Depression and Substance Use Disorders

Depression is a common and serious mental health condition that affects how a person feels, thinks and behaves. It can cause lasting feelings of sadness and hopelessness as well as a loss of interest in activities enjoyed before. Depression can also make it harder to function day-to-day and lower one’s quality of life. For many, it’s like living in dark shadows where feelings of hopelessness feel ever present.

There are some differences between adults and teens as to how depression shows up.  Adults may have a more depressed mood along with feelings of worthlessness or guilt. Teens, on the other hand, may show more irritability, anger and frustration. Teens may tend to isolate a bit more as well.  Adults with depression may lose weight while teens may either gain too much weight or not enough.  Both adults and teens may experience problems with sleep.[1]

People with depression may also have substance use disorder, and vice versa. Together, these are referred to as co-occurring disorders. Having co-occurring depression and substance use can make both conditions worse and harder to treat. A loved one may use substances to cope with their depression, but this can lead to using more and more of the substance to get relief, which, in turn, causes withdrawal symptoms, addiction (also referred to as a substance use disorder), and overdose. On the other hand, substance use can trigger or worsen depression symptoms, such as low mood, anxiety, irritability and suicidal thoughts.

How is depression diagnosed?

There is no single test that can diagnose depression. Instead, healthcare providers will use a combination of methods to assess your loved one’s symptoms, medical history and possible causes of depression. The assessment may include a physical exam and lab tests. These can be helpful to rule out issues caused by thyroid problems or not getting enough vitamins, for example.

Additionally, your loved one will be asked questions about their feelings, thoughts, behaviors and patterns. Sometimes they are asked to fill out a questionnaire or a rating scale like the Beck Depression Inventory to measure whether the depression is mild, moderate or severe.

The criteria for depression listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association, may also be used to evaluate your loved one. One of the most common forms of depression is Major Depressive Disorder[2].  Five or more of the following symptoms must be experienced for at least two weeks to be diagnosed:

• Depressed mood most of the day, nearly every day
• Loss of interest or pleasure in most or all activities most of the day, nearly every day
• Significant weight loss or gain, or changes in appetite
• Sleep problems (too much or too little) nearly every day
• Psychomotor agitation or retardation (being restless or slowed down) nearly every day
• Tired or loss of energy nearly every day
• Feelings of worthlessness or excessive guilt nearly every day
• Difficulty concentrating or making decisions nearly every day
• Continuing thoughts of death or suicide, or suicide attempts

To be diagnosed with depression, one of the symptoms must be a depressed mood or loss of interest or pleasure. Your loved one’s symptoms must cause significant distress or get in the way of their work or school, social life or other areas of functioning.

What kinds of substances are used by people who are depressed?

People with depression may use different substances for various reasons. Some may use them to cope with feeling sad, anxious, or hopeless. Others may use them to deal with stressors in their lives, such as trauma, abuse, grief or relationship problems. Some may use them to improve their mood or to temporarily increase feelings of pleasure.

Some of the more commonly used substances include:

• Alcohol: Alcohol is a depressant that slows down the central nervous system and affects mood, the way a person thinks, and behaves. Alcohol can temporarily reduce anxiety and increase relaxation but can also increase feelings of sadness, hopelessness, guilt and anger. Alcohol can also interfere with antidepressant medications and reduce their effectiveness.
• Cannabis: Cannabis or marijuana contains tetrahydrocannabinol (THC) and cannabidiol (CBD), among other compounds. Cannabis can have different effects on mood depending on the dose, the strain and the individual. Cannabis can sometimes reduce anxiety, stress and pain but can also increase paranoia (intense fear of being watched), psychosis (seeing or hearing things that aren’t real), and depression. Cannabis can also interact with antidepressant medications and affect the way they are processed in the body.
• Opioids: Opioids are drugs that include prescription painkillers, such as oxycodone (e.g., Oxycontin), hydrocodone (e.g., Vicodin) and morphine, as well as illegal drugs, such as heroin and fentanyl. Opioids act on the brain’s receptors and produce joyful feelings, relieve pain and may cause drowsiness. Opioids can temporarily mask depressive symptoms, but they can also worsen them by negatively impacting the brain’s natural reward system. Opioids can interact with antidepressant medications and increase the risk of serotonin syndrome, a potentially life-threatening condition.[3] Opioids can also slow one’s breathing, and can cause overdose and death. If your loved one is using opioids, be sure to have naloxone (e.g., Narcan) on hand and know how to use it.  You can find more information on its use and how to get it here.
• Stimulants: Stimulants are a class of drugs that include prescription medications, such as methylphenidate (e.g., Ritalin, Concerta) and amphetamine (e.g., Adderall), and illicit drugs, such as cocaine and methamphetamine. Stimulants act on the brain and body to produce alertness, energy, euphoria or joy, and confidence. Stimulants can temporarily improve depressive symptoms.  They can also worsen them by causing mood swings, anxiety, paranoia, psychosis and depression. Stimulants can interact with antidepressant medications and increase the risk of cardiovascular (e.g., heart and blood flow) problems, seizures and serotonin syndrome.

What are treatment recommendations for co-occurring depression and substance use?

The best treatment for co-occurring depression and substance use is integrated treatment that addresses both disorders at the same time. Integrated treatment can improve outcomes and quality of life for people with co-occurring disorders by treating the whole person. Learn more about what to look for in terms of co-occurring disorders treatment here.

In addition to talk therapy, medications are often considered as part of the course of treatment. These include antidepressants and mood stabilizers. Antidepressants can be helpful for some people, although it’s important to note that it may take a few weeks for the effects to kick in.  Sometimes a benzodiazepine (e.g., Xanax, Ativan, Klonopin) may be prescribed to help until the antidepressant works, but these medications can be misused, so caution is needed when prescribing.

In some cases, young people under the age of 25 may experience an increase in suicidal thoughts or behaviors when taking an antidepressant.  It’s especially important to watch closely for any signs of suicidal thinking. Don’t be afraid to ask your loved one about it – asking questions won’t make them more likely to consider suicide.

Medications to treat substance use disorder may also be recommended as part of your loved one’s treatment plan, especially for nicotine, alcohol and opioid use. If your loved one is using heavy amounts of alcohol or benzodiazepines, medications may be used in a supervised medical detox to reduce the risks of seizures.

Increasingly, psychedelics, or mind-altering drugs, are being tested as potential ways to treat depression.  Ketamine, psilocybin and LSD may work although a great deal of research is underway to better understand who might benefit the most, what dosage is needed and the best formulation.

Some people may also benefit from light therapy as the days get darker and there is less sunshine.  It uses artificial light to help lift one’s mood. [4]

Another form of depression treatment is electroconvulsive therapy, intended for those who have not responded to other treatments. Under anesthesia, a short burst of electric current is passed through the brain causing a seizure to help restore mood.[5]

In 2022, the Food and Drug Administration (FDA) approved SAINT for people with treatment-resistant major depressive disorder. SAINT uses advanced imaging to accurately target brain areas to deliver stimulation. It has been demonstrated treat patients effectively in as few as 5 days. It may be a good option for loved ones who have tried electroconvulsive therapy (ECT) and/or more widely prescribed antidepressants.[6]

It’s also important not to forget about the benefits of exercise. Any form of exercise including walking and yoga can help someone feel better.  Many loved ones may not feel like moving, but may reconsider if you or another family member or friend offers to do it with them.

How can I motivate my loved one to get treatment?

Learn more about motivating a loved one to get treatment and how to best support them here.  If you need a sounding board, moral support or help developing a plan, please reach out to us. Co-occurring disorders are complicated, but your loved one can get well, especially with your encouragement, love and support.