Many people who suffer from depression also abuse alcohol or other drugs; quite a few of them become dependent on alcohol or other drugs. The psychiatric community refers to the situation of suffering from two or more conditions simultaneously as comorbidity. The comorbidity of depression with substance abuse and dependence is substantial; unfortunately, such comorbidity adversely affects the course, treatment, and prognosis of each of the problems in people who suffer from both substance misuse problems and depression.
The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), published in 2000, is the standard classification manual of the American Psychiatric Association. It makes a distinction between substance abuse and substance dependence, defining substance abuse as “a maladaptive pattern of substance use manifested by recurrent and significant adverse consequences related to the repeated use of substances,” and defining substance dependence as “a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues use of the substance despite significant substance-related problems.” The major difference between the two terms is that an individual who is dependent on alcohol or another drug shows clear evidence of an inability to stop using the problematic substance, despite, for instance, drunk driving arrests, the loss of a job due to absenteeism, or a crumbling marriage. Men and women with depression are more likely to suffer from both substance abuse and substance dependence than are others.
A recent study showed that the relationship between depression and substance-related problems is somewhat different for men and for women. There is a greater association between major depression and drug dependence in men than in women, whereas there is a greater association between major depression and abuse of prescription drugs, sedatives, tranquilizers, and amphetamines (but not cocaine or hallucinogens) in women than in men. It may be that depressed women are more likely than depressed men to start down the road of drug abuse, but that depressed men are more likely than depressed women to become dependent on the abused drug.
Depressed patients who are alcoholics or drug addicts present therapeutic challenges. It is important that the patients address their drug dependence in order for them to maximally benefit from antidepressant medication and psychotherapy. Conversely, it is important that depressed addicts receive treatment for their depression in addition to detoxification from alcohol or drugs so that they can minimize the chances of relapsing into substance dependence.
Genetic studies show a link between depression and drug-related problems, particularly alcoholism, in families. It is hard to say whether depressed people drink more than others, whether drinkers get more depressed than others, or whether people with particular genetic vulnerabilities are simply more at risk for both depression and substance-related problems than other people.
Both depressive disorders and substance dependence are strongly linked to suicide. Individuals with both problems are at particularly high risk for suicide, and it is extremely important that their treatment address both issues. Treatment for depression, alcoholism, and drug abuse and dependence is available. In Milwaukee County, crisis lines at 211 and at (414) 257-7222 provide emergency referrals for suicidal people with depression and substance-related problems.
Depression and substance abuse and dependence are treatable medical illnesses. Real hope exists for people with both problems; help can mean the difference between suffering and recovery.
Joseph B. Layde, M.D., J.D.
Associate Professor
Department of Psychiatry and Behavioral Medicine
Medical College of Wisconsin