Depression and Addiction
Depression is a significant complicating factor in recovery from substance use disorders. Nearly all substance abusers show significant depression in the first several weeks of recovery. In most cases, the depression quickly subsides. Others, however, suffer from serious bouts of depression throughout their recovery.
The Continuum of Depression
Depression is a state of central nervous system inhibition that operates on a continuum between severe depression (i.e. severe central nervous system inhibition) and severe mania (i.e. severe central nervous system stimulation). When a depressed mood becomes so severe that it interferes with normal daily routines necessary to maintain interpersonal relationships, work activities or the maintenance tasks of life, it is identified as a mental disorder called depression.
Normal Mood States Related To Depression
It is normal and natural for healthy people to swing between mild and moderate states of stimulation and depression. We have good days and bad, we feel high and low. It is also common for people to experience an extreme mood state in response to severe psychosocial stressors such as the loss of a loved one, the loss of a job, serious financial setbacks, or other extreme life changes.
Normally, however, there are protective factors that prevent us from getting locked or trapped in extremely depressed or agitated states. These protective factors also keep us from rapidly cycling between the agitation and depression. Unfortunately, there are also risk factors that make us more likely to suffer from episodes of depression.
Risk and Protective Factors
It’s helpful to think in terms of protective factors and risk factors. Protective factors are ways of thinking, feeling, acting, and living our lives that protect us from depression. Once these protective skills have become a habitual part of our life, we find that it takes more stress and pressure to trigger our depression and that the episodes of depression become shorter and less severe.
Risk factors are ways thinking, feeling, acting, and living our lives that make us more vulnerable to depression. If these risk factors have become a habitual part of our life, we find that it takes much less stress and pressure to trigger our depression and that the episodes of depression become longer and more severe.
The good news is that we can learn to identify these risk and protective factors and make choices to learn and practice protective skills while eliminating or minimizing the use of risk factors.
Symptoms of Depression
The following list can be used to identify the symptoms of depression.
- Feeling sad, anxious, or “empty” mood
- Feeling pessimistic about yourself or your life
- Feeling helpless or hopeless
- Loss of interest in hobbies and activities that you once enjoyed
- Decreased interest in physical affection and sexual experiences.
- Unable to experience pleasure as a result of physical affection and sexual experiences
- Decreased energy, increased fatigue, or a sense of being sluggish or “slowed down”
- Difficulty concentrating or remembering things
- Difficulty making decisions
- Trouble sleeping restfully. This may include the inability to sleep, waking up many times during the night awakening early in the-morning, oversleep, or waking up without feeling rested
- Increase or decrease in appetite
- Overeating and weight gain?
- Poor appetite and weight loss
- Agitation, restlessness, or irritability?
- Persistent physical symptoms that do not respond to treatment, such as headaches, digestive disorders, and chronic pain
- Believing that life isn’t worth living that you would be better off dead, Thinking about, having a plan, or actually trying to kill yourself.
The Biopsychosocial Model of Depression
It is helpful to think about depression as a complex cluster of biological, psychological, and social responses that occur when a stressful event activates specific thoughts and feelings, and behaviors. In other words, depression is a biopsychosocial disorder. The biological factors in depression make a person more likely to experience serious depression in response to external situations and the thoughts and feelings they experience in reaction to those situations.
Biological depression results from an inhibited response of the brain and nervous system to internal and external events. Some people may be genetically predisposed to experience depression. Other people may be born with normal brain chemistry systems but experience high levels of debilitating stress or use alcohol, drugs, or other substances that interfere with or damage the normal brain chemistry systems and create physiological tendencies toward depression.
Antidepressant medications can be a helpful adjunct to treatment for people suffering from forms of depression that have a strong biological basis. From a biopsychosocial perspective, however, it becomes clear that purely physiological interventions for depression are not and cannot be the total answer for depression.
When medication is used in isolation from treatment designed to identify and change the psychological and social processes that are linked to the depression, the relief is often temporary. The brain chemistry is temporarily adjusted while the psychological and social processes that drive the depression continue. As a result there is often an escalating need for more or different antidepressant medications to keep the depressed mood in remission.
The most effective use of antidepressant medication in the treatment of depression that coexists with chemical dependency is as an adjunct to a structured recovery program that also includes cognitive behavioral therapy and involvement in structured self-help groups such as Twelve Step Groups.
Psychological Factors In Depression
Psychological depression is associated with specific ways of thinking (T), managing feelings (F), and acting (A). These TFA’s are usually activated by a trigger event that causes stress. The stress then activates depressive brain chemistry that is linked through long-term stimulus response conditioning to the depressive thoughts, feelings, and actions.
There is a link between what we think and the tendency to feel depressed. This process can be called depressive thinking and is generally based upon depressive thinking errors that lead a person to believe that they are powerless, helpless, and have little ability to impact or change themselves or their lives.
These depressive thoughts do not occur in isolation. They are linked with depressive images of past events or depressive fantasies of future outcomes that reinforce the thinking errors. The process goes like this: Something happens that activates a depressive thinking error, the imagery system responds to this error in thinking by providing vivid sensory images of past experiences and projected future occurrences that support the thinking error.
