The dual diagnosis of depression and substance use disorder (SUD) is prevalent. In fact, both conditions are so intertwined they often pose a “chicken or the egg” dilemma for a patient and the persons charged with the patient’s care.
Alcohol and drug addiction can lead to mental illness, but a belief exists that mental illness does not necessarily cause addiction. As the writers of this PsychCentral article attest, “Some mental illnesses, especially those that are not quickly diagnosed and treated, can trigger the use of alcohol and drugs.”
Nevertheless, when both conditions are left untreated, one can exacerbate the other, complicating the treatment process and ultimately endangering the life of the subject. Those conditions can wreak havoc on someone’s physical and mental health to such a degree that they may be compelled to take their own life. There are famous examples of this phenomenon: celebrities who have battled both conditions and lost their lives as a result.
One compelling example is rapper, singer, and producer Mac Miller, who was found dead in his Southern California home in 2018. Toxicology reports revealed that the 26-year-old died from an accidental overdose of fentanyl, cocaine, and alcohol. Two years before his death, Miller said in an interview that his drug use and depression were linked.
“I had a drug problem for a long time. It wasn’t just in music, but I definitely was going through a drug problem, and I think it was more my state of mind. I was just pretty depressed,” he said.
There is statistical evidence that substantiates this correlation. An estimated 20 percent of Americans with an anxiety or mood disorder like depression also have an alcohol or substance use disorder, states the Anxiety and Depression Association of America (ADAA).
What’s more, about 20 percent of people with an alcohol or substance use disorder also have an anxiety or mood disorder.
The good news is that having a drug or alcohol addiction and depression isn’t the end of the world. There is specialized dual diagnosis treatment available that can improve one’s quality of life.
Read on to find out more about the nature of depression, substance abuse, and professional treatment.
What is Mental Illness?
The American Psychiatric Association (APA) defines mental illness as health conditions marked by changes in emotion, thinking, behavior, or some combination of those aspects. Mental illnesses are also marked by distress and/or problems with functioning in social, work, or family activities.
People with mental health disorders often struggle with the obligations of daily life, including employment, social situations, and day-to-day tasks. People with depression can undoubtedly exhibit those signs as it is one of the most prevalent mental health disorders around. Other mental illnesses include:
- Bipolar disorder
- Borderline personality disorder
- Generalized anxiety disorder
- Obsessive-compulsive disorder (OCD)
- Panic disorder
- Eating disorders (anorexia, bulimia, binge eating)
- Personality disorders
- Post-traumatic stress disorder (PTSD)
Signs of Mental Illness
Mental illnesses such as depression affect people of every nationality, origin, educational, and socioeconomic level. A mental health disorder can occur at any age, but three-fourths of all mental illness starts at age 24, according to the APA.
What’s more, mental illness can impact people at varying degrees. For some, the condition may not interfere much with daily life, but for others it may be so debilitating that it requires hospitalization.
The Symptoms Common of All Mental Illness Include:
- Mood swings
- Excessive tension or worrying
- Appetite or weight changes
- Sharp increases in energy
- Sleep disorders, such as insomnia
- Racing thoughts or rapid speech
- Inability to experience pleasure
- Strong feelings of guilt or worthlessness
- Loss of interest in activities
- Feelings of helplessness
- Trouble concentrating
- Impaired judgment or impulsivity
Because depression is so pervasive, the unique characteristics of this mental health disorder are worth exploring.
What is Depression?
The APA’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the principal authority for psychiatric diagnoses, defines depression or major depressive disorder (MDD) as a “serious medical illness that affects how you feel, think and behave causing persistent feelings of sadness and loss of interest in previously enjoyed activities.”
The APA goes on to state that depression can lead to a variety of emotional and physical issues and that it is a chronic illness that requires long-term treatment.
The DSM-5 also states that the following criteria are needed to declare a depression diagnosis. A person must experience five or more symptoms during the same two-week period, and at least one of the symptoms should be (1) depressed mood or (2) loss of interest or pleasure:
- Depressed mood most of the day, nearly every day.
- Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day.
- Significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day.
- A slowing down of thought and a reduction of physical movement (observable by others, not merely subjective feelings of restlessness or being slowed down).
- Fatigue or loss of energy nearly every day.
- Feelings of worthlessness or excessive or inappropriate guilt nearly every day.
- Diminished ability to think or concentrate, or indecisiveness, nearly every day.
- Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
For a diagnosis of depression, these symptoms must cause someone clinically significant distress or impair them in social, work, or other areas of activity. The symptoms must also not be a result of substance abuse or another medical condition.
What Causes Depression?
Four factors can play a role in whether someone develops depression, according to the APA. These consist of:
- Biochemistry: The differences in certain chemicals in the brain may contribute to symptoms of depression.
- Genetics: Depression can occur for members of the same family.
- Personality: Persons with low self-esteem who are pessimistic and easily overwhelmed by stress are more likely to develop depression.
- Environmental factors: When someone is continuously exposed to violence, neglect, abuse, or poverty, particularly when they are young, it may make them more vulnerable to depression.
