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Depression and the Connection to Substance Abuse

The effects of depression are felt on a physical level in the form of sleeplessness, weight changes, inactivity and substance abuse. Problem drinking and drug abuse are more common in depressed individuals than in the general population. According to QJM: An International Journal of Medicine, men diagnosed with major depression are nearly three times more likely to develop a dependence on alcohol, while women with depression are over four times more likely to become alcohol-dependent.  Depressive disorders affect the health and productivity of the general population as well as the life of the individual. The National Institute of Mental Health reports that major depressive disorder affects almost 7 percent of American adults (almost 15 million), while dysthymic disorder affects 1.5 percent.  The World Health Organization notes that depression is one of the leading causes of disability around the globe. Substance abuse can worsen the course of depressive disorder, increasing the risk of outcomes such as:

  • Drug or alcohol addiction
  • Psychiatric hospitalization
  • Suicide attempts
  • Accidental or intentional overdose

Individuals who are diagnosed with depression and a substance use disorder are more likely to drop out of conventional substance abuse treatment programs before they finish rehab.

They are also more likely to relapse once they start a treatment program. Treatment for these co-occurring disorders must target both conditions in order for the patient to achieve long-lasting recovery.

Recognizing Depressive Disorders

How can you distinguish between depression as a psychiatric disorder and the blue moods that we all experience at times? With clinical depression, the severity of these moods is more intense, and symptoms last for longer periods of time. In order to meet the diagnostic criteria for major depressive disorder, the individual must experience at least five symptoms of depression for two or more weeks. Typical depressive symptoms include:

  • A predominantly low mood on most days of the week
  • Lack of interest in favorite activities
  • Physical exhaustion
  • Sleeping too much or too little
  • Unwanted weight loss or gain
  • Slow thinking or movements
  • Failure to focus on important tasks
  • Thoughts of death or suicide
  • Feelings of guilt, hopelessness or worthlessness

Dysthymic disorder, a milder form of depression, is characterized by less severe symptoms persisting for two years or more. People with dysthymic disorder may seem chronically unhappy, irritable or sullen. While the symptoms of this disorder may be less noticeable than major depression, the effects can persist for years. Many dysthymic individuals are unaware that they have a psychiatric disorder. Only a qualified clinician — a doctor, psychologist or psychiatrist — can make an official diagnosis of major depressive disorder. However, by learning to recognize the symptoms of this debilitating condition, you and your loved ones can prevent serious consequences like self-isolation, addiction and suicide.

How Does Depression Begin?

Depressive disorders can arise from a number of different sources, or from a combination of factors. Some of the most common contributing causes include:

  • Stressful situations that aren’t easily resolved, such as divorce, the death of a loved one, or a serious injury or illness
  • Physical health problems, such as heart disease, lung disease, diabetes, cancer, or alcoholism
  • A genetic predisposition to depression, or depressive moods in close family members
  • An imbalance of chemicals that regulate mood and energy levels, such as serotonin, dopamine and gamma-aminobutyric acid (GABA)
  • Structural abnormalities in the areas of the brain that regulate mood and memory

Imaging studies have shown that depression is linked to specific regions of the brain, and that these areas appear to be different in people with depressive disorders. Harvard Medical School points out that the hippocampus, amygdala and thalamus may be smaller or function less efficiently in people with depression.

Depression and Addiction

Does depression cause addiction by triggering a need for intoxication? Or does substance abuse cause depression by changing the way the brain functions? Depression and substance abuse intertwine on several levels:

  • Depression can trigger drug or alcohol use as a form of self-medication.
  • Drugs or alcohol can precipitate depression by altering brain chemistry.
  • The effects of intoxication or withdrawal can resemble the signs of a depressive disorder.
  • The neurological factors that cause depression may predispose the individual to alcohol or drug addiction.

Even for experienced clinicians, it can be difficult to tell the difference between clinical depression and the effects of drugs or alcohol. Many of the most widely abused substances are central nervous system depressants, including:

  • Alcohol: Includes beer and wine as well as hard liquor and spirits
  • Benzodiazepines: Includes sedative/muscle relaxants like Valium (diazepam), Ativan (lorazepam) and Xanax (alprazolam)
  • Cannabis: Includes smokable and edible forms of marijuana
  • Opiates: Includes illicit and prescription drugs derived from opium, such as heroin, morphine, codeine, hydrocodone and oxycodone
  • Barbiturates: >Includes powerful sedatives like Seconal (secobarbital) and Nembutal (pentobarbital)

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Substance-induced mood disorders occur when the psychological effects of drug intoxication or withdrawal cause abnormal emotional states. Withdrawing from cocaine, meth or other stimulants can cause changes in brain chemistry that lead to severe depression. Depression may also be a side effect of withdrawal from heroin or other opium-based drugs. Symptoms of substance-induced depression — fatigue, poor appetite, lack of concentration, tearfulness, suicidal ideation — resemble the symptoms of major depressive disorder. However, according to the U.S. Department of Health and Human Services, the symptoms of substance-induced depression usually resolve within a matter of days after the drug is cleared from the patient’s system. When depression is undiagnosed, getting clean or sober can actually make the symptoms worse. If alcohol or drugs have been used as a form of self-medication, the depressive symptoms may come to the forefront once the individual has been through detox. By the same token, if depression is treated in a mental health setting without addressing the problem of substance abuse, the patient may never be motivated to stop abusing drugs or alcohol, and depressive symptoms may never really be resolved.

