Alcoholism, Substance Abuse and Dependency CEUS - Chapter 7

The following chapter is taken from the Substance Abuse and Mental Health Services Administration site on their series of Treatment Improvement Protocols. In this section we will cover Part 1, Chapter 1 of this TIP. This chapter addresses managing depressive symptoms in Substance Abuse clients during early recovery. Included are the principles that supply the foundation of assessment and treatment with those who are recovering from Substance abuse and have depressive symptoms. The content includes a framework for treatment, a section on preparing yourself to work with these clients, screening and assessment, treatment planning, treatment and continuing care and treatment termination.

In Part 1, Chapter 2 that will be provided in another course at SpeedyCeus, “Substance Abuse Treatment and Depressive Symptoms” specific approaches will be illustrated in detail with case study vignettes. The approaches include behavior interventions, cognitive interventions, interventions with core beliefs and interventions with feelings.

Introduction

Overview

This Treatment Improvement Protocol (TIP) is designed to assist you—the substance abuse counselor—in working with clients who are experiencing depressive symptoms. These symptoms occur along a continuum of intensity from mild to severe. When they reach a certain level of intensity and frequency, they become consistent with a diagnosis of a mood disorder, such as major depressive disorder, dysthymic disorder, substance-induced mood disorder, or bipolar disorder. It is clear from clinical research and practice that a significant percentage of your clients have depressive symptoms. Some, but not all, will have these depressive symptoms in the context of a mood disorder diagnosis. Even if you will not be diagnosing and treating depressive illnesses—which is in the scope of practice of those mental and behavioral health professionals licensed in your State to diagnose and treat mood disorders, and capable of doing so—you will be providing substance abuse counseling to clients with these diagnoses and to clients with depressive symptoms but whose mood states do not reach a level that would warrant a mood disorder diagnosis (that is, clients whose symptoms do not meet the diagnostic criteria).

The contributors to this TIP have all had experience as substance abuse counselors or treatment researchers. They have used their understanding of the treatment process to make this TIP as relevant as possible to you. Although the focus of this TIP is on clients with substance use disorders who have depressive symptoms, some of the material presented should be useful to you in all your counseling work.

The term “depressive symptoms” refers to symptoms experienced by people who, although failing to meet DSM-IV-TR diagnostic criteria for a mood disorder, experience sadness, depressed mood, or “the blues,” and one or more additional possible symptoms listed in Figure 1.1, p. 5.

Depressive symptoms are common among clients in substance abuse treatment. Findings from a 2001–2002 national survey indicate that substance abuse counselors will encounter significant numbers of individuals with co-occurring substance abuse and depressive symptoms. Among people who have had past year contact with health personnel or social service agencies and who also have had a past year substance use disorder, 40 percent of those with an alcohol use disorder also had an independent mood disorder and 60 percent of those with a drug use disorder had an independent mood disorder (Grant, Stinson, Dawson, Chou, Dufour, Compton, et al., 2004). Also, of all the people interviewed, one third indicated that sometime during their lives they had had 2 weeks or more during which they had felt down most of the time; sad, blue, or depressed; or didn’t care about or enjoy the usual things (Compton, Conway, Stinson, & Grant, 2006). In general, women with substance use disorders have higher rates of cooccurring psychiatric disorders than men. Some studies suggest a higher rate of depressive symptoms in women, although other studies find no such differences.

The methods and techniques presented in this TIP are appropriate for clients in all stages of recovery. However, the focus of this TIP is on early recovery—that is, the first year of recovery—when depressive symptoms are particularly common.

Consensus Panel Recommendations

Although you have been trained in providing substance abuse treatment, that training most likely did not include management of your clients’ depressive symptoms. This TIP was designed to fill that gap. In particular, the Consensus Panel recommends:

All substance abuse treatment clients should be screened for depressive

symptoms.

You should be aware of the ways depressive symptoms can manifest in clients with substance use disorders and how those symptoms can affect substance abuse recovery.

You should be aware of the ways depressive symptoms can affect clients’ participation in treatment.

Substance abuse treatment for clients with substance use disorders and depressive symptoms should be client centered and integrated.

Several intervention methods have been used successfully to manage depressive symptoms in substance abuse treatment: behavioral, cognitive–behavioral, supportive, expressive, 12Step facilitation, and motivational interviewing.

