Treating Depression

with a Co-occurring Substance Abuse Disorder
& Addiction

Depression comes in many forms – If you believe you or a loved one is suffering from depression, contact a medical professional for an appropriate diagnosis.

The leading cause of disability around the world is not a physical disease, but a serious mood disorder known as depression, according statistics from the World Health Organization (WHO). WHO states that over 350 million people suffer from depression worldwide, and that only about 50 percent of these individuals will ever receive treatment. In the United States, over 15 million adults experience an episode of clinical depression in any given year (close to 7 percent of the population), according to the Anxiety and Depression Association of America. Depression has a severe impact on physical and emotional wellbeing, as well as personal relationships, occupational status, and financial health.

depression rate americans
Unlike ordinary sadness or grief, which occur temporarily after a loss, the symptoms of depression occur nearly every day for weeks — sometimes months or years — interfering with all aspects of an individual’s life. Depression can increase the risk of chronic illness, including the disease of substance abuse. Current Opinion in Psychiatry estimates that up to a third of clinically depressed people engage in drug or alcohol abuse. These chemical intoxicants can become a form of self-medication for soothing the feelings of low self-worth, hopelessness, and despair that characterize this psychiatric illness.
substance abuse and depression

Although substance abuse may be used to relieve symptoms, chemical intoxication can actually make depressive episodes more severe, increasing the frequency and intensity of negative thoughts and self-destructive behavior. A rehab program that addresses both depression and addiction may help to stop the progression of both disorders and empower the individual to build a healthy, sober life.

Recognizing Depression vs. the Blues

How does depression differ from a long case of the blues? It is important to remember that a mood disorder like depression is not the result of bereavement or a personal setback, such as the death of a loved one or loss of a job, but a chronic, progressive illness that may get worse without treatment. To meet the diagnostic criteria for depression established by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5),

a person must experience five or more symptoms of the disorder almost every day for at least two weeks, and these symptoms must not be related to a coexisting medical condition or the effects of substance abuse:

A low, depressed mood

A loss of pleasure or interest in daily activities

Persistent feelings of self-hatred, worthlessness, or guilt

Sleep disturbances (sleeping too much or too little)

Unintentional weight loss or gain

Physical fatigue

Low energy levels, with slower than usual responses and movements

Problems with concentration or memory

Persistent, intrusive thoughts about death or dying

Suicidal ideation or suicide attempts

The symptoms of depression cause noticeable problems with work, school, family life, and social relationships. People experiencing a depressive episode may have trouble getting out of bed in the morning due to a lack of energy, fatigue, and a loss of motivation. They may lose interest in hobbies or pursuits that they were once passionate about or avoid activities that used to give them pleasure. They may be frequently tearful, talk about harming themselves, or become obsessed with thoughts and images of death.

For the loved ones of a depressed person, dealing with the symptoms can be both frightening and frustrating. It is normal to try to cheer up a friend or to encourage them to “snap out of it”; however, depressive symptoms do not respond to these offers of help. The only way to treat this serious disorder effectively is through professional therapeutic interventions, such as behavioral modification, support groups, motivational therapy, and antidepressant medications.

Types of Depressive Disorders

Depression can take several different forms based on the severity, duration, and cause of its symptoms. According to Dialogues in Clinical Neuroscience, depression may be best understood as a spectrum of moods rather than a series of separate, clearly defined categories. For the sake of diagnosing and treating this serious disorder, psychiatric experts have identified several categories. Along with these categories, there are a number of depressive disorders associated with specific life stressors, psychological conditions, or emotionally taxing situations. These situational disorders share many of the symptoms of general depression, but they occur under specific circumstances and may resolve once these situations are changed.

Listed below are the most common subtypes of depression:

major depression signsmajor depression signs2Major depressive disorder, or MDD, is characterized by at least two weeks of a low, depressed mood, along with four or more additional symptoms of depression, such as suicidal thoughts, a loss of physical energy, sleep disturbances, or feelings of low self-worth. MDD is one of the most common forms of mental illness. The National Institute of Mental Health states that in 2013, nearly 16 million American adults, or almost 7 percent of the adult population, had at least one major depressive episode.

