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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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Appendix D—DSM-IV-TR Mood Disorders

In substance abuse treatment settings, you are likely to encounter clients with a variety of diagnoses of depressive illnesses. Most of these diagnoses fall in the category of Mood Disorders, as specified in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR; APA, 2000). You can, however, also work with people who have a diagnosis of Adjustment Disorder with Depressed Mood. Additionally, people with a variety of other psychiatric illnesses are susceptible to depression, and some of those illnesses are described in this appendix.

The descriptions of depressive disorders and their primary symptoms are taken from DSM-IV-TR. Please refer to the source document for a more complete description of these disorders.

1. Major Depressive Episode and Major Depressive Disorder

Major Depressive Disorder requires two or more major depressive episodes.

Diagnostic criteria:

Depressed mood and/or loss of interest or pleasure in life activities for at least 2 weeks and at least five of the following symptoms that cause clinically significant impairment in social, work, or other important areas of functioning almost every day

1.

Depressed mood most of the day.

2.

Diminished interest or pleasure in all or most activities.

3.

Significant unintentional weight loss or gain.

4.

Insomnia or sleeping too much.

5.

Agitation or psychomotor retardation noticed by others.

6.

Fatigue or loss of energy.

7.

Feelings of worthlessness or excessive guilt.

8.

Diminished ability to think or concentrate, or indecisiveness.

9.

Recurrent thoughts of death (APA, 2000, p. 356).

2. Dysthymic Disorder

Diagnostic criteria:

Depressed mood most of the day for more days than not, for at least 2 years, and the presence of two or more of the following symptoms that cause clinically significant impairment in social, work, or other important areas of functioning:

1.

Poor appetite or overeating.

2.

Insomnia or sleeping too much.

3.

Low energy or fatigue.

4.

Low self-esteem.

5.

Poor concentration or difficulty making decisions.

6.

Feelings of hopelessness (APA, 2000, p. 380).

3. Bipolar Episode and Bipolar Disorder

Bipolar disorder is characterized by more than one bipolar episode. There are three types of bipolar disorder:

1.

Bipolar 1 Disorder, in which the primary symptom presentation is manic, or rapid (daily) cycling episodes of mania and depression.

2.

Bipolar 2 Disorder, in which the primary symptom presentation is recurrent depression accompanied by hypomanic episodes (a milder state of mania in which the symptoms are not severe enough to cause marked impairment in social or occupational functioning or need for hospitalization, but are sufficient to be observable by others).

3.

Cyclothymic Disorder, a chronic state of cycling between hypomanic and depressive episodes that do not reach the diagnostic standard for bipolar disorder (APA, 2000, pp. 388–392).

Manic episodes are characterized by:

A.

A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary)

B.

During the period of mood disturbance, three (or more) of the following symptoms have persisted (4 if the mood is only irritable) and have been present to a significant degree:

(1)

increased self-esteem or grandiosity

(2)

decreased need for sleep (e.g., feels rested after only 3 hours of sleep)

(3)

more talkative than usual or pressure to keep talking

(4)

flight of ideas or subjective experience that thoughts are racing

(5)

distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)

(6)

increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation

(7)

excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)" (APA, 2000, p. 362).

Depressive episodes are characterized by symptoms described above for Major Depressive Episode.

4. Substance-Induced Mood Disorder

Substance-Induced Mood Disorder is a common depressive illness of clients in substance abuse treatment. It is defined in DSM-IV-TR as “a prominent and persistent disturbance of mood . . . that is judged to be due to the direct physiological effects of a substance (i.e., a drug of abuse, a medication, or somatic treatment for depression, or toxin exposure)” (APA, 2000, p. 405). The mood can manifest as manic (expansive, grandiose, irritable), depressed, or a mixture of mania and depression.

Generally, substance-induced mood disorders will only present either during intoxication from the substance or on withdrawal from the substance and therefore do not have as lengthy a course as other depressive illnesses.

5. Mood Disorder Due to a General Medical Condition

It is not as common to find depression due to a general medical condition in substance-abuse treatment settings, but it is important to note that depression can be a result of a medical condition, such as hypothyroidism or Parkinson's disease. The criteria for diagnosis are similar to Major Depressive Episode or a manic episode; however, the full criteria for these diagnoses need not be met. It is important in diagnosis to establish that the depressive symptoms are a direct physiological result of the medical condition, not just a psychological response to a medical problem.

6. Adjustment Disorder With Depressed Mood

Adjustment disorder is a psychological reaction to overwhelming emotional or psychological stress, resulting in depression or other symptoms. Some situations in which an adjustment disorder can occur include divorce, imprisonment of self or a significant other, business or employment failures, or a significant family disturbance. The stressor may be a one-time event or a recurring situation. Because of the turmoil that often occurs around a crisis in substance use patterns, clients in substance abuse treatment may be particularly susceptible to Adjustment Disorders. Some of the common depressive symptoms of an adjustment disorder include tearfulness, depressed mood, and feelings of hopelessness. The symptoms of an adjustment disorder normally do not reach the proportions of a Major Depressive Disorder, nor do they last as long as a Dysthymic Disorder. An acute adjustment disorder normally lasts only a few months, while a chronic adjustment disorder may be ongoing after the termination of the stressor.

7. Other Psychiatric Conditions in Which Depression Can Be a Primary Symptom

Sometimes depression is symptomatic of another mental disorder. This is particularly true when the nature of the mental disorder causes excessive distress to the individual. While, in this context, the depression is a symptom, it is still important to recognize its impact on the person and his or her ability to respond to substance abuse treatment.

Some of the psychiatric disorders in which depression can play a major role include:

A. Posttraumatic Stress Disorder (PTSD)

Symptoms include episodes of reexperiencing the traumatic event or reexperiencing the emotions attached to the event; nightmares, exaggerated startle responses; and social, interpersonal, and psychological withdrawal. Chronic symptoms may include anxiety and depression. PTSD is categorized as an anxiety disorder.

B. Anxiety Disorders, including Panic Disorder, Agoraphobia (fear of public places), Social Phobias, and Generalized Anxiety Disorder

Symptoms of anxiety disorders are most often on the anxiety spectrum, but the chronic stress faced by individuals with anxiety disorders can produce depressive symptoms including irritability, hopelessness, despair, emptiness, and chronic fatigue.

C. Schizoaffective Disorder and Schizophrenia

Individuals with schizoaffective disorder have, in addition to many of the symptoms of schizophrenia, a chronic depression with most of the features of Major Depressive Disorder. Because of the difficulty individuals with schizophrenia have in coping with the daily demands of living, depression is often a symptom. With both schizoaffective disorder and schizophrenia, the depression adds an additional dimension to treatment, specifically in helping the person mobilize in the face of their depression to cope with their illness.

D. Personality Disorders

People with personality disorders are particularly susceptible to depression. These individuals are at high risk for substance use disorders. As a result, it is not uncommon to find clients in substance abuse treatment with all three diagnoses. Because personality disorders are categorized in DSM-IV-TR as Axis 2 disorders (see DSM-IV-TR for a description of multiaxial assessment), it is common to find their depression diagnosed separately (from the personality disorder) as an adjustment disorder, dysthymia, or major depressive disorder.

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