You should be aware of the manner in which your attitudes toward clients with depressive symptoms can affect your ability to work with these individuals.

Substance Abuse Counselors— Scope of Practice

This TIP is designed for substance abuse counselors who have direct clinical contact with clients who have substance use disorders. The legal titles, levels, types of licenses, and certifications for substance abuse counselors differ across the 50 States and the District of Columbia. This TIP is intended to benefit all licensed or certified substance abuse counselors, regardless of their titles. The counseling activities described in this TIP are legally and ethically appropriate for substance abuse counselors to undertake in all 50 States and the District of Columbia. This TIP may also be beneficial for people preparing to become certified or licensed substance abuse counselors.

However, uncertified or unlicensed counselors should use these methods only under the supervision of an appropriately trained and certified or licensed substance abuse professional. Furthermore, maintaining collaborative relationships with mental health treatment providers for consultation and referral is recommended, either directly or through clinical supervision.

This TIP also provides useful ideas for dealing with depressive symptoms for those of you with advanced degrees and/or additional clinical experience.

top

Framework

This chapter provides basic information on:

• The nature of depressive symptoms.

• The relationship between depressive symptoms and the toxic or withdrawal effects of

substances.

• The relationship between depressive symptoms and substance use disorders.

• The effect of substances on recovery from depressive symptoms.

• Suicidality among clients in substance abuse treatment with depressive symptoms.

• How depressive symptoms affect treatment participation.

• The concept of integrated care for substance abuse and depressive symptoms.

• Special considerations related to the cultures of your clients.

• Your professional role and responsibilities in relation to clients with depressive

symptoms.

• Preparing yourself to work with clients with depressive symptoms.

• Screening and assessment.

• Treatment planning.

• Treatment.

• Continuing care and treatment termination.

The Nature of Depressive Symptoms

The term “depressive symptoms” is generally applied to a mood state of sadness, depressed mood, “the blues,” or other related feelings and behaviors (see Figure 1.1) that do not meet the diagnostic criteria for a DSM-IV-TR mood disorder. People who have depressive symptoms may experience considerable emotional pain and may have significantly impaired functioning in some areas.

TIP48_fig_1.1.jpg

Symptoms of depression exist on a continuum. At one end of the spectrum is the experience of sadness and other depressive symptoms occurring at appropriate times and for short periods, during which the individual successfully uses coping strategies. At the other end is clinical (or “major”) depression, as described in DSM-IV-TR. The line between depressive symptoms and psychiatric depressive disorders is a question of degree. Having depressive symptoms differs from having a major depressive disorder in terms of the number or severity of symptoms experienced by a client, not in terms of the types of symptoms. Only a professional credentialed to diagnose mental illness can determine for certain whether a client has a serious depressive disorder such as major depression, dysthymia, bipolar disorder, or substance-induced mood disorder (See Figure 1.3 on p. 8 for more information on substance-induced depressive symptoms). If you suspect that a client has a depressive illness, you should refer the client to a mental health professional for assessment, diagnosis, and treatment. Screening for depression, as discussed later in this chapter, will help you to decide when to refer.

Clients may have more or less intense depressive symptoms over time. This may be due to the client’s biology, stressful events in the client’s life, or the client’s stopping or starting substance use. For example, someone who is drinking heavily may have intense depressive symptoms that seemingly meet criteria for depressive illness except that the symptoms dramatically lessen in the weeks after initial abstinence from alcohol. Similarly, someone with major depression or dysthymia who is taking antidepressant medication over several weeks may also show fewer or no currently debilitating depressive symptoms. Conversely, a client who now demonstrates only mild depressive symptoms may be on his or her way to a significant depressive episode.

As with substance abuse, even though a person may be in remission from a depressive illness, the disorder remains. Prevention of and early intervention in recurrences must be addressed in treatment, especially in early recovery from substance use disorders. Many depressive disorders cycle and recur. If a client has a history of a mood disorder, the client and counselor should both be on the lookout for a recurrence of symptoms.

