Conclusions

The landmark NESARC has not only confirmed that mood disorders and substance use disorders are prevalent among American adults today, but also that their rates of co-occurrence are clinically significant. The traditional separation of treatment approaches and facilities for mood disorders versus alcohol and other substance use disorders is inadequate to meet the treatment needs of the large numbers of patients with problems in both areas. Furthermore, even when both types of disorders are acknowledged and addressed in a given patient, the notion of "primary versus secondary" disorder may also miss the mark, because mood disorders and substance use disorder tend to exacerbate each other in a vicious cycle. Thus, treatment for such comorbidity needs to be comprehensive to maximize the chances of success.

CT is demonstrably efficacious as a treatment for depression, but only a relatively sparse body of work supports its use in the treatment of substance use disorders. Nonetheless, evidence that CT is more effective than alternative treatments for substance use disorders, specifically when the patients are also depressed, demonstrates the promise of CT as a treatment for "dual-diagnosis" patients.

To adapt CT to the treatment of comorbid mood and substance use disorders, therapists need to keep the following factors in mind. First, a good case conceptualization and a well-established therapeutic alliance are essential to address the sensitive area of alcohol and other substance use. Second, it will likely take therapeutic finesse to engage patients in a therapeutic agenda that places the substance use problem on a par with the depressive disorder. One way of achieving this is to encourage patients to collect data on their use of alcohol and other drugs as part of their ongoing self-monitoring homework. Third, ongoing assessment is vital, because patients' alcohol and other drug-using status can change rapidly, perhaps interfering with treatment itself and increasing the risk of suicidality. Fourth, the risk of premature dropout from therapy is high and must be addressed assertively and preemptively, if possible. Finally, as the case study illustrated, CT can work in a complementary fashion with other treatment approaches, such as medications, group therapy, family therapy, and 12SF. CT can effectively modify the faulty beliefs that may needlessly pit one treatment approach against the other.

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