Depression Awareness Month 2023: Understanding the Dual Challenge of Addiction & Depression
Addiction and depression often occur together. Individuals in recovery should not be alarmed by dual diagnosis of addiction and depression or the recommendation to treat the two together. To help us understand this complex connection, we sat down with Dusuba Koroma, an esteemed addiction and mental health clinician, operating out of CleanSlate’s center in Tewksbury, Massachusetts.
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Dusuba Koroma
What led you to addiction treatment?
DK: At the beginning it was personal because I saw some addictive behaviors in a close family member. This was in 1999, in my final year of school, and I become the only one in my class to pursue addiction treatment. With that family setting bothering me, I wanted to know why people do the things they do in addiction and how the brain works in that process. I did my internship in addiction treatment, graduating in 2000. At the time, many people didn’t understand addiction, and many of my colleagues didn’t think I made a good choice. But I’ve never regretted it. I’ve always been drawn to the marginalized, to the underdog, and I wanted to make a difference in the lives of those rejected by society. It’s now been over 20 years I’ve treated addiction in community mental health centers.
How do you view relation between addiction and depression?
DK: The two are very correlated. It’s not that one precedes the other, but that each one has an impact on the other. It’s like the chicken and egg—each one contributing to the other from their onset.
Depression can raise the risk of substance use/misuse, the same way chemical intoxicants can be a way to self-medicate by numbing feelings of sadness. This makes depression the most common co-occurring psychological disorder with chemical dependency. According to research, alcohol is 2 to 3 times more likely to exacerbate depressive episodes than with someone who does not have issues with addiction.
How often do you encounter patients who are grappling with both addiction and depression?
DK: Almost all the time. Even for those who are in denial at first, when you probe further you find that they’re struggling with some form of depression and symptoms of anxiety too.
In what ways do therapeutic approaches differ when addressing both addiction and depression versus treating them separately?
DK: Patients are best served when both co-occurring disorders are addressed concurrently. Looking at them separately doesn’t produce the best treatment outcomes, because there may be trauma, sadness, or other underlying mental processes affecting them both. If these are left unaddressed, they can remain subdued. But in times of crisis a patient can feel compelled to go back to using as a way of coping. That’s why we try to dig in and approach both mental health and addiction together.
Medication assisted treatment, or MAT, is wonderful because it acts on the reward center of the brain to reduce impulsive behavior. But the underlying issues still need to be addressed concurrently to get the best outcome in the patient.
What are some particular challenges in treating the co-occurrence of addiction and depression?
DK: Resistance on the part of the patient can be a challenge. Some patients don’t want to take the time to invest in themselves. They don’t see hour-long sessions with a counselor as something they need. Lack of insurance is another barrier. Housing instability is a very big crisis in the lives of people who need the most help with addiction and mental health. Finding employment is also a challenge because of their history, along with legal issues that may prevent them from getting into the workforce. So they tend to give up on themselves, and don’t feel like it’s worth the fight. These are all serious issues we need to address in this population to help them lead productive lives.
Which clinical modalities do you favor in the treatment of dual diagnosis patients?
DK: I use a combination of cognitive behavioral therapy [CBT], dialectical behavioral therapy [DBT] and motivational interviewing [MI]. CBT helps patients increase awareness of things we need to look at, their thought patterns, how to strengthen their thinking, how their thoughts influence their feelings and how both thoughts and feelings influence behavior. DBT is empowering in regulating their emotions. I begin with MI to find what they’re committed to and what prevents them from achieving their potential. All three are evidence-based, practical and very good.
Can you explain the concept of self-medication in the context of depression and addiction?
DK: Self-medication is what a patient does when they are struggling inside themselves. They’re low, they don’t feel good, they use substances to make them feel a little better, and then it becomes habitual. They get stuck in a cycle of using. Many of my patients really don’t want to use, but they find themselves gravitating toward it anyway. Then their addiction becomes inevitable.
What role does the brain’s reward system play in the interplay between depression and addiction?
DK: When the brain’s neurotransmitters are low, certain substances provide relief. That’s why we do psych evaluations and recommend certain psychotropic medications, such as SSRIs, to make them feel better and increase their ability to live everyday life without illicit drugs or alcohol.
What role does family history play in the co-occurrence of addiction and depression?
DK: There are some genetic predispositions to addiction. Adult children of alcoholics have been found to be born with low levels of certain neurotransmitters, for example. Childhood exposure to emotional and mental stress and trauma are also major factors affecting the limbic system regulating emotions, impulses and motivation. So when I have a client who hasn’t addressed their childhood trauma, the healing hasn’t happened yet. I help them process their trauma and make progress. If we don’t, it will continue to hide there and come out during times of stress and make them go back to using.
What advice would you give to someone who is struggling with both addiction and depression?
DK: Address both. Don’t ignore one or the other. 12 Step programs help here, by getting people to look at themselves, self-reflect, make what changes they can in their lives, and bring out the best for them. So addressing it all is my recommendation.
Without revealing any identifying details, could you share any success stories or strategies that have been particularly effective for individuals with co-occurring addiction and depression?
DK: I have seen so many successes. I have one who has many years in recovery from opioid addiction but who came close to using again after suffering a loss. Instead this patient was empowered to connect with resources, reach out, be open, and not be overcome by emotion. I’ve had countless cases of patients empowering themselves in this way, which also builds self-esteem.
Self-development is also part of my strategy. I encourage my patients to go back to school, enter the workforce, and be productive. This gives them the self-confidence to face a difficult world.
How do you see the future of treatment for individuals with co-occurring addiction and depression?
DK: I’m very optimistic about it. The link between the two and the need to treat both concurrently is now widely recognized. Addiction is now seen as a brain disorder rather than as a moral failing. And counseling in both individual and group settings—which are very powerful and help people connect—continues to grow.
Any final thoughts?
DK: Comprehensive treatment is the way to go. We need medication and therapy, including group therapy. We need to help people connect with their resources and be their best, so they can overcome hurdles and barriers to recovery.
If you or a loved one is struggling with addiction and depression,
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