When Substance Abuse is Present
Substance abuse is defined as harmful or hazardous use of psychoactive substances such as drugs or alcohol. Abuse of a substance usually starts when someone develops a tolerance. That’s when someone will require a larger amount of a substance to achieve the effect a smaller dose once yielded.
That tolerance develops into a dependence when a user takes a substance to feel normal and experiences withdrawal symptoms once the drug leaves their body.
When someone declines into addiction, they will continue to use despite the harmful consequences and adverse effects involving health, professional, and/or legal ramifications.
The signs of abuse and addiction show through compulsive and destructive behaviors that a user exhibits. The DSM-5 establishes 10 or 11 criteria, depending on the substance, that describes “a problematic pattern of use of an intoxicating substance leading to clinically significant impairment or distress” occurring within a 12-month period.
A person who meets two or three of the following criteria have a “mild” disorder; four or five is considered “moderate,” and six or more rates as “severe.”
The Criteria Include:
- The substance is often taken in larger amounts or over a longer period than was intended.
- There is a persistent desire or unsuccessful effort to cut down or control the use of the substance.
- A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects.
- Craving, or a strong desire or urge to use the substance, occurs.
- Recurrent use of the substance results in a failure to fulfill major role obligations at work, school, or home.
- Use of the substance continues despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of its use.
- Important social, occupational, or recreational activities are given up or reduced because of use of the substance.
- Use of the substance is recurrent in situations in which it is physically hazardous.
- Use of the substance is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
- Tolerance, as defined by either of the following:
- A need for markedly increased amounts of the substance to achieve intoxication or desired effect
- A markedly diminished effect with continued use of the same amount of the substance.
- Withdrawal, as manifested by either of the following:
- The characteristic withdrawal syndrome for the substance (as specified in the DSM-5 for each substance).
- The use of a substance (or a closely related substance) to relieve or avoid withdrawal symptoms.
How Depression and Addiction Interact
When someone has a substance abuse issue and depression, the negative effects can grow. What’s more, if someone is in recovery and has both disorders, the depression can act as a relapse trigger. According to Psychology Today, the use of drugs and alcohol can interfere with depression treatment.
That’s if someone with both disorders gets any treatment at all.
Of the 20.2 million U.S. adults who have a substance use disorder, 10.2 million of them have a co-occurring mental illness, states the Substance Abuse and Mental Health Services Administration (SAMHSA). Yet only a fraction of them will get help for both disorders.
When both disorders are left untreated, “suicide also becomes a much more likely hazard,” wrote Dr. David Sack for Verywell Mind.
According to Sack, “Those who use substances are already at greater risk of taking their own life…When substance use is combined with depression, a leading cause of suicide, the risk of self-inflicted death grows exponentially.”
Depression and Drug Use: The Chicken or the Egg
Does it matter which of the disorders came first, depression or substance abuse? Actually, it does matter. The following section explains why.
When the Depression Comes Before the Substance Abuse
Someone who has major depression can experience profound sadness, hopelessness, isolation, and issues with food consumption and sleep. If the depression is untreated, that person can turn to substances to self-medicate.
“A drink or two, a line of cocaine or two, might temporarily relieve some symptoms, but the backlash when the chemical leaves the body brings the depression to new lows,” states an article in PsychCentral. This form of withdrawal depression can lead to more alcohol or drug abuse because the user will feel more compelled to eliminate negative feelings.
When both conditions are left untreated, a person can experience worsening physical health, the development of other mental health issues, a shorter lifespan, and even homelessness and incarceration.
When the Substance Abuse Results in Depression
Some drugs cause depression as well. Commonly abused medications that can produce depression include stimulant medications like Ritalin and Adderall and benzodiazepines such as Valium, Xanax, and Restoril.
Antiviral, heart and blood pressure, and hormone medications can also cause depression.
Treating Both Conditions at the Same Time
According to that same PsychCentral article, it does, indeed, matter whether someone had depression before a substance addiction or not. Someone who was depressed before they started to abuse substances will need to be in professional addiction treatment longer than someone whose depression was caused by drugs or alcohol.
If you fit either profile, the good news is that there is an effective treatment solution for people with co-occurring disorders such as depression and drug or alcohol use. This option is called dual diagnosis treatment.
The Dual Diagnosis Treatment Solution
Dual diagnosis offers you professional, specialized treatment that addresses your substance addiction and mental health illness.
The goal of dual diagnosis is to get you mentally and physically stabilized by removing the substance from your body via medical detoxification. The other goal is to psychologically treat the addiction by providing you with an array of therapy and counseling services to treat the mental illness while also identifying and addressing the root causes of your addiction.
After detox, it is recommended that you enter a residential program where you will receive ongoing therapy and counseling at a treatment facility. During this phase, you will also have access to therapies (cognitive behavioral therapy (CBT) and alternative therapies) to treat your mental health condition.
Along with support from addiction specialists, you will learn coping skills and mental health education to improve your well-being and maintain your sobriety.
Professional treatment also provides access to aftercare via alumni recovery programs, which offer the kind of community support that can guard you against relapse.