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Center for Substance Abuse Treatment. Managing Depressive Symptoms in Substance Abuse Clients During Early Recovery. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2008. (Treatment Improvement Protocol (TIP) Series, No. 48.)

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Managing Depressive Symptoms in Substance Abuse Clients During Early Recovery.

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Part 3, Managing Depressive Symptoms: A Review of the Literature, Section 2—Annotated Bibliography

Clinically Related Treatment and Intervention Studies

Reference: Ackermann, R. T., & Williams, J. W. (2002). Rational treatment choices for non-major depressions in primary care: An evidence-based review. Journal of General Internal Medicine, 17, 293–301.

Purpose: To review research on managing depressive disorders (including minor depression) in primary care settings.

Conclusions: The research evaluated provides only limited (i.e., mixed and small to moderate in effect size) support for the effectiveness of both antidepressant medications and those psychological interventions that have been tested in treating minor depression.

Methodology: The authors searched a number of major databases and other sources for guidelines and studies. Two independent reviewers abstracted data from the studies that were located and these data were synthesized using qualitative methods.

Summary of Results: The studies evaluated suggest that there are short-term improvements in depressive symptoms for individuals treated with paroxetine but not with amitriptyline. Also short-term improvements in symptoms were found for individuals who received problem-solving and cognitive-behavioral interventions. Strong evidence was found that the use of serotonin-selective reuptake inhibitors (SSRIs), in comparison to placebos, resulted in significant improvements in depressive symptoms. They also found some evidence that venlafaxine improved depressive symptom scores.

Reference: Allart-van Dam, E., Hosman, C. M. H., Hoogduin, C. A. L., & Schaap, C. P. D. R. (2003). The Coping With Depression Course: Short-term outcomes and mediating effects of a randomized controlled trial in the treatment of subclinical depression. Behavior Therapy, 34, 381–396.

Purpose: To evaluate the effectiveness of the Coping With Depression Course for treating depressive symptoms.

Conclusions: The intervention is effective at reducing depressive symptoms over a short-term (1-month) period.

Methodology: Researchers randomized 110 Dutch adults with subclinical depression into one of two treatment conditions: (1) assessment and advice only delivered in a group setting, and (2) a group Coping with Depression Course. Participants were recruited from the general population and were screened using the Composite Diagnostic Interview, a standardized interview for DSM-IV diagnoses. Individuals who were accepted for the study were also assessed using a battery of other instruments including the Beck Depression Inventory (BDI), which was used to assess depressive symptoms. A followup assessment was given a month after treatment.

Summary of Results: After completing the Coping with Depression course, participants had significantly larger reductions in depressive symptoms than the control group. Participants had significant increases in pleasing activities and social encounters, in their level of self-esteem, and in the frequency with which they received social support. The authors conclude that this intervention will help reduce depressive symptoms and, because of the relative ease with which it can be implemented, may help providers reach that segment of the population that currently does not seek services for depression (including those with subclinical levels of depressive symptoms).

Reference: Carroll, K. M., Nich, C., & Rounsaville, B. J. (1995). Differential symptom reduction in depressed cocaine abusers treated with psychotherapy and pharmacotherapy. Journal of Nervous and Mental Disease, 183, 251–259.

Purpose: To evaluate the relative effectiveness of an antidepressant (desipramine) and psychotherapy for depressive symptoms among individuals with cocaine use disorders.

Conclusions: Desipramine is an effective antidepressant for individuals with cocaine use disorders. Relapse prevention is associated with better substance-related outcomes among individuals with moderate to high levels of symptoms than is clinical management.

Methodology: An initial 121 subjects were recruited from a substance abuse treatment program, of which 109 completed the study. Subjects had to meet DSM-III-R criteria for cocaine dependence; not currently be dependent on opioids, alcohol, or barbiturates; not currently have a DSM-III-R Axis I disorder other than a depressive or anxiety disorder; not have been in substance abuse treatment in the prior 2 months; and not currently receiving treatment for any other psychiatric disorder. The interventions provided were manualized and delivered in weekly sessions over the course of 12 weeks. The researchers assessed participants prior to the start of treatment, weekly during the course of treatment, and after treatment concluded. Self-reports concerning substance use were confirmed with urine toxicology screens at each assessment. Depressive symptoms were assessed with the Beck Depression Inventory (BDI) and the Hamilton Rating Scale for Depression (HDRS). The researchers assigned participants to either a relapse prevention intervention based on Marlatt's model or a clinical management intervention adapted from the NIMH Collaborative Study on the Treatment of Depression. Some members from both groups also received desipramine, while the others received a placebo.

Summary of Results: At the initial assessment, 35 percent of subjects (n=37) had at least moderately high levels of depressive symptoms (meaning they had both a BDI score of ≥8 and a HDRS score of ≥7). Subjects who had that level of depressive symptoms attended a significantly greater number of treatment sessions (an average of 7.9 sessions compared to 6.9 for those with lower scores). Individuals with moderate or higher levels of depressive symptoms completed significantly more sessions of treatment if they were assigned to the relapse prevention treatment (an average of 10 sessions) than if they were assigned to the clinical management intervention (an average of 6). On the other hand, individuals with low or no depressive symptoms stayed longer in clinical management (an average of 7.4 sessions) than in relapse prevention (average of 6.5 sessions), but that difference was not significant. Individuals treated with desipramine also had significant reductions in depressive symptoms whether or not they had a depressive disorder.

Reference: Daughters, S.B., Braun, A.R., Sargeant, M.N., Reynolds, E.K., Hopko, D.R., Blanco C, et al. (2008). Effectiveness of a brief behavioral treatment for inner-city illicit drug users with elevated depressive symptoms: The life enhancement treatment for substance use (LETS Act!). Journal of Clinical Psychiatry, 69, 122–129.

Purpose: To evaluate the use of Life Enhancement Treatment for Substance Use (LETS Act!), a relatively brief, behavioral intervention based on the previously validated Behavioral Activation Treatment for Depression and designed to run for six sessions over a 2 week period.

Conclusions: The LETS Act! intervention provided in addition to inpatient substance abuse treatment appears to reduce symptoms of depression and anxiety and increase quality of life to a greater degree than inpatient substance abuse treatment alone.

