M40 Managing Depressive Symptoms in Substance Abuse Clients During Early Recovery
Part 1 – Chapter 1: Managing Depressive Symptoms in Substance Abuse Clients During Early Recovery
Purpose and scope
CSAT Addiction Counselor Certifications South Africa (ACCSA) manual focused on outpatient treatment (OT) settings.
Concentrates on depressive symptoms in substance use disorder clients, with emphasis on the early recovery phase (the first year).
Not a manual for DSM-IV-TR mood disorders; dedicated to depressive symptoms that accompany substance use disorders. Clients with diagnosed mood disorders require specialized mental health treatment.
Readers should integrate depressive-symptom skills into their practice and maintain collaboration with licensed mental health professionals.
Companion volume (Manual 47) covers clinical issues; this volume emphasizes administrative and organizational aspects.
Terminology and scope of practice
“Substance abuse” in this context covers alcohol and other substances as described by DSM-IV-TR; focus is on symptoms, not diagnostic mood disorders.
Counselors should screen for depressive symptoms and refer for thorough assessment when indicated.
Ethical practice: counselors must work within their licensure, seek supervision, and collaborate with mental health professionals as needed.
Consensus Panel recommendations (highlights)
Screen all substance abuse treatment clients for depressive symptoms.
Be aware of how depressive symptoms manifest in clients and their impact on recovery and treatment participation.
Integrate depressive-symptom care into client-centered substance abuse treatment.
Use multiple intervention methods (behavioral, cognitive-behavioral, supportive, expressive, 12-Step facilitation, motivational interviewing).
Counselor attitudes toward depressive-symptom clients can influence outcomes.
Scope of practice: depression-related symptoms can be addressed by substance abuse counselors in many contexts, with certain exceptions or state-specific restrictions.
Emphasis on collaboration, supervision, and referral when needed.
The Nature of Depressive Symptoms and their relation to substances
Depression exists on a continuum from mild sadness to major depressive disorder; the line is degree-based, not the type of symptom.
Distinguish depressive symptoms from normal sadness; normal sadness is tied to identifiable losses and short-lived, whereas depressive symptoms may be ongoing and impairment-related.
Depressive symptoms can be precipitated by life events (loss of loved one, job, finances), hormonal changes, brain chemistry, and medical conditions (e.g., hypothyroidism, B-12 deficiency).
Substance use and withdrawal can mimic or mask depressive symptoms; substances can both precipitate and worsen depressive symptoms.
Depressive symptoms can precede, follow, or co-occur with substance-use symptoms; integrated treatment is essential when two disorders interact.
Stress is a major risk factor for both substance use disorders and depressive symptoms; address stressors in treatment planning.
Suicidality: individuals with depression and/or substance use disorders are at higher risk; screen for suicidality in all clients with depressive symptoms.
Conceptual framework: integrated care and biopsychosocial perspectives
Integrated care: address both substance-use disorders and depressive symptoms in tandem; treat the client as a whole person.
The manual promotes viewing depressive symptoms as potentially primary (not merely secondary to substance use) and to be addressed directly.
Medications: role of psychoactive medications considered within a broader diagnostic evaluation by qualified clinicians; antidepressants may be effective when depressive disorders are diagnosed, often in conjunction with psychosocial treatment.
The goal is to intervene early to prevent recurrences and relapse during early recovery.
Interventions: a toolkit for depressive symptoms in substance abuse treatment
Major intervention families (Chapter 2):
Behavioral interventions: activate engagement in rewarding activities; example is behavioral activation and activity scheduling (Jacobson, Martell, & Dimidjian, 2001).
Benefits: reduces inertia and avoidance, increases energy and motivation; can be especially helpful in early recovery.
Cognitive-behavioral therapy (CBT): cognition mediates between environmental demands and responses; CBT changes thinking patterns and coping strategies; often a relapse-prevention foundation in substance abuse treatment.
