Alcohol-Induced Depressive Disorder: When Alcohol Causes Depression

Many substances can change your mood, especially by causing symptoms of depression.1 It is not uncommon for someone with alcohol use disorder to also have episodes of depressed mood. For some, their symptoms will be more intense and long lasting than what is typical or expected. These individuals may meet the criteria for alcohol-induced depressive disorder.

Alcohol-Induced Depressive Disorder

Alcohol-induced depressive disorder is one type of substance-induced depressive disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). These disorders can be caused by any substance, including prescription medication. When medication is the cause, the disorder is classified as “medication-induced.” 1

Approximately 0.26% of the United States adult population will develop a substance-induced depressive disorder.2

Your provider may diagnose you with alcohol-induced depressive disorder if you meet the following criteria:1

  • Persistent and prominent depressed mood, or markedly decreased pleasure or interest in activities.
  • Symptoms do not occur during the course of delirium, or changes in mental ability associated in confusion and lack of awareness of one’s surroundings. Delirium can occur during alcohol withdrawal.
  • Disruption in mood causes clinically significant distress or impairment in important areas of functioning (e.g., social or occupational).
  • Evidence to conclude that your the symptoms developed during or soon after intoxication, withdrawal, or exposure to a substance, AND the substance must be capable of producing the symptoms.
  • The mood disruption is not better explained by a depressive disorder that is not substance-induced.

Most individuals experience symptoms during or within 1 month of substance use.1 If symptoms continue after a substantial length of time after abstaining from substances, you may not qualify for this diagnosis.1

Notably, you do not need to meet the criteria for a substance use disorder in order to develop alcohol-induced depressive disorder. However, many individuals have both. Substance use disorders include substance-specific criteria, such as:1

  • The overarching use disorder (e.g., alcohol use disorder)
  • Intoxication
  • Withdrawal
  • Other substance-induced disorders

Treating alcohol misuse is often a critical part of resolving substance-induced depressive disorder symptoms.

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Types of Depressive Disorder Diagnosis

The DSM-5 lists several depressive disorders, including:1

  • Disruptive mood dysregulation disorder
  • Persistent depressive disorder, also referred to as dysthymia
  • Premenstrual dysphoric disorder
  • Substance/medication-induced depressive disorder
  • Depressive disorder due to another medical condition
  • Other specified depressive disorder
  • Unspecified depressive disorder
  • Major depressive disorder
  • Major depressive episode

Each type of depressive disorder has different symptoms and characteristics. The most distinct and best known are major depressive disorder and major depressive episode.

Major depressive disorder includes a significant change in functioning and at least 1 of the 2 hallmark symptoms: a loss of pleasure or interest in activities or depressed mood most of the day. Mental health professionals evaluate if you have had at least 1 symptom for a minimum of 2 weeks.1

Major depressive disorder is also characterized by experiencing 5, or more, of the following symptoms nearly every day:1

  • Feeling depressed (e.g., hopeless, sad) for most of the day OR being observed to look depressed to others (e.g., appearing tearful or disinterested)
  • Diminished pleasure or interest in almost, or all, activities
  • Significant weight gain or weight loss without dieting or exercising OR decrease in appetite
  • Sleeping too little or too much
  • Moving so slowly or so restlessly that others notice
  • Loss of energy or fatigue
  • Feeling worthless or excessive and inappropriate feelings of guilt
  • Lack of concentration or difficulty making decisions
  • Thoughts of death, recurrent suicidal ideation, having a plan or means (e.g., a firearm, prescription medication collected for the purpose of overdose) for suicide, of trying to take one’s own life

These symptoms must cause significant distress or impairment in important areas of your life for a mental health professional to make a diagnosis. .1

Alcohol-Induced Depressive Disorder vs. Other Depressive Disorders

Your provider will inquire about your history of symptoms and likely request collaborating information, whether from a loved one or a review of psychological and medical records. For some individuals, the use of substances can exacerbate existing symptoms, causing some difficulty determining the most appropriate diagnosis.1

For example, if you had no history of depression and then developed symptoms within the first few weeks of consuming alcohol, you would likely be diagnosed with alcohol-induced depressive disorder rather than an independent depressive disorder. If you had a history of depressed symptoms before using alcohol, a diagnosis of a depressive disorder and alcohol use disorder may better explain your symptoms.

Importantly, other depressive diagnoses may be considered if your depressive symptoms continue 4 weeks longer than expected based on the withdrawal timeline from alcohol.1

Studies indicate that major depressive disorder and alcohol use disorders often co-occur.3 A review of existing research suggests having one of these disorders doubles the chances of having the other.3 With this significant overlap, it can be challenging to diagnose accurately.

