BHOPB Research Department

Behavioral Health of the Palm Beaches is one of the only treatment centers in the world who performs and conducts their own drug and Alcohol Research. We feel it is of the utmost importance to determine experiential data based on clinical studies. We are happy to share this information in the hopes of helping other treatment centers get better outcomes for their patients as we are doing.

Dysthymia and Substance Abuse

By
Donald Mullaney, Ph.D., LCSW, Michael J. Weiner, Ph.D. & John W. McIlveen, M.Ed.
Behavioral Health of the Palm Beaches, Inc.

Naelys Diaz, Ph.D. & Gail Horton, Ph.D.
Florida Atlantic University, School of Social Work

Behavioral Health of the Palm Beaches would like to acknowledge Paul Peluso, Ph.D., Florida Atlantic University, School of Counselor Education, for his assistance in data analysis.

Mood disorders account for the vast majority of psychiatric disorders that occur in the world. In fact, according to the Global Burden of Disease study, which analyzed the impact of 107 major diseases on morbidity and mortality, mood disorders are currently the world’s most disabling condition (Ustun & Kessler, 2002). In a substance abuse treatment facility, and in the addictions field in general, clinicians provide treatment to a significant number of patients diagnosed with a substance abuse disorder and a co-morbid mood disorder. The ability to identify these conditions and begin to incorporate these issues into a patient’s overall treatment plan can be essential to helping the patient achieve long-term sobriety. In the end, the overall goal of treatment should be to assist the patient in their early recovery process and thereby increase their overall quality of life. Many patients, especially those with early onset mood disorders, may have developed substance dependency while attempting to self-medicate their condition. By addressing co-existing mood disorders in treatment and aftercare planning, we may be able to increase the patient’s chances of relapse-free early recovery.

It can be difficult to determine the nature of many mood disorders and their impact on a co-existing substance abuse disorder. A thorough assessment and testing process is crucial to determine which patients exhibit traits and symptoms that may be linked to a specific mood disorder. However, even if a patient undergoes a comprehensive assessment and testing process, the presence of a significant mood disorder may go misdiagnosed, or not be diagnosed at all. Dysthymia is one such chronic mood disorder that may impact a patient’s overall treatment outcome, as well as play a role in their aftercare and recovery process.

Dysthymia is an often misunderstood, under diagnosed and under treated mood disorder. Estimates of the prevalence of dysthymia in the general population range from 3% to 6%; however, one study shows that out of a sample of 30 patients who met DSM-III criteria for dysthymia, only 13 out of 30 were considered for a formal clinical diagnosis of the disorder (Shelton, Davidson, et. al., 1997). While other mood disorders may receive more attention, the awareness of the relationship between dysthymia and addictive disorders is also neglected. By looking at the results of a Google internet search, illustrated in the chart below, we can see the general lack of attention regarding this relationship.

One reason for this may be that dysthymia is often thought of as a “low-grade” form of depression. Frequently, patients may not exhibit obvious physical signs, and may not show drastic decreases in everyday functioning. Often sleep and appetite may not be impacted to a great degree. Evidence of dysthymic traits may be hard to interpret; often times, the patient may have shown signs of being “down”, or “glum”, for several years without the presence of a major depressive episode. While a dysthymic individual may recognize that they experience chronic sadness and a lack of enjoyment in most activities, they may not recognize the symptoms of the disorder to the degree a patient with major depressive disorder might. In effect, the dysthymic condition may become normalized by the patient; an individual begins to feel as if their state of chronic sadness is their “normal” state. Dysthymia may not require a specific acute event to trigger the condition, and some research suggests that family environment and development may have a relationship to the disorder. Several studies suggest that a dysfunctional childhood environment may also account for the unique features associated with dysthymia as opposed to other common mood disorders (Lizardi, Klein, et. al., 1995). Despite the commonly perceived notion of dysthymia as being “less-severe” than depressive disorders, its chronic nature can create conditions that may undermine a patient’s recovery.

Failure to diagnosis, or understand, the features of dysthymia as they relate to substance abuse and addiction can have multiple negative impacts on a patient’s treatment outcome and aftercare. By failing to recognize long-term dysthymic traits in a patient, we may be not addressing one of the primary factors in their development of substance dependence. This has a direct impact on aftercare planning, as a patient may not be educated regarding access to specific resources which may be able to assist them in addressing this issue. There are several other factors which increase the difficulty in recognizing dysthymic traits in substance dependent patients, especially those in the early stages of recovery. In fact, many patients can show features of dysthymia during their early stages of recovery, complicating our ability as clinicians to determine proper interventions for them as they strive towards the goal of long-term sobriety.

