Stephen M. Lange, Ph.D.

depressed women on doctors couch

Many individuals with addiction to alcohol or other drugs also suffer from co-occurring depressive disorders. When someone has both disorders independently of the other, each is considered a “primary disorder.” Alternatively, addiction can result in depressive symptoms that will improve with abstinence and recovery, and in this case, depression is considered a “secondary disorder.” Addiction is always a primary disorder; it is not the result of another disease. It is important to know that individuals who have both primary disorders have a more difficult time achieving sobriety and have higher suicide risk. When their depression is treated, their chances of achieving long term sobriety improve, and when their addiction is treated, their chances of recovery from depression improve. This brings home the importance of understanding depression, and when and how it should be treated.

To understand depression, it is important to recognize that depression, like addiction, is a disease, and it is hard to grasp how different depression is from sadness, grief, disappointment, or other painful emotions that make up the human experience. One symptom of depression is an intensely sad, low mood sometimes with irritable moods and anger, but depression symptoms affect not only emotions, but every aspect of life including physical health, appetite and nutrition, sleep, sex, thinking patterns, spirituality, energy level, and social relationships. Again, like addiction, depression can end careers, school, marriages, friendships, and it can kill.

It is also important to understand that depressive disorders vary in their severity and can be mild, moderate, or severe. Depression can be a recurring disorder, with periods of relief between recurrences, or it can be constant. Based on what we know about addiction and depression, everyone who has both addiction and a primary depressive disorder needs treatment for both disorders, regardless of the depression severity or its pattern.

Like most mental disorders, including addiction, depression has a strong biological component, and it also has strong psychological, social, and spiritual components. As with other mental disorders, what we know about depression is a fraction of what we need to know and someday, I hope, we will know.

When Does Depression Need to be Treated as a Primary Disorder?

For patients and addictions specialists, an important question is how to decide when  depression should be considered a primary disorder and treated. This is a matter of debate, and research results are not conclusive. Generally, one way to determine whether someone has a primary disorder of depression is timing. For example, if you are receiving addictions treatment and had depression as a child, whether or not it was diagnosed at the time, and started using substances as an adolescent, then it’s reasonably certain that you have both depression and addiction, and that both are primary disorders. You need to be treated for both as soon as possible, and treated as if your life depends on it, which it does. However, this scenario might not apply to you. You might start addictions treatment and have depression symptoms, and it is unclear which came first. The second approach, then, is to wait until you have one to four weeks of sobriety and then assess your depression symptoms. If your depression symptoms improve with sobriety, then it is reasonable to conclude that your depression is secondary to addiction and that treatment for depression is not necessary. If you have achieved weeks of sobriety, and still meet the criteria for a depressive disorder, then it is likely a primary disorder and needs to be treated along with your addiction. Then there is the third approach, and this is where the debate takes place. Perhaps everyone starting addiction treatment who has symptoms of depression should be treated for depression regardless of whether depression is a primary or secondary disorder, and then should be reevaluated when they have a few weeks of sobriety. What is correct for you? In the first instance, if your depression predates your addiction, there really should not be a debate: Treat both. If you have been sober for months or years, practicing recovery principles, and you experience depression, there should not be a debate: Treat both. If you are just starting out and have just arrived in treatment, or if you are a family member of someone just starting out in treatment, there is no absolutely correct answer to the question of whether to treat depression immediately vs. wait for sobriety. I would be very skeptical if someone told me that they are certain of the correct answer. This is where your judgement and the judgement of your treatment team is essential.

How is Depression Treated?

Based on a large body of research, the best treatment for depression is a combination of medication and psychotherapy. There are different types of psychotherapies that are considered effective treatment for depression, including Cognitive Behavioral Therapy (CBT) and Interpersonal Psychotherapy. One fact to accept, and this is difficult, is that psychotherapy takes work and patience, and accepting that fact can be difficult for someone in pain who wants relief. As well, patience is even more difficult for people who have addiction, as Bill Wilson and Dr. Bob Smith wrote many years ago. Part of First Step is accepting that we have no control over how fast we heal; it is dangerous to believe that we are so powerful that we can determine how long healing should take.

Medication treatment for depression is complicated for people with addiction. A very helpful AA Pamphlet, AA Member- Medications and other Drugs discusses this in some depth. It was written by AA members who are also physicians with the help of two AA allies. One point the pamphlet authors make is that people with addiction are more likely to misuse medication, even nonaddictive medication, than others. People with addiction react differently to medications than others and may feel a compulsive need to take more than they are prescribed. They stress the importance of working with physicians who have  experience with addiction, and for patients with addiction to practice complete honesty with their physicians. This is especially important because while most antidepressant medications are not addictive, several do have addiction potential. Without skill and without honest communication, a physician’s prescription pad can be a lethal weapon. Think about honesty and recovery as well: If you cannot practice honesty with your physician, you are very fragile and in danger of relapse already, and need to get support from your sponsor and others.

