By Dennis C. Daley, Ph.D
Dr. Daley is Professor of Psychiatry and Social Work
One of the most moving talks I ever heard was given by former U.S. Senator George McGovern. He spoke eloquently about his daughter Terry, who had both alcoholism and depression. He gave a detailed account of all that he, his wife and many others did to help Terry recover, only to be shocked and saddened late one December evening when a police officer and minister came to his home to tell the McGoverns that Terry was dead. She had gotten drunk, passed out in the cold and froze to death.
In a book he wrote to tell this story, simply titled Terry (1997), Senator McGovern provides a heart wrenching description of the life and tragic death of his beloved daughter.
This book provides insight on the experiences of Terry as well as her family whose personal suffering was every bit as awful as Terry’s. The book also shows how alcoholism combined with depression often worsens the course of recovery.
Addiction and depression are common comorbid conditions. The Epidemiologic Catchment Area study conducted by the National Institute on Health reported that almost one-third of individuals with depression had a co-existing substance use disorder at some point in their lives (Regier et al, 1990). The National Comorbidity Study found that men with alcohol dependence had rates of depression three times higher than the general population; alcohol dependent women had four times the rates of depression (Kessler et al, 1997). Studies of clinical populations also show high rates of these combined disorders (Salloum, Daley & Thase, 2000; Daley & Moss, 2002). Many clients have recurrent major depression, dysthymia (a chronic form of depression) or both major depression and dysthymia, also called “double depression.”
Clients with addiction and depression often have other DSM IV diagnoses including bipolar, anxiety, personality or other addictive disorders. In one of our recent studies of 153 new clients seeking treatment at 6 different substance abuse clinics, clients had a mean Beck Depression Inventory of 18.8 (sd=13.0), which is in the moderate range, and a mean Beck Anxiety Inventory score of 23.3 (sd=21.8), which is in the moderate to severe range. Although these clients were new admissions to substance abuse clinics, 31.4% were taking antidepressants; 10.5% mood stabilizers; 8.5% anti-anxiety medications; and 7.8% anti-psychotics.
Women often develop the mood disorder first while men frequently develop the addiction first. For many, these disorders become linked over time with symptoms of each worsening the other. These conditions are often chronic and must be managed over the long run.
Many studies and books document the adverse effects of addiction, depression or dual disorders on the family and its members (Daley, in press; Mondimore, 1999; Rosen & Amador, 1996; Yapko, 1999). Children of alcoholics or opiate addicts are at increased risk for substance abuse, conduct problems, anxiety disorders and mood disorders. Parental substance abuse underlies many family problems such as divorce, spouse abuse, child abuse and neglect, welfare dependence and criminal behaviors (Daley & Miller, 2001). Children of depressed mothers are at increased risk for a psychiatric disorder; the prevalence of “multi-problem” children is over eight times higher among families with a depressed parent (Yapko, 1999).
Studies conducted by this author and colleagues at Western Psychiatric Institute and Clinic of the University of Pittsburgh Medical Center show that clients with addiction and depression are at higher risk for suicidal and homicidal behaviors, poorer treatment adherence, higher relapse rates to either disorder, and higher re-hospitalization rates (Cornelius et al, 1997; Salloum et al, 1996; Daley & Zuckoff, 1998 & 1999).
In a quality improvement study of 140 outpatients (most with mood disorders and addiction), conducted in our clinic, clients rated the adverse effects of their dual disorders on their families as “serious.” Problems resulting from their disorders included emotional and economic burden for the family, neglect and abuse, irresponsibility, and loss of children to other relatives or Child Welfare Services (Daley & Salloum, 1996).
Professional treatment and involvement in recovery can make a significant positive impact on clients and their families in managing the disorders and improving the quality of life.
There are many effective treatments for depression including interpersonal psychotherapy, cognitive behavioral therapy and supportive counseling; anti-depressant medications; and electroconvulsive therapy (ECT). There are also many effective treatments for addiction including behavioral therapies and counseling, and sometimes, the use of medications.
Treatment should be “integrated” and go beyond symptom reduction by helping the client engage in a recovery process (Daley & Thase, 2000). Recovery aims to help the client manage the disorders over the long-term by making changes in self and lifestyle and may occur in any of the major domains of functioning listed in Table 1 below (Daley, 2000).
Following are important points to keep in mind regarding professional treatment and recovery:
Having either addiction or depression raises the risk of having the other disorder. Anyone with a clinical depression should be assessed for a substance use disorder. Conversely, anyone with a substance use disorder should be assessed for a depressive disorder. Establishing abstinence for several weeks or longer is often needed to accurately diagnosis depression.
While many depressive syndromes improve with abstinence from substance use, some clients continue to experience depressive disorders that require treatment. Sobriety does not guarantee improvement in mood, and some clients’ moods will worsen after they get sober. A client and family must accept that at best, partial recovery will occur if both disorders are not adequately addressed. A client cannot expect to get the full benefits of treatment for the depression if he or she continues to drink alcohol or use other drugs. Nor can the substance use disorder be effectively treated if significant mood symptoms persist.
As in all disorders, adherence to treatment is necessary in order to get the maximum benefit. Since dual diagnosis clients show worst treatment adherence rates compared to those with only one type of disorder, this issue should be considered when developing a treatment plan. Motivational, treatment induction and outreach efforts often help improve consumer adherence and impact positively on outcome (Daley & Zuckoff, 1998 & 1999; Kemp et al, 1998; Miller & Rollnick, 1991; Walitzer, Derman & Connors, 1999; Zuckoff & Daley, 2001).
