relationship, financial, work, and/or legal problems, depression may develop. Quite often, the more one’s life falls apart due to the use of alcohol or drugs, they more they may be tempted to cope by using them.
Treatment for Comorbid Depression and Substance Use Disorder
Whenever depression co-occurs with substance use disorder, it’s crucial to treat both disorders simultaneously with a dual diagnosis treatment approach. Treating only the substance use disorder or only the depression, without addressing the other, is not as successful as treating them both simultaneously.
Therapeutic approaches may include:
Cognitive Behavioral Therapy (CBT)
Years of research have found that cognitive behavioral therapy is one of the most effective treatments for major depression and other types of depression. Negative thought patterns and distorted underlying beliefs play a major role in depression. They fuel feelings of depression and lead to self-destructive behaviors, such as using substances. Cognitive behavioral therapy focuses on helping individuals recognize and change these irrational thought patterns while identifying and modifying unhealthy core beliefs.
Most addiction treatment programs include group therapy in their arsenal of therapeutic modalities. Unlike individual therapy, group therapy gives individuals struggling with SUD and comorbid depression the opportunity to discuss the challenges they experience with others who can relate to them. Since individuals with depression often withdraw from others, group therapy can help diminish the painful feelings of loneliness and isolation.
Many individuals with depressive disorders respond well to medication. Antidepressants and other drugs can help alleviate the depressed mood as well as other symptoms, such as difficulties sleeping, that frequently accompany depression. It’s important to note that, while medication can be very helpful, it often takes several months of trial and error to determine which medication will be the most beneficial without too many side effects. Medications may also be a necessary aspect of treatment to alleviate symptoms of withdrawal and help with cravings.
Both substance use disorder and depression always affect the whole family. Depressive disorders do as well. That’s why family therapy is a crucial part of treatment for comorbid depression and SUD. Family therapy can help family members understand how depression and SUD fuel each other and create unique challenges for those struggling with both. It also helps the entire family address and process their emotions in a safe setting, work on communicating more effectively with each other, and learn how to provide support in an appropriate way without enabling.
Dialectical Behavior Therapy (DBT)
Dialectical behavior therapy is a specific form of cognitive behavioral therapy. It targets four key areas: emotional regulation, interpersonal effectiveness, core mindfulness, and distress tolerance. By learning and applying new skills in each of these areas, DBT can help alleviate mood symptoms and reduce the urge and perceived need to self-medicate with substances. Dialectical behavior therapy can be especially effective for individuals struggling with persistent suicidal thoughts.
Treatment Goals for Comorbid Depression and SUD
The primary goals of dual diagnosis treatment for comorbid depression and substance use problems are to help individuals achieve initial sobriety and/or abstinence, alleviate symptoms of depression, reduce or eliminate cravings for drugs and alcohol, learn effective ways to manage both disorders, and maintain their sobriety after treatment ends. When individuals who live with both depression and substance use disorder participate in evidence-based, integrated treatment, they can do all these things. They have a chance to move forward toward a life guided not by the symptoms of their substance use or depressive disorder, but rather, by their choice and their personal vision of happiness.