Methodology: The authors randomly assigned 44 clients seeking services for drug dependence disorders to receive either the LETS Act! intervention provided during recreational periods in addition to standard treatment or to receive the standard treatment alone. Participants who completed treatment received a minimum of 60 days of inpatient treatment. All participants had at least mild depression as determined by having Beck Depression Index-II (BDI-II) scores of 10 or greater. While participants with serious mental illness are often referred from the treatment facility where care was provided and hence not included in the pool from which participants were drawn, a number of participants in both groups met diagnostic criteria for a co-occurring mood or anxiety disorder (54.5 percent of those in the LETS Act! group and 68.2 percent of those in the control group). Specifically, 36.4 percent of the LETS Act! group had major depressive disorder and 22.7 percent had a bipolar disorder in comparison to 40.9 percent and 31.8 percent, respectively, of those in the control group. Participants were evaluated at treatment entry, at the conclusion of treatment, and 2 weeks after treatment concluded.

Summary of Results: Participants who received the LETS Act! intervention reported significantly greater improvements in regards to depressive symptoms (as measured by both the BDI-II and the Hamilton Rating Scale for Depression), anxiety symptoms, and enjoyment/reward experienced in day-to-day activities from baseline to the conclusion of treatment than did those who received standard treatment alone. Participants in both groups reported a decrease in depressive symptoms over the course of treatment, but those who received the LETS Act! intervention reported a further decrease in depressive symptoms during the 2 weeks following treatment, while those who received standard treatment only did not. Participants in the LETS Act! group also reported significantly greater satisfaction with their treatment experience than did those in the control group. The LETS Act! group had better retention than the group who just received the standard treatment, with 18 of 22 in the LETS Act! group available for the 2-week posttreatment assessment compared to 14 of 22 in the control group, but this difference was not significant.

Reference: Gottheil, E., Thornton, C., & Weinstein, S. (2002). Effectiveness of high- versus low-structure individual counseling for substance abuse. American Journal of Addiction, 11, 279–290.

Purpose: To evaluate the relative effectiveness of two types of individual counseling (i.e., high-structure, behaviorally oriented and low-structure, facilitative care) for the treatment of clients with substance use disorders.

Conclusions: For clients with elevated levels of depressive symptoms, a more highly-structured behavioral intervention is associated with better abstinence rates, while the reverse is true for those who have lower levels of depressive symptoms.

Methodology: The researchers evaluated data on 80 individuals who were seeking treatment for substance abuse problems at a publicly-funded outpatient treatment program over a 12-week period. Participants were randomly assigned to receive one of two types of individual counseling delivered by counselors who had been trained and evaluated in the use of that specific treatment model: (1) highly structured, behaviorally oriented counseling (HSB) or (2) low-structure, facilitative counseling (LSF). Two independent evaluators judged counselor adherence to the model, and they were in agreement that models were consistently and appropriately implemented. A number of different measures were used to assess participants, including the Beck Depression Inventory (BDI) for depressive symptoms and the Addiction Severity Index for the severity of the substance use disorder. Urine drug screens were given at each treatment session. Participants also provided self-ratings of treatment benefit.

Summary of Results: There were no significant differences between the two treatment groups in terms of client self-ratings of treatment effectiveness, counselor ratings of effectiveness, number of sessions attended, duration of stay in treatment, or number of drug-free urine samples provided. The authors did find individuals with BDI scores of 17 or greater provided significantly more drug-free urines during treatment if they attended the HSB counseling, while those with BDI scores of 16 or less provided significantly more drug-free urine samples if they attended LSF counseling.

Reference: Nunes, E. V., & Levin, F. R. (2004). Treatment of depression in patients with alcohol or other drug dependence: A meta-analysis. JAMA: Journal of the American Medical Association, 291, 1887–1896.

Purpose: To perform a meta-analytic review on the efficacy of antidepressant medications for individuals with co-occurring depression and substance use disorders.

Conclusions: Antidepressants have a modest beneficial effect in this population. Medication should be provided along with a psychotherapeutic intervention in order to provide the greatest benefit to patients.

Methodology: The authors searched the PubMed, Medline, and Cochrane Collaboration databases for research from 1970 to 2003 regarding the use of antidepressants for patients with co-occurring depression and substance use disorders. They selected only studies that used random assignment and placebo controls; used diagnostic criteria from the DSM-III, III-R, or IV; diagnosed patients through diagnostic interviews; and reported outcomes regarding depressive symptoms. They found a total of 14 studies that met their inclusion criteria (5 using tricyclic antidepressants, 7 using selective serotonin reuptake inhibitors [SSRIs], and 2 involving other antidepressant medications). Meta-analytic methods of data analysis were used to compare data across studies and determine overall findings.

Summary of Results: The authors found that antidepressants were effective for treating depression in individuals with substance use disorders. Evidence-based psychosocial interventions appear to add to the overall effectiveness, and the authors suggest that such interventions be used first before prescribing medication and continued while the patient is receiving antidepressants. Antidepressants had a greater effect on individuals who had at least a week of abstinence in a treatment setting prior to being prescribed the medication, and the authors recommend that diagnoses of depression and decisions to use antidepressants be made after the patient has established at least a brief period of abstinence. When medications were effective at reducing depressive symptoms, they also tended to reduce the amount of substance use, but the effect was not large enough (in most cases) to be associated with a significant difference in length of abstinence. Findings regarding the preferred medication for treating depression were mixed, but the authors suggest that SSRIs be used initially and, if ineffective, be replaced with another type of antidepressant.

Reference: Palmer, J. A., Palmer, L. K., Michiels, K., & Thigpen, B. (1995). Effects of type of exercise on depression in recovering substance abusers. Perceptual and Motor Skills, 80, 523–530.

Purpose: To evaluate the effectiveness of different types of exercise programs for relieving depressive symptoms in clients with substance use disorders.

Conclusions: Anaerobic exercise (in the form of bodybuilding activities) resulted in significant decreases in depressive symptoms among individuals in recovery from substance use disorders, but such decreases were not seen with aerobic exercise or aerobic exercise in combination with anaerobic.

Methodology: The authors tested three different types of exercise programs with a group of 45 clients in an inpatient substance abuse treatment program: aerobic (aerobic step exercise), anaerobic (bodybuilding) and a combination of the two (circuit training). Clients were randomly assigned to an exercise program. Depressive symptoms were evaluated using the Center for Epidemiological Studies—Depression scale.

Summary of Results: Individuals enrolled in the bodybuilding group had significant reductions in depressive symptoms after completing the program, but there were no significant decreases in symptoms for participants in the other two exercise groups. The authors suggest several possible explanations for the effect the bodybuilding program had on client depressive symptoms: (1) this exercise program, unlike the other two, gave participants clear indicators of gains in strength that could have given them a feeling of mastery they otherwise lacked; (2) clients worked as teams in the bodybuilding program and the social bonds that developed as well as the peer encouragement of compliance may have added to the benefit.