Alcohol-induced depressive disorder

To assist in differentiating between diagnoses, the DSM-5 outlines the following common factors of a substance-induced disorder:1

  • You present with clinically significant symptoms of a relevant mental disorder
  • Evidence from physical examination, laboratory testing, or history indicates that the disorder developed within one month of substance intoxication or withdrawal, AND that the consumed substance is capable of producing symptoms
  • Symptoms not only present during delirium
  • Causes clinically significant impairment
  • Other mental health condition(s) do not better explain the symptoms, evidence that can support substance/medication-induced can include
    • Disorder occurred after exposure, severe intoxication, or withdrawal from the substance
    • Full mental health disorder did not continue after a withdrawal period

It’s important to differentiate between co-occurring major depression and alcohol use disorder and alcohol-induced depressive disorder. Alcohol-induced depressive disorder tends to be more severe in terms of risk of:3

  • Relapse
  • Depressive symptoms
  • Suicidality

Risk Factors for Alcohol-Induced Depressive Disorder

Generally, the risk for developing a substance-induced mental health disorder increases with the frequency of use and quantity of the substance.1

When compared to individuals with major depressive disorder and no substance use disorders, individuals diagnosed with substance-induced depressive disorder were found more likely to:2

  • Be male
  • Be Black
  • Have no more than a high school diploma
  • Lack insurance
  • Come from an economically depressed area and/or have a lower income
  • Report family history of substance use disorder and antisocial behavior
  • Have a higher than average 12-month history of adverse life events
  • Be less likely to say they experienced depressed mood
  • Express more DSM-5 major depressive disorder criteria, primarily:
    • Feelings of worthlessness
    • Insomnia or hypersomnia (i.e., excessive daytime sleeping or sleepiness)
    • Thoughts of death
    • One or more non-fatal attempts to take their own life

A follow-up study found that individuals who met the criteria for a substance induced-depressive disorder were more likely to:4

  • Be non-white
  • Have lower levels of education
  • Be uninsured

It was also discovered that these individuals were more likely to meet the criteria for alcohol misuse and dysthymia (persistent depressive disorder).4

Long-Term Outcomes of Alcohol-Induced Depressive Disorder

Regardless of the severity of symptoms, most symptoms are likely to improve quickly with maintained abstinence from the problematic substance.1 For most people, symptoms will resolve within one month of complete cessation and will no longer meet the criteria for the full mental health disorder.

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However, exceptions do exist, mainly longer-standing substance-induced disorders (e.g., alcohol-induced neurocognitive disorder).1

A preliminary study found there are biological and clinical features that may assist physicians with distinguishing between alcohol-induced depressive disorder and other forms of depression.3 Researchers hope these results will lead to more effective therapeutic approaches.

Treatment of Alcohol-Induced Depressive Disorder Diagnosis

If diagnosed with alcohol-induced depressive disorder, your symptoms will likely resolve approximately a month after complete cessation of alcohol use.1

If symptoms continue afterward, you may benefit from professional care. Treatment for co-occurring alcohol use disorders and depressive disorders can include:5

  • Therapy
  • Medication
  • Support groups, like Alcoholics Anonymous (AA)

Preliminary research suggests that reducing the consumption of alcohol and general treatment of depression be beneficial.6 There appears to be some modest evidence to suggest antidepressant therapy for individuals with comorbid depressive disorder and alcohol use disorder can improve symptoms.6

Some studies suggest monitoring abstinence prior to treatment with antidepressants or similar medications. Evidence has shown the benefit of the combined treatment of antidepressants, including sertraline (Zoloft), and the alcohol dependency medication naltrexone (Vivitrol, Revia). This combination can improve both the dependency on alcohol and mood symptoms.6

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Resources

  1. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. American Psychiatric Publishing.
  2. Blanco, C., Alegría, A. A., Liu, S.M., Secades-Villa, R., Sugaya, L., Davies, C., & Nunes, E. V. (2012). Differences among major depressive disorder with and without co-occurring substance use disorders and substance-induced depressive disorder: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. Journal of Clinical Psychiatry, 73(6), 865-873.
  3. Farré, A., Tirado, J., Spataro, N., Alías-Ferri, M., Torrens, M. & Fonseca, F. (2020, July 02). Alcohol induced depression: Clinical, biological and genetic features. Journal of Clinical Medicine, 9(8), 2668.
  4. Magidson, J., Wang, S., Lejuez, C., Iza, M. & Blanco, C. (2013, May 03). Prospective study of substance-induced and independent major depressive disorder among individuals with substance use disorders in a nationally representative sample. Depression and Anxiety, 30(6), 538-545.
  5. McHugh, K. & Weiss, R. D. (2019, October 21). Alcohol use disorder and depressive disorders. Alcohol Research: Current Reviews, 40(1), 3-10.
  6. Foulds, J., Adamson, S., Boden, J., Williman, J. and Mulder, R. (2015, October 01). Depression in patients with alcohol use disorders: Systematic review and meta-analysis of outcomes for independent and substance-induced disorders. Journal of Affective Disorders, 185, 47-59.

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