One key to understanding the relationship between dysthymia and substance abuse lies in recognizing its chronic nature. Just as addictive diseases have a progressive, chronic nature, so does dysthymia. As opposed to an episode of depression, which may be directly linked to an acute event (particularly in adulthood), the progression of dysthymia and its severity can be difficult to determine. Once identified, change in the dysthymic patient can be a slow and gradual process, similar to the recovery from chronic alcoholism or other addictive disorders. However, the link to dysthymic traits and long-term psychological dysfunction is clear. In one long-term study, 19% of patients diagnosed with dysthymic disorder (with or without major depressive episodes) reported a suicide attempt over a five-year follow-up period. A comparison group of patients diagnosed with major depressive disorder reported no suicide attempts over the same time period (Klein, Schwartz, et. al., 2000). This higher incidence of suicide attempts may indicate an increased vulnerability of patients with this disorder to engage in self-destructive or abusive behavior in an attempt to address their psychiatric issues. In a substance dependant individual, or a patient in the early stages of recovery, this type of behavior can clearly put the patient at risk of relapse.

Despite the need for a comprehensive examination of the full impact of dysthymia on substance abuse disorders, research in this particular area is limited. However, a few empirical investigations have addressed related issues, including one study which indicated that individuals diagnosed with substance abuse disorders and dysthymic disorder seek out substance abuse related treatment at a much higher rate than those individuals diagnosed with substance abuse disorders only (Westermeyer, Eames & Nugent, 1998). The study additionally noted that there was a clear pattern of higher relapse in patients who experienced a persistent recurrence of their dysthymic mood symptoms (Westermeyer, Eames & Nugent, 1998). Again, the evidence appears to suggest that there is a link between dysthymia and relapse patterns.

Here at Behavioral Health of the Palm Beaches (BHOPB), in collaboration with the Florida Atlantic University (FAU) School of Social Work and School of Counselor Education, our assessment, education and research department is compiling data in order to examine the relationships between dysthymic traits, substance abuse, number of treatment episodes, suicide attempts and quality of life. Through this study, we may be able to continue to improve on our assessment and treatment planning process, as well as continue to improve our aftercare planning for our patients who may suffer from co-existing mood disorders. Preliminary findings, using patient data collected from results of the Millon Clinical Multiaxial Inventory (MCMI) (Millon, 1997), indicate very high levels of dysthymic traits in our patient population. The chart below, prepared by Paul Peluso, Ph.D., LMHC, Program Coordinator for the School of Counselor Education at FAU, illustrates these findings.

Common Mood Disorders in BHOPB Patients as Measured by MCMI Testing

In regards to treating individuals who are diagnosed with co-morbid dysthymic disorder and substance abuse disorders, or show strong dysthymic traits, a key to effective patient care appears to be increasing our awareness and understanding of dysthymic symptoms. As mentioned earlier, there appears to be a clear pattern of under treatment regarding dysthymia. In a study published in 1997, a review of a sample of 410 patients with a dysthymia diagnosis indicated that only 41.3% received antidepressant treatment, and only 56.3% received some form of psychotherapy (Shelton, Davidson, et. al., 1997). Our lack of understanding regarding the long term impact and prevalence of dysthymia may play a role in the lack of attention it has received. Relapse prevention is the key goal of substance abuse treatment. For patients to begin their recovery on solid ground, aftercare planning and directing patients to resources where their dual diagnosis issues can be addressed is of primary importance. This is even more crucial in dealing with dysthymia, where there is evidence of a clear link between relapse and recurrence of symptoms, even when a patient has some significant periods of sobriety.

Dr. Evan Zimmer, M.D., medical director and chief psychiatrist at Behavioral Health of the Palm Beaches, notes that individuals with a dysthymic diagnosis can respond well to anti-depressants, however, he additionally states that it is best to “err on the side of caution in treatment”. “Most people in early recovery may be experiencing symptoms of acute withdrawal”, notes Dr. Zimmer, and he cautions against immediately using medication without fully engaging the patient in the recovery process. He goes on to note that many patients can continue to improve their functioning and overall quality of life by continuing to commit to an involvement in 12-step groups and programs.