Reference: Peck, J. A., Reback, C. J., Yang, X., Rotheram-Fuller, E., & Shoptaw, S. (2005). Sustained reductions in drug use and depression symptoms from treatment for drug abuse in methamphetamine-dependent gay and bisexual men. Journal of Urban Health, 82, i100–i108.

Purpose: To determine the relationship between methamphetamine use and depressive symptoms in the gay and bisexual male population.

Conclusions: A significant portion of depressive symptoms reported by people with methamphetamine use disorders beginning treatment is substance-related and those symptoms typically improve during and after treatment.

Methodology: Study participants were 62 gay or bisexual men seeking treatment for methamphetamine dependence. Researchers assessed depressive symptoms using the Beck Depression Inventory (BDI) weekly during treatment and at 26 and 52 weeks after treatment completion. Participants also provided urine drug screens three times a week during treatment. Participants were randomly assigned to one of four treatments (cognitive-behavioral therapy based on the Matrix model, contingency management, cognitive-behavioral therapy plus contingency management, and a cognitive-behavioral therapy intervention developed specifically for gay men). All four interventions ran for 16 weeks.

Summary of Results: According to their initial assessment, 28.5 percent of participants had moderate to severe levels of depression (i.e., BDI scores of 19 or greater), 44.8 percent had mild to moderate levels (BDI scores of 10 to 18), and 26.6 percent had no to mild depressive symptoms (BDI scores of 9 or less). A number of participants (52.9 percent) also met criteria for a diagnosis of a mood disorder at some point during their lifetimes, and 28.4 percent had a lifetime diagnosis of major depression specifically. There were no statistically significant differences in depressive symptoms among individuals in different treatment conditions either before or after treatment (at either followup evaluation), but all four interventions did result in reductions of depressive symptoms over time, with the largest drop in symptoms occurring during the first week of treatment. Using a mixed regression model, the authors determined that methamphetamine use in the 5 days prior to assessment with the BDI strongly predicted higher levels of depressive symptoms (p<.0001), but that depressive symptoms did not predict subsequent use of methamphetamines.

Research Related Studies

Reference: Airaksinen, E., Larsson, M., Lundberg, I., & Forsell, Y. (2004). Cognitive functions in depressive disorders: Evidence from a population-based study. Psychological Medicine, 34, 83–91.

Purpose: To determine the level and types of cognitive impairments resulting from different depression-related diagnoses in a general population sample.

Conclusions: Minor depression does not result in reduced cognitive performance, while other depressive spectrum disorders (i.e., major depression, dysthymia, mixed anxiety-depression disorder) do result in reduced cognitive performance.

Methodology: The authors selected a group of participants (n=1,093) from a larger Swedish general population sample who had been identified as having depressive disorders (using the Schedules for Clinical Assessment in Neuropsychiatry). They studied two regular DSM-IV diagnoses (68 individuals with major depression and 28 with dysthymia) and two DSM-IV research diagnoses (25 with mixed anxiety-depression disorder and 66 with minor depression), and compared them to a control group of 175 individuals who had no pathological symptoms and were not taking any psychoactive drugs. All subjects were administered a battery of cognitive tests.

Summary of Results: Minor depression (as diagnosed according to the DSM-IV research disorder definition) was not associated with an increase in cognitive deficits, while all other depressive disorders evaluated were associated with significantly higher levels of such deficits.

Reference: Angst, J., Sellaro, R., & Merikangas, K. R. (2000). Depressive spectrum diagnoses. Comprehensive Psychiatry, 41, 39–47.

Purpose: To determine the prognostic significance of major depressive disorder, dysthymia, recurrent brief depression, and minor depression.

Conclusions: People who have long-term depressive symptoms may switch between different diagnostic categories of depressive disorders. This lack of longitudinal stability leads the authors to conclude that depression should be conceived of as a spectrum rather than a set of discrete diagnoses.

Methodology: The authors looked at data from 591 Swiss, young adults (selected from participants in a larger study) over a 15-year period. Of this initial group, 69 percent participated in at least one followup assessment. Participants were assessed for depressive symptoms using the Symptom Checklist-90-Revised and were diagnosed according to DSM-III-R (i.e., major depression, dysthymia, minor depression) and International Classification of Diseases 10 (ICD-10) (recurrent brief depression) diagnostic categories. In order to determine the longitudinal stability of initial diagnoses, the authors looked at the most severe diagnosis that could be assigned at each of the five followup assessments, and, based upon that, determined what (if any) changes occurred in diagnosis.

Summary of Results: The authors found diagnostic categories changed frequently for individuals between sub-diagnostic levels of depressive symptoms to levels of symptoms qualifying for a diagnosis, as well as between different diagnostic categories. In particular, there was little stability for the diagnosis of minor depression, with only one of 40 individuals who received that diagnosis meeting criteria for that same diagnosis again during the followup period.

Reference: Blume, A. W., Schmaling, K. B., & Marlatt, G. A. (2001). Motivating drinking behavior change: Depressive symptoms may not be noxious. Addictive Behaviors, 26, 267–272.

Purpose: To better understand the relationship between depressive symptomatology and motivation to change drinking-related behavior.

Conclusions: Lower levels of depressive symptoms may make an individual more willing to engage in substance abuse treatment.

Methodology: These researchers evaluated 75 participants with alcohol use disorders (63 with alcohol dependence) who did not have a co-occurring drug use or psychotic disorder. Participants were recruited through fliers and newspapers ads from the general population. The researchers administered the Beck Depression Inventory (BDI) to assess depressive symptoms and the Brief Readiness to Change Questionnaire to assess readiness to change alcohol-related behavior. Other measures were used to assess negative drinking-related consequences (the Losses Of Significance Self-Report Questionnaire-Revised [LOSS-QR]), drinking rates (the Steady Pattern Chart from the Comprehensive Drinker Profile), and self-efficacy (the Situational Confidence Questionnaire-42 [SCQ-42]).

Summary of Results: In the initial assessment, 11 individuals had BDI scores in the minimally depressed range, 2 had scores in the mild to moderate range, and 2 had moderate to severe depression scores. Researchers found a significant correlation between depressive symptoms (i.e., BDI scores) and greater motivation to change (i.e., being less likely to be in a pre-contemplation stage and more likely to be in the contemplation or action stages). There was a significant correlation between LOSS-QR scores and BDI scores, but not between SCQ-42 scores and BDI scores. Also, depressive symptoms were not associated with increased alcohol use during the course of the study.

