What are the treatment guidelines for depression in patients with substance use disorders?

Updated: Aug 06, 2020
  • Author: Jerry L Halverson, MD; Chief Editor: David Bienenfeld, MD  more...
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The following are recommended in first-intention treatment during the first episode of MDD with comorbid substance use disorder:

  • Full-time hospitalization or
  • Close monitoring in consultation (at least weekly)
  • Electrocardiographic evaluation prior to treatment
  • Substitution treatment initiated in response to opioid dependence

Also consider the following in first-intention treatment of patients with severe alcohol addiction:

  • Close biologic monitoring - Complete blood count, blood electrolytes, liver and renal function
  • Treatment of physical withdrawal syndrome
  • Antidepressant treatment - Prescribed after reassessment of mood and once appropriate care for physical withdrawal syndrome has ended

First-intention medications and other treatments for MDD with comorbid substance use disorders include the following:

  • Severe substance use disorders (except alcohol and nicotine) - SSRI; SNRI; α2 antagonist; disease management involving a team specialized in addictology, psychoeducational groups, or psychotherapy focusing on addictive relapse prevention; concurrent treatment of MDD and addiction
  • Severe comorbid alcohol addiction - SSRI, SNRI, α2 antagonist, structured psychotherapy
  • Active smoking - SSRI, SNRI, α2 antagonist, structured psychotherapy, concurrent treatment of MDD and smoking cessation

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