Regarding other effective treatment interventions for dysthymia, it is crucial for clinicians to be aware that patients who suffer from dysthymia have a long history of chronic unhappiness, and may have significant difficulty accepting that there can be an improved quality of life for them. Just as in a long-term chronic addictive disorder, the process of change can be slow. While the clinician may need to be direct in making the patient aware of self-defeating behaviors, they may find that the patient has functioned somewhat adequately for so long with this disorder that they lack the ability to make a connection between their thoughts and behaviors. This may be particularly true when looking at their pattern of substance abuse and the progression of their addictive disease.  A cognitive behavioral approach, where the patient is gradually introduced to the idea of how thoughts affect feelings, and in turn determine behaviors, may have a greater impact on their overall success in treatment. Dysthymic patients, as opposed to those suffering from other mood disorders such as major depressive episodes, may need to focus less on examining and reframing acute events that precipitated their condition, but an overall shift in their basic belief system. Group therapy may also be helpful, as peer participation in the group process can give valuable feedback to the patient regarding how their own negative basic belief system has exacerbated both their dysthymia and substance abuse condition. Theodore Millon, creator of the MCMI, notes that several researchers have shown that interpersonal therapy may also have some effectiveness in treatment of dysthymia, as patients focus on development of social skills and resolving specific problems in their lives (Millon, 1999). This approach may have some value when there is a limited time frame in which to work with a patient, as interpersonal therapy focuses on specific events that may be helping to maintain the patient’s dysthymic state.

The substance abuse clinician is in the unique position of being able to integrate some interventions regarding dysthymia into the overall treatment experience. However, considering the relationship between relapse and a reoccurrence of symptoms of dysthymia, aftercare planning is crucial in assisting the patient as they are being discharged. Several studies have shown the importance of an integrated treatment approach to dysthymia that employs an active case management program to provide patients with options and referrals for not only continued medical care, but other related social support systems (Primm, Tzolova-Iontchev, Taylor, 2000).

Our main goal as substance abuse clinicians still remains helping the patient achieve long-term abstinence and increasing their quality of life by giving them the tools they need for a solid early recovery. However, by neglecting the issue of dysthymia and its impact on patients who suffer from it, we may be failing to address one of the key issues involved in recovery – preventing relapse. Further research, such as the research projects we are currently involved in at BHOPB, will continue to shed light on the issue of dysthymia, and allow us to develop knowledge that can assist our patients to reach their recovery goals.

REFERENCES

Brin, S., Page, L. (1998). www.google.com. Retrieved October 16, 2006.

Klein, D.N., Schwartz, J.E., Rose, S. & Leader, J.B. (2000). Five-year course and outcome of dysthymic disorder: A prospective, naturalistic follow-up study. American Journal of Psychiatry, 157:6, 931-939.

Lizardi, H., Klein, D.N., Crosby-Ouimette, P., Riso, L.P., Anderson, R.L. & Donaldson, S.K. (1995). Reports of the childhood home environment in early-onset dysthymia and episodic major depression. Journal of Abnormal Psychology, 104:1, 132-139.

Millon, T. (1999). Personality-Guided Therapy. New York: John Wiley & Sons, Inc.

Millon, T., Davis, R., Millon, C. (1997). Manual for the Millon Clinical Multiaxial Inventory-III (MCMI-III) (3rd ed.). Minneapolis: NCS Pearson.

Primm, A.B., Tzolova-Iontchez, I., Taylor, C.M. (2000). An integrated approach for dually diagnosed patients in a substance abuse treatment program: Case presentation. Substance Abuse, 21:2, 120-126.

Shelton, R.C., Davidson, J., Yonkers, K.A., Koran, L., Thase, M.E., Pearlstein, T. & Halbreich, U. (1997). The undertreatment of dysthymia. Journal of Clinical Psychiatry, 58:59-65.

Ustun, T.B. & Kessler, R.C. (2002). Global burden of depressive disorders: The issue of duration. British Journal of Psychiatry, 181:181-183

Westermeyer, J., Eames, S.L., Nugent, S. (1998). Co-morbid dysthymia and substance abuse: Treatment history and cost. American Journal of Psychiatry, 155:1556-1560.