Of all of the mental health disorders, major depression is the most common mental illness in the United States. It is more common in women than men, and it affected 15.7 million American adults aged 18 and older (6.7 percent of the entire adult population) in 2014, according to the National Institute of Mental Health (NIMH).
Depression may be diagnosed when sadness, lack of ability to feel pleasure, loss of interest in activities, low energy levels, poor self-image, or difficulties concentrating affect everyday life functions for a period of at least two weeks. Depression can range from mild to moderate to severe, with Psych Central reporting that severe depression is the most common type.
About half of the adult population (aged 12 and older) in the United States drank alcohol in the month before the 2013 National Survey on Drug Use and Health (NSDUH), more than 9 percent abused illicit drugs, and just over 8 percent were classified with a substance abuse or dependency issue in the previous year. Using prescription medications beyond the scope of medicinal use or for recreational purposes, any use of an illegal drug, or problematic alcohol use patterns may be considered substance abuse. When substance abuse becomes compulsive and individuals are unable to control their usage, a substance use disorder (SUD), or addiction, may be diagnosed.
Substance abuse disorders and mood or anxiety disorders co-occur around 20 percent of the time, the Anxiety and Depression Association of America (ADAA) reports. Co-occurring, or dual diagnosis, disorders are diagnosed when an individual suffers from two disorders simultaneously, such as depression and SUD. The journal Current Opinion in Psychiatry estimates that about a third of those battling major depression also have a substance use disorder. Depression may increase the possible side effects of substance abuse and vice versa, and both may interfere with treatment for each disorder. It is widely accepted, as published by the National Institute on Drug Abuse (NIDA) that individuals diagnosed with co-occurring disorders benefit from integrated and comprehensive treatment models that treat both disorders as primary conditions and manage the symptoms of both disorders simultaneously.
Recognizing Problematic Substance Abuse and Depressive Symptoms
It is perfectly normal to feel sad at times and not necessarily a problem to drink alcohol on occasion and in moderation. There does come a point, however, when depressive symptoms and/or patterns of substance abuse are cause for concern. When depression and problematic substance abuse are combined, symptoms and health risks may be exacerbated as well.
Symptoms of depression may include:
- Feelings of sadness, emptiness, or anxiousness that are persistent
- Lowered energy levels and fatigue
- Consistent feelings of worthlessness, shame, or guilt
- Pessimism or hopelessness
- Thoughts of suicide and death
- Change in sleep patterns: oversleeping or insomnia
- Trouble focusing or concentrating
- Irritability and restlessness
- Loss of interest in activities that might have been previously enjoyed
- Changes in appetite and weight gain or loss
- Physical symptoms that have no medical basis (e.g., headaches, stomach upset, or chronic pain)
All of these symptoms of depression can be heightened with substance abuse. For example, alcohol is a central nervous system depressant that slows down some of the functions of the body and brain, and it may make depression worse. When someone abuses a psychoactive substance, like alcohol or illicit drugs, neurotransmitters in the brain that enhance pleasure may be activated. Over time, this overstimulation of brain chemicals may cause their natural production to wane, and when the substance then wears off, a low may occur and levels of dopamine, serotonin, or norepinephrine may bottom out. Depression, anxiety, restlessness, insomnia, difficulties concentrating, suicidal thoughts, and irritability are common withdrawal symptoms.
When someone also suffers from depression, emotional withdrawal symptoms may be more pronounced and intense. Coupled with depressive symptoms, the following signs of problematic substance abuse or addiction may be observed:
- Inability to control the amount or length of time abusing drugs or alcohol
- Alcohol or drug abuse interfering with school, work, or family obligations and responsibilities
- Mood swings, erratic behavior, and shifts in personality
- Withdrawing and refraining from participating in social situations or activities
- Drug or alcohol tolerance levels increasing and more of the substance being needed in order to feel the desired effects
- Ignoring negative consequences and continually abusing drugs or alcohol in risky or hazardous situations
- Still abusing drugs or alcohol in full awareness of, and in spite of, any potential personal, physical, or emotional side effects
- A marked change in personal appearance: lack of interest in personal hygiene, weight gain or loss, etc.
- Change in sleeping and eating patterns
- Financial problems or getting into legal trouble
- Withdrawal symptoms occur when substance is not present
Both substance abuse and depression can interfere with daily life tasks, and family members and loved ones may notice the outward signs. Mood swings may be more pronounced in someone battling both depression and substance abuse, as may changes in energy levels, appetite, and sleep patterns.