One of the difficult facts about medication treatment for depression, generally, is that there are many antidepressant medications. Some will work for any one individual and some will not. This means that you may need to try several medications before finding the one that is right for you. A trial of a single medication can take 6-8 weeks, and patients often abandon a medication too soon. Sometimes patients will decide that no medication will work after their first medication trial does not lead to improvement. Finally, antidepressant medication is daily medication. I regularly meet people who try to take their medication as needed, “only on bad days,” and are disappointed when they find out that this does not work. For medication to work, it is essential to commit to trying a medication for 6-8 weeks before deciding whether it works, to trying more than one medication if necessary, and to taking  medication as prescribed.

I strongly encourage my patients to have their medications prescribed by a psychiatric practitioner, either an MD or ARNP trained in psychiatry. Some primary care physicians manage psychiatric medications well, but their practice model is not conducive to the management of psychiatric medications, which is too labor intensive for a primary practice. As already mentioned, everyone with addiction needs to find providers who are skilled at treating patients with addiction.

Medications, Psychologists, Psychiatrists, Bill W., and Dr. Bob

Some people who practice the 12-Steps believe that you are not in recovery if you take antidepressant medications. Ask them to please show you where in the AA or NA book you can find this information. Also ask if they have read the AA Big Book chapter “The Family Afterward” that that says, in part, that G-d has endowed this world “with fine doctors, psychologists and practitioners of various kinds” and that “their services are indispensable” (p.133). Finally, ask them if the Big Book encourages us to judge each other or to tell each other what to do. Read the AA pamphlet mentioned above and especially its warning to disregard medical advice by lay people. Then make up your mind.

Healthy Behaviors and The Cycle of Depression

Whether it is visiting family, attending church, synagogue, temple or mosque, running,walking in the woods, gardening, working out, playing the piano, or other, one of the symptoms of depression is that we hoard energy and hole up in out “lairs.” This means that we stop the activities that are physically, spiritually, and emotionally healthiest for us. To break the cycle of depression, it is important to gather our willpower and energy to restart one healthy activity at a time. Because all-or-nothing thinking is a depression symptom, I always warn patients that they are not going to suddenly recover from depression by going to church, running… or other, but that they should restart the activity merely because it is healthy. Feeling their moods lift will be a welcome change if it happens, but no one should expect one change in life to be a silver bullet.

Most first line depression medications increase the brain’s ability to use Serotonin and/or Norepinephrine. There are two healthy habits that help accomplish the same objectives. Sunlight exposure increases Serotonin availability in the brain, and moderate physical exercise increases Norepinephrine availability. Sunlight exposure between breakfast and lunch also resets our brain’s clock and helps with daytime alertness and nighttime sleep. Of course, consult your doctor before starting to exercise or increasing your sun exposure.

Spending time each day rating our day on a one to five scale of healthy mood versus depressed mood can help us realize that our mood is not constant and does change. It is too easy to believe that our depression is permanent and unchanging. When we understand that our moods are not constant, we can begin to see light at the end of the tunnel. This practice can also help us recognize when we have what Solution Focused Psychotherapy calls “islands of health.” Knowing where our islands are can help us build more islands.Other healthy habits include practicing gratitude and mindfulness meditation.

Peer support from NAMI is another great healthy idea.

Mind and Body are One System

There are physical illnesses that can mimic depression and can co-occur with depression. Some of these are undiagnosed diabetes mellitus, hypothyroidism, adrenal insufficiency, low testosterone in both males and females, and depressions that are related to menstrual cycles. Vitamin D deficiency and deficiencies in some B vitamins can worsen depression. Part of an evaluation for depression should be a history and physical examination with labs. This can take some convincing and insisting. Not all physicians take a holistic view. Some believe that a problem is either psychiatric or physical as if mind and body are not one interactive system. This is called Descartes’ Error, which is also a title of a good book.

If you have depression as a primary disorder you can collaborate with your physician, to explore how nutritional supplements, including vitamins and omega-3 fatty acids, can help depression.

Take Away Lessons as Bullet Points

1. People with addiction can have depression as a co-occurring primary disorder.

2. Untreated primary depression is dangerous for people with addiction (and for people who do not have addiction, too!).

3. Treatment should include both psychotherapy and medication treatment.

4. Treatment for depression takes time and work. Sticking to a treatment plan is important for success. Practice patience.

5. Our healthy habits can help us recover from both depression and addiction. Spiritual practice, meditation, exercise, and sun exposure are some of these healthy habits.

6. Our minds and bodies are one living system. Making sure that your mood is not adversely affected by medical issues is an important part of depression treatment. There may be some nutritional supplements that can help your depression.

Steve Lange is a grateful family member of amazing women in recovery. He is also a psychologist who works with those in active addiction and recovery. Steve has appeared on radio and in print as an expert in mental health, addiction, and child development. He is an avid admirer of Bill and Lois W., and Dr. Bob.