Supportive therapy: focus on reducing symptoms, restoring self-esteem, and building adaptive functioning through empathy, encouragement, and here-and-now relational focus.
Expressive therapies: address and reframe disavowed or distorted feelings to make them constructive for recovery.
Motivational interviewing (MI): client-centered, directive approach to resolve ambivalence toward change; leverages acceptance, support, and discrepancy identification.
12 Steps as a tool: AA-style interventions offer peer support, self-inventory, accountability, and non-judgmental acceptance; steps can be applied to depressive-symptom work (e.g., Step 1 acceptance of powerlessness over depression; Step 2 belief in a power greater than self; Step 4‑inventory of thoughts, feelings, and behaviors).
Choosing among interventions: a flexible toolkit, not a cookbook
There is no one-size-fits-all approach; counselors tailor interventions to client needs, stage of change, culture, and resources.
Build competence gradually; expand the toolkit as confidence grows.
Evidence-based thinking for clinicians
Evidence-based thinking combines research evidence, clinical experience, client needs and values, supervisor input, and contextual constraints.
Remain adaptable to changes in client needs and new information.
The therapeutic relationship and core counseling skills
The therapeutic alliance is central to successful outcomes; it involves trust, empathy, warmth, nonjudgment, and collaboration.
Key skills include reflective listening, empathic understanding, and accurate interpretation.
The relationship supports client engagement in treatment and the capacity to pursue change.
Client-centered, integrated treatment planning
ASAM PPC-2R (ASAM, 2001) is cited as an excellent guide for integrated planning in co-occurring disorders.
Client-centered planning involves collaborative goal setting and education about options and trade-offs.
Integration means planning for both substance-use and depressive-symptom targets, including how depressive symptoms may cue cravings, and monitoring progress in both domains.
The treatment plan evolves with the client and may require revisions as symptoms change.
The role of medications in treating depressive symptoms with substance-use disorders
While pharmacotherapy can help, the manual emphasizes medical diagnostic assessment to determine depressive disorders and appropriate pharmacological treatment.
Evidence shows antidepressants can help depressed patients with substance-use disorders, but medication is most effective when combined with psychosocial interventions and when abstinence is established or underway.
A meta-analytic review indicated antidepressants show modest benefits in this population; medications should be adjuncts to psychosocial therapies and not stand-alone treatments.
The client learning and cognitive processes underpinning change
Depressive symptoms relate to Beck’s cognitive triad: negative views of self, world, and future.
Clients often show automatic distorted thinking (e.g., jumping to conclusions, discounting positives, black-and-white thinking).
Therapists help clients identify and test these thoughts, reframe beliefs, and develop adaptive coping strategies.
Self-efficacy and expectations of change (self-efficacy) are emphasized; strategies include breaking tasks into smaller steps and mental rehearsal.
Countertransference, supervision, and self-care
Counsellors may experience strong emotional reactions to clients who are depressed or suicidal; ongoing clinical supervision is essential.
The manual highlights the importance of counselors separating their own experiences from clients’ experiences and maintaining healthy boundaries and self-care.
The ethical and cultural dimensions of depressive-symptom work
Cultural competence and sensitivity are required when working with diverse client populations; DSM criteria and cultural factors interplay with symptom expression.
Frame issues in culturally specific ways; respect power dynamics, family structures, and communication styles; adjust interventions to fit client culture.
The “whole person” perspective and symptom interrelationships
Treating the whole person means considering biology, thoughts, beliefs, emotions, and behaviors as part of a system.
Symptoms of depressive states interact with substance-use symptoms; depressive symptoms can contribute to relapse or interfere with recovery efforts.
Helping the client see connections among sleep, appetite, energy, and mood can guide effective interventions.
Screening and assessment principles
Screening begins at intake and continues through treatment; integrate substance-use and depressive-symptom assessment.
Screen for suicidality in all clients with depressive symptoms; refer to qualified mental health professionals for diagnostic evaluation.