Underlying Causes of Co-Occurring Depression and Substance Abuse
Substance abuse may provide initial relief of depressive symptoms and therefore be attractive to someone battling depression, while depressive symptoms can be brought on by substance abuse and withdrawal. There are potential overlapping factors to consider when discussing what may cause these two disorders to co-occur, including possible biological or genetic contributions and environmental factors. Both substance abuse and mood disorders like depression may be more likely to occur in an individual with genetic predispositions or a family history of addiction or depression, the journal Addiction Science & Clinical Practice reports. There may even be some genes that are involved in the onset of both disorders that may be present in someone battling co-occurring depression and substance abuse.
Neurobiological pathways, or specific regions of the brain, may also explain why some people may be more likely to develop a substance use disorder or mood disorder than others. The regions responsible for emotional regulation, motivation, impulse control, and decision-making may not be as fully developed, or may be less functional, in some individuals, which may make it more likely that they will abuse substances or battle a mental health disorder at some point in their lifetime.
The Society for Neuroscience published that depression may be related to lowered function in the amygdala, and brain responses to stressful stimuli may be able to predict depression. Findings reported in the journal Brain Research also indicate that the stress reaction and amygdala are affected by addiction. Vulnerabilities in these brain functions may predict substance abuse, and substance abuse may in turn increase depressive symptoms.
Using drugs or alcohol before the prefrontal cortex and other areas of the brain are fully developed may also damage neural pathways related to impulse control, decision-making, memory, and mood regulation, and increase the risk for addiction or mental illness later in life. The same may be true of stress or early childhood trauma, as chronic stress over stimulates these regions and may also cause long-term damage.
Concerns for Long-Term or Untreated Substance Abuse and Depression
There are a multitude of physical, interpersonal, and emotional health issues related to substance abuse and depression, which can each be compounded when these disorders co-occur. Substance abuse can get in the way of treatment for depression and interact with medications that may be prescribed. Conversely, depression may encourage an individual to turn to substance abuse as a way to self-medicate symptoms instead of using healthier coping mechanisms.
If left untreated, both depression and substance abuse can have disastrous consequences. Suicide is the 10th leading cause of death in the United States, according to the Centers for Disease Control and Prevention (CDC), and accounted for 41,149 deaths in 2013. Approximately 836,000 individuals were seen in American emergency departments for self-inflicted injuries in 2011 as well. When depression goes untreated, the risk for suicide may increase exponentially, which may be further heightened by substance abuse. Depression is the number one risk factor in youth suicides, the Depression and Bipolar Support Alliance (DBSA) reports. DBSA also postulates that large-8 medium-12 columns of completed suicides in America are caused by depression.
Long-term drug and alcohol abuse can create health problems, such as:
- Heart disease
- Lung infections or disease and respiratory complications
- Contraction of infectious diseases
- Skin infections
- Kidney damage or disease
- Liver damage and disease
- Hypertension or hypotension
- Irregular heart rate
- Brain damage
- Overdose or death
- Damage to veins and blood vessels
- Cognitive defects
Drug and alcohol addiction may create difficulties with family and interpersonal relationships; cause an individual to have problems with the law, in living situations, or at work; create financial difficulties; and increase mental health complications.
Discussing Depression and Substance Abuse with a Loved One
If co-occurring substance and abuse and depression are suspected, specialized treatment is likely to be highly beneficial in building a foundation for recovery. Unfortunately, only 2.5 million of the 22.7 million people needing treatment for a substance abuse or dependency in 2013 actually received it. Of those who didn’t seek help, around 95 percent didn’t see the need, NSDUH published. A trained professional can help families and loved ones plan a structured intervention, which is a meeting between the individual and all those affected by the substance abuse. When someone also battles depression, the intervention may need to be carefully planned and executed to avoid a judgmental or confrontational approach.
When talking to a loved one about substance abuse or depression, it is best to find a time when the person is not intoxicated or agitated. Citing specific examples of how the disorder(s) impact relationships, daily life, or particular individuals may be helpful. It is also important to use “I” statements and not to come across as aggressive or negative, but instead to be supportive and reassuring. Stay firm, outlining clear-cut boundaries, expectations, and explanations of consequences if help is not sought, while also expressing faith in the individual. It is also beneficial to have researched potential treatment programs and to have a clear plan of action. When individuals have a history of violent or harmful behaviors toward others or themselves, it is best to enlist the help of a professional. Mental health professionals, primary care doctors, and substance abuse professionals may all be able to help with an intervention or with providing necessary resources. The main goal of an intervention is to help the person see the need for treatment and enter into it willingly.
Depression and substance abuse are often treated with a combination of therapy and medications. Medical or mental health professionals may perform an assessment and consider all medical, mental health, and family histories when planning care. Someone suffering from major depression, or who is heavily chemically dependent on drugs or alcohol, may need a more comprehensive treatment program. Chemical dependency is influenced by the length of time using drugs or alcohol, the amount used at a time, the age of substance abuse initiation, genetic and personal physiology, family history of addiction, type of drug abused and method of abuse, and environmental influences. The presence of co-occurring depression may also increase the level of dependency on drugs or alcohol.
