New training guidelines from federal mental health officials aim to improve
the treatment of addiction patients who are displaying depressive symptoms
that fall short of diagnosable depression.
"Treatment Improvement Protocol (TIP) 48: Managing Depressive
Symptoms in Substance Abuse Clients During Early Recovery" was issued in
April by the Center for Substance Abuse Treatment, an agency of the Substance
Abuse and Mental Health Services Administration, to offer best-practices
guidelines for substance abuse counselors, most of whom are not licensed to
The new TIP is geared toward clinicians working in public and private
treatment facilities, as well as clinical supervisors in the mental health,
criminal justice, primary care, and other health care settings. The
publication is designed to enhance the training of substance abuse treatment
counselors, including describing for them the best ways to work with patients
with depressive symptoms, how to screen and assess such patients, and when to
refer patients with diagnosable depression for medical treatment.
This information is expected to be very helpful to many people in the
addiction treatment field. "Given the high prevalence of depressive
disorders among substance abusers, this TIP addresses a very common problem
seen by clinicians," said Marc Galanter, M.D., a leading expert in
addiction treatment, in an interview with Psychiatric News.
The TIP is not intended to help its target audience—substance abuse
counselors—diagnose or treat depressive illnesses that are of a severity
that qualify them for a DSM-IV diagnosis, because doing so would be
outside of their scope of practice. The counseling recommendations described
are, however, "legally and ethically appropriate for substance abuse
counselors to undertake in all 50 states and the District of Columbia,"
the TIP points out.
The new guidelines were developed because depressive symptoms can interfere
with the recovery of substance abuse patients and their ability to participate
in treatment, according to the TIP's authors. Problems caused by depressive
symptoms in treatment can, for example, include poor concentration that can
interfere with group-therapy sessions or participation in a 12-step
The TIP focuses on the first year of recovery from addiction, which is when
depressive symptoms are particularly common.
Chapters describe topics such as the nature of depressive symptoms, their
relationship to withdrawal effects, suicidality in people recovering from
substance abuse, how depressive symptoms affect treatment participation, and"
approaches and psychosocial interventions" for substance abusers
with depressive symptoms.
A literature review of studies on depressive symptoms is included in the
TIP and focuses on research that addresses both clinical and administrative
issues in the care of substance abuse patients with depressive symptoms.
The TIP stemmed from clinical research and the experience of clinicians
pointing to the fact that many substance abuse patients have depressive
symptoms. A 2002 national survey found that 40 percent of people with alcohol
use disorder who were treated for substance abuse also had a mood disorder
independent of their alcohol use. The survey found that 60 percent of people
with a substance use disorder not related to alcohol use had an independent
"These findings indicate that it is likely you will encounter clients
with substance use disorders who have depressive symptoms—as many as
half of the clients you see," according to the TIP, which was approved
by an advisory board of clinicians led by Richard Rosenthal, M.D., a professor
of clinical psychiatry at Columbia University College of Physicians and
Among the recommendations of the experts who wrote the TIP are the
"TIP 48: Managing Depressive Symptoms in Substance Abuse
Clients During Early Recovery" is posted at<www.kap.samhsa.gov/products/manuals/tips/pdf/TIP48.pdf>.▪