Examples of screening tools: Centre for Epidemiologic Studies Depression Scale (CES-D; 20-item form; score range 0
ightarrow 60); Beck Depression Inventory II (BDI‑II; 21 items).Screening tools alone do not diagnose mood disorders; clinical evaluation is essential for DSM diagnoses.
Observing client behavior, mood, affect, and participation provides important data beyond self-report.
Assessment and treatment planning workflow (summary)
Intake screening for depressive symptoms; if signs are present, refer for a comprehensive assessment.
DSM-IV-TR mood disorders require a qualified mental-health professional’s evaluation.
If a depressive disorder is diagnosed, coordinate with appropriate clinicians; otherwise manage depressive symptoms within substance-abuse treatment when appropriate.
Use ASAM PPC-2R as guidance for placement and treatment planning across life areas.
Ongoing reassessment to detect emerging depressive symptoms or recurrences; adjust treatment plans in collaboration with clients.
The path to continuing care and treatment termination
Termination should consider potential re-emergence of depressive symptoms; provide anticipatory guidance about relapse risk and recurrence.
Prepare the client for life after counseling; discuss maintenance strategies, and provide crisis resources and a relapse plan.
Reassure clients that depressive-symptom recurrence does not reflect personal failure and can be managed with timely care.
Case-based vignettes (Intro to Part 2)
Vignette 1: Behavioural Interventions (Cherry, 34-year-old, benzodiazepine dependence, heavy drinking, sleep problems, divorce; focus on relationship-building, problem-solving, behavioral activation, and simple stepwise tasks such as a back-porch coffee routine to start the day).
Vignette 2: Cognitive Interventions (John, college student; depressed mood and relationship breakup; focus on negative self-talk, cognitive restructuring; use of thought records and homework to identify automatic thoughts and alternative interpretations).
Vignette 3: Interventions With Core Beliefs (Sally, long-term stimulant use and grief; identify all-or-nothing core beliefs; use belief-challenge strategies to explore alternative life roles such as Teamsters organizer; address grief and self-blame; use experiential discussions to test beliefs).
Vignette 4: Interventions With Feelings (Shirley, multiple divorces, retirement; focus on affective therapy; grief processing; safety, group dynamics; addressing shame and anger; grief work, and creating safety to express distress in sessions.)
The four vignettes illustrate a structured approach to intervention types: behavioural, cognitive, beliefs, and affective therapies. They demonstrate how to build therapeutic alliance, assess readiness, identify goals, test beliefs, and help clients move toward recovery with a combination of strategies tailored to each client’s needs.
Practical takeaways for exam preparation
Be able to explain how depressive symptoms interact with substance-use disorders and why integration matters.
Describe the core intervention families and when to apply them.
Understand the role and limitations of screening tools (CES-D, BDI‑II) and the necessity of clinical assessment for mood disorders.
Articulate how to build and sustain the therapeutic alliance and manage countertransference.
Recall the major stages of change and related MI concepts; recognize the importance of self-efficacy and client empowerment.
Explain the role of medications in co-occurring depressive symptoms and substance-use disorders and the need for proper medical assessment.
Be prepared to discuss organizational considerations for implementing depressive-symptom care in treatment programs (Part II).
Part 2 – Chapter 1: An Implementation Guide for Administrators
Purpose and scope
Guides administrators and supervisors on implementing depressive-symptom care within substance-use treatment programs.
Emphasizes organizational change, readiness, training, supervision, and fidelity to evidence-based practices.
Rationale for implementation
Depressive symptoms are common in treatment populations; addressing them improves engagement, retention, and outcomes.
Benefits include enhanced staff competence and better cross-disciplinary collaboration, risk management, and potential funding opportunities.
Organizational change framework (conceptual parallels to client treatment)
Change is a process; implementation has stages: exposure, adoption, implementation, and routine practice (institutionalization).