Also known as dysthymic disorder, or dysthymia, this condition is marked by low moods and depressive symptoms that continue for two or more years. Individuals with persistent depressive disorder may appear to be chronically gloomy, irritable, or moody, but these traits could actually be signs of a mood disorder. Symptoms may not be as severe as the signs of a major depressive episode, but the effects on quality of life can be just as severe.

Depressive episodes alternating with periods of high energy, elation, or impulsive behavior may be signs of bipolar disorder. Many individuals with bipolar disorder experience episodes of major depression that last for weeks or months, with less frequent cycles of energetic activity and elevated mood. It can be difficult to diagnose an individual with bipolar disorder without tracking these mood changes over an extended period of time

postpartumHaving a baby is a life-altering experience, but for many women, the transition to motherhood causes emotional difficulties. The American Psychological Association estimates that up to 16 percent of women will have depressive symptoms after giving birth. New mothers with a history of depression or anxiety, women under financial or personal stress, and women with inadequate social support are especially vulnerable to postpartum depression. Hormonal imbalances after pregnancy, nutritional deficiencies, and exposure to chemical toxins may also play a role in this form of depression.

Also known as seasonal affective disorder, or SAD, this condition is triggered by changes in light and temperature that accompany the seasons of the year. People with SAD may report lower moods, loss of energy, sleep disturbances, and weight changes at specific times of the year. Although most people with SAD experience depression in the darker winter months, some individuals are negatively affected by the transition from winter to spring.

In psychosis, the individual experiences a break with reality, in which the person may see or hear things that aren’t there (hallucinations), or believe things that aren’t real (delusional thoughts). People with other forms of depression may be affected by periods of psychosis, in which they feel persecuted or pursued by others, or believe that unseen entities are telling them to harm themselves. Psychotic depression is usually temporary, but it may result in hospitalization and the need for immediate, acute treatment.

All types of depression require prompt attention and intensive, specialized treatment. Recognizing the signs and symptoms of depression, and being willing to provide support to someone experiencing those symptoms, can prevent serious harm to the individual and loved ones.

Investigating the Causes of Depression

Depression is one of the most common, and most debilitating, mood disorders, yet researchers still haven’t determined the exact cause of this condition. There are several popular theories about the roots of depression, including the following:
Brain structure

The National Institute of Mental Health notes that the brains of some individuals with depressive disorder are structurally different from those who do not have depression. MRI imaging studies reveal that the areas of the brain that are responsible for mood, cognition, metabolic function, and sleeping have a unique appearance in people who have serious mood disorders.

Environment and childhood experience

A disorderly home environment or a history of physical, sexual, or emotional abuse in childhood can increase the chances of developing depression in adolescence or adulthood. Trauma therapy can be extremely useful for processing unresolved memories and healing the suppressed emotional wounds that can contribute to depression later in life.


The neurological differences that distinguish people with depression are at least partly hereditary. According to Stanford University, genetic research shows that people who have a close relative, such as a parent or sibling, with depression are 20-30 percent more likely to suffer from depression themselves. Unlike diseases that are linked to a specific, defective gene, such as cystic fibrosis, depression is more likely to be linked to several genes.

depression and genetics rate increase
Situational factors

Although the losses that we all experience do not necessarily cause depression, a severe setback can trigger a depressive episode. For instance, the death of a loved one or a bitter divorce could send a person into a period of grief and bereavement, which may turn into depression if the emotions surrounding that loss are not adequately resolved. Unlike bereavement, depression is often accompanied by feelings of worthlessness, self-loathing, or the desire to die.

Brain chemistry

Neurologists and pharmacologists have long pursued the connection between brain chemistry and depression in an effort to offer solutions to this disabling condition. Depression has been linked to imbalances in the brain chemicals, or neurotransmitters, that regulate emotional states, moods, energy levels, and appetite, such as serotonin, norepinephrine, and dopamine.

