TIP 48: Part 1, Chapter 1, Managing Depressive Symptoms in Substance Abuse Clients During Early Recovery

TIP 48: 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.

Depressive symptoms are common among clients in substance abuse treatment. 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.

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 co-occurring psychiatric disorders than men. Some studies suggest a higher rate of depressive symptoms in women, although other studies find no such differences.

These findings indicate that it is likely you will encounter clients with substance use disorders who have depressive symptoms—as many as half of the clients you see. Initial intake personnel are charged with identifying clients who are experiencing depressive symptoms when they enter treatment.

However, depressive symptoms may appear at any time during substance abuse treatment. Look for pertinent notes in the client’s chart and follow up on any indications that your client is experiencing symptoms of depression.

When they occur, depressive symptoms can interfere with clients’ recovery and ability to participate in treatment. For example, someone with a depressive symptom such as poor concentration may have more difficulty paying attention to group therapy sessions or listening to another member share experiences in a 12-Step meeting.

Thus, counselors must gain the skills necessary within their licensure and scope of practice to promote recovery in individuals with substance use disorders and depressive symptoms that affect their ability to participate fully in treatment.

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.

This TIP is not about treating any mood disorder as defined in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision (DSM-IV-TR; American Psychiatric Association [APA], 2000).

Clients with diagnosed mood disorders (e.g., major depression,
dysthymia, cyclothymia, bipolar disorder, substance-induced mood disorder) need specialized treatment from a trained and licensed mental health professional.

However, it is important for you to be aware of the impact of these depressive symptoms on clients’ recovery and your need to have the clinical skills to interact more effectively with these clients, who may or may not have a diagnosed mood disorder. (A review of mood disorder diagnoses is included in Appendix D of this TIP.).

What’s Included

Consensus Panel Recommendations

Substance Abuse Counselors—Scope of Practice


The Nature of Depressive Symptoms

Depressive Symptoms and Related Feelings and Behaviors

Screening for Depression

Depressive Symptoms

When Individuals Are Experiencing Normal Moods

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

The Relationship Between Depressive Symptoms and
Substance Use Disorders

Effects 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

Approaches and Psychosocial Interventions for Working With Depressive Symptoms

And Much More….


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Behavioral Health Rehabilitative Specialist & Addiction Counselor

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