Six key factors influence implementation success: population/community fit, staff capabilities/licensure, facilities/resources, policies/procedures, regulations, interagency networks, and reimbursement.
Distinguish between paper implementation, process implementation, and performance implementation. The goal is to achieve true performance implementation (tangible client outcomes).
Foster an organizational climate that supports risk-taking, ambiguity tolerance, and continuous improvement; celebrate progress and learn from setbacks.
The Change Book and implementation science references
The Change Book (ATTC, 2004) and Fixsen et al. (2005) synthesis on implementation research are foundational.
Use the Fixsen framework to guide assessment, capacity building, training, supervision, and fidelity measurement.
Readiness assessment and planning (How-To framework)
How-To 2.1–2.6 cover assessment of organizational readiness, team formation, and readiness checks.
Key questions for readiness include alignment with mission, staff turnover, training needs, policies to update, facilities, regulations, and interagency relationships.
Team organization: appoint a lead, secure CEO buy-in, assemble an implementation work group including consumer/family representatives, clinical leaders, and administrative leaders.
Establish an oversight committee to receive findings and guide strategic decisions.
Determine what resources are needed, including funding, training, supervision, and partnerships.
Develop a plan for adoption and addressed outcomes; identify existing strengths that can serve as foundation.
Assessing organizational readiness and planning for change (What to evaluate)
Consistency with mission; obstacles (staff turnover, funding, policy changes, facilities, regulations).
Opportunities created (new funding, collaboration, community relations).
Determine the organization’s stage of change and plan adoption steps accordingly.
Identify internal and external resources to support change; ensure alignment with stakeholders’ needs.
Policies, procedures, and fidelity for depressive-symptom care
Sample policies 1–6 provide templates for staff training, recruitment, screening and referrals, treatment planning, discharge planning, clinician performance appraisal, and quality assurance.
Plan for modifying existing policies to accommodate depressive-symptom care; ensure alignment with state regulations and licensure requirements.
Fidelity checklists (Appendix C) help monitor adherence to active elements of the intervention and prevent drift.
Emphasize integration: depressive-symptom treatment should be coordinated with substance-abuse treatment; ensure joint development of treatment plans and shared information with appropriate confidentiality.
Staffing, training, supervision, and organizational capacity
Distinguish four staff groups: administrative/support, clinical staff, counselors designated to manage depressive symptoms, and clinical supervisors.
Checklists (1–4) outline competencies across these groups and can identify gaps in training or supervision needs.
Training recommendations include MI, CBT, IPT, and supportive-expressive approaches; emphasis on building therapeutic alliance, managing resistance, and handling suicidality.
Recommendations for trainer credentials and continuing education; supervision should include direct observation or taped sessions; regular booster trainings are advised.
Financing, community relationships, and continuity of care
Reimbursement considerations: depressive-symptom services can often be billed under substance-use diagnoses; clarify payer requirements.
Explore new funding opportunities (foundations, grants); consider partnerships with universities for research funding.
Develop community referral networks and collaboration with mental-health providers; create a culture of cross-disciplinary care and continuity.
Maintaining fidelity and organizational continuity
Fidelity is essential; use the fidelity checklists to maintain adherence to the active elements of depressive-symptom interventions.
Plan for ongoing supervision, updates, and booster trainings to sustain changes and prevent drift.
Institutionalization occurs when new practices become routine; maintain a culture of continuous quality improvement.
Implementation challenges and strategic considerations
Avoid drift by maintaining alignment with evidenced-based practices; allow for local adaptations only within fidelity constraints.
Monitor outcomes (dropout rates, depressive-symptom reductions, referrals to QMHP, relapse rates) and adjust as needed.
Address cultural competence and diverse learning styles; tailor implementation to the agency’s client population and workforce.
The Sample Policies (high-level overview)
Policy 1: Clinical staff training and competency – mandatory depressive-symptom screening and training.
Policy 2: Recruitment, training, supervision – designate positions; standardized training and ongoing supervision.
