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Updated on January 26, 2022

Depression and Addiction

How are Depression and Substance Use Connected?

About one-third of people with clinical depression have a substance use disorder (SUD).1

Depressed people may drink alcohol or use drugs to relieve depression. But in reality, these substances can trigger and intensify depressive symptoms. 

When depression and SUD coexist, the person has a dual diagnosis or co-occurring disorders

Treatment is far more effective and successful when it addresses both conditions concurrently.

Understanding Depression 

Depression is a chronic, progressive illness. 

It can last for weeks, months, or even years. It may get worse over time if not treated. 

Depression can greatly affect a person’s physical and emotional well-being, personal and social relationships, work, and financial health. 

Around 280 million people across the world have depression.2 In the U.S., over 15 million adults experience a depressive episode each year.3

Symptoms of Depression

A person must show at least 5 of the following symptoms to be diagnosed with depression:4, 5

  • Depressed mood
  • No interest or pleasure from hobbies or daily activities
  • Unintentional weight loss or gain
  • Sleeping too much or too little
  • Fatigue
  • Lack of energy
  • Engaging in activities like pacing or hand wringing, or the inability to sit still
  • Slowed movements or speech
  • Persistent feelings of worthlessness or guilt
  • Problems with memory, concentration, or decision-making
  • Constant thoughts about death, dying, or suicide

Types of Depressive Disorders

There are many types of depressive disorders. Here are 4 of them:6, 7

Major Depressive Disorder (MDD)

MDD is a common mental health disorder in the U.S. 

MDD is the leading cause of disability in the U.S. for people between 15 and 44 years old. It affects over 16 million American adults and occurs in more women than men.3

According to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), MDD is characterized by:4, 8

  • At least 2 weeks of depressed mood along with 4 or more symptoms 
  • Having no direct relationship to a coexisting medical condition or substance abuse

MDD can lead to severe impairments that interfere with major life activities.  

If left untreated, MDD can persist or recur throughout a person’s life.

Persistent Depressive Disorder

Persistent depressive disorder, also known as dysthymia, is a milder form of depression. 

People with dysthymia have low moods and depression symptoms for 2 years or more. 

Dysthymia’s symptoms may not be as severe as those of MDD. Still, its effects on a person’s quality of life are just as serious.

Bipolar Disorders

People with bipolar disorder experience both mania and depression. 

Mania is characterized by elevated mood, hyperactivity, or euphoria, while depression is associated with a low mood. 

A person with bipolar disorder will experience depression mixed with less-frequent manic episodes over the course of weeks or even months.

It’s difficult to diagnose bipolar disorder without tracking these mood changes.

Seasonal Affective Disorder (SAD)

Variations in light and temperature trigger SAD, a type of depression in which seasons affect a person’s mood. 

For example, people with winter-pattern SAD feel depressed in winter but feel better in spring.

To be diagnosed with SAD:9

  • The person must have major depression symptoms or symptoms specific to winter-pattern or summer-pattern SAD
  • The depressive episodes must occur during distinct seasons for at least 2 consecutive years
  • The episodes must be more frequent than other depressive episodes

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Understanding Substance Use Disorder (SUD)

A substance use disorder (SUD) is the repeated misuse of alcohol, drugs, or other substances. 

According to the DSM-5, these are the 10 drugs that can lead to substance-related disorders:4

  1. Alcohol
  2. Cannabis
  3. Opioids
  4. LSD and other hallucinogens
  5. Cocaine and other stimulants
  6. Sedatives, hypnotics, or anxiolytics
  7. Inhalants
  8. Caffeine
  9. Tobacco
  10. Other or unknown substances

Symptoms of Substance Use Disorder (SUD)

A person must meet 2 or more of these 11 criteria within 12 months to be diagnosed with a SUD:4, 10

  1. A developed tolerance, in which people must consume more drugs or alcohol to get its rewarding effects
  2. Experiencing withdrawal symptoms that can only be relieved by taking more drugs or alcohol
  3. Taking drugs or alcohol in larger amounts or for longer than intended
  4. Having the desire to quit substance use but with no success
  5. Spending a lot of time getting or using the substance and recovering from substance abuse
  6. Continued use despite problems caused by drugs or alcohol
  7. Giving up important activities because of substance use
  8. Failure to fulfill essential obligations due to substance use
  9. Recurrent substance use leading to dangerous behavior, like driving under the influence
  10. Continued substance use despite relationship problems
  11. Excessive cravings and urges

The severity of SUD is classified based on the number of met criteria: 

  • Mild: 2 to 3 criteria
  • Moderate: 4 to 5 criteria
  • Severe: 6 or more criteria

Understanding Co-Occurring Disorders

People with co-occurring disorders have 2 or more mental health disorders. 

These co-occurring disorders may happen at the same time. It’s also possible that one condition exists before or after the other.1

Conditions that can co-occur with substance use disorders (SUDs) include:11

  • Anxiety disorders
  • Major depression
  • Bipolar disorder
  • Borderline personality disorder (BPD)
  • Antisocial personality disorder (ASD)
  • Attention-deficit hyperactivity disorder (ADHD)
  • Schizophrenia
  • Psychotic illness

Dual diagnosis can cause additional or combined problems from one or both disorders.

Each condition can make the other worse, which also makes rehabilitation harder. For example, SUD can worsen depression symptoms, increase the likelihood of hospitalization, and interfere with treatment. 