How Is Depression Treated?

Depression is a chronic condition that may never be completely cured; however, symptoms can be managed effectively through a combination of psychotherapy, behavioral modification training, and participation in support groups. If talk therapy alone can’t resolve the symptoms of depression, antidepressant medication can be a valuable addition to the treatment plan.

Cognitive behavioral therapy (CBT) has proven to be highly effective method for changing the negative thought patterns associated with depression.

Feelings of hopelessness, low self-worth, and despair are treated as learned thought patterns that can be replaced with positive, self-affirming beliefs. According to JAMA Psychiatry, CBT is an effective therapy for depressed individuals in all age groups, and positive results continue over time. The therapeutic strategies learned in CBT can be applied to co-occurring disorders like anxiety, personality disorders or substance use disorders.

With consistent, medically supervised use, antidepressant medications can improve symptoms in a matter of weeks. Antidepressants in the SSRI category (selective serotonin reuptake inhibitors) are considered to be first-line pharmaceutical treatment for depression. These medications include popular drugs like Prozac (fluoxetine), paroxetine (Paxil) and citalopram (Celexa). When SSRIs are not effective, older antidepressants in the tricyclic or MAOI (monoamine oxidase inhibitors) may be prescribed instead. According to the Depression and Bipolar Support Alliance, depressive symptoms improve with treatment in up to 80 percent of cases. Unfortunately, nearly two-thirds of depressed individuals either do not seek or do not receive treatment for this serious, disabling disorder. Out of those individuals who struggle with both depression and substance abuse, only a small percentage receive research-based, dual diagnosis treatment for both conditions.

Types of Depression

Atypical Depression

However, there is a form of clinical depression that does not present itself as straightforwardly. This is known as “atypical depression,” where the symptoms are surprising and, indeed, atypical to the condition. The “atypical” in the name does not mean that this is a rare condition – it is found in 36 percent of all cases of depression – only that it is different from classical depression.

Symptoms of Atypical Depression

If you have atypical depression, you might:

  • Sleep a lot (hypersomnia) instead of being unable to sleep
  • Overeat (hyperphagia) instead of losing your appetite
  • Gain weight instead of losing it

In cases of hypersomnia and hyperphagia, the excess sleep is defined as 10 hours per day (or two or more hours a day than usual); the weight gain is defined as at least 5 pounds. There are other, more nuanced symptoms of atypical depression. You may actually experience happiness at good news, but the feelings do not last and are quickly replaced by more common depressive sensations. In fact, this symptom – known as mood reactivity – is one of the criteria for diagnosing atypical depression. If a positive experience makes you feel more than 50 percent happier than you did before the experience, your doctor knows that you do not have major depression and can prescribe the appropriate course of treatment for you. In another symptom, you may feel incredibly lethargic and completely drained of energy. While this is standard to victims of both classical and atypical depression, atypical depression is different because sufferers feel as though they are physically unable to move – as though they are being physically restrained from getting out of bed, for example. Atypical depression also can make you excessively sensitive to criticism and negative feedback. If this sensitivity negatively impacts your job or academic performance, and it causes stress in your personal and everyday life, your medical practitioner can use this to diagnosis atypical depression. Similar to other depressive and mood disorders, women are more likely to develop atypical depression than men. Atypical depression is also found more in teenagers than adults, but it can continue into adulthood if not detected and treated. Other conditions, such as substance abuse, anxiety, and somatization disorder – where the patient has chronic physical symptoms with no evident physical cause – are more common in atypical depression than classical depression.

Chronic Depression (Dysthymia)

Dysthymia, also known as chronic depression, its effects are not as severe as those of major depression, but it lasts longer – upwards of two years. While the impact is not as crushing, the persistent, lingering effects of dysthymia are still serious cause for concern.

Diagnosing dysthymia is not easy, because it does not present as clearly as major depression. Given that it is diffused over a significant period of time, dysthymia is often simply brushed off as a negative disposition or a long-term bad mood. It often escapes the attention of the people who may be able to notice a problem because of how habitual the symptoms of dysthymia can appear.

Because of this, even people who have dysthymia may not know that they have a depressive condition. Unable to understand why they do not enjoy life as much as they used to, they are at risk for developing other comorbid conditions, such as an eating disorder (never leaving the house and relying on comfort food), substance abuse, and even suicidal thoughts and behaviors.

