Co-occurring MDD and Problematic Alcohol Use

Abstract

Mark had been a strong student in high school and was admitted to a good college. During his freshman year, he joined a fraternity and started drinking heavily at least weekly, at times several times a week, with his fraternity brothers. Although he often blacked out from drinking, he was not concerned about it because most of his friends had similar experiences. Despite continuing to engage in heavy drinking throughout his 4 years of college, he was able to reduce his alcohol use during midterms and finals and ultimately graduate with a 3.0 GPA. During junior year, he had his first major depressive episode after his girlfriend broke up with him because of his excessive arguing and "embarrassing" behavior while intoxicated. Mark grew to rely on heavy drinking as a strategy to cope with his low mood. Upon graduating from college, Mark started his own business in sales, which was moderately successful. After college, he experienced several bouts of depression, especially during the winter, which would last several months and typically improve in the later spring or summer. Mark's alcohol consumption pattern remained consistent after college as he continued to drink moderately a few nights during the week and more heavily on weekends. His alcohol consumption did not immediately cause problems at work because he was self-employed and therefore was able to start working later on the days he was hung over. In addition, his job involved seeing clients and going to social events, which often involved alcohol and served to support his continued heavy drinking. Mark continued to affiliate with friends who had similar drinking patterns to his, so he did not consider his alcohol consumption excessive. At age 24, after being arrested for driving under the influence (DUI), he reduced his drinking for a short period of time but resumed his old pattern within 6 months. Mark first presented to therapy at age 27 to seek treatment for depression, reporting moderate to high levels of distress regarding his decreased productivity. Additionally, he reported low mood, low motivation, difficulty sleeping, fatigue, and irritability. He noted that the only thing that would give him pleasure was to go out with his friends "partying." Mark also reported developing tolerance to alcohol, continuing to drink despite complaints from his girlfriend, and not going to work a few mornings each month because of hangovers. In the context of the intake evaluation, Mark was told that he met criteria for both major depressive disorder (MDD) and mild, recurrent alcohol use disorder (AUD). At first, Mark minimized the consequences of his alcohol consumption saying that it was "normal." Mark's clinician was trained in treating co-occurring disorders with an integrated approach and began to address his alcohol use by using techniques consistent with motivational interviewing [1]. Accordingly, during the initial treatment sessions, through the use of MI techniques, the clinician engaged Mark in a discussion about the role of alcohol use in his life and its impact on his goals and mood. Through daily mood and behavior monitoring, it emerged that heavy drinking on a weekday was often followed by lower productivity at work, which would then trigger negative thoughts about himself and low self-esteem. The clinician was then able to highlight the discrepancy between Mark's goal of being productive and successful at work and his drinking behavior. Furthermore, an association between Mark's pattern of heavy drinking on Saturdays and experiencing low mood and feelings of worthlessness on Sundays was acknowledged. Progressively, Mark agreed to reduce his drinking and, through cognitive-behavioral therapy (CBT) techniques, was able to also experience an improvement in depressive symptoms.