Reference: Brown, S. A., Inaba, R. K., Gillin, J. C., Schuckit, M. A., Stewart, M. A., & Irwin, M. R. (1995). Alcoholism and affective disorder: clinical course of depressive symptoms. Journal of Psychiatry, 152, 45–52.

Purpose: To compare the severity of depressive symptoms and changes in those symptoms among men who had alcohol dependence, affective disorders, or both alcohol dependence and an affective disorder while they were in treatment for substance abuse or an affective disorder.

Conclusions: There is a more rapid decrease in depressive symptoms among individuals who have a primary alcohol dependence disorder (even if they also have a secondary affective disorder) in comparison to individuals who have a primary affective disorder (with or without a secondary alcohol dependence disorder).

Methodology: The authors assessed 54 male veterans who had entered either a substance abuse treatment program (n=27) or mental health treatment program (n=27). Of those in the substance abuse treatment program, 12 also met DSM-III criteria for a secondary, co-occurring major affective disorder at some point during their lifetime (determined by having had one or more episodes of depression during drinking and no major depressive episodes prior to the onset of their alcohol use disorder). Of those in mental health treatment, 12 also met DSM-III criteria for a secondary, co-occurring alcohol dependence disorder (determined by having met criteria for alcohol dependence at some point after the onset of their affective disorder). Individuals with antisocial personality disorder, drug dependence, other DSM-III axis I diagnoses predating their alcohol dependence or affective disorder, severe medical impairment, and no available relative/friend to confirm their history were excluded from the study. Subjects in both groups were also matched according to age, socioeconomic status, marital status, education, length of abstinence, and time in treatment. The severity of depressive symptoms was evaluated using the Hamilton Depression Rating Scale. Participants were assessed at treatment entry and weekly for 4 weeks thereafter.

Summary of Results: Men who had a primary alcohol use disorder, whether or not they also had an affective disorder, had significant reductions in depressive symptoms following treatment when compared to those who a primary affective disorder. Specifically, men with a primary alcohol dependence disorder had a 49 to 63 percent reduction in depression scale scores; those with a primary affective disorder diagnosis had a 14 to 16 percent reduction if they did not receive medication. The authors found that a minimum of 3 weeks of abstinence from alcohol was necessary to determine consistently whether individuals with elevated depressive symptoms actually had co-occurring disorders. They also found that different depressive symptoms had distinct rates of change within each group.

Reference: Charney, D. A., Palacios-Boix, J., Negrete, J. C., Dobkin, P. L., & Gill, K. J. (2005). Association Between Concurrent Depression and Anxiety and Six-Month Outcome of Addiction Treatment. Psychiatric Services, 56, 927–933.

Purpose: To determine the effect of symptoms of anxiety and depression (assessed at treatment entry) on substance abuse treatment measures during the course of treatment.

Conclusions: Depressive symptoms measured at program entry have a small but significant relationship with decreased service use and abstinence, even after controlling for other confounding factors. Individuals with depressive symptoms combined with symptoms of anxiety fared significantly poorer than those with symptoms of only one of the two disorders.

Methodology: Clients with substance use disorders (n=326) who were entering a substance abuse treatment program were evaluated by trained interviewers using the Addiction Severity Index, the Beck Depression Inventory, and the Symptom Checklist 90-Revised to assess substance use disorder severity and symptoms of depression and anxiety. Participants were then enrolled in an outpatient treatment program, which lasted from 6 to 9 months and included random urine drug screens. At 6 months after the initial assessment, study participants were again assessed regarding symptoms and treatment outcomes (e.g., days abstinent, length of stay in treatment). Participants were contacted whether or not they remained in treatment for the full 6 months. In analyzing the effect of depression and anxiety symptoms, the authors controlled for variables that are known to affect treatment outcomes (e.g., severity of substance use disorder, length of treatment stay).

Summary of Results: In the initial assessment, 32 percent (n=105) had symptoms of both anxiety and depression, 15 percent (n=49) had depressive symptoms alone, and 16 percent (n=53) had symptoms of anxiety alone. Only 40 percent of clients with both anxiety and depression symptoms were abstinent after 6 months in treatment, compared to 73 percent of those who had depressive symptoms alone, suggesting that the combination of depression and anxiety symptoms is a particular problem in substance abuse treatment. Of the total sample, 56 percent were abstinent at 6 months. Individuals with symptoms of depression (with or with concurrent symptoms of anxiety) were more likely than others to require inpatient detoxification, The authors note that individuals with symptoms of both anxiety and depression were more likely to be dependent on prescription opioids and/or benzodiazepines and that that might account in part for low levels of abstinence in that group.

Reference: Conner, K. R., Sorensen, S., & Leonard, K. E. (2005). Initial depression and subsequent drinking during alcoholism treatment. Journal of Studies on Alcohol, 66, 401–406.

Purpose: To determine whether higher levels of depressive symptoms at treatment entry had an effect on client response to treatment for alcohol use disorders.

Conclusions: Depressive symptoms evaluated at treatment entry predict poorer drinking-related outcomes during the first month of treatment but have little relation to outcomes during the second and third months.

Methodology: The authors used data from 1,726 individuals enrolled in the National Institute on Alcohol Abuse and Alcoholism's Project MATCH study. Depressive symptoms were evaluated using the Beck Depression Inventory (BDI). Participants were enrolled in one of three treatments (i.e., Motivational Enhancement Therapy, 12-Step Facilitation Therapy, Cognitive-Behavioral Therapy) over a period of up to 3 months and were assessed over that 3-month period.

Summary of Results: Depressive symptoms, as assessed at treatment entry, did have a significant relationship to poorer drinking outcomes (both in terms of drinks per drinking day and percentage of days abstinent) at the 1 month assessment but not at the 2 or 3 month assessments. Depressive symptoms also decreased over time, and the mean BDI score of treatment entry of 10.1 had fallen to 7.4 by the 3 month assessment.

Reference: Curran, G. M., Booth, B. M., Kirchner, J. E., & Deneke, D. E. (2007). Recognition and management of depression in a substance use disorder treatment population. American Journal of Drug and Alcohol Abuse, 33, 563–569.

Purpose: To determine the relationship of depressive symptoms to relapse.

Conclusions: Clients with moderate to severe levels of depressive symptoms (i.e., those with Beck Depression Inventory [BDI] scores of 20 or greater) were more than four times as likely to return to substance abuse 3 months after treatment than were those with lower levels of depressive symptoms.

