Depression

MENTAL HEALTH & ADDICTION

Most people have felt depressed at some point in time. This experience involves a blend of emotions such as pain, anger, resentment, hopelessness, fear, fatigue, etc. Depressed symptoms are a general mood state and part of a normal human experience. Clinical depression is when that mood state starts to take over and occupy someone’s mind and body for the majority of the time. In terms of clinical conditions that can accompany an addictive diagnosis, depression is the most common. An algorithm for treating this involves a few primary steps:

Determine if the symptoms are present for a Depressive Episode
Diagnose which ‘flavor’ of depression this is
Review potential modifiers such as severity or episode frequency

Depressive Episode

The symptoms necessary for a depressive episode, as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM V), are listed below. To meet the criteria for the diagnosis, you must have at least 5 of these for 2 continuous weeks.

Depressed mood or irritability most of the day, nearly every day
Loss of interest or pleasure in most activities of life
Sleep disruption, either as insomnia or hypersomnia (sleeping way too much)
Excessive feelings of guilt or worthlessness
Loss of energy
Concentration problems
Appetite changes, usually with losing weight but sometimes gaining considerable weight
Physical manifestations of your mood such as feeling constantly restless or sluggish
Suicidal thoughts or intent

Flavors of Depression

Once we’ve established that you have a depressive episode, we would try and determine its form. The most common examples of a full depressive diagnosis are as follows:

Major Depressive Disorder
Bipolar Depression
Substance-Induced Depression
Depression Secondary to a Medical Problem
Adjustment Disorder with Depressed Mood

Accurate Diagnosis

To diagnose a pure major depressive disorder, it should ideally be during a period of low or limited substance use. This is actually a modifier condition in the diagnosis, itself. If there is active addiction occurring, you still could have primary major depression, but we would have to wait and see once you make the steps to sober up.

In structured treatment, we usually give someone about 2 weeks of time while monitoring symptoms. If the depressive episode continues to be strong 2 weeks into recovery, we would diagnose a major depressive episode and offer medication options. If the depression resolves quickly once the person stops using or drinking, we have our answer that it was more likely a substance-induced depression.

Bipolar

Bipolar depression is complex and requires a prior history of mania. Mania can be quite severe and destructive for people, so it tends to be hard to miss. It involves symptoms of elevated mood, racing thoughts, irritability, impulsivity, and loss of sleep. The best way to think about mania is a mental state similar to that from severe cocaine or amphetamine use.

We are cautious about a bipolar depression diagnosis because the treatment often involves stronger medications with more severe side effects. In other words, if you have bipolar depression, you deserve treatment for it, but we really want to be accurate about making that diagnosis.

Medical Conditions

There are a few common causes of depression secondary to a medical condition. Three common examples include thyroid disease, following a heart attack, or sleep apnea. Depressive episodes are very common in those conditions. With thyroid disease such as hypothyroidism, treatment using thyroid medication almost certainly clears up the depressive symptoms and the person starts to feel much better.

After heart attacks, there is up to a 50% rate of experiencing a depressive episode, and this seems to be independent of the fears and discouragement around the heart attack itself. There are strong neurologic ties between the heart and the brain and these likely play a role in this form of depression.

Sleep Apnea

With sleep apnea, disruptions in airflow during sleep can impede someone from getting good restful nights. This eventually takes a toll on mood and a few other health problems as well. Sleep apnea is commonly diagnosed through a formal sleep study and treatment often involves a special pressure unit the person wears while sleeping to improve airflow.

Finally, an adjustment disorder with depressed mood is the clinical terminology for situational depression. This is when a person experiences the symptoms of depression connected to a divorce, death in the family, or layoff from a job. If this seems to be the driving root of the depression, we may avoid prescribing antidepressant medications to treat the condition. Instead, supportive psychotherapy or cognitive behavioral therapy would be the treatments of choice to focus on healthy coping skills.

Severity, Single Episode or Recurrent

We pay attention to the severity of a depressive episode. Clinical research is more supportive of antidepressant medication for people with moderate or severe conditions. Mild cases of depression often can be treated by psychotherapy alone. Also, single episodes of depression (the most common) deserve medication approaches but usually for a maximum of 6 months. Beyond that time, the person would usually benefit from trying to taper off the medication.

This is different from recurrent episodes (this means someone has experienced multiple depressive fights over their lifetime). For recurrent cases, someone likely needs a maintenance antidepressant medication both for stability and preventing the return of depressive symptoms.

Treatment Strategy

Below is a simple stepwise algorithm for medications to target depression. This is a large topic, so keep in mind this approach is just scratching the surface. A sensible strategy is to try one of these medications, see if it is tolerated, and increase the dose as appropriate. The length of treatment should be a minimum of 4 weeks (unless it’s absolutely intolerable) and lasts for around 6 months. Then the medication can often be tapered off unless the problem is more of a recurrent form of depression. Please talk to your provider about this if you think you might have a major depressive disorder as your dual diagnosis.

First-tier options – Selective Serotonin Reuptake Inhibitor (SSRI)

Fluoxetine (Prozac)
Sertraline (Zoloft)
Escitalopram (Lexapro)
Citalopram (Celexa)
Paroxetine (Paxil)
Fluvoxamine (Luvox)

Second tier options – Serotonin-Norepinephrine Reuptake Inhibitor (SnRI)

Venlafaxine (Effexor)
Duloxetine (Cymbalta)
Desvenlafaxine (Pristiq)

Third tier options / Combination approach meds (these meds can often be used in addition to SSRI or SnRI meds, or are sometimes used on their own)

Bupropion (Wellbutrin)
Mirtazapine (Remeron)
Aripiprazole (Abilify)

Conclusions

Clinical depression is a severe and exceedingly common health problem, especially for people with addictive issues. The person can often feel very discouraged and self-critical. Don’t feel ashamed if you experience depression. This is a disease process just as is alcoholism or drug addiction. We use health approaches and different strategies to help you heal. Embracing the sick role, acknowledging it, and committing to getting some help for yourself will make a big difference.

Having a good understanding of depression, the nuances of the diagnosis and sensible medication approaches can help you to feel more empowered to work with your treatment provider effectively. This will magnify your results in achieving remission from depression.