Policy 3: Screening and referral – intake depressive-symptom screening; referral procedures to QMHPs.
Policy 4: Treatment planning, recording, discharge – integrated treatment planning and documentation; cross-team communication.
Policy 5: Counsellor performance appraisal – link to depressive-symptom competencies.
Policy 6: Evaluation and quality assurance – annual reporting on depressive-symptom service effectiveness.
Appendices and tools for implementation
Appendix B: CES-D scale (including the 20 items and scoring sheet).
Appendix C: Fidelity checklists for general principles and specific interventions (behavioral, cognitive, beliefs, affective).
Appendix D: DSM-IV-TR mood disorders definitions (Major Depressive Episode, Dysthymic Disorder, Bipolar disorders, Substance-Induced Mood Disorder, Mood Disorder due to medical condition, Adjustment Disorder With Depressed Mood).
Appendix E–F: Advisory panel and field reviewers, documenting peer and regulatory review processes.
Strategic implications for administrators (exam-ready points)
Organizational readiness and climate are as important as clinical efficacy; leadership must model change, communicate a clear vision, and provide resources.
Regular evaluation and feedback loops (formative evaluation) are essential for sustaining change.
Build strong clinical supervision structures to bridge administration and frontline practice.
Part 3 – Managing Depressive Symptoms: A Review of the Literature
Part overview and goals
Synthesizes clinical and administrative literature on depressive symptoms in substance-use contexts.
Distinguishes depressive symptoms from diagnosable mood disorders; treats depressive symptoms as a continuum with major depression.
Highlights epidemiology, nosology, comorbidity with substance-use disorders, and treatment modalities.
Definitions: depressive symptoms vs mood disorders
Subthreshold depressive symptoms (minor depression) exist on a continuum with major depressive disorder; they may impair functioning and predict risk for major depression.
Various classifications (RDC, DSM-IV-TR criteria) define non-major depressive disorders with varying thresholds (e.g., 2–4 of 9 criteria; mood disturbance plus impairment).
Subclinical depressive symptoms are clinically meaningful and may warrant intervention, especially in substance-use populations.
Epidemiology and nosology
Minor depression lifetime prevalence estimates vary; some studies place mild depression around 8–11% in certain populations, with rates differing regionally.
A notable finding: subthreshold depressive symptoms correlate with increased risk of later major depression; the trajectory appears to be dynamic rather than fixed.
Gender and cultural differences exist in presentation and prevalence; some data show higher rates of depressive symptoms in women across many studies.
About 75% of persons with mild depression report more than one depressive episode over time; impairment varies with the number of symptoms.
Comorbidity with substance-use disorders and outcomes
Prior substance-use disorders increase the odds of mild depression; comorbidity is common and clinically significant.
In clinical samples (e.g., Project MATCH), elevated depressive symptoms predict poorer treatment engagement, higher dropout, and poorer early outcomes; effects may attenuate with sustained treatment and targeted interventions.
In polysubstance-use samples, higher depressive symptoms at intake predict lower abstinence at discharge, even after controlling for other factors.
Some studies show that depressive symptoms during treatment predict relapse risk and poorer long-term outcomes; others suggest certain treatments (e.g., CBT-based or interpersonal therapies) can improve both mood and substance-use outcomes.
Treatments and modalities for depressive symptoms in substance abuse settings
Psychotherapy modalities (CBT, IPT, MI, supportive-expressive) show efficacy for depressive symptoms in general and when combined with substance-use treatments.
Pharmacotherapy (antidepressants) can be beneficial, particularly in individuals with diagnosed depressive disorders or subtypes; however, antidepressants are typically most effective when combined with psychosocial interventions and after a period of abstinence or reduced use.
Meta-analyses indicate antidepressants have modest effects in patients with comorbid depression and substance-use disorders; psychotherapy often enhances outcomes alongside pharmacotherapy.
