It is well-established that the concordance rate for depression and substance use disorder is high—somewhere between 45-65 percent. Depression among persons with opioid use disorder is no exception and because of the pharmacodynamics of opioids including high tolerance, there is a bidirectional relationship with pain and hyper analgesia. We have reported on this since the 1970s. The apparent high prevalence of depression among persons with opioid use disorder is so common that some have suggested that everyone in opioid maintenance be treated for depression.
To address these questions, Stein and co-workers surveyed 440 consecutive persons seeking inpatient opioid detoxification and used the Patient Health Questionnaire-2 (PHQ-2) to screen for depression. To assess the “Perceived Need for Depression Treatment” (PNDT), participants were asked, “Do you believe you should be treated for depression?” Respondents were given four response options:
- Not depressed
- Perceive need for depression treatment
- Depressed/Don’t want treatment
- Currently being treated
The results were remarkable. Nearly two out of three persons screened positive for depression yet only 8.2% were being treated for depression prior to admission. Screening positive for depression was associated with a 2.95 (95%CI 1.82–4.81, p<.005) fold increase in the expected odds of PNDT.
Why Does This Matter?
The mortality rate for untreated or undertreated depression in the general population is between 15-20 percent. Given that at least 45% of persons with substance use disorder are depressed and impulsive, the mortality rate is certainly higher, whether from direct and intentional suicide or by a reckless lifestyle, accidental or intentional overdose. As a result, careful evaluations and treatment are needed throughout the treatment process. But sadly, this is the exception and not the rule.
What to do?
Detoxification program staff should screen patients for depression, and if a clinical diagnosis is confirmed, discuss and educate the patient about treatment options and the relationship with substance use disorder.
Bottom line is that screening for, and addressing depression, should be central to all treatment planning and differentiated from post -acute-withdrawal-syndrome. When identified, continuing care is mandatory, because the cost of failure is too high.