Start with the urgent part. If you or someone you know is struggling or having thoughts of suicide, call or text the 988 Suicide & Crisis Lifeline at 988 or chat at 988lifeline.org, and in life-threatening situations call 911 [1]. Depression and heavy drinking together raise the stakes on that sentence, which is why it sits at the top of this page rather than the bottom.
The rest of the page is for the decision after that one. Depression is an illness that can affect anyone, regardless of age, race, income, culture or education, and research suggests that genetic, biological, environmental and psychological factors play a role [1]. When it sits alongside drinking, the two stop being separate problems in practice, whatever the diagnostic paperwork says.
Covered below: why the order of arrival matters less than it feels like it does, how each condition deepens the other, what an assessment can and cannot separate, what treating both together actually involves, and what a discharge plan has to carry. Our hub on co-occurring disorders covers the broader territory.
Which came first, and why the answer matters less than people think
Families argue about this. Clinicians mostly do not.
Many people with substance use disorders also experience other mental disorders like depression, anxiety, or bipolar disorder [2]. Depression is the one most families recognize, and the relationship runs in more than one direction at once.
Shared causes account for part of it. Stress, trauma and genetics can push a person toward both a substance use disorder and another mental disorder, without either one causing the other [2]. NIMH says much the same about depression on its own terms: research suggests that genetic, biological, environmental and psychological factors play a role [1].
The practical consequence is small and freeing. Nobody has to win the argument before treatment can start. An assessment describes what is true now, and that is enough to build a plan on.
How depression and substance use reinforce each other
Alcohol is a depressant, and that is not a figure of speech.
The short-term effect is relief, which is exactly what makes the pattern durable. NIAAA’s own screening questions ask whether a person has continued to drink even though it was making them feel depressed or anxious, or adding to another health problem [4]. A question is only worth asking on a screening form if a lot of people answer yes to it.
The longer-term effect runs through the brain itself. NIDA puts mood disorders on the short list of conditions whose affected brain areas are also altered by substance use [3]. That is the mechanism behind a pattern people describe without needing a mechanism: it used to help, and now it does not, and stopping feels worse than continuing.
There is a third loop that gets less attention, and it is the social one. Depression is linked to increased health care costs and other health conditions such as heart disease and diabetes [1]. Add drinking, and the same person is now managing a mood disorder, a drinking problem and a shrinking amount of money, work and goodwill. Each of those makes the next one harder to face sober.
Where to start in Georgia when both are in play
Promises Atlanta, in Dacula, Georgia, publishes medical detox, residential rehab and aftercare planning. Its own what-to-expect page says medical detox there is offered on a case-by-case basis, so ask about it on the first call. The campus describes itself as a place for people with substance use disorders and co-occurring mental health conditions. Say on the first call that depression is part of the picture, because it changes what level of care fits.
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Promises Atlanta is part of our family of treatment centers. See the Promises Atlanta campus.
Why treating one without the other usually fails
Sequential treatment sounds orderly and tends not to work.
NIDA is direct about the order of operations: it is usually better to treat these health issues at the same time rather than separately [3]. NIMH puts the reason in one word, coordination, and defines integrated care as mental health and substance use treatment delivered together so care is more convenient and better joined up [2].
The failure mode of split care is easy to picture. A program treats the drinking and sends someone home sober into an untreated depression. Or a therapist treats the depression while the drinking quietly cancels the work between sessions. Neither clinician is doing anything wrong. The plan is.
Symptoms in a combined presentation are often more persistent, severe and resistant to treatment than in patients who have either disorder alone, which is an argument for more coordination rather than for lower expectations [3].
Assessment: separating substance-induced symptoms from an independent disorder
The assessment is a conversation about timing, not a laboratory result.
Accurate diagnosis is key for treating co-occurring substance use and mental disorders, since symptoms may overlap [2]. With depression the overlap is close to total. Low mood, broken sleep, no appetite, no interest in anything and a flat sense of the future describe a depressive episode. They also describe two weeks of heavy drinking.
Clinicians work with the sequence instead. Low mood that predates the drinking by years, or that stays put once the body has cleared, is treated as its own illness. Low mood that lifts with abstinence and returns each time drinking resumes is treated differently. Neither answer changes what happens in the first week, which is stabilization.
Where drinking has been heavy and daily, that first week carries medical risk of its own. Mild withdrawal generally consists of anxiety, irritability, poor sleep and a lost appetite; severe withdrawal is usually characterized by shaking hands, sweating, a raised pulse and blood pressure, and nausea [5]. Seizures and true delirium tremens are the most extreme forms, and those outcomes can lead to fatal consequences [5]. A history of severe or repeated withdrawals, delirium tremens or seizures makes someone a poor candidate for a social detoxification setting [5].
If someone is having a seizure, is unresponsive or has trouble breathing, call 911. For a mental health crisis, or for thoughts of suicide, call or text 988.
Our explainers on medical detox and withdrawal symptoms set out what supervision involves.
Integrated dual diagnosis treatment, level by level
What changes between the rungs is intensity. What should not change is who holds the plan.
Withdrawal management comes first where it is needed, and it is a medical stage rather than a psychological one. Mood is an unreliable guide during it, for the plain reason that withdrawal itself flattens mood and wrecks sleep [5]. Nobody should be handed a lasting verdict on their depression in that window.
Inpatient rehab is where the two halves are supposed to meet, held by one team. That is the integrated care NIMH describes, delivered in one place [2]. That is the thing to test when comparing programs, and one phone question tests it: who is responsible for the depression side of this plan?
Step-down and outpatient care is where most of the depression work actually happens, because it takes place in the life the person is going back to. It is also the stage people quietly drop out of. Our guide to levels of care explains how the rungs relate.