Methodology: The authors examined depressive symptoms and substance abuse treatment outcomes among a group of 126 clients consecutively admitted to a Veterans Affairs intensive outpatient treatment program. Depressive symptoms were measured with the BDI and the authors' analysis compared clients with moderate to severe levels of depression (i.e., with BDI scores of 20 or higher) to those with lower levels of depressive symptoms. All participants received the same course of intensive outpatient treatment.

Summary of Results: The mean BDI score for participants at treatment entry was 21.3, normally considered as representing severe depression. At treatment exit, the mean BDI score had fallen to 14.5. Individuals who entered treatment with BDI scores of 20 or greater were more than four times as likely to return to using substances by their 3 month,post-treatment assessment. For individuals with BDI scores of 20 or greater, the use of antidepressant medication was associated with significantly lower rates of relapse (with 40 percent of those receiving medication relapsing to use compared to 70 percent of those who did not receive antidepressant medication).

Reference: Dodge, R., Sindelar, J., & Sinha, R. (2005). The role of depression symptoms in predicting drug abstinence in outpatient substance abuse treatment. Journal of Substance Abuse Treatment, 28, 189–196.

Purpose: To determine the effects of depressive symptoms on short-term abstinence for individuals in outpatient treatment.

Conclusions: After controlling for other treatment and demographic variables, the authors found that elevated levels of depressive symptoms at treatment entry were significantly associated with lower rates of abstinence at discharge.

Methodology: The authors assessed 827 individuals attending an outpatient substance abuse treatment program at treatment entry and upon the leaving the program. The Beck Depression Inventory (BDI) was used on treatment entry to assess depressive symptoms (scores of 11 to 17 were coded as indicating mild depression and scores of ≥18 as having a clinically significant level of depression). Random urine and Breathalyzer tests prior to discharge were used to confirm reports of abstinence in 73 percent of cases, with the remainder being determined by client self-report. In analyzing data, the authors controlled for a number of potentially confounding factors including race, age, length of stay in treatment, primary substance of abuse, and frequency of substance use at time of admission.

Summary of Results: After controlling for potentially confounding factors associated with abstinence rates, the authors found that higher BDI scores were associated with significantly lower rates of abstinence at discharge from treatment after up to 350 days of treatment. This finding remained true for BDI scores below 18 (the cut-off point for clinically significant depression); while the effect for lower BDI scores in decreasing abstinence was smaller than for higher BDI scores, it was still significant.

Reference: Doumas, D. M., Blasey, C. M., & Thacker, C. L. (2005). Attrition from Alcohol and Drug Outpatient Treatment: Psychological Distress and Interpersonal Problems as Indicators. Alcoholism Treatment Quarterly, 23, 55–67.

Purpose: To explore the relationship between program attrition, symptoms of anxiety and depression, and interpersonal problems among a treatment seeking population with substance use disorders.

Conclusions: There is a significant association between failure to complete treatment and elevated levels of symptoms of depression and/or anxiety.

Methodology: The authors studied 120 consecutive admissions to an intensive outpatient substance abuse treatment program. Depressive symptoms were evaluated at treatment entry using the Beck Depression Inventory (BDI).

Summary of Results: The treatment retention rate for participants was 67 percent (33 percent dropped out early). The BDI measures for those who dropped out (a mean score of 18.9 on the BDI) were significantly higher than for those who completed treatment (mean BDI score of 12.7). Anxiety symptoms were also significantly higher for participants who did not complete treatment compared to those who did complete treatment.

Reference: Janiri, L., Martinotti, G., Dario, T., Reina, D., Paparello, F., Pozzi, G., et al. (2005). Anhedonia and substance-related symptoms in detoxified substance-dependent subjects: A correlation study. Neuropsychobiology, 52, 37–44.

Purpose: To determine the relationship of anhedonia (i.e., the lack or loss of the ability to experience pleasure) to substance craving among individuals with substance use disorders.

Conclusions: Craving and anhedonia are positively correlated among people with opioid use disorders but not among those with other types of substance use disorders. Anhedonia, a common depressive symptom, may be a factor in research findings that demonstrate a high level of craving among individuals with co-occurring depression and substance use disorders.

Methodology: The authors looked at 70 substance abuse treatment clients from three Italian treatment programs. Three different instruments were used to evaluate anhedonia and the results from all three were evaluated together. Other scales were used to evaluate withdrawal and craving.

Summary of Results: Drug craving was significantly correlated with anhedonia among individuals with opioid use disorders but not for those who had other types of substance use disorders.

Reference: Joosen, M., Garrity, T. F., Staton-Tindall, M., Hiller, M. L., Leukefeld, C. G., & Webster, J. M. (2005). Predictors of current depressive symptoms in a sample of drug court participants. Substance Use and Misuse, 40, 1113–1125.

Purpose: To evaluate which factors may help predict elevated depressive symptoms among individuals entering substance abuse treatment.

Conclusions: Five variables (described below) are significantly associated with elevated levels of depressive symptoms in this population.

Methodology: The authors evaluated 4,775 individuals entering a Kentucky drug court program using the Addiction Severity Index and the Brief Symptom Inventory (BSI) (the latter to assess depressive symptoms). The BSI depression scale had participants rate the degree of discomfort they felt as a result of depressive symptoms on a five point scale ranging from 0 (no discomfort) to 4 (extremely discomforting). A multiple regression analysis was performed to determine the most significant correlates of depressive symptoms.

Summary of Results: In the initial assessment, 31.4 percent of participants had no significant (i.e., ones that caused discomfort) depressive symptoms, 37.4 percent had a “little bit,.” 19.4 percent had a moderate level, 9.4 percent had “quite a bit,” and 2.4 percent had an extremely high level. The average level of significant depressive symptoms was .73, which fell between none and a little bit. After multiple regression analysis, the significant correlates of depressive symptoms were (1) perceived overall health in the past 6 months, (2) having been hospitalized for a psychological problem, (3) having difficulties with one's family in the past 6 months, (4) having had conflicts with people outside one's family in the past 6 months, and (5) being female. The authors conclude that the presence of such factors are reasonable indications that clients entering treatment may have been or are currently at risk for depression.

Reference: Karno, M. P., & Longabaugh, R. (2007). Does matching matter? Examining matches and mismatches between patient attributes and therapy techniques in alcoholism treatment. Addiction, 102, 587–596.

Purpose: To reanalyze data from the National Institute on Alcohol Abuse and Alcoholism's Project MATCH study to determine whether matching clients to particular treatments based on personal characteristics (such as depressive symptoms) improved treatment outcomes.

