Antidepressants and Alcohol – A Guide to SSRIs in Addiction Treatment

Antidepressants and alcohol or drug treatment.

Ever heard the saying “you can’t use drugs to treat a drug problem?”

If you have - forget it, because it's based on dangerous and outdated thinking that just blocks you from valid recovery options. Instead, think of depression and addiction as brain diseases - and medications as tools that facilitate brain healing and a return to normal functioning.

Are antidepressants right for you?

Before taking any antidepressant you need to make sure that your substance abuse doesn’t cause your depression, because if it does:

1. You don’t need SSRIs or any other antidepressant – you just need to stop using or drinking and your depression will evaporate
2. Antidepressants won’t help anyway

However, if you suffer with independent depression and addiction issues, then SSRIs may reduce your depression, whether you stop using or drinking or not.

Read on to learn more about:

• Which substances can cause depression and how to know if you’ve got independent or substance-abuse-caused depression.
• What to do if you’re not sure or can’t tell?
• The importance of integrating medications, therapies and other forms of addiction treatments.
• Diagnosing yourself (a self test)  – do your symptoms meet the diagnostic criteria for depression?

Which Substances May Cause Depression?

Are you taking a drug or alcohol capable of pushing you into depression?

With substance abuse and mood disorders, especially pre-abstinence, it’s sometimes hard to tell if the substance abuse caused the depression or if the depression exists independently of the substance abuse.

While addictions of all forms may cause work and relationship problems that increase your risks for depression, the abuse of certain substances can alter brain chemistry to induce a mood disorder directly.

Abusing any of the following substances may result in substance-induced depression:¹

• Alcohol
• Cocaine
• Meth
• Opiates
• Hallucinogens
• Marijuana
• Benzodiazepines
• Other sedative drugs

Is Your Depression Substance-Induced?

Depression and addiction go hand in hand. According to data from the National Epidemiological Survey on Alcohol and Related Conditions, 20.5% of people meeting the criteria for current alcohol dependence also have concurrent major depression – this is almost 4 times the prevalence seen in the general population; and among alcohol dependent people seeking treatment, 40.7% have at least one independent mood disorder.² 

• Depression can lead to self-medicating and addiction 

Or

• Abuse alone can lead to depression (and further self medicating)

And unless one condition came first, it’s often hard to know what’s causing what. Here are some differentiation strategies...

Signs that your substance abuse caused your depression include:³

• You abuse a substance that’s known to cause depression and you take it heavily enough to plausibly induce a mood disorder.
• Your depression evaporates on its own with sustained abstinence (with a period of days to months of abstinence).
• Your substance abuse precedes your depression.

Signs of independent depression include:⁴

• Your depression precedes your substance abuse or feelings of depression precede binges.
• You have a strong family history of depression.
• You stay depressed during periods of sustained abstinence (4 weeks or longer)
• You have severe depressive symptoms and only minor or moderate substance use – your depression is greater than would be expected given your quantity of substance use.

What if You Can’t Tell?

So what do you do if you don’t know what’s causing your depression?

According to the Canadian Addiction and Mental Health Centre (CAMH):⁵

• If you can maintain abstinence for a stretch and you have mild depression it’s best to wait for between 4 to 12 weeks before starting pharmacotherapy (medication therapy). If the depression doesn’t ameliorate over this period, then consider starting medication but realize that it’s very difficult to get an accurate psychiatric diagnosis until at least 3 to 6 months of abstinence.
• If you have severe depression or signs indicate a mood disorder that’s independent of your substance abuse (such as a strong family history of depression) your doctor may want to try antidepressants anyway without waiting for the 4 to 12 week period of abstinence.
• If you can’t or won’t maintain abstinence, and there is reason to suspect primary depression, your doctor may want to try antidepressants or other medications even while you continue to use or drink.
  

In some studies, depressed active-drinking alcoholics provided SSRI antidepressants experience improved mood and show some reductions in their alcohol intake. 

