The Soft Signs of Alcohol and Other Drug Involvement

Patients with comorbid depression and substance abuse are generally more likely to complain about their depression than to express concern about their use of alcohol and other drugs (see Evans & Sullivan, 2001). Some of the "soft signs" of comorbid substance abuse in a patient who otherwise does not volunteer much information about this problem are as follows (the patient may exhibit several of these signs):

1. The patient's attendance is poor. He/she fails to show up for sessions, has flimsy excuses for postponing appointments, and cannot provide convincing answers as to why it took so long to return the therapist's phone calls.

2. After many sessions, the therapist still does not have a clear picture of how the patient occupies his/her time on a daily basis. Upon further questioning, the patient remains vague.

3. A patient who is on prescribed medications for depression complains that the medication is "not working," and that he/she wishes to be off it. The patient summarily blames symptoms such as hypersomnia and general feelings of malaise on the pharmaco-therapy.

4. The patient demonstrates odd changes in vocal quality and/or verbal content on the phone, either in live conversation or on voice mail.

5. The patient is surprisingly reluctant to invite a family member to a therapy session, even when the therapist provides a strong rationale to explain the potential utility of eliciting the family members' observations about the patient.

6. The patient seems impaired in the sessions themselves. He/she may be drowsy, slur words, and demonstrate inappropriate, shifting, and/ or incongruous affect.

These are the sorts of problems to which therapists can allude when they make their gambit to communicate that the patient's depression may actually be complicated by a substance abuse issue. The astute clinician is ever-mindful of drawing data-based conclusions; therefore, endeavors to obtain corroborating evidence before assuming that the apparent signs of substance abuse indeed reflect a verifiable problem with alcohol and other drugs.

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