Comorbidity
dealing with depression and addiction
Feeling depressed or low in mood is an everyday experience. What people mean when they say that they are “depressed” covers a lot of ground ranging from suicidal thoughts to distressing unhappiness to just being bored or fed up. The seriousness of the statement is often, but by no means always, reflected in an individual’s facial expression and general demeanour. So, getting an accurate understanding of the seriousness of the depression is all important.
Depression is very commonly reported among people attending alcohol and drug services. The survey (see table) may have overestimated the prevalence, nonetheless, the scale of the problem is such that agencies will need to be able to identify those individuals needing referral to specialist mental health services and those who can be helped by addiction practitioners.
Assessing severity of depression
① For practitioners making a clinical judgement, the presenting symptoms are most important. It is common for people who are not depressed to express sadness, anxiety, worry, tiredness, low self esteem, frustration, and anger. It is more likely to indicate depression if they talk of a persistent low mood, hopelessness, tearfulness, guilt, loss of interest in activities, indecisive and poor concentration, lack of enjoyment, seeing no future, suicidal thoughts, no point to life, weight loss, early waking, bleakness.
② Rating scales are useful and objective albeit less reliable for people who are drinking or taking drugs, especially if they are intoxicated. A score >=15 on the PHQ9 or >=15 on CORE-10 is suggestive, but not diagnostic, of depression or a mental health problem. A suitably qualified practitioner is needed to make a diagnosis.
③ If there is a history of depression or self-harm then this is a good guide both to the nature of the current problem and its likely course. For people who self-harm watch out for a pattern of escalation in drinking or drug use, number of drugs taken in an overdose and the seriousness of the self-harm. For people who have completed a detoxification, stay vigilant: low mood and suicide attempts are common for months afterwards, perhaps to do with facing up to the reality of their circumstances or perhaps some biological readjustment.
Knowledge of a person’s circumstances is likely to set expectations: for example a recent loss, trauma, or poor quality of life will leave others unsurprised that somebody is depressed but may lead them to underestimate the severity of their low mood.
There are obvious reasons why people with an addiction problem experience low mood. Firstly, dependence is itself a stressful state to be in and commonly expressed as depression. Secondly, the consequences of addiction are mainly negative resulting in multiple losses. Thirdly, there may be a sense of being out of control and a pessimism about recapturing better times.
A particular risk occurs post detoxification and this may persist for months (see table). In the short term brain functioning is destabilised by withdrawal of alcohol or drugs and may be a factor in mood change but also realising the damage done socially from years of addiction may be a depressing experience longer term.
Risk factors for suicide
◼︎ Age – increases with age
◼︎ Gender – more common in men
◼︎ Mental health – personality problem or mental illness
◼︎ Symptoms – hopelessness, anger, guilt, insomnia, low mood
◼︎ History – previous suicide attempts
◼︎ Substance use – dependence, intoxication, withdrawal
◼︎ Circumstances – relationship problems, social isolation
◼︎ Stressors – legal/investigations, bereavement, financial
◼︎ Health – chronic pain, loss of mobility, terminal illness
◼︎ Lethal means – firearms, large quantity of medication
This is what to do about it…
Family, friends and colleagues at work are more likely than helping agencies to have regular contact with people who experience depression. Everybody needs to be able to respond, effectively and within their competences, to someone saying that they are depressed. Deciding what to do can be difficult even for experienced mental health practitioners. Ask yourself these four questions…
➊ How severe is the low mood?
“Tell me about your mood right now?” - get an overview :: “Have you been thinking about harming yourself?” - check out the worst thing that could happen :: “What are you doing for the rest of the week?” - check out if the person sees a future. You can go on to explore other signs of the severity of the depression if needs be.
Getting an accurate picture of the severity of low mood is essential to making the right response. People with moderate or severe symptoms need to be assessed by a qualified mental health professional.
➋ Is there a clear cause for the low mood?
“Tell me when did you start to feel depressed?” - understand the duration and possible cause :: “Do you think that there is something in particular causing you to feel like this?” - a direct attempt at finding the cause.
If a cause can be identified then it makes sense to try to address it. Often there are multiple reasons associated with a poor quality of life, and a psychosocial intervention will be the most helpful. Antidepressants are not indicated unless the depression is particularly severe.
➌ Is the person intoxicated?
“What have you taken/drunk today?” - make it clear you know the person is intoxicated and find out what they have taken.
People do reckless things when intoxicated. It is not possible to assess the severity or even presence of depression and the question is whether or not the person needs to be in a place of safety or with someone who can ensure their safety.
➍ Is this a life threatening situation?
Low mood can be overcome. It is up to the practitioner to keep an individual alive so that they have the chance to recover. A good way to assess a situation is the Four Ps…
Have there been previous suicide/self-harm attempts?
Has a plan to commit suicide been made?
Adding up the risk factors, what is the probability of doing it?
What protective factors are there?
A supportive psychosocial intervention such as Social Behaviour and Network Treatment will be effective for most people attending addiction services with mild to moderate depression. Additional antidepressant treatment may be helpful but only for people with a moderate to severe depression. The evidence for prescribing antidepressants is weak and any benefits may derive from the sedative effect of medication. People with pre-existing mental illness or newly diagnosed severe depression are best cared for by mental health practitioners.
Use the CORE10 Questionnaire for a preliminary test of psychological wellbeing