Note – Given the many millions of people dealing with both depression and substance abuse as co-occurring disorders, there is a real scarcity of research on the efficacy of medications to treat mood disorders among this actively using population.  Many studies historically rejected actively using alcoholics or drug users to reduce confounding variables that would cloud the interpretability of data. Fortunately, this situation is now changing for the better.

What Are the Recovery Odds?

If you’ve got depression and addiction, here’s some good news:

• Sustained and integrated treatment will get you feeling a lot better and using a lot less – and you can expect to start feeling better within weeks and continue to improve your quality of life for lasting benefits.

So you should feel optimistic and excited about your chances for a better life, so long as you’re willing to do the hard work of recovery - because the truth is, co-occurring depression complicates treatment and you can’t expect a quick fix. Research shows that if you take a large pool of people with serious mental health and addiction issues, it takes between 3 and 4 years of integrated treatment for half of this pool of dually diagnosed people to attain stable and lasting sobriety.

While this may seem daunting, it’s worth noting that even those people who don’t achieve lasting sobriety by 3 or 4 years typically experience at least some reduced substance use and often substantial improvements in quality of life.⁶

Take Home Message

• Integrated treatment, which may include antidepressants and other medications, works well, even for people with serious mental illness.
• Treatment takes time and is best viewed as an ongoing process, rather than something to finish quickly.
• Even those people who don’t achieve full abstinence or remission usually benefit from treatment and medication – through reduced substance use and decreased depressive symptoms.
• People with less severe mental illness can expect quicker recovery times.

Can You Just Treat the Depression?

Although you could treat the depression alone – and not address the substance abuse/addiction – you are more likely to reduce the severity of the mental illness by addressing the depression and the substance abuse/addiction at the same time or by tackling the substance abuse first.

Here’s why:⁶

• The substance abuse may be the primary cause of the depression, and if you can reduce or eliminate the substance abuse, the depression may go away without need for further treatment.
• Even if the depression exists independently of the substance abuse, drug or alcohol abuse almost certainly worsens the situation and complicates treatments.  The abuse of certain drugs and alcohol can reduce the effectiveness of psychiatric medications and reduce treatment compliance - and people abusing drugs and alcohol often experience behavioral and relationship difficulties that can worsen mood. 
• Studies on antidepressant use among active alcoholics show that medications can help to reduce depression, but even when they do, they don’t have a strong impact on reducing drinking. 

Also, when looking only at alcohol, we can see that:

• Heavy drinking causes longer-lasting depressive episodes.
• Depression during abstinence and recovery is a significant risk factor for relapse.²

So whether or not substance abuse causes your depression, you need to treat your substance abuse as something that’s inextricably linked to your depression.

Of course, in some situations, a person might seek help for their depression but feel unable or unwilling to address their substance use or abuse. In such cases, mental health workers might recommend antidepressants anyway, as a harm reduction attempt that’s better than nothing.

Combining Medications and Therapies

In many situations, when faced with co-occurring substance abuse/addiction and depression, doctors and psychiatrists will recommend a combination model of treatment that includes:

1. Psychosocial interventions, like CBT therapy, motivational interviewing and community mutual self-help group attendance (AA/NA or similar)
2. Psychiatric medications, like SSRI antidepressants
3. Anti-craving medications, such as Suboxone or methadone for opiates, naltrexone or others for alcohol, or nicotine replacement medications, for tobacco

A recent study published in the American Journal of Psychiatry illustrates the value of combination therapies. In this study, researchers gave depressed alcohol dependent study subjects either a placebo, an antidepressant (setraline), an antidepressant and an alcohol dependence medication (naltrexone) or naltrexone alone. All subjects also received weekly cognitive behavioral therapy.

Results

The study results illustrate the synergistic effect of combination treatment.