In addition, there are significant individual and cultural differences in how people talk about depressive symptoms. Counselors need to listen carefully to what clients say and probe for clarification. For instance, many people say they are “stressed.” This could range in meaning from having too much work to a significant symptom of depression.

top

changes (e.g., graduation, marriage, divorce, birth of a child, starting a new job), past losses and traumatic events (sometimes forgotten), hormonal changes, and brain chemistry. Note that some of these life changes are generally viewed by society as positive. Nonetheless, they can initiate depressive symptoms in some people. It is a natural part of the human experience to feel a sense of loss and regret when making a change, whether it is positive or negative.

People with certain medical conditions, such as hypothyroidism and B-12 deficiency, may have depressive symptoms (e.g., low energy, fatigue, weight gain, poor concentration and memory) as part of their clinical presentation. Therefore, a physical examination is recommended to rule out medical conditions that might mimic or enhance a depressive illness. Finally, the experience of “hitting bottom,” entering substance abuse treatment, and beginning a sober life can precipitate depressive symptoms or even a depressive illness.

Depressive symptoms may also correlate to the high level of stress that often accompanies substance abuse, including financial problems; job loss; and alienation from friends, significant others, and family members. Clients using alcohol or drugs often neglect their health as well as friends, family, work, hobbies, and other sources of normal satisfaction. This in itself can lead to depressive symptoms or depression. Stress is one of the most important risk factors, not only for the development of substance use disorders, but also for the development of depressive symptoms.

Some people have depressive symptoms during some periods of their lives and depressive illnesses during other periods (see Managing Depressive Symptoms: A Review of the Literature, Part 3, at www.kap.samhsa.gov). Clients who experience a period of depressive symptoms appear to be at increased risk of an episode of major depression or other depressive illnesses. Thus, it is important for the substance abuse counselor to monitor the client’s depressive symptoms on a regular basis (see the screening and assessment section of this chapter, p. 20).

The Relationship Between Depressive Symptoms and the Toxic or Withdrawal Effects of Substances

Intoxication and/or withdrawal from certain substances can lead to depressive symptoms. The DSMIV-TR provides a description of behavioral, physiological, and psychological symptoms related to each class of drug. If these symptoms are significant enough, they may be characterized as a substance-induced mood disorder (see Appendix D for a description of this disorder). These drug-induced symptoms can last as long as an individual continues to take substances and may or may not improve with abstinence. This may be because of toxic effects on the nervous system of chronic exposure to substances.

Depressive symptoms can linger for 3 to 6 months after abstinence and must be treated in counseling. Because appropriate treatment for depressive symptoms has been shown to improve substance-related outcomes (Dodge, Sindelar, & Sinha, 2005), addressing depressive symptoms must be of concern to you as a substance abuse treatment counselor. Depressive symptoms typically associated with common substances of abuse are detailed in Figure 1.3 (p. 8).

The Relationship Between Depressive Symptoms and Substance Use Disorders

Substance use disorders relate to depressive symptoms or a depressive disorder in a variety of ways. Having a substance use disorder increases the risk of experiencing depressive symptoms or a depressive disorder. Similarly, having a depressive disorder increases the odds of having a substance use disorder (Nunes, Rubin, Carpenter, & Hasin, 2006).

Depressive symptoms can precede, follow, or co-occur with substance abuse symptoms. In many cases, it is important to understand the evolution of these conjoint symptoms in each client’s history. Depressive symptoms can result from the direct effects of alcohol or drugs on the central nervous system or from withdrawal of those drugs as described in Figure 1-3. Cocaine intoxication and withdrawal can produce

symptoms that look like major depression, except that they typically reduce in intensity in a matter of days after abstinence is initiated (Husband, 1996). An individual with a substance use disorder may experience depressive symptoms as a result of the losses or life problems caused by the substance use over time. The person may have lost a job, an important relationship, or financial security, and feel depressed, yet not meet criteria for a depressive disorder.

Untreated depressive symptoms can influence the client’s response to substance abuse treatment and the ability to remain substance free over time. For example, perhaps one of your clients who has recurrent depressive symptoms and cocaine dependence refuses to take her antidepressant medications as prescribed. She demonstrates a pattern of relapse to drug use when she uses cocaine to boost her mood during periods of depression. In his book Darkness Visible: A Memoir of Madness (1992), author William Styron provides an excellent and detailed description of how his depression significantly worsened after he stopped drinking alcohol. He felt that his alcoholism initially covered up his depression, which became intolerable after he quit drinking, causing him considerable anguish.

