New evidence is overturning the long-held view that patients with co-occurring mental health and substance use disorders must achieve abstinence from drugs before treatment for depression can begin. There were sound reasons for adhering to this view, including clinician concern about drug interactions and recognition that depressive symptoms brought on by substance abuse are difficult to separate from clinical depression itself. As the field continues to refine screening tools that distinguish the disorders, however, new treatment approaches are being developed and assessed.

In a study that reinforces the need to revisit traditional management of these conditions, NIDA-funded researchers Drs. Edward Nunes and Frances Levin of Columbia University in New York City reviewed 33 years of published literature on the treatment of depression in the context of ongoing substance abuse. They found that antidepressant treatment is not sufficient for these patients, and they emphasize the need to integrate the treatment of depression and substance abuse. The investigators examined 44 placebo-controlled clinical trials published from 1970 to December 2003; 14 followed a rigorous methodology and were included in the study. Drs. Nunes and Levin used meta-analysis—a technique that synthesizes data from similar studies and determines how much particular factors affect outcomes—to examine the effects of antidepressant medication in approximately 850 patients with co-occurring substance abuse. They found that treating the depression of patients with co-occurring substance abuse conveys moderate benefit. Patients who responded to the antidepressant treatment also showed a reduction in substance abuse. However, cessation rates were generally low, even among studies demonstrating positive effects of antidepressants. Drs. Nunes and Levin suggest that clinicians first treat the depression with an evidence-based psychosocial intervention, followed by antidepressant medication if the depression does not improve.

"The study provides quantitative evidence on the benefit of treating depression in those with co-occurring substance abuse and supports integrated treatment of both disorders. Cognitive behavioral therapy is a good first approach for treating these patients, but the findings show the efficacy of antidepressant medications for patients with coexisting depression and substance abuse," says Dr. Ivan Montoya of NIDA's Division of Pharmacotherapies and Medical Consequences of Drug Abuse. Some clinicians worry that treating a patient's depression distracts attention from treating their co-occurring substance abuse. But Dr. Montoya says, "Patients may attach less stigma to seeking treatment for depression than substance abuse. Clinicians are increasingly finding that they have an opportunity to treat substance abuse in patients who present with depression; now, they have quantitative evidence to support the decision of concurrent treatment."

Source

Nunes, E.V., and Levin, F.R. Treatment of depression in patients with alcohol or other drug dependence: A meta-analysis. JAMA 291(15):1887-1896, 2004.
[Abstract]

Volume 19, Number 4 (December 2004)