Depression Assessment: Substance Use Problems

Substance use problems - drinking alcohol, using drugs or misusing prescription medications in a way that interferes with a person’s daily activities - are common among people experiencing depression. Almost 1/3 of those with depression also have substance use problems and those with both depression and substance problems are at a greater risk for suicide compared to depressed people who do not use substances problematically (Davis, Uezato, Newell, & Frazier, 2008). The term “dual diagnosis” is often used for people who have problems with depression and substance use.
Common Symptoms of Substance Use Disorders
Use of certain substances, including alcohol, nicotine, caffeine and (in some states) cannabis is legal and relatively commonplace in the United States. Many people may use these substances infrequently or in amounts that do not cause interference with daily life. This level of interference in daily life is a key factor in determining if someone has a substance use problem. For example, it may not be problematic for a healthy person to have one beer with friends on a Friday. By contrast, drinking to intoxication and driving home puts the individual and others at risk and would be one example of interfering with daily life. Another potential signal of a substance use problem is when someone has made repeated unsuccessful attempts to stop or cut back in using a substance.  Additional signs include if someone is requiring larger amounts of a substance over time to achieve the same effect and/or experiences negative physiological symptoms when the substance is not used.
Why Do Substance Use Problems and Depression Occur Together?
Scientists are still in the process of understanding the association between depression and substance use. In this case, the old debate about the chicken and the egg is a good analogy. For example, it is plausible that using substances in a problematic way creates additional life stressors , which make people more susceptible to depression. For example, a person who drinks heavily may receive a DUI and have pending legal problems, and then experience depression in reaction to the stress. By contrast, the “self-medicating” hypothesis suggests people experiencing depression use substances to dull emotional pain or to escape self-critical thoughts. For example, someone who is depressed drinks to intoxication every night in order to tune out negative thoughts and fall asleep. Although relatively rare, in some cases, depressive symptoms only occur while someone is experiencing negative physiological symptoms from reducing or stopping a substance. In that case, the symptoms are not indicative of true depression but rather are attributed to the substance itself.
Common Treatment Approaches
In many cases, depression and substance use can be treated at the same time. Often combined treatment strategies train and support people in developing healthy coping strategies that can be substituted for using substances.  However, in some cases, substance use may need special attention in treatment. For example, in cases of more severe substance use, safely cutting back on a substance may require medical oversight. In those cases, reducing substance use and helping the body to safely adjust to decreased use in a safe, medical setting is critical prior to focusing on depression. In addition, in cases where a person clearly began having problems with substance use prior to any depressive symptoms, focusing on the substance problem as the primary issue may be most useful. Twelve step programs such as Alcoholics and Narcotics Anonymous and SMART Recovery are by far the most commonly used treatments for substance problems and research suggests they are beneficial for some people (Humphreys, 2003). The programs are widespread within the US and participation is free. Cognitive-Behavioral Therapy has also been shown effective for substance use problems. It is not uncommon for people to be unsure about or resistant to the idea of cutting back substance use. In those cases, a technique called Motivational Interviewing helps people to explore their mixed feelings about changing their substance use. 

Davis, L., Uezato, A., Newell, J. M., & Frazier, E. (2008). Major depression and comorbid substance use disorders. Curr Opin Psychiatry, 21(1), 14-18. doi:10.1097/YCO.0b013e3282f32408
Humphreys, K. (2003). Alcoholics Anonymous and 12-step alcoholism treatment programs. Recent Dev Alcohol, 16, 149-164.