It is important to remember that both problems and their symptoms are primary illnesses and would probably occur without the influence of the other. In this context, an integrated treatment plan, addressing both disorders, is essential.

Sometimes, one disorder precedes the other. For example, people who are sober from alcohol or drugs for months or years can later develop an episode of depressive symptoms or major depression. Similarly, people recovering from a depressive disorder can develop alcohol or drug abuse or dependence years after the end of treatment or during a course of treatment. The important point to remember, regardless of which disorder came first, is that both substance abuse and depressive symptoms need to be treated concurrently.

A substance use disorder can contribute to a delay in seeking treatment among those with depressive symptoms. It can also interfere with a client’s successful transition from inpatient care to ambulatory treatment.

Substance use can cover up depressive symptoms, making it hard to identify depression until a client stops using substances and remains sober for days, weeks, or longer. For example, Steve had been dependent on alcohol for 8 years and drank large quantities nearly every day. He also had depressive symptoms that preceded his alcoholism, but his alcohol use covered them up. Although Steve sought help for his depressive symptoms over the years, treatment was only partly effective because he continued drinking heavily and minimized his alcohol problem. After detoxification, when he began working on a program of recovery, Steve’s depressive symptoms actually worsened. Since he was used to reducing his depressive symptoms with alcohol, his mood symptoms caused strong cravings and thoughts of using alcohol. It was clear that in order to help him stay sober, Steve needed evaluation and treatment for his depressive symptoms.

Effects of Substances on Recovery From Depressive Symptoms

Substance use, abuse, or dependence can cause depressive symptoms to worsen and complicate recovery from a depressive illness. These effects may also interfere with a client’s response to medications or other therapeutic interventions. Helplessness and hopelessness are common experiences for clients with substance use disorders and those with depressive symptoms. Having both tends to compound these reactions.

Hopelessness and relapse to alcohol and drug use are interrelated. Hopelessness creates a psychological environment that supports drug relapse. At the same time, drug relapse may increase the experience of hopelessness. The combined effect of relapse and hopelessness is to make treatment more difficult. The client may be more resistant to following the treatment plan and may blame lack of improvement on such external factors as medications, the treatment program protocols, other clients in the program, or the counselor’s skills.

Depression and hopelessness, combined with alcohol and/or drug use, may also increase the potential for violence to self or others. The client may be at higher risk for thinking about, planning, or acting on suicidal thoughts.

Suicidality Among Clients in Substance Abuse Treatment With Depressive Symptoms

Two populations with the highest rates of suicide are people who are depressed and people with a substance use disorder diagnosis (Center for Substance Abuse Treatment [CSAT], 2005c; Kessler, Berglund, Borges, Nock, & Wang, 2005). As a result, all clients with substance use problems and depressive symptoms should be screened for suicidality. TIP 42, Substance Abuse Treatment for Persons With Co-Occurring Disorders (CSAT, 2005c), provides detailed information appropriate for both screening and assessment of suicidality.

There is no generally accepted and standardized instrument that can accurately measure suicide potential. Suicide screening and assessment scales can be used as aids, but if a client shows signs of being at risk of suicide, these scales are not a substitute for a thorough clinical interview by a qualified mental health clinician, during which client and counselor can talk openly about suicidality. Any client showing warning signs or risk factors for suicidality should be assessed by a mental health professional specifically trained in conducting suicidal risk evaluations (APA, 2000) (see also Decision Tree on When To Refer a Client, p. 37). Most clients with suicidal ideation want a path out of their pain without harming themselves. It is their current perception, however, that such a path isn’t available to them.

1. Clients will not make a suicide attempt if they promise the counselor to not harm themselves.

FACT: A variety of circumstances can influence suicidal behavior. A promise by a client not to harm himself may not apply when a client is confronted with a variety of environmental, interpersonal, and psychological stressors. A “commitment to treatment” plan is generally considered more useful than a “no-suicide pact” (Rudd, 2006).

2. Talking about suicidal thoughts will put the idea in a client’s head and make the problem worse.

FACT: Most clients want to talk about their suicidal thoughts and plans with someone. Talking with a nonjudgmental, accepting person about suicide can offer relief (Gliatto & Rai, 1999).

