David McDaniel, MSW, LSW
It’s disheartening when clients report someone in their life told them, “You’re depressed because you drink too much,” or “You drink too much because you’re depressed.” Those statements are simplistic and downplay challenges clients face when they struggle with two mental health conditions: a substance use disorder and depression. They’re told this complex situation is easily cured with a simple solution: just stop doing that.
When clients present with two (or more) mental health conditions, there’s a “comorbidity” between the conditions. That’s a bleak-sounding word, however it just means a client is experiencing the simultaneous presence of two or more conditions. This isn’t unusual for people with substance use disorder. In fact, the Substance Abuse and Mental Health Services Administration (SAMHSA) notes that, “People with substance use disorders are at particular risk for developing one or more primary conditions or chronic diseases,” particularly anxiety and depression.
In a 2008 issue of Current Opinion in Psychiatry, researchers examined the comorbidity of depression and substance use disorders and reported, “Nearly one-third of patients with major depressive disorder also have substance use disorders.” Not only can depression and substance use disorders co-exist, but each has the ability to intensify the emotional toll of the other. Plotting a therapeutic journey requires a careful assessment of how and when trauma led to depression, then to substance use as a coping mechanism.
American veterans are a population especially vulnerable to comorbid depression and substance use. As if that wasn’t enough, it’s estimated between 15% and 30% of veterans — especially younger veterans — can also develop Post-Traumatic Stress Disorder (PTSD) during their lifetime. They’re overwhelmed by all three conditions – depression, a substance use disorder, and PTSD – and find themselves attempting to untie a Gordian knot of symptoms and emotions.
As therapists, we assess the client’s presenting conditions, both individually and in tandem, then collaborate to find the most effective and trauma-informed path forward. Do we start by helping the client sustain a newly won sobriety by mindfully avoiding subjects that might deepen depression? Do we intentionally explore painful experiences causing depression and leading to self-medication? We probably need to do it all, of course, but the order and methods look different for everyone.
When memories and emotions surface after substances are out of their systems, clients have told me, “I wasn’t ready for this.” It can be a shock to realize their trauma is still there, turbulent emotions reappearing for the first time in months or even years. In order to feel better, they may have to temporarily feel worse, and that’s intimidating no matter their determination.
Withdrawal and relapses can be major speedbumps hindering efforts to address underlying mental health issues. Within the first month following release from inpatient drug or alcohol treatment centers, 40-60% of individuals experience a relapse. Up to 85% relapse within the first year. Lapses (brief periods of use then a return to sobriety) and relapses (resuming consistent use) can be triggered by returning to environments and/or social situations that don’t support sobriety, or deep depression and trauma coming to the surface now that self-medicating has lessened or stopped.
Before starting therapy sessions, I recommend waiting until a client has both stopped using substances and detoxed successfully. It’s not reasonable to expect much progress in outpatient therapy if a client isn’t sober or is suffering from withdrawal during sessions. As a therapist, I can’t provide the day-to-day monitoring and medical support needed to detox safely. That level of care should come from a doctor specializing in substance use recovery or from a residential program providing around-the-clock support.
Once detox is completed, we can rebuild and rediscover healthy coping skills and self-care that support continued sobriety, while also starting to work on depression and trauma. For many, psychotropic drugs, antidepressants, and mood stabilizers, prescribed at an effective maintenance dose, can lessen symptoms of depression. That, in turn, can alleviate some of the anxiety that led to substance use in the first place. I offer clients the analogy of building a stable foundation (relieving debilitating depression or anxiety) before trying to build the house (creating a treatment plan and embarking on deeper healing work). Medications aren’t necessary or appropriate for everyone, of course, but are worth considering.
It can be overwhelming for clients in recovery to face both the need to avoid substances, and the hard work of unearthing the pain and trauma beneath the substance. It’s a best practice to explore the idea of comorbidity with clients and — with their input — generate a plan for navigating the dual (or multiple) roads that wait to be traveled.