Nonpharmacologic strategies with some evidence include aerobic exercise and coping with depression (CWD) programs; evidence is stronger for structured behavioral activation and cognitive-behavioral approaches.
Subclinical depressive symptoms have less robust evidence for standalone pharmacologic or psychological treatments; interventions like CWD show promise but are not universally curative for subthreshold depression.
Subclinical depressive symptoms and specific populations
Several studies indicate gender differences in the relationship between depressive symptoms and substance-use problems; depressive symptoms may interact differently with drinking patterns in men vs. women.
Some subpopulations (e.g., methamphetamine users, gay/bisexual men) show particular patterns in depressive symptoms and cravings, often modifiable with targeted psychosocial interventions.
Implementation and organizational implications from the literature
Despite evidence of benefit, gaps exist between research and practice; effective implementation requires organizational readiness, clinician training, and fidelity to evidence-based practices.
The literature emphasizes the importance of adaptable, multi-modal treatment packages that address mood and substance-use issues in tandem rather than isolation.
Key quantitative references and takeaways (illustrative, representative data)
Minor depression prevalence (NCS): around 0.10 (10%) lifetime in general population; subthreshold depressive-symptom syndromes show substantial impairment and relapse risk.
In Project MATCH, elevated Beck Depression Inventory (BDI) scores predicted more drinking in month 1 but not in months 2–3, suggesting early engagement challenges; depressive-symptom trajectories can shift with treatment.
Across several studies, depressive-symptom severity at intake and during treatment predicted relapse risk, dropout, or reduced abstinence; pharmacotherapy combined with psychotherapy improved outcomes in some samples.
A meta-analysis by Nunes & Levin (2004) found antidepressants have a modest beneficial effect for patients with co-occurring depression and substance-use disorders; best results observed when combined with psychosocial interventions and after a short period of abstinence.
Substantive conclusions from Part 3
Elevated depressive symptoms impair recovery from substance-use disorders and predict relapse and dropout when not adequately addressed.
There is growing consensus that depressive symptoms exist on a continuum with diagnosable depression, and interventions should consider subthreshold presentations.
Effective treatment typically combines psychotherapy with pharmacotherapy, adapted to the patient’s severity, stage, and comorbidity.
Part 4 – Appendices and Tools
Appendix B: Centre for Epidemiologic Studies Depression Scale (CES-D)
20-item self-report scale; asks respondents to rate symptom frequency over the past week.
Items cover mood, anhedonia, sleep, sleep quality, appetite, energy, concentration, feelings of hope, guilt, irritability, social engagement, and suicidal thoughts.
Scoring: items are typically summed to yield a total score in the range 0-60.
The CES-D is not a suicidality instrument; suicidality requires separate assessment.
Appendix B provides the actual item wording and the scoring table.
Appendix C: Fidelity Checklists
Fidelity Checklist 1: General underlying principles (respect, understanding, strengths-based approach, follow-up, etc.).
Fidelity Checklist 2: Behavioral interventions (identify changeable behaviors; set achievable goals; involve supports).
Fidelity Checklist 3: Cognitive interventions (identify automatic thoughts; test accuracy; develop alternative explanations).
Fidelity Checklist 4: Beliefs interventions (test core beliefs; elicit alternatives; connect beliefs to behavior and feelings).
Fidelity Checklist 5: Affective interventions (identify painful feelings; create safe space; address defenses and grief resolution).
Appendix D: DSM-IV-TR Mood Disorders (high-level DSM criteria)
Major Depressive Episode/Major Depressive Disorder: depressed mood or anhedonia for at least 2 weeks with ≥5 of 9 specified criteria; functional impairment.
Dysthymic Disorder (Persistent Depressive Disorder): depressed mood most of the day for most days over at least 2 years with at least two other symptoms.
Bipolar Disorder: includes distinct manic/hypomanic episodes; subtypes 1, 2, cyclothymia.
