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Treatment Planning for Depression
Based in part on TIP 48: Managing Depressive Symptoms in Substance Abuse Clients During Early Recovery
Dr. Dawn-Elise Snipes
Executive Director:

– Identify instruments to guide treatment planning
– Identify the causes of depression
– Identify behavioral interventions
– Identify cognitive interventions
– Identify emotional Interventions
Effects of Depression on Treatment
– The client with depressive symptoms may have difficulty in any or all of the following areas:
– Ability to follow instructions and keep appointments.
– Ability to focus and benefit from group
– Energy to participate in program activities.
– Motivation for change.
– Ability to make appropriate decisions about treatment needs and goals.
– Belief that he or she can be helped.
– Responsiveness to reinforcements.
– Ability to handle feelings.
– Ability to handle relations with others.
– Ability to attend to (and not disrupt) group activities.
– Ability to avoid relapse after treatment is completed.

Placement Issues
– Acute crisis and dangerousness to be stabilized #1
– Biomedical conditions and complications #2
– Emotional, behavioral or cognitive issues (See assessment instruments, next slide)
– Readiness for change for EACH issue/objective
– Improve mood
– Address sleep hygiene
– Improve nutrition
– Reduce caffeine
– Increase exercise
– Relapse or continued problem potential
– Recovery environment
Screening Instruments: Emotional
– Severity Measure for Depression, Adult(Patient Health Questionnaire [PHQ-9])
– Zung Self-Rating Depression Scale
– Center for Epidemiologic Studies Depression Scale (CES-D), NIMH
– Severity of Posttraumatic Stress Symptoms, Adult (National Stressful Events Survey PTSD Short Scale [NSESS])
– Severity Measure for Generalized Anxiety Disorder, Adult

Screening Instruments: Cognitive
– Attributional Style
– Hardiness and Perceived Stress Scales
– Stress Awareness/Hardiness
Causes of Depression
– Biochemical imbalance
– Norepinepherine (focus, motivation)
– Glutamate (energy)
– Serotonin (contentment, relaxation, pain, sleep, hunger, heart rate)
– Dopamine (motivation, memory, focus, pain, energy)
– Thyroxine
– Sex hormones
– Cortisol

Causes of Depression
– What is causing the biochemical imbalance
– Physical
– Lack of quality sleep
– Exhaustion/burnout/ “stress”
– Poor nutrition
– Chronic pain
– Diabetes
– Vitamin D deficiency
– Anemia
– Other illnesses such as MS, lupus, fibromyalgia, chronic fatigue, lyme disease, stroke…
Causes of Depression
– What is causing the biochemical imbalance
– Physical
– Side effects of medications
– Varenicline (smoking cessation)
– Statins (cholesterol)
– Hormone-based birth control
– Interferon (cancer, hepatitis)
– Heart medications (beta blockers, calcium channel blockers)
– Anticonvulsants
– Singulair (Asthma) (BBW 3/2020)
– Isotretinoin (acne)

Interventions Physical
– Changing Behaviors
– Identify a behavior that can be addressed:
– Keep it simple and achievable.
– Break big problems down into smaller, achievable components.
– Identify the goal (outcome) the client would like to achieve:
– Make the goal measurable so the client can know when he or she has achieved it.
– Explore ways the client has achieved similar goals in the past.
– Identify barriers (internal and environmental) to success and identify what parts the client can control.
– Identify how those barriers can be overcome in specific behavioral terms. Make addressing the barrier something to do, rather than something not to do.
– Identify supports and specific steps needed to achieve success
– Elicit a commitment and take action to achieve the goal

Interventions: Physical
– Get a physical to rule out hormone imbalances, physical issues causing lack of energy, fatigue, difficulty concentrating, sadness, irritability
– Address nutrition to provide building blocks
– Cut out caffeine 12 hours before bed
– Stay hydrated
– Improve sleep hygiene and sleep 7-9 hours each night without waking
– Get moderate exercise 30 minutes a day
– Get more sunshine 5-15
– Review medications for side effects
– Address chronic pain with TENS, massage, stretching, meditation, acupuncture, mild to moderate exercise, hot or cold pads, ergonomics (work, sleep, sofa)
– Consider pharmacological interventions

