Substance Abuse & Mood Disorders

Comorbid Mood Disorders and Addiction

Substance abuse and substance use disorders (SUDs) are not uncommon among people who struggle with mental illnesses like mood disorders. When a person has a substance use disorder and a mental illness, they are said to have a co-occurring (or comorbid) disorder.

For people with both mood and substance use disorders, guidelines in the Diagnostic and Statistical Manual used by mental health professionals indicate that the mood disorder is the primary disorder as long as it is not the result of the effects of drugs or alcohol.⁵ In order for the mood disorder to be primary, the symptoms of that disorder must have been evident before substance use issues occurred and should also continue when the drugs or alcohol are not in use.⁵ With a diagnosis of both a mood disorder and an SUD, the focus then becomes finding out whether the mood disorder is primary or substance-induced so that the appropriate treatment approach can be determined.⁵ 

Substance use disorder is the clinical or diagnostic term used to describe addiction—it is a serious disorder that develops as a person’s use of alcohol or drugs begins to interfere with their ability to function in everyday life and negatively impacts their health, home, social, and work life.² Signs, symptoms, and associated behavioral changes may include a lack of control over substance abuse, confusion, violence, secretive behavior, ceasing previously enjoyed activities in order to use drugs or alcohol, and continuing to use even though the person knows it has a negative impact on their life.² 

Co-occurring disorders interact with and affect each other—the symptoms of one can affect the course and prognosis of the other.¹ Mental illness and addiction are more closely linked than you might imagine; according to the National Institute on Drug Abuse (NIDA), around half of the people with a mental illness develop SUDs, and vice versa.³ The reasons for this are not cut-and-dry and involve a complex interplay of genetics, exposure to stress and traumatic events, and chemical changes in the brain.³ Treatment can be more challenging for people with co-occurring disorders, but specialized rehab that integrates the management of both can make a huge difference in effectively addressing the patient’s therapeutic needs and improve treatment outcomes.

Mood Disorders and Substance Abuse

A mood disorder is a mental illness that affects a person’s emotional state.⁴ Some examples of mood disorders include major depression, seasonal affective disorder, and bipolar disorder I and II. Anxiety disorders are a separate diagnostic category but can also have an impact on your mood.

Symptoms of mood disorders may include feeling sad, empty, irritable, hopeless, or manic. Those with bipolar I disorder may experience manic episodes preceded by and followed by either hypomanic or major depressive episodes, resulting in periods of expansive or elevated moods being punctuated by bouts of sadness or depressed mood.¹⁵

Research has shown that people living with both a mood disorder and a substance abuse issue tend to have more severe symptoms and are harder to treat than people having only one of these issues.⁵ However, while substance abuse and mood disorders are believed to influence each other, the reasons why this happens aren’t entirely understood—sometimes people have a mood disorder before they start abusing substances and, at times, a mood disorder results from substance abuse.⁶

Depression and Substance Abuse

Depression, also known as major depression or clinical depression, is a severely debilitating condition that causes significantly lowered mood, difficulty functioning, and feelings of hopelessness or worthlessness for a period of at least 2 weeks. Other forms of depression include:⁷

• Persistent depressive disorder (or dysthymia), in which a person may experience varying levels of depression severity, but with symptoms being continuously present for at least 2 years.
• Postpartum depression, in which a major depression may develop either during pregnancy or after a woman gives birth.
• Psychotic depression, which occurs when a person has severe depression and psychotic symptoms, such as delusions or hallucinations.
• Seasonal affective disorder (commonly abbreviated as SAD), which is depression that develops in association with a decrease in sunlight. It generally occurs in the winter and involves social withdrawal, weight gain, and increased sleep.

Depression and substance abuse often occur simultaneously; people who abuse substances may be more likely to suffer from depression and vice versa. The reasons for this are not entirely well understood; however, genetic factors, early exposure to stress or trauma, gender, and underlying brain issues can influence the development of co-occurring disorders.¹ It’s also theorized that self-medication may play a role. In such cases, people experiencing the negative symptoms of their mental health disorder may attempt to self-medicate with drugs or alcohol as a way to feel better or escape feelings of despair. In these instances, though there may be some perceived short-term relief, it can not only drive the development of an addiction and other substance-related health issues, but may ultimately serve to worsen or complicate the course of the underlying depression.