As with other types of chronic mental illness, there are usually several factors involved in the development of depression. A family history of depression, for example, may be combined with a history of past trauma or the breakup of a marriage to make an individual more vulnerable to depression.

Depression and Addiction

Research has revealed that many of the factors that contribute to depression also play a part in substance use disorders. Imbalances in brain chemistry, family history, and past trauma, for instance, are frequently involved in both depression and addiction. In addition, the physical and psychological effects of addiction may mask the signs of depression or worsen the symptoms of this psychiatric illness.

Psychiatric Times notes that there is a strong connection between alcoholism and major depression. In a nationwide study of 43,093 adults age 18 years and over, for those found suffering from a current alcohol addiction, the was evidence that over 20 percent of them also met the criteria for that of a comorbid major depressive disorder.

Alcoholism and Mood Disorders

Survey respondents in search of treatment for an alcohol use disorder were over 40 percent more likely than the general population to have at least one mood disorder.

There is a strong connection between alcoholism and major depression.

Alcohol is a central nervous system depressant that may initially function as a stimulant, but that quickly intensifies feelings of lethargy, drowsiness, and depression. Alcohol use, which lowers inhibitions and impairs judgment, also increases the risk that a depressed individual will attempt suicide. According to the American Association of Suicidology, at least half of individuals who attempt suicide have some form of depression, and people with depression are 25 percent more likely than non-depressed individuals to display suicidal behavior.

Treatment for Co-occurring Disorders

Alcohol and drug abuse can worsen the course of a depressive disorder by aggravating the symptoms of depression, increasing the likelihood of hospitalization, and interfering with the course of treatment. Individuals who are being treated for depression while using drugs or alcohol are unlikely to see positive outcomes from therapy. Substance abuse impairs motivation and decreases the effectiveness of therapeutic interventions. In addition, alcohol or drugs can have dangerous interactions with the medications used to treat depression.

The most effective approach to treating depression is a program that integrates mental health and recovery services at the same facility, with a staff of professionals who are cross-trained in both fields.

Getting Help for Depression and Co-Occurring Addiction

Living with a family member or spouse who is in a depressive episode can be both painful and stressful. It is natural for loved ones to feel helpless, frustrated, and even emotionally drained by their experiences dealing with depression.

Approaching a relative or friend about depression and substance abuse is very hard, but it can also prevent serious harm to the individual. Without help, it is likely that the addictive disorder and the depression — both chronic illnesses — will continue to get worse until the individual becomes severely ill. It is even possible that an intervention by loved ones may help to prevent a suicide attempt and save the individual’s life.

People struggling with depression often feel isolated, profoundly lonely, and powerless. Offering support and practical solutions could make an enormous difference in the way a depressed person feels about the future.

Here are a few tips on how to talk effectively and compassionately with someone who has a depressive disorder combined with drug or alcohol addiction:

Be honest about the problem

Offering false reassurances or encouraging the individual to cheer up will not help the situation. People with depression cannot simply change their moods or their attitudes toward life — if they could, they would probably never choose to remain depressed.

Be empathetic

It is difficult to view life from the perspective of a seriously depressed person. Using empathy, or the ability to see the world through someone else’s eyes, can help reduce the frustration and impatience that family members may feel.

Be nonjudgmental

When dealing with a person who has depression and an addictive disorder, it is crucial to remember that both conditions are a form of illness, not lifestyle choices. Before criticizing another person who is depressed and abusing drugs or alcohol, remind yourself that these are symptoms of a disease that affects people from all walks of life.

Be prepared to offer solutions

Depression is often characterized by low levels of motivation and an inability to make decisions. If your loved one agrees to get help, you should be prepared to offer specific resources and to help make arrangements to access those services.

Woman in recoveryMental health professionals can be valuable partners in the process of intervening on behalf of someone who has depression. With the guidance of a therapist, families can learn about the facts behind depression and develop a better understanding of how to relate to someone who has this disorder. If substance abuse is a factor, a therapist or intervention specialist can provide guidelines on how to effectively get help for someone with depression.