3. Changing a client’s perception of the events in her life will change her suicidality.

FACT: Events are only one variable in an individual’s suicidality. Other variables include the individual’s interpersonal support system; psychological variables such as depressive symptoms, depressive illness, despair and emptiness; cultural values and influences regarding suicidal behavior; and access to a method for suicide (Rudd, Joiner, & Rajab, 2001).

FACT: People sometimes impulsively act on suicidal thoughts, without a well-defined plan (Rudd et al., 2001).

Some “do’s” for working with clients who have suicidal thoughts or plans include:

1. Seek the clinical support and input of supervisors, consultants, and treatment team members.

2. Obtain the informed consent of the client to consult with a supervisor, appropriate mental health professionals, and referral resources about the client’s care.

4. Encourage clients to talk about their suicidal ideation, whether plans have been considered or made, and whether a method (a gun or medication, for instance) is available. This is important information to have when you consult with a supervisor or mental health professional.

5. Don’t allow yourself to be sworn to secrecy about the client’s suicidal thoughts or intent.

6. Engage the client in participating in a plan of care to intervene with suicidal thoughts and/or behaviors.

7. If possible, involve the client’s family and significant others in supporting the client.

8. Have a clear understanding of the ethical, legal, and agency guidelines in working with clients who are suicidal. (See also the forthcoming TIP,

Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment, and [CSAT, in development a].)

Depression can affect almost any area of functioning. As a result, the client with depressive symptoms may have problems such as the following:

Difficulty in concentrating and integrating materials, such as program rules and program assignments.

Lack of energy to participate in substance abuse treatment program activities such as group therapy, family therapy, 12-Step meetings, and recreational activities.

As a substance abuse counselor, you want your clients to achieve abstinence and an improved quality of life. Addressing depressive symptoms is a part of reaching both those goals. Clients with depressive symptoms may have difficulty relating to other clients. They may see themselves as different and distance themselves from other clients and may not be interested in participating in group activities. Vignettes 2 and 4 in chapter 2 of this TIP demonstrate techniques for dealing with some of these challenges.

Because clients with depressive symptoms are more likely to relapse after treatment is completed (see

Managing Depressive Symptoms: A Review of the Literature, Part 3, at www.kap.samhsa.gov), the work you do with clients to reduce depressive symptoms will yield added benefits in terms of supporting abstinence.

The Concept of Integrated Care for Substance Abuse and Depressive Symptoms

Integrated treatment for both problems is the standard of care for clients with substance abuse and depressive symptoms or any co-occurring mental disorder. Integrated interventions are specific treatment strategies or therapeutic techniques in which interventions for two or more co-occurring disorder diagnoses or symptoms are combined in a single session or interaction, in a series of interactions, or in multiple sessions over time (CSAT, 2005a). These can be acute interventions to establish safety, as well as ongoing efforts to foster recovery.

You can make a basic error if you treat clients as a collection of parts rather than as individuals who are trying to integrate all their experiences and feelings into a single understanding of themselves. An example of this is when the client’s substance abuse and depressive symptoms are treated as though they are separate issues. While in some ways, these problems are indeed separate (e.g., each has its own history, symptoms, treatment approaches, and neither “goes away” just because the other is addressed), they cannot be separated because they exist in the same person at the same time.

The case example of Steve, provided earlier in this chapter, illustrated the problems encountered when depressive symptoms or substance abuse are treated independently. If counselors try to treat only the substance abuse, the depressive symptoms get in the way and vice versa.

It is also important to note that substance abuse and depressive symptoms may interact in various ways. For example, the personal exploration central to recovery from substance use disorder may bring to the surface memories or feelings that activate or exacerbate depressive symptoms. Loss of the “old friend” that substance abuse and associated lifestyles represent may cause grief. Similarly, depressive symptoms are known to be cues for craving (see Managing Depressive Symptoms: A Review of the Literature, Part 3, at www.kap.samhsa.gov) or may contribute to feelings that all change, including recovery, is impossible.

For all these reasons, care for the person with substance abuse problems and depressive symptoms must be integrated. This means treating each disorder as “primary” (i.e., having its own cause and course) but also treating each within the context of the other.

Further discussion of the concepts of integrated care can be found in TIP 42 (CSAT, 2005c).

End of this section

Chapter 7

Managing Depressive Symptoms in Substance Abuse Clients During Early Recovery