Perhaps for this reason, the National Institute of Mental Health estimates that around 1.5 percent of the American population has dysthymia. Almost 50 percent of patients in an outpatient setting report being chronically depressed.

It is possible for the patient to experience an attack of major depression, even while suffering from dysthymia. This phenomenon is known as “double depression.”

Worryingly, even this does not prompt patients to seek treatment, because they have gotten so used to their chronic depression. They delay seeking treatment, and even if/when treatment is administered, it takes a long time for any effects to show because of how deep the patient is in the depression.

Chronic Depression Symptoms

Other recognizable symptoms of chronic depression may be:

  • Insomnia
  • Fatigue
  • Excessive amount of sleep
  • Cognitive impairment
  • Hopelessness and despair

These symptoms may be familiar; they are also found in people who have major depression. The difference here is that for people with dysthymia, these symptoms are not as pronounced, but they can last for years.

However, like major depression, the effects of dysthymia are enough to disrupt daily life. The condition is also twice as prevalent in women than men.

Psychotic Depression

What Is Psychotic Depression?

In the context of mental health, psychosis refers to a patient losing contact with reality. Symptoms of psychosis are:

  • Hallucinations, such as hearing voices or seeing things when there is no such stimuli
  • Paranoid delusions, or the fear that the patient is being persecuted
  • Cognitive impairment
  • Catatonia

Psychotic depression is characterized by the usual symptoms of major depression – insomnia, feelings of worthlessness, anxiety, inability to enjoy pleasurable activities, etc. – with some manifestation of psychosis. The causes of psychotic depression are still not understood, but it is believed that an imbalance of a hormone known as cortisol (which is secreted in the adrenal glands, for release during times of stress) may be associated.

Psychotic depression is different from other disorders where psychosis is present, like schizophrenia, because patients with psychotic depression are aware of their psychoses; that is, if you have psychotic depression, you will know that the voices you hear are not real.

The shame or embarrassment inherent can make psychotic depression difficult to diagnose. If you feel that this describes you, you should seek help as soon as possible.

When major depression is present with psychotic depression (by some estimates, as frequently as in 50 percent of cases of diagnosed depression), the delusion fits the condition; if you have both disorders occurring simultaneously, you might associate your depression with being persecuted for doing something wrong. Alternatively, you may feel your depression is a punishment for a real or imagined wrongdoing. In your depressive state, you may feel that the punishment is justified, intensifying the feelings of worthlessness and misery.

A symptom known as psychomotor agitation is also associated with psychotic depression. You may be constantly restless and unable to sit still for any length of time. You cannot stop fidgeting or bouncing your legs up and down. Being aware of doing this, but not being able to stop, can exacerbate the depression.

Psychotic depression is fairly rare among people who are diagnosed for major depression. It is found in only about 15 percent of cases.

As with most mood and depressive disorders, women are more susceptible to psychotic depression than men,especially women who have recently given birth and who are at risk for postpartum depression.

Patients with psychotic depression are at an increased risk for suicidal thoughts or behaviors.

Dual Diagnosis Treatment for Depression

Substance abuse compounds the challenges of treating depressive disorders. The symptoms of depression, including fatigue, poor concentration and a sense of hopelessness, pose serious obstacles to recovery. Novel approaches to treatment are required to overcome these barriers and provide effective, long-lasting recovery services.

Mindfulness-based therapy is one of the most recent trends in dual diagnosis treatment for depression and addiction.

Drawn from Eastern philosophy and the principles of cognitive behavioral therapy, mindfulness training counteracts the impulsivity of substance use disorders and the hopelessness of depression.

According to CNS Spectrums, the application of mindfulness-based therapies can improve depressive symptoms such as:

  • Poor concentration
  • Low self-worth
  • Emotional instability
  • Suicidal thoughts

Dialectical behavior therapy (DBT), a treatment modality developed by psychologist Marsha Linehan, is a prototype for mindfulness-based training. DBT was originally developed as a therapeutic approach for helping hard-to-treat, chronically self-destructive patients with borderline personality disorder. Today, DBT is being applied to the treatment of co-occurring disorders like depression and addiction with great success. Stress management training is another important component of a comprehensive dual diagnosis treatment plan. People with depression have difficulty handling stressful situations at work, home or in social settings. Learning how to manage stress can help dual diagnosis patients avoid emotional triggers for substance abuse.

Stress reduction therapies include:

  • Guided meditation
  • Acupuncture
  • Massage
  • Yoga
  • Exercise therapy
  • Martial arts

At Futures of Palm Beach, we blend traditional approaches to dual diagnosis treatment with alternative therapies to provide a holistic healing experience. At our exclusive residential treatment center in Palm Beach County, Florida, we offer evidence-based recovery services in a spa-like setting far from the chaos of everyday life. For more information about our individualized dual diagnosis treatment plans, call our toll-free number today.

Some services listed may not be included in our core program. An admissions counselor will be able to provide you a complete list of core services. Information provided for educational purposes. Premium services or programs may be arranged through your therapist or case manager.