depressive mood states. The presence of a mood disorder may be mistakenly concluded if the patient is evaluated under the influence of or during active withdrawal from certain substances (Quello, Brady, and Sonne, 2005). For example, a patient under the influence of alcohol can manifest symptoms of mania or hypomania. In contrast, symptoms of alcohol (and/or cocaine) withdrawal may appear as dysphoria and depression (DSM-IV). While screening for depression typically occurs at SUD treatment intake, assessment and diagnosis are most accurately determined after withdrawal is complete and abstinence has been achieved (Brown and Schuckit, 1988). However, it is recognized that the severity of depressive symptoms must be carefully assessed, and immediate treatment may be required for severe depression and in order to initiate treatment (Quello, Brady, and Sonne, 2005).

Behavioral Treatments

Recent efforts to treat depression and substance use disorders have focused on integrated treatments (Brown et al., 1997; Weiss et al., 2000). As described above, CBT is among the most powerful behavioral treatments for depression and also has proven efficacy for substance use disorders. A manual for CBT with substance use disorders is available from the National Institute on Drug Abuse (Carroll, 1998). Only one study has compared CBT for depression with a relaxation training control, i.e., condition plus treatment as usual for alcohol in patients who are currently alcohol dependent and with elevated depressive symptoms (BDI score > 9). CBT participants showed, on average, significant improvements in depressive symptoms relative to participants in the control condition. The average effect size was 0.85. CBT participants showed, on average, more abstinence and reduced drinking at 3- and 6-month follow-up. Changes in depressive symptoms were reported to mediate the number of drinks ingested daily (Brown et al., 1997).

More recently, a comparison of LETS Act!, a manual-based intervention modification of the Behavioral Activation Treatment for Depression for the SUD inpatient population, was compared with a control group of usual treatment. The results showed that, on average, LETS Act! participants had greater reductions in depressive symptoms compared with the usual treatment group. This potentially promising treatment is unique in that it provides initial data in the development of a specialized depression-centered treatment for SUD patients with depressive symptoms (Daughters et al., 2008).

Box 6-2 describes other integrated treatment models of care that have been used in substance abuse disorder settings. Both of these models were sites for the Substance Abuse and Mental Health Services Administration’s Women, Co-Occurring Disorders Study. Results from this study provided



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