Research on psychological therapies provides support for the use of integrated psychological treatments for comorbid depression and AOD use disorders [165, 600]. However, the small number of studies, variation in study results, and small sample sizes used in these studies highlight the need for larger trials to be conducted in this area [601].
The majority of studies to date have examined the use of integrated treatments that adopt a CBT approach [272, 386, 432, 602, 603]. In a review of the literature, Hides and colleagues [601] note that CBT appears to yield superior results for symptoms of depression and AOD use when compared to no treatment, but there is little evidence demonstrating that CBT is more effective when compared with other forms of psychological therapy (e.g., relaxation training, MI, integrated MI/CBT). As a way of enhancing CBT, it has been suggested that CBT be combined with other evidence-based psychological approaches, such as contingency management (see Chapter B5). The combination of CBT plus contingency management has been found to be more effective than either CBT or contingency management alone in the treatment of this comorbidity [418, 604, 605].
Baker and colleagues [386] examined the effectiveness of a brief CBT intervention targeting amphetamine use, and found that a reduction in depressive symptoms accompanied a reduction in amphetamine use, suggesting that interventions designed to reduce AOD use may have promising outcomes for symptoms of depression.
Another approach showing promise in the treatment of comorbid AOD use and depression is behavioural activation. Originally developed in the 1970s, behavioural activation is based entirely on behavioural strategies [606]. The therapy is based on the notion that problems in the lives of vulnerable people reduce their ability to experience positive reward from their environments, leading to symptoms and behaviours characteristic of depression. Behavioural activation aims to activate clients in specific ways that will increase rewarding experiences in their lives. It also focuses on processes that reduce activation, such as escape and avoidance behaviours including AOD use.
There is empirical evidence to suggest that behavioural activation is just as effective in treating depression as combined cognitive and behavioural techniques and antidepressant medication [607, 608]. Behavioural activation has the added benefit of being more time efficient and less complex than most other psychotherapies, and can therefore be delivered by less experienced therapists [608]. Another advantage of behavioural activation is that it incorporates some essential components of AOD treatment, such as social support, emotional expression, reordering of life priorities, stress management, avoidance reduction, symptom control and health education [609].
To date, three small RCTs have found support for the use of behavioural activation among people with AOD use disorders. The first examined the efficacy of adding behavioural activation for depression to standard inpatient AOD treatment among a small sample of illicit drug users with depressive symptoms [610]. The authors found that patients who were randomised to receive behavioural activation demonstrated significantly greater improvements in depression at post-treatment compared with standard care alone. They also reported significantly higher treatment satisfaction scores. The same treatment was subsequently compared with an attention control condition among people in residential AOD treatment, and was found to be superior in terms of treatment retention and levels of activation [611]. A third trial examined the efficacy of behavioural activation paired with standard smoking cessation strategies (including NRT) compared with standard smoking cessation strategies alone (including NRT) [612]. Participants randomised to receive behavioural activation demonstrated greater reductions in depressive symptoms and a higher rate of smoking abstinence than did those randomised to receive standard smoking cessation strategies. Collectively, these pilot studies provide promising support for the use of behavioural activation among individuals with comorbid depression and AOD use, however, further trials are needed. A large RCT comparing the efficacy of behavioural activation added to standard AOD treatment with standard AOD treatment alone is currently underway in Australia.
Lastly, although still in the early stages, there is preliminary support for mindfulness-based relapse prevention in the treatment of co-occurring depression and AOD use [613].