• After 14 weeks of treatment, subjects given the combination of naltrexone and setraline made greater gains in both reducing depressive symptoms and drinking than subjects given either medication alone.⁷

Matching Treatments to Readiness to Change

Though it’s important to treat addiction and mental illness at the same time, it’s OK to treat each situation at different intensities, depending on your wants and readiness to change.

For example, if you’re ready to treat depression but ambivalent about treating alcohol addiction, it might be better to start with antidepressants and CBT for the depression and motivational enhancement therapy for the alcohol addiction, rather than full-on rehab treatment, which doesn’t really match with your ambivalence about change and which isn’t as likely to produce a positive outcome.⁸

Beyond Medications – Therapies and Social Support

The Value of Therapies

By getting therapy you learn applicable skills that help you maintain your sobriety and manage mental health disorder symptoms.

If you’re dealing with serious depression or any other serious mental illness, therapy alone probably isn’t enough to get you feeling significantly better, for this you need to combine effective psychiatric medications and therapy.⁹

The Value of the 12 Steps for Those with Co-Occurring Depression and Substance Use Disorders

Does AA help with depression?

Although AA and other 12 steps programs are known primarily as abstinence-focused peer support groups they also seem to help alleviate symptoms of depression.

These groups help by increasing the likelihood of abstinence and reduced overall consumption, but they also mediate change by offering increased social support and promoting positive social interactions and feelings of self efficacy.¹⁰

The bottom line – These groups get you out of the house and can help you stay clean and sober, but they also get you socially involved with others, involved in helping others and they increase your sense of hope and self-efficacy.

Aren’t Antidepressants Addictive Too?

Antidepressants aren’t addictive, but they will induce a state of physical dependency and you will experience antidepressant withdrawal symptoms if you stop taking your medication too suddenly.

Though your body becomes dependent on these medications for normal functioning, these pills aren’t considered addictive - since you won’t:

• Have to keep increasing your dose to get the same effects
• Crave them or take more than recommended to get high
• Lose control of your use¹¹

Testing Yourself for Current Depression

So are you depressed?

If you think you might be, it’s well worth talking to your doctor or another qualified mental health professional about getting a diagnosis and for treatment options, but for a head-start on this, take this quick and easy test that may shed some light on your situation.

This test, called the Epidemiologic Studies Depression Scale (CES-D) is a quick and easy questionnaire developed by researchers at the National Institute of Health that can help you self-diagnose:

1. Major depression
2. Moderate depression
3. No depression¹²

The Epidemiologic Studies Depression Scale Test

Match each of the following test statements with one of the following answers:

• Rarely or none of the time
• Some or a little of the time
• Occasionally of a moderate amount of the time
• Most or all of the time

1. The answer you pick should be the one that best describes how you’ve been feeling over this past week.
2. You will need to count your answers at the end of the test, so keep track of how many of each answer you score.

The Test

1. I was bothered by things that usually don't bother me.
2. I did not feel like eating; my appetite was poor.
3. I felt that I could not shake off the blues even with the help from my family and friends.
4. I felt that I was not as good as other people.
5. I had trouble keeping my mind on what I was doing.
6. I felt depressed.
7. I felt that everything I did was an effort.
8. I felt hopeless about the future.
9. I thought my life had been a failure.
10. I felt fearful.
11. My sleep was restless.
12. I was unhappy.
13. I talked less than usual.
14. I felt lonely.
15. People were unfriendly.
16. I did not enjoy life.
17. I had crying spells.
18. I felt sad.
19. I felt that people disliked me.
20. I could not get "going".

Scoring

1. For each “Rarely or none of the time” answer – give yourself 0 points
2. For each “Some or a little of the time” answer – give yourself 1 point
3. For each “Occasionally of a moderate amount of the time” answer – give yourself 2 points
4. For each “ Most or all of the time” answer – give yourself 3 points

If your total score is:

1. 22 or greater - you may have major depression
2. 15 to 21 - you may have mild to moderate depression
3. Less than 15 - you likely do not have current depression