"You're standing at a precipice, and you look down. There's a voice -- and it's a little quiet voice -- that goes 'jump.' It's the same voice, the same voice [that says], 'just one.' There's a voice that goes, 'jump,' and the idea of 'just one.'" -- Robin Williams, in a 2006 interview with Diane Sawyer.
Robin Williams' sobriety was intact when he died of apparent suicide last Monday, according to his widow Susan Schneider. Though no one will ever know what exactly led to that night, Williams had previously provided some insight into the interaction between depression and addiction. During a 2006 interview, Williams discussed his relapse into alcohol addiction after 20 years of sobriety. In hindsight, it's hard not to see his words as commentary on the twinned characteristics of both alcoholism and depression, from someone who struggled with both.
In this, Williams was not alone. Almost 28 percent of Americans with alcohol dependence (the clinical term for alcoholism) also have a major depressive disorder (such as clinical depression), according to the National Institute on Alcohol Abuse and Alcoholism.
A person with an alcohol dependence is 3.9 times more likely to have a major depressive disorder than someone without alcohol dependence and there's even some evidence that the genes which make someone susceptible to depression are related to the genes that put people at risk for alcoholism.
But despite the common co-occurrence and possible genetic link between alcoholism and depression, research about treating both at the same time is still in its infancy. Traditionally (and what is still the norm today), the medical education, scientific research and clinical approach to treating depression and alcoholism is siloed off into different departments.
Alcohol is a depressant that slows down your central nervous system and alters thinking, speech and reactions, but it can also make people feel a sense of euphoria and well-being at first. Because of this, scientists aren't sure whether most people begin drinking to medicate pre-existing depression, or if people are depressed because of the consequences of alcoholism. But the two conditions can lock someone into a seemingly unending cycle of drinking, depression from the consequences of drinking and then more drinking to relieve the pain.
"That's why it's so critical for us to think about how to weave in treatment for depression in chemical dependency settings, and on the flip side of that begin to more sensitively assess and treat in a non-confrontational manner, problematic or risky drinking [in depression patients],” said Stephanie Gamble, Ph.D., an assistant psychiatry professor at the University of Rochester Medical Center. “So we can nip these things in the bud before they grow into a full-blown problem."
Approaching the conditions simultaneously, according to Gamble, may turn out to be the most effective way to treat both.
"When folks would show up at mental health centers with a substance abuse problem, a referral is often made for them to go and get substance abuse counseling first -- get cleaned up, and then get your depression treated," explained Gamble in a phone interview with The Huffington Post. "The problem with that sequential treatment is that when someone experiences both depression and a substance abuse disorder, they become so intertwined that the depression itself can undermine a person's attempt at sobriety."
"For the patients that I've seen that experience co-occuring depression and alcohol dependence, it's a double whammy," Gamble continued. "If you need to go to group [therapy] three times a week, but you can't even get out of bed to take a shower, that's going to undermine your attempts at an outpatient chemical dependency program."
Gamble is embarking on pilot studies assessing the feasibility of treating people with alcohol dependency and depression with both traditional substance abuse therapy and interpersonal psychotherapy. Her 2013 uncontrolled study, which followed 14 women over 32 weeks, found that their drinking behavior, depressive symptoms and interpersonal functioning improved significantly over the course of therapy and was sustained at follow-up.
Charles O'Brien, Ph.D. M.D., an addiction psychiatrist at the University of Pennsylvania School of Medicine and the founder of the Center for Studies of Addiction at the school, is another researcher intent on addressing both conditions simultaneously, but from a pharmacological perspective. O’Brien published a double-blind, controlled study in 2010 that assessed the effectiveness of treating 170 participants with either naltrexone, a drug that reduces alcohol cravings, sertraline, a drug that treats depression and anxiety, both drugs, or neither drugs.
O’Brien treated participants for 14 weeks and found that the group which received both drugs had higher alcohol abstinence rates (53.7 percent) and a longer average period before relapse (98 days) than the groups which received only sertraline or only naltrexone. In fact, those groups had abstinence rates and relapse periods that were comparable to the control group, which received no drugs at all -- 23.1 percent abstinence, with a 26-day delay before relapse.
“The best results occur when you treat both simultaneously,” said O’Brien in a telephone interview with HuffPost. “It’s not a good idea to say we’re only going to concentrate on one thing at a time — they should be getting simultaneous treatment for multiple disorders."
Because the groups were small and the follow-up times so short, O’Brien hopes that other research groups will attempt to replicate his findings with longer, or longitudinal studies.
“The brain is the cause of all of this,” O’Brien continued. “Addiction is a brain disease. Depression is a brain disease. Not many doctors know about the brain.”
Need help? In the U.S., call 1-800-273-8255 for the National Suicide Prevention Lifeline.