Therapies and Interventions

The treatment of depressive disorders with co-occurring addiction can be challenging. Depressive symptoms such as low motivation, low self-worth, and a flat emotional affect may imitate the effects of chemical intoxication or withdrawal. Dialogues in Clinical Neuroscience notes that in order for the treatment team to distinguish between the effects of depression and substance abuse, the client must undergo a thorough psychiatric assessment.

Although major depressive disorder is one of the most serious, debilitating types of mental illness, it is also very treatable with the right combination of therapeutic strategies. The American Psychological Association confirms that with the help of qualified, licensed mental health professionals, depressed individuals can be treated, and their families can recover hope for the future.

Some of the most effective, research-based interventions for depression include:

treating depression
The most widely prescribed medications for depression are drugs in the SSRI category, such as fluoxetine (Prozac), citalopram (Celexa), and sertraline (Zoloft). These drugs correct chemical imbalances by increasing the level of serotonin, a neurotransmitter that affects mood, to the brain. SSRIs are now considered to be frontline pharmaceutical treatment for depression, as they have relatively mild side effects compared to older antidepressant medications.
CBT addresses the dysfunctional thoughts and actions that affect people with mood disorders like depression. Rather than delving into the roots of depression, CBT focuses on identifying and transforming self-defeating ideas and repetitive self-talk, such as “I’m worthless,”“I’ll never feel better,”or “I might as well drink, my life is so bad.”Such negative thoughts can be replaced by more positive messages, while maladaptive coping skills can be replaced with more effective approaches to life’s stressors and triggers.
Unlike older, confrontational approaches to rehab and recovery, MI takes a positive, encouraging perspective, engaging the client in the recovery process through an active collaboration with the therapist. MI, as a therapeutic strategy, can be highly effective for individuals with depression, who have difficulty finding and maintaining internal sources of motivation.
If a history of trauma is a factor in a client’s depression or substance abuse, trauma therapies like Seeking Safety and Eye Movement Desensitization Reprocessing (EMDR) can help. These therapies help to reprocess troubling memories and resolve old sources of emotional pain, so the client can move on through the process of recovery and rehab.
Family Systems Therapy treats the client’s household unit as a whole, and the diseases of depression and addiction as family problems rather than individual disorders. Therapeutic goals for families include educating loved ones about depression and addiction, improving communication among family members, setting realistic boundaries, and establishing an environment at home that supports sobriety.

When substance abuse occurs with a depressive disorder, treatment must focus on both disorders at the same time. Treatment plans must be developed that take the client’s depressive symptoms — such as low motivation, low energy levels, and feelings of hopelessness — into account, while addressing the addictive behavior. In the initial stages of recovery, inpatient treatment at a residential recovery facility may be recommended, especially if the individual expresses suicidal thoughts or has a history of suicide attempts.

Man in RecoveryIn an inpatient setting, clients can go through detox and rehab with the 24-hour support and supervision of a staff of clinicians and therapists. Once the client is ready to progress to the next stage of recovery, a partial hospitalization program or outpatient program will offer a higher level of independence and self-determination. Clients must be monitored closely at every stage of rehab to ensure that their level of treatment is appropriate for their current psychological status. Throughout substance abuse treatment, core interventions such as individual therapy, group therapy, 12-Step programming, and family or marriage counseling provide a stable support network and a foundation for psychological healing.

Starting the Path to Recovery

Depression can have devastating effects on an individual’s wellbeing and on the lives of loved ones. Fortunately, the feelings of sadness, worthlessness, and despair that mark depression can be greatly reduced through research-based therapies. Many clinically depressed individuals have also shown considerable improvement in their symptoms through pharmacotherapy. To maximize the outcomes of treatment, clients should have a range of resources available that address their psychological, medical, and psychosocial needs.

Statistics confirm that alcohol addiction and drug addiction are more common among people with depression than in the population as a whole. Individuals with both mental illness and substance abuse disorders require integrated treatment plans that encompass their mental health needs as well as their need for detox and rehabilitation.

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