Conclusions: Interventions that have a strong focus on emotional material appear to be less effective for clients with high levels of depressive symptoms.

Methodology: The sample for this study was drawn from participants in Project MATCH and included 137 individuals who received treatment for alcohol use disorders at one of the Project MATCH treatment sites. Participants were enrolled in either a cognitive/behavioral coping skills training program, a motivational enhancement program, or a 12-Step facilitation program. Depressive symptoms were evaluated using the Beck Depression Inventory (BDI) and scores below 9 (n=73) were considered low, scores between 10 and 18 (n=39) were considered medium, and scores of 19 or higher (n-25) were considered as representing high levels of depressive symptoms.

Summary of Results: Clients with high levels of depressive symptoms (but not those with lower levels of depressive symptoms) who received treatment with a low focus on emotionally-charged material had significantly higher levels of abstinence. Clients who had high levels of depressive symptoms and who received therapy which directed them away from highly emotional material were abstinent on 98.2 percent of the days in the year following treatment compared to 87 percent of those with high levels of depressive symptoms who did not attend that type of treatment.

Reference: Kessler, R. C., Zhao, S., Blazer, D. G., & Swartz, M. (1997). Prevalence, correlates, and course of minor and major depression in the national comorbidity survey. Journal of Affective Disorders, 45, 19–30.

Purpose: To determine the incidence, prevalence, correlates, and course of both minor and major depression in the general US population.

Conclusions: Minor depression should not be considered a “natural” reaction to environmental stress but rather a type of depressive disorder that should receive serious attention from clinicians.

Methodology: The National Comorbidity Study (NCS), from which the data in this article are drawn, is a large (n=8,098) general population survey of the prevalence and correlates of DSM-III-R disorders conducted between 1990 and 1992. The survey used structured interviews to examine psychiatric symptoms and demographic factors. In addition to diagnosing depressive disorders, the survey was used in this article to analyze minor depression (a condition in which individuals met all major depression criteria except that they only had between 2 and 4 Criterion A symptoms and had no history of major depression or dysthymia). Impairment from depressive disorders (including minor depression) was evaluated by asking respondents whether or not their depression was interfering with their lives, whether they had ever seen a doctor and/or other professional about their depression, and whether they ever took medication for their depression. The analysis in this article also separated two different levels of major depression, one involving 5–6 DSM-II-R symptoms and the other involving 7–9 symptoms

Summary of Results: The authors found a lifetime prevalence of minor depression in the general population of 10 percent. Individuals with mild depression were less likely to have any co-occurring mental or substance use disorder than were individuals with major depression (54.4 percent and 73 percent respectively had another disorder). The age of onset was about the same for minor and major depression. Almost 75 percent of persons with minor depression report more than one depressive episode. Symptom severity was correlated with the number of episodes and their duration. Over their lifetimes, people with mild depression showed fewer episodes of shorter duration than those with major depression. The level of impairment for minor depression was lower (42 percent reported impairment) than for major depression, with 5–6 symptoms (49.7 percent reported impairment) or 7–9 symptoms (68.2 percent reported impairment) but still represented a considerable burden. Unlike major depression and dysthymia, rates of minor depression showed significant regional differences, with rates highest in the West and lowest in the South.

Reference: Kodl, M. M., Fu, S. S., Willenbring, M. L., Gravely, A., Nelson, D. B., & Joseph, A. M. (2008). The impact of depressive symptoms on alcohol and cigarette consumption following treatment for alcohol and nicotine dependence. Alcoholism: Clinical and Experimental Research, 32 (1), 92–99.

Purpose: To evaluate the relationship of elevated depressive symptoms to abstinence from tobacco and alcohol following treatment for alcohol and tobacco dependence.

Conclusions: Elevated depressive symptoms are associated with lower rates of abstinence from alcohol (but not tobacco) following treatment.

Methodology: The authors used data collected for the Timing of Alcohol and Smoking Cessation Study (TASC), a randomized clinical trail that evaluated the relative effectiveness of concurrent and nonconcurrent treatments for clients who had both alcohol and tobacco dependence. Data were available for 462 participants who were assessed for depressive symptoms using the Beck Depression Index-II (BDI-II) and alcohol and tobacco use upon treatment entry and 6, 12, and 18 months after treatment. Participants were considered to have elevated depressive symptoms I they had BDI-II scores of 14 or greater (which equates to having at least mild depression according to the BDI-II).

Summary of Results: Participants who reported high levels of depressive symptoms at each of the followup assessments (6, 12, and 18 months after treatment) also reported significantly lower levels of abstinence from alcohol in the 6-month period prior to the assessment than did those with lower levels of depressive symptoms. Elevated depressive symptoms were also related to significantly more drinks per month and a significantly greater number of days drinking in the prior 6 months. Additionally, elevated depressive symptoms at the baseline and first two followup assessments were associated with non-abstinence from alcohol during the 6-month period following the assessment. Elevated depressive symptoms increased the odds of drinking during the next 6 months by a factor of 1.67. However, elevated symptoms of depression were only related to increased smoking at the 6-month assessment and were not related to any increase in subsequent smoking.

Reference: Moscato, B. S., Russell, M., Zielezny, M., Bromet, E., Egri, G., Mudar, P., et al. (1997). Gender differences in the relation between depressive symptoms and alcohol problems: A longitudinal perspective. American Journal of Epidemiology, 146, 966–974.

Purpose: To determine the effect of depressive symptoms on alcohol problems in relation to gender.

Conclusions: Depressive symptoms are consistently associated with significantly higher levels of subsequent alcohol-related problems for women but not for men.

Methodology: Researchers interviewed a random, general population sample of adults (n=1,036) in 1986, 1989, and 1993. They used the Center for Epidemiologic Studies Depression (CES-D) Scale to assess past month depressive symptoms and the National Institute of Mental Health Diagnostic Interview Schedule to assess alcohol problems and heavy alcohol use. Participants were considered to have a high level of depressive symptoms if they scored 18 or higher on the CES-D or if they reported having had treatment for depression in the year prior to the assessment. Selected sociodemographic variables were also assessed and analyzed in relation to depressive symptoms. Data were analyzed using logistic regression models.

Summary of Results: After the logistic regression analysis, the authors found a significant and consistent association between high depressive symptoms and later alcohol use disorders among women. For men, however, they found no consistent or significant association between alcohol use disorders and later development of depressive symptoms.