Substance-Induced Mood Disorder: mood disturbance attributable to substance effects or withdrawal.
Mood Disorder Due to a Medical Condition; Adjustment Disorder with Depressed Mood; and other psychiatric conditions in which depression can be a symptom.
Appendix E–F: Advisory Meeting Panel and Field Reviewers
Documentation of experts contributing to the manual; indicates a broad, multidisciplinary review process.
Key numerical and definitional takeaways to memorize for exams
Depressive symptoms are common in substance-use-treatment settings; up to around half of clients may present with depressive symptoms at intake or during early recovery. Represented as a rough estimate in the text (≈50%).
CES-D: 20-item scale; score range 0-60; used to monitor depressive symptom changes over time.
DSM-IV-TR mood disorders include Major Depression, Dysthymia, Bipolar Disorder, Substance-Induced Mood Disorder, Mood Disorder due to a medical condition, and Adjustment Disorder with Depressed Mood.
The Stages of Change (Prochaska & DiClemente): Precontemplation → Contemplation → Preparation → Action → Maintenance.
When antidepressants are used in substance-abuse populations, they show modest benefits on average; most effective when combined with psychotherapy and after an initial period of abstinence.
The ASAM PPC-2R model guides cross-discipline placement and treatment planning for patients with co-occurring substance-use and depressive symptoms.
Integration and exam-ready synthesis
The material emphasizes that depressive symptoms should be treated in an integrated, client-centered, and evidence-based manner within substance-use treatment.
Organizational readiness, staff competencies, fidelity, and supervision are critical for successful implementation of depressive-symptom interventions in treatment facilities.
The four vignettes (Cherry, John, Sally, Shirley) illustrate concrete applications of behavioral, cognitive, beliefs-based, and affective interventions, highlighting the importance of the therapeutic alliance, client goals, and adaptive testing of beliefs and feelings.
Real-world relevance and ethical considerations
Ethical responsibility to refer for mood-disorder diagnoses when appropriate; maintain collaboration with mental-health professionals.
Culturally competent practice is emphasized; understanding cultural beliefs about depression, stigma, and help-seeking influences engagement and outcomes.
The manual underscores the need for ongoing supervision, self-care for counselors, and robust organizational supports to sustain changes in clinical practice.
Exam-friendly connections and takeaways
Define depressive symptoms and distinguish them from mood disorders; understand why screening and referral are essential.
Be able to list and describe intervention families (behavioral activation, CBT, IPT, MI, supportive/expressive therapies, and leverage of 12-Step resources).
Explain integrated treatment planning and how depressive symptoms can cue cravings; understand ASAM PPC-2R usage for planning.
Recall the role of medications in comorbid depressive-symptom and substance-use populations and why medical evaluation is essential.
Explain the organizational steps for implementing depressive-symptom care in an outpatient program, including readiness assessment, team formation, policy development, training, supervision, and fidelity monitoring.
Quick reference formulas and scales to remember
CES-D total score range: 0 o 60.
Depressive symptom thresholds and DSM criteria are described in Appendix D (DSM-IV-TR mood disorders); memorize how subthreshold symptoms relate to full mood disorders and relapse risk.
The Stages of Change model stages: Precontemplation, Contemplation, Preparation, Action, Maintenance.
Depressive-symptom–treatment outcomes in the literature often show that integrated care improves engagement and reduces relapse risk, though medication effects are typically modest and best when combined with therapy.
Final exam pointers
Understand the rationale for treating depressive symptoms in substance-use treatment and the risks of neglecting mood symptoms during early recovery.
Be able to discuss how to assess suicidality and when to refer for psychiatric evaluation.
Be prepared to describe how to structure a client session around the four vignette focus areas (behavior, thoughts, beliefs, feelings) and how to incorporate MI, CBT, IPT, and supportive interventions.
Explain the role of organizational readiness and fidelity in sustaining depressive-symptom interventions beyond pilot phases.