There are several levels of treatment for co-occurring disorders, including:
- Outpatient services: Individuals receive treatment on site and may schedule sessions, trainings, and meetings around other obligations, returning home afterwards.
- Intensive outpatient programs (sometimes called day programs): This is a comprehensive treatment model where individuals attend structured programs during the day and return home at night.
- Partial hospitalization program: This therapy is performed on an outpatient basis and provides short-term, intensive treatment.
- Medical detox: This is the safe removal of substances from the body in an inpatient capacity; medical detox is medically monitored and may use medications.
- Residential treatment programs: Comprehensive care is provided around the clock in a structured environment where individuals stay on site and participate in scheduled sessions, trainings, educational programs, and support groups; these programs may include alternative or holistic methods as well.
- Inpatient rehabilitation or hospitalization: Medical and mental health stabilization programs are performed, and medical care is provided 24/7 in a specialized facility.
Medications Used in Treatment
The initial goal of both mental illness and substance abuse treatment is medical stabilization. This is often accomplished through the use of pharmaceuticals. Antidepressant medications are commonly used in treating depression. Selective serotonin reuptake inhibitors (SSRIs), including Celexa, Paxil, Zoloft, Prozac, and Lexapro, and serotonin norepinephrine reuptake inhibitors (SNRIs), such as Effexor XR, Cymbalta, and Pristiq, are some of the most regularly used pharmaceutical products, as well as the atypical antidepressant Wellbutrin, as reported by NIMH.
Individuals who also battle co-occurring substance abuse disorders may need to modify medications in order to avoid possible complications or negative drug interactions. For instance, older antidepressant medications like tricyclic drugs are not recommended for individuals battling opioid abuse or dependency, as they may cause dangerous levels of sedation and a high risk of fatal overdose, the National Drug Strategy publishes. All medications must be prescribed and supervised by professionals to ensure no negative interactions take place.
There are also several medications that are used during medical detox and recovery to reduce drug withdrawal symptoms and cravings, including buprenorphine products, methadone, naltrexone, benzodiazepines, and medications for specific symptoms like anti-anxiety, anti-nausea, or antiseizure medications. Again, medical professionals may need to be careful with certain medications that may not be recommended for the treatment of co-occurring disorders in some cases.
Certain combinations of medications may be beneficial in the treatment of both depression and substance abuse too. For example, Psychiatric Times reports use of the antidepressant sertraline in combination with the opioid antagonist naltrexone, used for the treatment of alcohol dependence. Research showed that individuals had higher abstinence rates and fewer depressive symptoms during this clinical trial.
Behavioral Care and Mental Health Support
Once an individual is stabilized, additional therapies can be used to promote sustained recovery. Therapy and research-based treatment models for co-occurring depression and addiction or substance abuse often involve behavioral therapies such as Cognitive Behavioral Therapy, or CBT. Patterns of self-destructive behaviors are often influenced by negative thoughts and potential environmental or social triggers, and CBT seeks to help individuals modify these thoughts and behaviors into more positive actions. By recognizing what may trigger a depressive episode or relapse, individuals can better learn healthy management strategies and how to cope with stress more successfully. Individual and group therapy, as well as homework sessions, educational programs, and life skills training sessions are often included in CBT.
Family therapy works with the entire family as a whole to help form a healthy support system by reframing the family system. Yoga, meditation, nutritional plans, exercise programs, and the introduction of healthy creative outlets may all be beneficial in occupying the mind, improving health, and helping to naturally and positively affect happiness levels to prevent relapse to both depression and substance abuse. Recovery services may include the use of peer support or 12-Step programs. Individuals may need to find a 12-Step group that allows for the use of maintenance medications, however, as medications are often needed during recovery from depression.
A Brighter Future after Depression and Substance Abuse
Substance abuse and depression co-occur at relatively high rates and may be caused by a combination of environmental and biological factors. Both disorders have inherent risks and should not go untreated for long periods of time. Depression can interfere with substance abuse treatment and vice versa, and symptoms of both disorders are heightened by the other disorder.
Suicide is a real concern for someone battling depression and substance abuse. Those suffering should be closely monitored, and self-harming behaviors and suicidal ideations should always be taken seriously. Help is available in many forms. Depending on the severity of the depression, or the level of dependency on drugs or alcohol, the type of care may differ. Medical stabilization is the primary goal of mental illness and substance abuse treatment, which should then be followed by therapy and mental health support services. Both depression and substance abuse are treatable disorders with the right level of care and support.