The affective system responds to the imagery by creating brain chemistry changes (such as lower Serotonin levels) that depress the mood. The feeling of depression is used as further evidence and the emotional confirmation that the depressive thinking errors are in fact correct. The process is called emotional reasoning and is based upon the mistaken belief “if I feel this way it must be true.” The depression creates an urge to stop trying and withdraw from the situations or relationships that are the focus of the depressive thinking. If these urges are acted upon the person reduces stimulation through social withdrawal which reinforces the brain chemistry state associated with depression. The resultant boredom and lack of social interaction and reality testing that result from the isolation further reinforces the depressive physiology and the depression continues to intensify as a result of progressive cycle.
In some cases the depression begins with physiological factors that depress the nervous system and result in a diminished ability to respond. In other cases the depression results from the habitual use of ways of thinking and behaving that are based in a fundamental assumption of helplessness, frustration, and powerlessness to make a change or to impact the world or life. In still other cases people are caught up in legitimately stressful and often catastrophic events which lead to stress degeneration and then to depression. For most patients two or more of these causative factors are linked together to create the depression.
Patterns of Depression & Addiction
In addicted people, depression often presents itself in one of four common patterns: Substance Induced Depression, Depression Induced Substance Abuse, Situational Depression in Sobriety, and Co-occurring Addiction and Depression. To avoid relapse it is critical to recognize these four types of depression and to match patients to appropriate treatment strategies.
Chemical Dependence and Depression: Common Patterns
- Substance Induced Depression
- Depression Induced Substance Abuse
- Situational Depression in Sobriety
- Co-occurring Addiction and Depression
Substance-Induced Depressions are caused by the use, abuse and addiction to alcohol and other drugs and the depression quickly remits in early recovery without special treatment. Depression Induced Substance Abuse occurs when patients suffering from depressive illness start using alcohol or other drugs to medicate or manage the symptoms of depression and then becomes dependent upon those substances.
Situational Depression in Sobriety occurs in some chemically dependent patients who experience extreme stressors in recovery. The depression is clearly linked to the mismanagement of specific problems in sobriety. The depression is relieved when these problems are identified and effectively managed.
Co-occurring Depressive Illness occurs when patients are suffering from both chemical dependency and an independent depressive illness. These patients typically have a family history of substance abuse and addiction, a family history of depression or other mood disorders. The history reveals that the symptoms of the depression predated the chemical abuse and that as the addiction progressed so did the severity of the depression. There is often a vacillating symptom pattern. The depression temporarily goes into remission when the patient is drinking or drugging only to return in a severe form when the patient attempts abstinence. With co-occurring depressive illness both the chemical dependence and the depression need to be treated simultaneously.
Treatment and Recovery
Whenever depression becomes severe enough to interfere with ongoing addiction recovery it is serious enough to seek specific help for managing the symptoms.
Although it is possible to recover from depression, there is no one correct way to do it. Different people use different recovery tools. What works well for one person may not work very well for another. Yet there are general principles and basic tools that are effective for a large number of people.
This means that putting together a recovery program from addiction and depression will require learning about the choices that are available. It means being willing to put together an initial recovery plan and being open to adjust the details of that plan in order to make it work more effectively. In recovery we seek progress not perfection. We take small steps that make us feel a little bit better. We learn from those steps, and then take other small steps
Fortunately the recovery plans for addiction and depression are closely related. Many of the things that help people stay comfortably sober also help them to manage their depression. This means that a recovery plan that meets the needs of both addiction and depression can be developed. If you’re already in recovery from addiction this is good news. You already know and have practiced many of the recovery skills needed to manage depression. All you will need to do is to learn a few additional techniques. Here are some ideas that you can use as a check-list.
- Recognize the presence of chemical dependency and depression by evaluating all chemically dependent clients for depression and all depressed clients for chemical dependency.
- Stabilize the client from severe symptoms of acute withdrawal, post acute withdrawal, and depression using an adequately controlled environment and appropriate medications. Evaluate and implement appropriate suicide precautions during stabilization. Caution should be taken not to prescribe antidepressants for transient states of substance-induced depression or for complaints about normal depressed states associated with early recovery or normal life stressors.
- Educate the client about both chemical dependency, depression, and the reciprocal relapse process.
- Develop and monitor involvement in a structured recovery program consisting of psychoeducation, group and individual therapy, and self-help group involvement which needs to be initiated and maintained.
- Develop a plan with the patient and significant others in the patients life for what actions will be taken should they relapse to either alcohol and drug use or should depression occur. Prepare an early intervention strategy that will be used if relapse does occur.
- Help the client to identify their unique profile of problems related to the chemical dependency and the depression. Both addictive thoughts and behaviors that activate an urge to use alcohol and drugs and depressive thoughts that activate feelings of depression need to be identified and managed.
- Develop a personalized list of relapse warning signs that can lead from stable sobriety and normal mood to chemical dependency and depression. The high risk situations that activate these warning signs need to be identified and management strategies developed.
- Develop management strategies for each warning signs that includes challenging irrational thoughts, managing unmanageable feelings, and changing self-defeating behaviors related to the warning signs.
- Reduce the frequency of treatment sessions as the client becomes involved in self-help groups.
- Schedule regular follow-up sessions to monitor for relapse warning signs. By doing so the door is left open for the client to access frequent help at the earliest sign of problems.
Depression and Relapse – The Book
Terry Gorski’s book on Depression and Relapse will be published by Herald House Independence Press: : Depression and Relapse by Terence T. Gorski