Causes of Depression
– What is causing the biochemical imbalance
– Emotional
– Depression
– Lack of pleasure
– Stress
– Anger
– Fears activating the HPA Axis
– Abandonment/isolation/rejection
– Failure
– Loss of control
– Emotional dysregulation
Emotional Interventions
– Keep a daily log of nutrition, sleep, things that trigger emotional distress and ways you cope, and share with your counselor to identify patterns, themes and effective interventions
– Develop a stress management plan
– Identify methods that help you deal with anger, anxiety and depression
– Do things that make you happy
– Address guilt (Understand guilt as anger, Address “necessary guilt,” Guilt bill of rights)
– Address grief
– Learn distress tolerance skills to assist in distress
– Focus on the positive for 20 minutes per day
Causes of Depression
– What is causing the biochemical imbalance
– Cognitive
– Cognitive distortions
– All or nothing
– Availability heuristic
– Emotional reasoning
– Personalization
– Overgeneralization
– Jumping to conclusions
– Magnification and minimization
– Negative global, stable attributions
– Extremely internal or external locus of control
– Ineffective problem solving skills (
Addressing Negative Self Talk & Cognitive Distortions
– Identify the situations that make the client feel uncomfortable. (Asking someone out, job interview, seeing a cop)
– For each uncomfortable situation, make a list of the uncomfortable feelings the client experienced
– Ask the client to identify the first thought that comes to mind when he thinks of the uncomfortable situation. Then identify other thoughts that often arise with this situation. Try to identify a theme from the thoughts. (ABCDEs)
– Identify how the thought(s) limits the client’s options in life.
– Help the client identify different ways of thinking about the situation that can lead to better options.
– Explore the impact of the new way of thinking on emotional responses and thoughts

Interventions: Cognitive
– 5 steps to challenge beliefs that limit options for change:
– Listen to the client’s beliefs about the problem
– Help the client reframe the belief from a truth (unchangeable) to a thought (changeable)
– Help the client alter beliefs to include options for changing the problem or changing reactions to the problem. (What parts of this situation or your reaction can you change to improve the next moment?)

Interventions: Cognitive
– Learn about the connection between thoughts, feelings and actions
– Identify and address/challenge cognitive distortions with
– Daily distortions logs
– Worksheets and videos
– Learn about attributions and address negative global, stable attributions
– Keep a log of negative, global, stable attributions and restructure them to be more specific and changeable. (Group: Thoughts basket)
– Learn about locus of control and how to moderate an extremely internal or external locus of control
– Keep a log of stressors or things that make you feel helpless and hopeless and identify what parts are within your control and what parts are not.
– Develop effective problem solving skills based on the problems that trigger your depression (Start by reading 7 Habits)
– Increase feelings of self-efficacy
Causes of Depression
– What is causing the biochemical imbalance
– Social
– Lack of social support
– Interpersonal conflict (Friends, family, work, social media)
– Interpersonal losses
– Ineffective communication skills
– Poor self-esteem
Social Interventions
– Learn about healthy relationships
– Identify healthy relationships you currently have
– Improve self esteem (your relationship with yourself)
– Identify issues that need to be addressed in current relationships to make them healthy
– Identify 3 people with whom you could develop a healthy support system
– Learn skills to handle conflict
– Learn effective communication skills
– Learn how to ask for what you need
Causes of Depression
– What is causing the biochemical imbalance
– Situational
– Losses (grief)
– Relationships
– Death
– Freedom
– Dreams
– Sense of order in the world (control/hope)
– Self-esteem
Causes of Depression
– What is causing the biochemical imbalance
– Environmental
– People in the environment
– Noise
– Toxins/allergens
– Sensory overload or deprivation
– Depression triggers
Interventions: Environmental
– Develop strategies to increase positive people and buffer against negative people in the environment
– Address noise with white noise machines, ear plugs, talking to roommates
– Eliminate toxins/allergens that may be making you feel depressed (fresh paint), or keeping you from sleeping well
– Create a calming corner in your house and at work where there isn’t too much (or too little) stimulation, and there are triggers for happiness
– Depression can impact almost any area of functioning
– Depressive symptoms are on a continuum and can wax and wane
– Treatment planning needs to be individualized to address:
– Acute crisis and dangerousness
– Biomedical conditions and complications
– Emotional, behavioral or cognitive issues
– Readiness for change for EACH issue/objective
– Strengths for addressing each issue
– Break larger tasks into chunks
– Relapse or continued problem potential
– Stage of readiness for change
– Recovery environment