Dual Diagnosis: Depression and Addiction

Clinical depression is one of the most common co-occurring conditions found alongside a wide variety of mental health issues, however, depression and addictive disorders are particularly common concurrent diagnoses. This occurs for several reasons:

• Addictive disorders typically incur multiple negative consequences including loss, relationship problems, decline in job performance and poor self-esteem.

• Addictive disorders cause mood instability and vulnerability to depression.

• Individuals with symptoms of depression may seek relief in the use of substances or other compulsive behaviors involving such mood-altering activities as gambling, sex and eating.

Types of Depression

There are two basic types of depressive illness: endogenous depression and situational depression. Both typically involve the same symptoms and, in many cases, are treated similarly. Significant differences between an endogenous depression and a situational depression do exist, however. These differences often determine the length of treatment necessary and the type of measures taken for prevention of additional depressive episodes.

Endogenous Depression

An endogenous depression is one in which a biological predisposition to depression is present. Typically, there is a family history of depression that reveals a genetic tendency toward depressive illness. It is not unusual for individuals with an endogenous depression to have close family members such as parents, siblings and children who are also affected by the illness. While this type of depression can occur with or without significant stress, periods of intensified stress will typically cause a more acute depressive episode. Individuals with an endogenous depression may have recurring and severe episodes throughout their lives. Many will experience long periods of low-level depression (dysthymia) in between more severe episodes. Medication is frequently used to manage an endogenous depression during severe episodes as well as the periods in between.

Situational Depression

A situational type of depression can occur without a genetic or biological predisposition to depressive illness. An episode of situational depression typically occurs in response to adverse life circumstances and is consequently considered to be a reactive condition. Situational depression is usually triggered by a single incident such as job loss, illness, bereavement or divorce; however, several stressors usually occur simultaneously during such life crises. This type of intensified stress causes one’s usual coping skills to become overtaxed. For example, divorce may be complicated by a financial crisis, loss of social supports and poor job performance all of which in combination severely impact one’s ability to function. These types of situational stressors are not always present in the lives of those who have a more biologically-based type of depression.

Co-occurring Addiction and Depression

Addiction and depression are closely related for many people and the two conditions interact in various ways. One condition may cause or significantly exacerbate the other. Those with the dual diagnosis of addiction and depression develop the co-occurring conditions in various ways as well. For some, depression came first and for others, addiction was the original illness. Despite how addiction and depression came to co-exist, all individuals with these dual conditions require treatment that will address both simultaneously in order to achieve full recovery.

Addiction as an Attempt to Self-Medicate Depression

Individuals with depressive symptoms naturally seek relief from their debilitating effects and many will use addictive behavior in an attempt to cope with depressive symptoms. Any depressive illness–whether endogenous or situational –can be worsened and prolonged by the use of addictive behaviors. Typically, a ‘synergy’ of symptoms occurs. Both depressive symptoms and addictive symptoms begin to build and fuel each other when addictive behaviors are used during depression. Momentary relief found in the use of addictive behaviors will, over the long run, exacerbate and prolong a depressive episode. If addictive behaviors are relied upon to relieve symptoms over a prolonged period, eventually the effects of addictive behaviors themselves become a second and equally significant problem.

Ingestive addictions (drugs, alcohol and food) as well as process addictions (such as gambling, sex and shopping) can both be used to ‘self-medicate’ the problematic symptoms of depression. Anxiety, dysphoria and sleep problems are common depressive symptoms individuals attempt to alleviate with addictive behaviors. The inappropriate use of mood-altering behaviors or substances to cope with such symptoms significantly increases the risk for developing an addictive disorder during an episode of depression. This occurs because of a ‘rebound’ effect: addictions are used to ‘medicate’ depression/depression worsens with addiction and more addictive behaviors are used to ‘medicate’ the worsening depression. A ‘vicious cycle’ of dual disorders begins to feed itself until appropriate dual diagnosis treatment breaks that cycle.

Depression as a Reaction to Addiction

Any addiction triggers a multitude of negative feelings such as guilt, sadness, shame, hopelessness, helplessness, powerlessness, anger, anxiety and fear. These emotional experiences are very similar to those found in episodes of depression that occur without addiction. Addictions progress in their debilitating effects and begin to erode one’s resiliency and sense of well-being. Additionally, depression builds with the increasing unmanageability of life and the subsequent sense of powerlessness that accompanies addiction. Consequently, many addicted individuals will develop a clinical depression as a direct result of their addiction. In this type of dual diagnosis experience, both disorders—the addictive condition and the depression—must be treated at the same time if full recovery is to occur.

Treatment

The treatment of co-occurring depression and addiction requires a dual treatment approach that views both as a primary condition. Dual diagnosis treatment implements and co-ordinates a plan for relief from symptoms of both disorders. The overall goal of such treatment is to resolve both the depressive illness and the addictive disorder so that a successful recovery from both occurs.

Individuals trained in treating dually diagnosed individuals understand each condition and can create individualized treatment plans to address both simultaneously. Therapies used for each disorder are combined into one manageable and effective treatment plan. Those with co-occurring depression and addiction may use antidepressants, psychotherapy and traditional substance treatment modalities such as education, addiction counseling and self-help groups to create a comprehensive plan for resolving both. Relapse prevention planning for dual disorders will involve strategies to keep both acute episodes of addiction and depression from recurring.

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