Alcoholism and Depression Often Coexist and Fuel One Another

Examining the differences in cause and treatment for alcohol-induced depression versus depression-induced alcoholism

This article is part of a Wise & Well Special Report: The United States of Depression.

The first time I really became aware of the deep connection between alcoholism and depression was when my father first went into detox back in 2007. I watched him spiral into a person who could barely talk, barely function and clearly couldn’t make healthy decisions for his well-being. I knew he had suffered from depression for a long time, but seeing the seriousness of his alcohol use that seemed to ramp up alongside the depression was truly a scary experience for a daughter.

As a former mental health nurse, I knew that alcoholism and depression were hard to treat alone, never mind together. My education background informed me of that and I certainly saw it in practice, but witnessing it in a family member engendered the most powerless feeling I’ve ever felt.

My father had been on antidepressant medication for a long time, which lessened the symptoms, but only slightly. The medication seemed to work even less the more he drank. And the worse his depression got, the more he drank. The more he drank, the worse his depression got. It felt like a black hole with each condition pulling the other, spiraling toward an inevitable collapse.

A one-two punch

Mark Rego, MD, a psychiatrist who has worked with people with co-occurring depression and alcohol use disorders, says that the conditions are most definitely linked and once they co-occur it can be quite challenging to treat both. Once each condition becomes entrenched, Rego explains, it can be difficult to separate and treat either one, which is why dual diagnosis programs began to crop up over the last few decades.

The aim of dual-diagnosis programs is integrated treatment for both comorbid mental health and substance abuse disorders. However, Rego told me that successful treatment of both conditions is often rare.

Indeed, a 2019 research review published in Alcohol Research Current Reviews showed that a co-occurrence of depression and alcohol use disorder was associated with greater severity and a worse outcome than either condition alone. While this review is the most comprehensive reviews of research on this topic to date, it is still lacking in definitive answers around coexisting depression and alcoholism.

However, there are some differences in outcomes depending on what condition started first.

It seems that the initial presence of depression may be a strong indicator of poor prognosis in co-occurring depression and alcohol use issues. Rego states that if depression exists first, and an alcohol use disorder comes second, it is quite difficult to treat depression even once the patient becomes sober. Soon, each condition develops into two independent issues, each with their own unique challenges.

“Where there used to be one condition, now there are two,” Rego said.

This claim is also backed up in the 2019 review and is observed in treatment centers looking at addiction as well. However, on the flip side, there may be greater success in treatment for depression that was induced by heavy alcohol use but only if depression was never present and there are no genetic factors at play — something that can be hard to determine with certainty.

As I reflect on the research and discussions with Rego, I can see how this was true for my father as well. His depression started when he was quite young. Also, he likely inherited mental health issues from his own father who received electroconvulsive therapy for severe depression that began after he returned from the war.

There are many out there who struggle with depression and alcoholism, yet we don’t yet know enough about the links, risks, and successful ways to treat it. It’s rarely talked about in the general public and, as I mentioned, research on the link is lacking. However, it might be important to look at the differences between alcohol-induced depression and depression-induced alcoholism. Particularly around future research for treatments and diagnosis when depression begins first.

Alcohol-induced depression

Research shows that depression that was ignited by alcohol use has a higher chance of successful treatment than alcohol abuse ignited by depression. However, this type of depression is rare and exists mainly in people with no genetic or previous history of depression.

This condition presents first as a sudden onset of depressive symptoms only after a period of heavy alcohol use. Secondly, these symptoms subside completely within 3–4 weeks of completely stopping alcohol use. In fact, what defines true alcohol-induced depression is the fact that the symptoms resolve after a period of sobriety, Rego says.

If symptoms do not resolve, then likely the depression is a genetically influenced or entrenched condition that existed in the individual prior to the onset of alcoholism. In his practice, Rego says he’s rarely encountered anyone with co-occurring depression and alcoholism who did not already have a predisposition for depression and as such, depression often persists long after the person gets sober.

Depression-induced alcoholism

When alcoholism comes secondary to depression, things get complicated regarding prognosis and treatment, Rego says.

The 2019 review suggests that this may be the most common presentation within the general public, as it is more serious and thus likely to show up in clinical settings. Regardless of whether alcohol use seems to come first or is used as self-medication for depression, an existing precursor for depression makes both conditions highly linked and hard to treat. Research suggests that both conditions may have similar genetic and causal factors as well, which means that alcohol use disorder and depression may trigger each other back and forth resulting in a poor prognosis.

The back-and-forth triggering nature of alcohol abuse secondary to depression seems to fit with what happened to my father as well. Also, both conditions just seem to worsen over time and separate into two distinct problems that exacerbate each other, as Rego has mentioned. Even when my father went to detox and got sober, his depression persisted strongly after he was sober. However, once sober, his depression medications and lifestyle changes seemed to finally help him for quite a few years. Then once a few life stressors took hold, his depression spiraled again, despite whatever treatment he had been on. Soon after, he began drinking again which set off a cascade of worsening alcoholism and depression.

My father’s cause of death was cirrhosis of the liver due to lifelong alcohol abuse. But I always felt that the root cause was this spiraling link between severe depression and his subsequent alcoholism.

Can treatment improve outcomes

In my father’s case, he did show some improvement in both conditions after treatment. His trajectory followed similarly along with what research suggests in that once you safely remove alcohol, you can then tackle depression.

Rego says that once both conditions are present, depression is hard to treat while active alcoholism exists. In his practice, he has often seen that depression medications don’t work properly when heavy alcohol use is present. However, this doesn’t follow a straight line for many people.

Because of this, current research suggests that identifying and treating depression as early as possible is likely the best way to prevent both conditions from igniting and influencing each other. Perhaps a focus on early prevention may stop the spiral sooner. This is obviously easier said than done considering early detection of depression is still challenging.

We also can’t forget that the root causes of depression are still not fully understood either. A multitude of factors contribute to the onset of depression, not just genetics and family history as suggested in the alcohol and depression research. There are clear links between depression and socio-economic factors as well as a history of childhood trauma. Both of these issues are still not getting enough attention in research or treatment discussions. I have found this frustrating when I look back at my father’s story as he suffered serious childhood abuse and struggled to maintain his work and home responsibilities resulting in financial issues as well.

It is clear that co-occurring alcohol use disorder and depression create adverse outcomes. Perhaps there needs to be a concerted effort to research the spiraling nature of these conditions. At least we know that for true alcohol-induced depression, the treatment is to remove alcohol. But for depression-induced alcoholism, the picture is still unclear. However, tackling depression at the earliest stage possible can have favorable outcomes. Therefore, a focus on prevention rather than tertiary treatment may be the way to go. I’m fairly certain this would have made a difference in my father's life and would likely help others as well.

This article is part of a Wise & Well Special Report: The United States of Depression. If you or a loved one is depressed, it’s vital to talk about it. Because depression increases the risk of suicide, consider calling the confidential National Suicide Prevention Lifeline at 1–800–273-TALK (8255) for English, 1–888–628–9454 for Spanish, or call or text 988. Global support in 44 languages is available from Befrienders Worldwide.

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