Alcohol and Depression

Alcohol is one of the most commonly abused (and most easily obtained) substances in the world.⁹ Although some may look to drinking as an easy, temporary escape from depressive symptoms, it could also fuel an alcohol addiction. Furthermore, alcohol abuse can be a key contributing factor in the development of depression. In some cases, it can be difficult to determine which disorder came first, as people who have alcohol-induced depression present with the same symptoms as those who have a primary diagnosis of clinical depression with alcoholism.¹⁰

 When a person regularly abuses alcohol, they can easily become stuck in the cycle of physical dependence and addiction. Physical dependence means that a person needs alcohol (or drugs) to function and feel normal. When a person with alcohol dependence stops using, they may be at risk of developing withdrawal symptoms that can be physically and mentally uncomfortable (and even dangerous, should complications like seizures arise), so many people relapse or continue abusing alcohol as a way of preventing or avoiding these symptoms.

Dangers of Self-Medicating for Depression

Just as drug abuse is sometimes a cause of depression, depression can also be a gateway for drug and alcohol abuse because many people use substances as a way of escaping negative emotions and symptoms. Emotional suffering, distress, and feeling overwhelmed by hopelessness and sadness may be temporarily relieved by drug or alcohol use. However, when the effects of the substances wear off, you will experience an influx of those negative feelings again, which only perpetuates the cycle of abuse; to avoid the negative feelings, you continue using. As people continue to self-medicate and abuse drugs and alcohol, their chance of developing a dangerous addiction rapidly increases.⁸

Although people may think that abusing alcohol or drugs takes the edge off their symptoms, it is not an effective or advisable way of dealing with depression. Professional treatment is the only recommended way to help reduce symptoms of depression and address substance abuse; treatment for depression can help reduce the risk of substance abuse, and treatment for substance abuse can help reduce the risk of depression. Effective treatment to address both depression and addiction may include a combination of medication and psychotherapeutic interventions like counseling or 12-step groups.¹

Bipolar Disorder and Substance Abuse

Bipolar disorder is a severe mood disorder that results in dramatic shifts in mood, behavior, energy levels, and thought processes that can last for days or weeks. One key difference between major depression and bipolar disorder is that, in addition to depressive symptoms (in most cases), people with bipolar disorder experience mania, a period of extremely elevated mood that is often accompanied by irritability, unpredictability, impulsivity, and, in some cases, suicidal behavior.¹²

There are several forms of bipolar disorder, including:^12,16

• Bipolar I, which causes one or more episodes of mania—periods of elevated or irritable mood accompanied by an increase in energy or activity—that last for most of the day, every day for at least a week (or are so severe that hospitalization is required). Some people with bipolar I experience psychotic symptoms such as delusions and hallucinations. Most people with Bipolar I experience depressive symptoms, but this is not always the case.
• Bipolar II, where people shift back and forth between depressive episodes and hypomanic episodes, but do not experience a full manic episode. Impulsivity is a characteristic feature of bipolar II, and may contribute to an increased likelihood of substance use and suicidal attempts.
• Cyclothymic Disorder, which involves cycles of depression and hypomanic episodes (though less persistent and of lower intensity than those associated with bipolar II) lasting for a period of at least 2 years for adults.

Scientists aren’t entirely sure what causes bipolar disorder but believe that chemical imbalances in the brain, genetics, stress, and trauma are potential risk factors.¹² Drug abuse can worsen, mimic, or induce symptoms of bipolar disorder and substance abuse only serves to exacerbate the problems caused by the disorder.¹³ People with bipolar disorder are often likely to abuse substances as a way to alleviate the problems and symptoms caused by their condition.

In particular, people with bipolar disorder commonly abuse alcohol, which can worsen the prognosis of the disorder and make it more difficult to treat. Additionally, some research has shown that alcohol withdrawal may trigger bipolar symptoms.¹⁴

How Treatment Can Help

Although co-occurring addiction and bipolar disorder can be challenging to treat, and research is limited, some evidence has demonstrated the effectiveness of a combination of psychiatric medications and a combination of behavioral therapeutic interventions, such as cognitive behavioral therapy, relapse prevention groups, and further encouragement of participation in 12-step groups. Behavioral therapy may use an integrated approach to simultaneously address both the mental health issues as well as the substance use disorder to strengthen recovery efforts and additionally minimize relapse risks.¹⁴

Sources

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12. National Alliance on Mental Illness. (2017). Bipolar disorder.
13. National Institute of Mental Health. (2018). Bipolar disorder.
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15. Johns Hopkins University. (n.d.). Mood Disorders.
16. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.