Co-Occurring Disorders--Substance Use Disorder and Depression

The concordance rate for patients of psychiatric illnesses and substance use disorders is estimated between 45-65%. Among the treatment population, it is even higher. Accurate evaluation utilizing a patient-centered, dual treatment modality is tricky for many clinicians.

Historically, substance use disorders (SUDs) were considered secondary conditions caused by a primary psychiatric illness, most likely depression or anxiety disorder, or stressful or traumatic circumstances. This is known as the “self-medication hypothesis”. As seemingly logical and appealing as this may be, the best available evidence suggests otherwise. Through sophisticated imaging of the brain, we know that drugs of abuse themselves change the brain in areas responsible for emotions, reward, focus and motivated behavior, thus creating symptoms of unipolar and bipolar depression and anxiety disorders. This “chicken or the egg” question becomes moot, because all debilitating conditions are addressed as “primary” during high quality comprehensive treatment, when provided by highly trained professionals. Addictive disease is a multifaceted neurobiological disease requiring multimodal treatment.

As I have reported earlier, the combination of psychosocial, psychotherapeutic, pharmacologic, and neuromodulatory treatment modalities are needed for optimal diagnosis, individualized treatment and long-term recovery.

Ask the ExpertRegrettably, many motivated patients complete treatment and remain abstinent but also remain depressed for months, only to be told to attend more meetings and read more recovery literature. This is not harmful advice in and of itself, but does nothing to alleviate symptoms of depression and the suffering of the patient. Untreated or underrated depression is serious. Between 15-20% of these individuals commit suicide. Among those in recovery, relapse is assured (self-medication) followed by full blown symptoms of their addiction.

Co-occurring disorders are common in medicine and must be addressed as such. Time is an important dimension in determining the effectiveness of any intervention. In the case of persons with substance use disorders and depression or anxiety disorder, time itself seems like the enemy, because their drug of choice will make them feel temporarily better, almost immediately.

Five years ago, the Institute of Behavioral Health led by Robert DuPont, MD a close friend and colleague, convened an expert panel of which I participated to address the standards of care for those with SUDs. The evidence was analyzed and discussed by a plethora of experts from differing disciplines. The number one recommendation was that continuing care for five years should not be the exception, but the new standard of care, whereby all symptoms and co-occurring conditions can be monitored, treated and responded to, in a timely manner.

Why Does This Matter?

The incidence of relapse after treatment is high, especially in the first six months. Untreated conditions such as depression may worsen after abstinence. When this occurs, the patient observes and considers that if sobriety makes them feel more depressed or more anxious, they lose hope and will relapse.


A. Benjamin Srivastava, MD; Mark S. Gold, MD, DFASAM, DLFAPA
Vice Versa?: Part 1 and Part 2, 77- 100
Directions in Psychiatry. VOLUME 37, 2017, Number 2