There are many effective psychosocial treatments for addiction, depression and dual disorders (Daley & Moss, 2002). Depressions of low to moderate severity often respond to therapy alone while more severe cases require medications in addition to therapy. Many effective therapies for depression and addiction are described in clinical manuals; clinicians should become aware of these evidence-based treatments and integrate clinical strategies in their work with clients (eg., see McLellan et al, 2000; NIDA 1999 and 2000; Sammons & Schmidt, 2001; Weissman, Markowitz & Klerman, 2000). The National Clearinghouse on Drug and Alcohol Information (NCADI) publishes free treatment manuals describing behavioral therapies found to be effective in clinical trials sponsored by the National Institute on Alcohol Abuse and Alcoholism (NIAAA), and the National Institute on Drug Abuse (NIDA). NIAAA has manuals on twelve-step facilitation therapy, motivational enhance therapy, and cognitive-behavioral coping skills training. NIDA has manuals on individual drug counseling, group drug counseling, cognitive-behavioral therapy, contingency management, relapse prevention and cue extinction. The challenge for clinicians is to provide integrated treatment that addresses both the addiction and the depression.
Many effective medications are available for the treatment of depression, especially more severe, chronic or recurrent types. Although all types of antidepressants are effective, the newer SSRI’s have fewer side effects than others and are less lethal in overdose. Some clients require the addition of a second antidepressant or a mood stabilizer to effectively treat depressive symptoms. Maintenance pharmacotherapy is needed for clients with recurrent major depression (Kupfer et al, 1992). The risk of recurrence decreases substantially for clients who remain on medications even after significant periods of remission for depression.
Medications can help addicted clients safely and comfortably withdraw from the physical symptoms associated with dependence. There are several other uses for medications as well, but these are usually used in combination with counseling. Methadone (Dolophine) or LAAM (ORLAAM) are “replacement” medicines for opiate addicts who have had trouble staying off opiates by other methods. They allow the addict to function without needing heroin or other opiates. Naltrexone (Trexan) is an “antagonist” used to counteract or “block” the euphoria produced by opiate drugs; it can also produce a withdrawal syndrome. Buprenorphine is a mixed “replacement and blocking” agent that reduces cravings for opiates, reduces withdrawal, and blocks euphoria. Naltrexone (ReVia) reduces cravings and helps reduce the severity of alcohol relapses. Disulfiram (Antabuse) is an aversive drug that makes the person who drinks alcohol when taking it very sick. Buproprion (Zyban) reduces craving for nicotine, and nicotine gum (Nicorette), path (NicoDerm), or nasal spray (Nicotrol) all help the person wean off nicotine over time.
A combination of medication and therapy is often the most effective treatment approach for many disorders including depression, addiction, or both (Sammons & Schmidt, 2001).
ECT can be used when medications and/or therapy are not effective, or medications cannot be taken because of pregnancy or some other reason. ECT is mainly used with severe forms of depression, uncontrollable mania and some forms of schizophrenia. It can help with suicidality as well. ECT involves a brief application of an electrical stimulus to the brain, which causes a generalized seizure. Despite the bad press ECT has received, it is safe, effective and can be life-saving.
Clients with more severe and debilitating disorders often need case management, psychiatric rehabilitation, vocational rehabilitation, and/or social services to address other significant problems.
Depression alone and in combination with addiction is one of the highest risk factors for suicide (Cornelius et al, 2001; Shea, 1999; Daley, in press). Clients can benefit from learning to identify and manage warnings signs of suicide such as: 1) increased thoughts about suicide or that life isn’t worth living; 2) talking more about suicide; 3) preparing for death by making out a will; 4) giving away important possessions; 5) worsening of mood (i.e., feeling much more depressed or hopeless; 6) decrease in interest in life (school, work, hobbies, friends, other activities); 7) changes in appetite, sleep or energy (often symptoms of a depressive episode); 8) increased use of alcohol or other drugs; and 9) significant changes in personal appearance or habits.
The experiences and needs of the family should be considered, too (Daley & Miller, 2001; Daley & Sinberg, 1996; Mondimore, 1999; Papolos & Papolos, 1997; Rosen & Amador, 1996). Involvement in professional treatment and/or self-help programs can be very beneficial for families. Families need information, support and practical help in dealing with a loved one’s disorders. The impact of depression and addiction should always be considered on the client’s children as well.
Since recovery from depression and addiction is an ongoing process, clients should be encouraged to participate in self-help programs (e.g, mental health or depression support groups, AA, NA or dual recovery programs). There is no single path to recovery so it helps for clients to have options from which to choose.
A client with major depression has a 50% risk of a second episode; if a second episode is experienced the risk of another episode is 70%; and if a third episode is experienced, the risk of recurrence is 90%. Hence, major depression is recurrent for at least half of those who experience it (Thase, 1999). Similarly, addiction is a chronic condition for many and relapses are common. Since relapse of one disorder impacts on relapse to the other, clients benefit from learning to identify and manage relapse warning signs as well as high-risk situations unique to them (Daley & Roth, 2000). Reducing relapse risk should be a major emphasis of professional treatment as well as recovery.
Addiction and depression are common co-occurring disorders associated with numerous adverse effects on the client and family. When possible, treatment should be integrated and address both the mood and addictive disorders. Clients should be encouraged to get involved in an ongoing recovery process, particularly since these disorders are chronic and long-term for many. Often, a combination of therapy and medications is needed. Self-help programs are an excellent source of ongoing support.
Table 1: Areas of Focus in Recovery from Addiction and Depression
Client Support Groups:
Integrated Treatment of Substance Abuse & Mental Illness