Reference: Ramsey, S. E., Kahler, C. W., Read, J. P., Stuart, G. L., & Brown, R. A. (2004). Discriminating between substance-induced and independent depressive episodes in alcohol dependent patients. Journal of Studies on Alcohol, 65, 672–676.

Purpose: To determine how accurate classifications of substance-induced depression are for clients in treatment for alcohol use disorders.

Conclusions: A significant percentage of cases that are reported as “substance-induced” depression in individuals with alcohol use disorders (more than 25 percent in this study) do not remit after 1 year of abstinence.

Methodology: The authors looked at a subsample of 95 individuals from a larger study on treatment effectiveness for individuals with alcohol dependence. Participants were assessed using the Structured Clinical Interview for DSM-IV Disorders (SCID) and the Beck Depression Inventory (BDI). They qualified for the study if they met DSM-IV diagnostic criteria for a substance-induced mood disorder with depressive symptoms as well as for alcohol dependence.

Summary of Results: In the year following treatment, more than 25 percent of the depressive episodes originally evaluated as substance-induced were reclassified as resulting from an independent major depressive disorder. Participants who had a prior history of major depressive disorder and/or who had lower levels of alcohol dependence more likely to have their disorder reclassified as independent major depressive disorder during that period.

Reference: Rao, S. R., Broome, K. M., & Simpson, D. D. (2004). Depression and hostility as predictors of long-term outcomes among opiate users. Addiction, 99, 579–589.

Purpose: To determine the relationship of client hostility and depression to long-term treatment outcomes in individuals with opioid use disorders.

Conclusions: Among individuals with opioid use disorders not exposed to treatment, depressive symptoms are associated with somewhat better outcomes in terms of substance use and criminal activity.

Methodology: The authors used data from a sample of 727 methadone maintenance clients enrolled in the National Institute on Drug Abuse's (NIDA) Drug Abuse Treatment Outcome Study. All participants were enrolled in methadone outpatient treatment at the start of the study and completed at least one of the two followup assessments (conducted 1 and 5 years after the initial treatment). The Symptom Check List-90 (SCL-90) scale was used to assess depressive symptoms and hostility. The authors relied on self-reports of substance use at the 1-year assessment but confirmed self-reports at the 5-year assessment with urine toxicology screens. Logistic regression analyses were used to evaluate the ability of assessed depression and hostility to predict treatment outcomes.

Summary of Results: For clients who did not have any treatment in the year prior to the 1-year followup assessment, depressive symptoms were associated with lower rates of heroin use (the odds of weekly use were 38 percent lower for individuals who had depressive symptoms). At the 5-year assessment, depressive symptoms again only had a significant relationship to outcomes for individuals who had had no treatment in the prior year—for that group, depressive symptoms were associated with lower rates of arrest and less weekly cocaine use. There was also a strong, significant association between higher scores on the SCL-90 rating for depressive symptoms and lower rates of self-reported arrest during the prior year.

Reference: Rapaport, M. H., Judd, L. L., Schettler, P. J., Yonkers, K. A., Thase, M. E., Kupfer, D. J., et al. (2002). A descriptive analysis of minor depression. American Journal of Psychiatry, 159, 537–643.

Purpose: To describe minor depression in detail including the symptoms, disability associated with it, stability, and relationship to other disorders.

Conclusions: Minor depression is a persistent problem characterized by its affective and cognitive symptoms, not by the neurovegetative symptoms seen in more severe types of depression. Minor depression can be independent of other depressive disorders, can be a less severe but stable episode in the course of a major depressive disorder, or can be a transitional state in people transitioning to or from major depression. Minor depression should be seen as part of a spectrum of depressive disorders, rather than seeing all depressive disorders as unique and discrete conditions.

Methodology: The researchers evaluated data from subjects in three diverse metropolitan areas. Data were gathered from 162 subjects (out of an initial 226) with minor depression who remained in the study for 4 weeks. Researchers defined rigorous and complex criteria for making a diagnosis of minor depression. They also excluded individuals with another current depressive disorder, individuals with a number of other mental disorders, and individuals using certain psychotropic medications. All individuals in the study were treated with a placebo and evaluated regularly during a 4-week period.

Summary of Results: In evaluating the persistence of minor depression, the researchers found that 2.2 percent of the initial 226 developed major depression over the course of the study, and 6.2 percent spontaneously recovered, suggesting that minor depression is not a transient disorder. The most common depressive symptom endorsed by individuals with minor depression was sad mood, followed by irritable mood, problems with concentration and decision-making, a pessimistic outlook toward the future, and anhedonia. Given the entire symptom profile, the authors conclude that minor depression is characterized by its affective and cognitive symptoms, not by the neurovegetative and reverse neurovegetative symptoms seen in more severe types of depression. Of the 162 subjects who completed the study, 32 percent (n=52) had a history of major depressive disorder, suggesting that a past diagnoses of major depressive disorder should not be used as exclusion criteria for minor depression. Those individuals who did have a past diagnosis of major depressive disorder did not differ in terms of depressive symptom severity or functional disability from those who did not have such a past diagnosis. For some clients, minor depression may be a transitional state in the development of major depression, and 2.2 percent of the subjects in the study developed major depression during the 4-week period.

Reference: Riehman, K. S., Iguchi, M. Y., & Anglin, M. D. (2002). Depressive symptoms among amphetamine and cocaine users before and after substance abuse treatment. Psychology of Addictive Behaviors, 16, 333–337.

Purpose: To determine whether methamphetamine users' reports of higher rates of depressive symptoms (in comparison with rate reported by cocaine users) result from the drug itself or other factors.

Conclusions: The high levels of depressive symptoms reported by methamphetamine users are in part the result of higher rates of polysubstance use and major depressive disorder among users. After controlling for those factors, rates of depressive disorders do not vary significantly between cocaine and methamphetamine users.

Methodology: The authors analyzed data from 2,176 participants in the National Institute on Drug Abuse's (NIDA) Drug Abuse Treatment Outcome Study. Depressive symptoms were measured using the Symptom Check List-90 (SCL-90) and initial interviews that asked about depressive symptoms in the year prior to treatment. Respondents were reassessed 1 year after treatment conclusion and only respondents for whom followup data were available were used in the study.

Summary of Results: Prior to treatment, respondents who reported regular methamphetamine use but not regular cocaine use and those who reported regular use of both drugs had significantly higher scores of depressive symptoms as measured by the SCL-90. They also reported significantly higher rates of lifetime diagnoses of major depressive disorder. Individuals who reported regular use of both cocaine and methamphetamine also had significantly higher rates of other types of substance use than did those who reported regular use of only cocaine or methamphetamine. After controlling for lifetime diagnoses of major depressive disorder and polysubstance use, rates of depressive symptoms did not differ significantly among regular users of cocaine, methamphetamine, or of both drugs.

