Published November 11, 2016
In Part One of this Expert Summary series, RIA explored the multifaceted subject of substance abuse and mental illness.
Are people with mental illness more likely to abuse drugs? Or does abusing drugs contribute to mental illness? There are no easy answers to these complicated questions, but the high rate of co-occurrence for these problems is prompting experts to advocate for better screening and treatment options for patients who present with both.
In Part Two, we look at the most common co-occurrence—depression and alcohol use disorder (AUD).
Although many people associate alcohol with “good times,” there is also the old adage of drinking to “drown your sorrows.” This can be the case for those who are clinically depressed and turn to alcohol as a form of self-medication. On the other hand, there are people whose depression only manifests after they begin abusing alcohol. Determining which problem came first is often the key to effective treatment for both issues.
As stated in Part One, there is often a “chicken or the egg” problem when discussing co-occurring (or “co-morbid”) substance abuse and mental illness. In the case of alcohol and depression, treatment professionals try to determine whether a person’s drinking precedes his or her depression or whether the depression precedes their drinking.
An ongoing large-scale research study has been conducted since 2001 to assess drinking and co-occurring conditions among the U.S. population. The most recent National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) showed that 13.9 percent of the population met criteria for AUD during the past year; 29.1 percent reported they experienced AUD at some point in their lifetime.
The NESARC study also found that people with AUD were 3.7 times more likely to experience a major depressive disorder than those without AUD. Other research has shown that when people experience both AUD and depression, both conditions tend to more severe and are more difficult to treat than when they appear alone.
Interestingly, women are more likely to have depression first, then an alcohol use disorder, while the opposite is true for men—they are more likely to experience AUD first and depression subsequently.
There are two primary reasons alcohol misuse can lead to depression. The first is psychosocial—if a person has problems with alcohol, it can lead to further problems in life. For example, relationships can deteriorate, there could be job loss due to poor performance, or even trouble with the law. Any of these undesirable situations can lead to negative emotions that lead to a major depressive disorder.
The second reason is biological. Although drinking alcohol initially can feel stimulating, alcohol is a depressant, which means it lowers the function of neurotransmitters in the central nervous system. The immediate effects include slower movement, lack of coordination and slurred speech. In the long term, alcohol causes lasting effects in the brain. The misfiring of certain neurotransmitters, such as serotonin, is directly related to clinical depression (not to be confused with temporarily “feeling bad” after a bout of heavy drinking, which goes away after a few days).
A study released by the National Institute on Alcohol Abuse and Alcoholism found that people with a history of alcohol dependence, even including people who have quit drinking, were four times more likely to experience major depression in comparison to those without a history of AUD.
For some people, depression precedes AUD. Studies show that nearly a third of people with depression also have problems with alcohol. Many depressed people turn to alcohol or drugs in an attempt to escape or make themselves feel better, but they unfortunately are only exacerbating the problem. As noted above, the misuse of alcohol affects the brain in ways that can make depression worse.
There also is research saying certain genetic risk factors are present in both AUD and major depressive disorder, so there may be a genetic predisposition for certain people with depression to also become dependent on alcohol.
A Yale University study compared rates of AUD in people with and without depression, and found higher current and lifetime rates of AUD in the depressed population.
Due to the complicated nature of co-occurring of AUD and depression, achieving a successful outcome can be challenging. And, in patients who are able to successfully address both problems, there remains a significant danger of relapse, especially if and when they face difficult life circumstances that test their capabilities and resolve. Also, researchers have found that patients with dual diagnosis have a lower rate of completing formal treatment and attending follow-up sessions.
Fortunately, specialized treatment programs for dual diagnosis are more becoming more common and available, as there is growing awareness of the need for closer collaboration between professionals in the mental health and addiction treatment fields. These collaborative efforts provide the best avenue for recovery, and researchers and clinicians alike continue to explore innovative approaches to help people manage and recover from these two disorders.
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People with co-occurring alcohol and depression problems face serious challenges when seeking treatment. There is still stigma attached to both substance abuse and mental health disorders. People experiencing both alcohol dependence and depression may feel a double dose of shame which keeps them from seeking help.
As discussed in Part One of this series, another barrier to treatment is that, in the U.S., separate treatment programs and services are in place to treat each problem. Alcohol use disorder is often addressed through alcohol-specific treatment programs or mutual-help programs such as Alcoholics Anonymous, while major depressive disorders are often handled through psychiatrists, counselors or psychologists with expertise in depression and other mental health disorders. However, most addiction treatment programs are not geared to handle clinical depression, and people in treatment for depression seldom receive appropriate treatment for substance use disorders.
Then, of course, there is the simple fact that a dual diagnosis is harder to treat than a single one. People with co-occurring disorders have a worse prognosis for treatment success, which is particularly worrisome because they also demonstrate a higher rate for suicide attempts and deaths. Therefore, finding a proper treatment solution is crucial.
As more is learned about the neurobiology of addiction and depression, more treatment strategies are being evaluated and offered. A 2003 study found that fewer than half of the nation’s drug and alcohol treatment programs had a full-time doctor or nurse on staff. However, collaboration between addiction treatment professionals and the medical community is on the rise, which bodes well for successful patient outcomes.
The first step addressing comorbidity is to try to answer the “chicken or the egg” question – is the patient suffering from alcohol-related depression, or depression-related AUD? Oftentimes, this only can be answered after a period of abstinence from alcohol. Studies have shown that a certain degree of depression is ameliorated after people stop drinking for a few weeks. If depression persists after abstinence, there are treatment options which can help not only with depression, but also with preventing a relapse into drinking. Cognitive Behavior Therapy (CBT) and Motivational Interviewing (MI) are two therapies that have shown strong effectiveness in dealing with dual diagnosis of alcohol and depressive disorders. CBT is generally administered as a short-term psychological treatment where a patient works with a therapist to identify negative thinking, behavior and emotional responses, and develops skills to change them. MI is also a goal-oriented counseling approach, first used with AUD, where the therapist facilitates and engages the person’s intrinsic motivation in order to change behavior.
Anti-depressant medication also may be part of a patient’s treatment. Although effective in reducing depression, these medications have not yet shown any significant effect on curbing drinking by themselves. However, they may help reduce drinking indirectly, by reducing the depressive feelings that lead some people to drink.
A handful of FDA-approved medications, including Isulfiram (Antabuse), Naltrexone (ReVia, Vivitrol), and Acamprosate (Campral), can be used to reduce alcohol cravings, but they do not address co-occurring depression.