Symptoms of Co-Occurring Disorders

Co-occurring disorders can have overlapping symptoms like: 

  • Quitting hobbies or social activities
  • Denying or refusing to acknowledge the problem
  • Defensiveness
  • Strained relationships
  • Social isolation
  • Risky behaviors

Because of overlapping symptoms, diagnosis, whether it’s for an addiction, mental health disorder, or both, can be challenging.

To avoid confusion, a person should abstain from alcohol or drugs to receive a proper diagnosis.

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Depression and Substance Abuse

Among people with recurrent major depression:7

  • 16.5% have an alcohol use disorder
  • 18% have a drug use disorder

There are 3 possibilities for why depression and SUD can occur together:8, 12, 13, 14

1. Genetics

Both substance abuse and some mental disorders can run in families. 

Stress, trauma, and other environmental factors can be caused by genetic factors that pass down through generations.

2. Self-Medication

Depressed people may use drugs or alcohol as a form of self-medication. Although these substances may provide temporary relief, they can worsen symptoms of depression. 

This creates a situation where one condition cyclically affects the other.

3. Brain Changes

Substance use may cause brain changes that make a person prone to developing a mental health disorder.

Alcohol use can increase the risk of suicide in a depressed person.15

Drugs can worsen depression in the long run and increase the risk of developing a drug addiction.13

Treatment for Depression & Co-Occurring Addiction

People must be treated for depression and substance abuse simultaneously for a successful recovery.

If the person is treated only for depression but still uses alcohol or drugs, the substance can decrease the treatment’s effectiveness. Alcohol and drugs can also interfere with medications. 

Simply stopping alcohol or drug use without addressing depression is also not effective. This action may cause withdrawal symptoms, worsen depression, and increase the risk of relapse. 

The best course of treatment for co-occurring conditions is an integrated approach. It combines multiple techniques proven effective against substance use and mental health disorders. 

These techniques include:12, 14, 16, 17

Medications

Antidepressants can reduce depressive symptoms. 

There are also different medications for different SUDs like:11

  • Methadone, buprenorphine, and naloxone for opioid use disorder
  • Naltrexone for opioid and alcohol use disorders
  • Acamprosate and disulfiram for alcohol use disorder

There are also medications for easing withdrawal symptoms during the detoxification process. 

Cognitive Behavioral Therapy (CBT)

This therapeutic treatment teaches people how to change their thinking and behaviors that may increase the risk of substance use. CBT also helps people build coping skills.

Dialectical Behavioral Therapy (DBT)

This approach is designed to reduce self-harm behaviors like suicide attempts and drug abuse.

Contingency Management (CM) 

Also called motivational incentives, these programs provide vouchers or rewards for healthy behavior. 

The incentives are exchanged for items like a gym membership or movie tickets. 

Motivational Enhancement

This approach helps people increase motivation. This is necessary to make positive changes during the treatment process.

Mutual Support Groups

In mutual support groups, members can share frustrations, celebrate successes, find resources, share referrals, and exchange tips. 

Examples of such groups are Narcotics Anonymous (NA), Alcoholics Anonymous (AA), Double Trouble in Recovery (DTR), and SMART (Self-Management and Recovery Training) Recovery.

Residential Treatment

In residential treatments, people live at a facility for the duration of treatment. 

Mental health professionals will provide support and medication while people learn to manage their co-occurring disorders.

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Resources

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  1. Davis, Lori et al. “Major depression and comorbid substance use disorders.Curr Opin Psychiatry vol. 21,1 :14-8.
  2. Depression.World Health Organization. 13 Sept. 2021.
  3. Understand Anxiety & Depression.Anxiety & Depression Association of America.
  4. Diagnostic and statistical manual of mental disorders (5th ed.).American Psychiatric Association. Arlington, VA: American Psychiatric Publishing. 2013.
  5. Torres, Felix. “What Is Depression?American Psychiatric Association. Oct. 2020.
  6. Benazzi, Franco. “Various forms of depression.Dialogues in clinical neuroscience vol. 8,2 : 151-61.
  7. Quello, Susan B et al. “Mood disorders and substance use disorder: a complex comorbidity.Science & practice perspectives vol. 3,1 : 13-21.
  8. Major Depression.National Institute of Mental Health. Oct. 2021.
  9. Seasonal Affective Disorder.National Institute of Mental Health.
  10. Understanding Alcohol Use Disorder.National Institute on Alcohol Abuse and Alcoholism.
  11. Common comorbidities with substance use disorders.National Institute on Drug Abuse. Apr. 2020.
  12. Comorbidity: Substance use disorders and other mental illnesses.National Institute on Drug Abuse. Aug. 2018.
  13. Addiction and Health.National Institute on Drug Abuse. July 2020.
  14. Substance Use and Co-Occurring Mental Disorders.National Institute of Mental Health. Mar. 2021.
  15. Pompili, Maurizio et al. “Suicidal behavior and alcohol abuse.International journal of environmental research and public health vol. 7,4 : 1392-431.
  16. Kelly, Thomas M, and Dennis C Daley. “Integrated treatment of substance use and psychiatric disorders.Social work in public health vol. 28,3-4 : 388-406.
  17. Substance Use Disorders.National Alliance on Mental Illness. May 2020.

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