Medication considerations when both are present
Two prescriptions is normal. Two prescribers who never speak is the risk.
NIMH names medications, talk therapy including telehealth and online options, and brain stimulation therapy among the depression treatments it is working to improve [1]. It also says plainly that medication can treat alcohol addiction while other medication eases the symptoms of many mental disorders [2]. On the drinking side, the Food and Drug Administration has approved three: naltrexone, acamprosate and disulfiram, none of them addictive, and any of them usable alongside therapy or a mutual-support group [4].
This page publishes no doses, no schedules and no ranking of one medication against another. Those belong to a prescriber who has examined the person in front of them, and what that prescriber chooses depends on the individual and the substances involved [3].
The one piece of practical advice worth giving is administrative. Bring every current prescription, and the name of whoever wrote it, to the assessment. An antidepressant stopped abruptly because nobody at intake knew about it is an avoidable setback.
Therapies with evidence for co-occurring presentations
The evidence base is not exotic. The coordination is the hard part.
The behavioral therapies NIMH names for co-occurring presentations are cognitive behavioral therapy, contingency management and motivational interviewing, all of which work by building coping skills [2]. For the drinking itself, NIAAA describes talk therapy delivered by licensed therapists and aimed at changing drinking behavior, with mindfulness-based approaches among the examples [4]. Neither list is exotic, and that is the point: the ingredients are ordinary and the coordination is what is scarce.
Our overviews of substance abuse counseling techniques and dialectical behavior therapy describe what those sessions look like from the inside.
Relapse risk and what aftercare needs to cover
A discharge plan that covers only the drinking has covered half the risk.
Symptoms in co-occurring presentations are often more persistent, severe, and resistant to treatment [3], so the weeks after an intensive stay deserve more structure than they usually get. Depression frequently becomes more visible once the drinking stops, because the drinking was blunting it. That is not a sign the treatment failed. It is the reason the second half of the plan exists.
Four things belong in writing before discharge. A prescriber named, with an appointment date. A therapist who knows about both conditions. A person to call on a bad night, by name and number. And the 988 line written down somewhere it will be found, because a depressive episode does not schedule itself around office hours [1].
NIAAA’s own summary is worth keeping in view here: no matter how severe the problem may seem, evidence-based treatment with behavioral therapies, mutual-support groups or medications can help people with alcohol use disorder achieve and maintain recovery [4]. A return to drinking is information for the plan rather than a verdict on the person. Our page on how to get into rehab covers what the first call involves.
Frequently Asked Questions
Is it depression, or is it the drinking? Often both, and the assessment answers it by timing rather than by test. Symptoms may overlap, which is exactly why accurate diagnosis matters. Low mood that predates the drinking, or that persists for weeks after it stops, is treated as an illness in its own right. Low mood that tracks the drinking cycle is treated differently. Either way the first week is about stabilization.
Will my antidepressant be stopped in treatment? Not as a matter of policy, and not by anyone who has not examined you. Medications can lessen the symptoms of many mental disorders, and separate medications treat alcohol addiction, so the usual outcome is one plan holding both rather than a choice between them. Bring the medication and the prescriber’s details to the assessment so the decision is made with the facts in the room.
What should I do tonight if someone is talking about suicide? Treat it as urgent. If you or someone you know is struggling or having thoughts of suicide, call or text the 988 Suicide & Crisis Lifeline at 988 or chat at 988lifeline.org, and in life-threatening situations call 911. Do not leave the person alone while you arrange help, and do not wait for a scheduled appointment to raise it.
Do I need a psychiatrist as well as a counselor? Frequently, and what matters is that they share a plan. Integrated care combines mental health and substance use treatment so people get coordinated care in one place. Prescribing sits with a medical clinician, while behavioral treatment is provided by licensed therapists. Ask any program you are considering who owns each half and how often they speak.
Does insurance cover treatment for both conditions? Usually in some form, though the details decide everything. Marketplace plans must include mental health and substance use services among the essential health benefits, and they cannot apply yearly or lifetime dollar limits to that care. What is authorized still depends on the policy, the employer and the level of care. Marketplace plans must also provide parity protections, so limits on this care cannot be more restrictive than the limits on medical and surgical care. Those limits include care management, such as being required to get authorization of treatment before getting it. We claim no network status with any carrier, so check your own member ID.
Sources
- National Institute of Mental Health. Depression. National Institutes of Health. https://www.nimh.nih.gov/health/topics/depression
- National Institute of Mental Health. Finding Help for Co-Occurring Substance Use and Mental Disorders. National Institutes of Health. https://www.nimh.nih.gov/health/topics/substance-use-and-mental-health
- National Institute on Drug Abuse. Co-Occurring Disorders and Health Conditions. National Institutes of Health. https://nida.nih.gov/research-topics/co-occurring-disorders-health-conditions
- National Institute on Alcohol Abuse and Alcoholism. Understanding Alcohol Use Disorder. National Institutes of Health. https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/understanding-alcohol-use-disorder
- Center for Substance Abuse Treatment (2006). Detoxification and Substance Abuse Treatment, TIP 45, Chapter 4: Physical Detoxification Services for Withdrawal From Specific Substances. SAMHSA, NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK64116/
- HealthCare.gov. Mental health and substance abuse health coverage options. US Centers for Medicare and Medicaid Services. https://www.healthcare.gov/coverage/mental-health-substance-abuse-coverage/
This page is for general information and is not medical advice. Only a licensed clinician who knows your history can tell you what is right for you. If you or someone you know is in immediate danger, call 911. For free, confidential support 24/7, call or text 988.
Author
Chief Medical Officer,
The Recovery Village
