So many of our clients face the challenges of both addiction and depression that a working knowledge of depression has become a prerequisite for addiction counselors.
Nicholas A. Roes, PhD
Up to 25% of the population might have at least one lifetime episode of depression,1 and the percentage is much higher among addicts. Many theories persist about the cause of depression. Biologic factors seem to play a role but don't by themselves determine who gets de-pressed. People with depression think thoughts that keep them depressed, so cognitive interventions can be successful. Environmental factors and personal choices may also contribute to depression.
When discussing depression, clinicians may refer to an episode. This means that the DSM-IV diagnostic criteria for depression have been met. When the episode is over, this is referred to as remission. When the remission is a result of treatment, this is called response. When a full remission occurs for a specified period of time, it's called recovery. The term relapse is used to describe an early return of the symptoms, and recurrence describes a new episode after recovery.
Symptom subtypes of major depression include vegetative symptoms such as weight loss, insomnia, and loss of appetite. A smaller subgroup has reverse vegetative symptoms (weight gain, hypersomnia, and increased appetite).
Learning about medication
A psychiatrist usually uses a pharmacologic intervention for the depression; this often helps the client focus on nonpharmacologic interventions, as well. Addiction counselors need to know what prescribed antidepressants can and can't do, and to understand the range of possibilities that may result from the pharmacologic intervention.
If possible, speak with your staff psychiatrist to learn what the realistic expectations are for each medication your clients take. This will help you support the client's realistic expectations. Medication is helpful to some clients with depression and is not helpful to others, and addiction counselors can provide important support for their clients in both cases.
Your client may be in any of three phases of pharmacologic treatment. During the acute phase, medicine is prescribed to help with the symptoms of active depression. There may be a continuation phase to prevent the client from relapsing and a maintenance phase designed to prevent recurrence. Full response to the most commonly used antidepressants usually takes 4 to 6 weeks, and you may observe some additional benefits after 8 to 12 weeks.
The most brilliant psychiatrist in the world cannot learn all the relevant information in what is often a 15-minute session with a client. A counselor at a residential treatment program will have a great deal more opportunity to observe the client, and the counselor's impressions of how the client is handling the medication can be valuable. Pharmacologic interventions have varying degrees of success, and it's important for the counselor to communicate with other treatment team members.
When the desired effects are not achieved during the acute phase, the psychiatrist will probably select from among four approaches. Sometimes the recommendation will be for higher dosages or longer time periods of the same medication, and other times the psychiatrist will try a different medication. The psychiatrist may add another medication (not an antidepressant) to help the original prescription work, or he/she may add another antidepressant to work in combination with the original.
A dosage that has been successful during the acute phase of treatment may be used during the continuation phase. When long-term medication maintenance therapy is not indicated, the continuation phase includes a tapering-off period.
The maintenance phase may be lifelong, but there is little guidance for psychiatrists in this area. So far, no studies have indicated harmful long-term effects on internal organs, and long-term use of antidepressants has been shown to be helpful in many cases.1
Emphasizing the client's role
When clients improve, it's important for counselors to help clients recognize their own contributions to the changes. The following questions can be helpful in this process:
“You mentioned that you think the medication you're taking is helping. How are you working with the medication to better your life?”
“In your mind, what does the medication you're taking allow you to do that you might not otherwise be able to?”
“What are you able to do as a result of feeling better from taking the medication?”
“How much of the change you've experienced is a result of the medication, and how much do you think is of your own doing?”2
It's important to help your clients understand their role in decisions to get out of bed, go to work, relate better to their family, and be a happier person. Otherwise they may expect that too much depends on “finding the right medicine” and not enough on other things more within their control.
Nicholas A. Roes, PhD, has written hundreds of articles and several books, including
Solutions for the ‘Treatment-Resistant’ Addicted Client (Haworth Press, 2002; reviewed in the January 2003 issue of