Reference: Sexton, H., Lipton, R. I., & Nilssen, O. (1999). Relating alcohol use and mood: Results from the Tromso study. Journal of Studies on Alcohol, 60, 111–119.

Purpose: To understand the relationship between alcohol use and depressed mood in a general population sample.

Conclusions: While the relationship between drinking and depressed mood is not strong in the general population, drinking appears to increase the chances of experiencing a depressed mood among both male and female immoderate drinkers and for moderately drinking men. However, moderate drinking by women did not predict depressed mood but instead depressed mood appeared to be predictive of later drinking.

Methodology: Researchers twice interviewed a general population sample of 8,260 (4,407 female) Swedish adults, with the second interview occurring 7 years after the first. Depressed mood was measured with a single question on the survey. Current ability to cope and sleep disturbance were also measured with other items. Drinking was measured by three questions addressing the frequency of beer, wine, and liquor consumption and a fourth addressing the frequency of inebriation. Individuals who reported drinking to inebriation at least once per month were classed as immoderate drinkers.

Summary of Results: In this sample, 329 women and 1076 men were considered immoderate drinkers and 4,078 women and 2,777 men were considered moderate drinkers. For male drinkers, whether or not they were assessed as moderate or immoderate drinkers at the initial interview, drinking was associated with increased reports of depressed mood at the second assessment. For women who were immoderate drinkers, this proved to be the case as well. However, for women who were moderate drinkers at the initial assessment, drinking was not associated with increased rates of depressed mood and depressed mood appeared to be predictive of less subsequent drinking.

Reference: Solomon, A., Haaga, D. A., & Arnow, B. A. (2001). Is clinical depression distinct from subthreshold depressive symptoms? A review of the continuity issue in depression research. Journal of Nervous & Mental Disease, 189, 498–506.

Purpose: To review existing literature in an attempt to determine if subdiagnostic depressive symptoms are part of a continuum of depressive disorders or represent a distinct condition that must be considered distinct from depressive disorders.

Conclusions: While evidence is still inconclusive, the authors believe that the majority of studies support the idea that there is a manifest and latent continuum of depressive symptoms that includes both subdiagnostic levels of symptoms and diagnosable depressive disorders.

Methodology: The authors reviewed research on subclinical depressive symptoms, focusing almost entirely on studies that make use of clinical interviews rather than on studies that use self-report measures such as the Beck Depression Inventory.

Summary of Results: The authors note a number of problems with research to date on subclinical depressive symptoms (e.g., a lack of agreement on definitions) as well as some of the more interesting findings from that research. They also review some of the more important findings from the literature on subclinical depressive symptoms. They note that the research does suggest that the significance of subclinical depressive symptoms may be different for individuals who have had prior episodes of a depressive disorder than for those who have not. Also, two studies have found that people with subclinical depressive symptoms who have one or both of the two symptoms necessary for a diagnosis of major depression (i.e., anhedonia and pervasive depressed mood) are likely to have a clinically significant impairment as a result of their depressive symptoms, while those individuals with depressive symptoms who do not have those two specific symptoms are unlikely to have a significant impairment. Finally, a number of studies have found that people with depressive symptoms have many of the same problems correlated with their symptoms that people with depressive disorders have correlated with their disorders (e.g., an elevated risk for future episodes of major depression, a family history of major depression, co-occurring psychiatric and/or medical disorders).

Reference: Strowig, A. B. (2000). Relapse determinants reported by men treated for alcohol addiction: The prominence of depressed mood. Journal of Substance Abuse Treatment, 19, 469–474.

Purpose: To evaluate which relapse determinants are most associated with relapse to alcohol use among men with alcohol use disorders.

Conclusions: Depressed mood is the most common determinant for relapse among men with alcohol use disorders.

Methodology: The author evaluated relapse determinants in a group of 93 men who attended treatment for alcohol use and had relapsed during the year following treatment. He made use of categories derived from Marlatt's model of relapse, which were presented to study participants in the form of a questionnaire. All participants were male; they had a mean age of 47.8 and a mean of 15.6 years of education.

Summary of Results: The reason for relapse most often endorsed by participants was depressed mood (reported in 26.9 percent of cases), followed by weighing consequences (in 15.1 percent), impulsive action (in 9.7 percent), and social pressure (in 8.6 percent). These results are consistent with earlier research that also found “depressed mood” to be one of the most common relapse determinants.

Reference: Weaver, G. D., Turner, N. H., & O'Dell, K. J. (2000). Depressive symptoms, stress, and coping among women recovering from addiction. Journal of Substance Abuse Treatment, 18, 161–167.

Purpose: To determine what changes occur in terms of depressive symptoms, stress, and use of coping mechanisms among women in recovery from substance use disorders.

Conclusions: Among women with substance use disorders, depressive symptoms decrease significantly over the course of recovery, but can remain high for some individuals. The risk of continued depression is greatest for those who are married or living with a partner.

Methodology: The authors evaluated 102 women (age 18 or older) who had 1 to 5 years of recovery from substance use disorders. Participants were identified through the Community University Partnership Project II survey, which provided baseline data for participants prior to treatment and recovery. Participants were assessed through face-to-face interviews. Depressive symptoms were evaluated using the Center for Epidemiologic Studies Depression Scale (CES-D).

Summary of Results: More than half (n=57) of the women had a prior diagnosis of clinical depression. The mean score on the CES-D was 12.45, with approximately 33 percent scoring in the range indicating high risk for depression (i.e., scores of 16 or greater). However, 20 percent of the sample continued to have high (≥16) scores for depression after having been in recovery for at least a year. The only demographic factor that was found to be significantly related to depression scores was marriage or cohabitation and that was positively related to depression. Higher levels of depression were also significantly related to higher levels of certain types of perceived stress (i.e., financial, physical health related, and emotional health related). There were significant decreases in stress between pre-recovery and recovery for participants, with the mean stress score falling from 27.68 to 14.62. The study also found that significant changes in the coping strategies used by participants before entering recovery and during recovery, and in recovery were less likely to use passive or negative strategies (e.g., procrastinating, keeping feelings to oneself, blaming others) and more likely to use active or positive strategies (e.g., developing to plans to handle problems, expressing feelings, seeing humor in situations).

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