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Co-Occurring Disorder Series: Understanding Depression and Substance Use

Conventional wisdom often says that people use substances to “self-medicate” to deal with underlying issues, or in more technical language, people use substances because they are trying to cope with a mental illness. This certainly is true for a significant percentage of people with a substance use disorder (SUD), but it is also necessary to be fair and say that it is not true for all cases.

For example, there are some with chronic pain issues that have become addicted as a result of being on certain medication, such as opiates, for long periods of time. When addicted, it is difficult for anyone to get off any substance they have been using for any significant period of time.

And then there are drugs that can play a part in causing mental illness, such as hallucinogens causing a psychotic episode. It is important to understand this so that we can get our friends, family, and loved ones the best and most appropriate care possible. For the purposes of this article, first in a series on mental illness and SUD, we will be looking at individuals that have a confirmed mental illness along with a SUD.

What Are SUDs And Depression?

While we all have an image in our heads of the people associated with the terms “drug user” or “depressed,” it is important to have a good definition of what we are talking about, as those images may be scarily accurate at times. For example, depression doesn’t always quite look the way one would think.

In fact, there are individuals with serious substance use problems that may hold down a job and be upstanding members of the community. While our thoughts and ideas may hit the mark, the truth is human behavior is so complex that our ideas very rarely cover 100% of the population.

SUD is presented in the DSM 5 on a continuum of mild to severe, depending on how many symptoms are present. The more symptoms, the more serious the disorder and the more risk the person is at in life overall. These symptoms include (APA, 2013):

  1. Taking the substances in larger amounts and for longer than intended.
  2. Wanting to cut down or quit but not being able to do it.
  3. Spending excessive personal time obtaining the substances.
  4. Craving or a strong desire to use substances.
  5. Repeatedly unable to carry out major obligations at work, school, or home due to substance use.
  6. Continued use despite persistent or recurrent social or interpersonal problems caused or made worse by substance use.
  7. Stopping or reducing important social, occupational, or recreational activities due to substance use.
  8. Recurrent use of substances in physically hazardous situations.
  9. Consistent use of substances despite acknowledgment of persistent or recurrent physical or psychological difficulties from using the substance.
  10. Tolerance as defined by either a need for markedly increased amounts to achieve intoxication or desired effect or markedly diminished effect with continued use of the same amount.
  11. Withdrawal manifesting as either characteristic syndrome or the substance is used to avoid withdrawal.

So we can see the impact of SUD on a person’s life by the symptomology here and the problems that arise from continued and increasing use. Or to put it more concisely, the more a person cuts off parts of their life for substance use, the worse the problem has become.

Major Depressive Disorder

Major depressive disorder (MDD) is categorized as a mood disorder, but it is more useful to look at it as a disorder of the mood that affects the whole person, biologically, psychologically, emotionally, socially, and spiritually.

It is an important distinction to note that everyone has bad days and that everyone will feel down at some point or have sad events in their lives. MDD is beyond that. This is depression that has lasted a significant amount of time, several weeks with almost daily symptoms before it can actually be diagnosed as MDD. The crucial thing to remember is that the symptoms have to impact a person’s daily life, causing some noticeable distress. Looking at the symptom list directly, it consists of nearly daily occurrences of the following (APA, 2013):

  1. A depressed mood most of the day. This mood might be characterized by sadness, hopelessness, or feeling numb. Some many also feel bouts of anger not connected to a specific event.
  2. Markedly diminished interest or pleasure in all or almost all activities most of the day.
  3. Significant weight loss when not dieting or weight gain.
  4. Inability to sleep or oversleeping.
  5. Psychomotor agitation or retardation.
  6. Fatigue or loss of energy.
  7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional).
  8. Diminished ability to think or concentrate or indecisiveness.
  9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, a suicide attempt, or a specific plan for committing suicide.

This is a lot of information to take in and the diagnostic criterion was presented to give a pretty specific picture of what it looks like to have a SUD and MDD. It cannot be said enough, however, that if you or someone you know is showing signs of struggling with substances, mental health, or life in general, please seek help. Help can come in the form of your physician, a therapist, your local community health services, or other trained professionals. It’s crucial to get the help you need.

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Looking At The Numbers

When we look at the numbers regarding addiction and depression, one of the first things that come up is the criteria used to determine if a person has both a mental illness and a SUD. Simply put, that takes time and training and a longer answer for proper assessment and diagnosis of these conditions will come in the second part of this series.

Right now we will look at the best statistics that we have when looking at a co-occurring disorder. We’ll start with the overall numbers in general to see what this population looks like as a whole and then narrow down to the statistics for SUD and depression.

According to the Substance Abuse and Mental Health Services Agency, the segment of the Department of Health and Human Services that “leads public health efforts to advance the behavioral health of the nation… reduce the impact of substance abuse and mental illness on America’s communities (SAMHSA, 2016),” there are approximately 8.9 million people or roughly 3% of the country that will have a co-occurring disorder of some kind. All statistics presented are for adults age and 18 and up, unless said otherwise.

To put this in further perspective, SAMHSA (2014) also reports that approximately 43 million people, or 18% of the population, have experienced mental illness in their lifetime. By these numbers, 20% of people with a mental illness have, or will develop, a substance use disorder. For the specific group of people with SUD and at least MDD as a diagnosed mental illness, the numbers are sad and it is estimated that MDD is one of the mental illnesses that is most highly correlated with SUD. There are every year approximately 2.5 million people that will suffer from SUD and MDD (SAMHSA, 2014). This is a problem of a massive scale.

The numbers unfortunately do not lie: almost 1% of the whole country struggles with not one but two difficult mental and behavioral issues. What they do not say is that hope and help are available. Assessments, interventions, and treatment protocols designed specifically for tackling both issues at once, called integrated treatment, is showing a lot of promise and is increasingly becoming the standard of care among the nation’s behavioral health care providers.

For more information, please read the next article in this continuing series. It will focus on assessment and treatment and how to help yourself and your loved ones through the process.

Click Here To Read Co-Occurring Disorder Series Part 2: Assessment and Intervention

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