How well do you know the Wizard of Oz? Chances are you remember that Dorothy is accompanied by the Lion, Tin Man and Scarecrow, but do you remember which one she meets first? Does the Lion help to bring the Tin Man to life? Was it the Scarecrow who tempted the Lion from the forest? Sequence is essential to the story.
Similarly, our life stories develop around causes and effects. You could probably guess that risky sexual behaviors, substance abuse, and depression go together. But which of these lions, tigers and bears are causes and which are the results?
It may seem like a silly question: if risky sex, drugs and depression all eventually tend to get mashed up together, who cares which one comes first? But in fact, this is one of the most important questions in substance abuse treatment and recovery. Think of it like the relationship between heart disease and chest pain: if you treat the pain instead of the underlying cause of heart disease, the pain will come back again and again.
What if, as popular opinion holds, depression is a cause of substance abuse? Do depressed people "self-medicate" with sex or substances in order to feel better, only to find themselves eventually addicted? In that case, treating the substance abuse by itself is like treating chest pain – eventually depression will bring back the symptom of addiction, and the individual will relapse again and again.
Now imagine addiction is the cause and depression is the symptom. In this case, treating addiction kills both birds with one stone – with the cause of addiction gone, so is the symptom of depression. Sure there's some grey area here. For example, maybe it's impossible to treat depression until an addiction is under control. But the heart of the question remains: what is at the root of this combination of challenges you wouldn't wish on the wickedest witch?
The answer comes from a study of 18,924 teenagers, the population in which so many of these challenges start. Which teenagers abstained, who experimented, and who were heavy users? Who was depressed? And how did these behaviors change when measured one year and again the next?
It turns out that teens who experiment with sex and drugs are likely to be depressed a year later. But teens who are depressed are no more likely to have experimented with risky sex and drugs the next year. So much for self-medicating the symptoms of depression; instead, it seems that risky behaviors come first and depression follows.
However, beyond this important headline, the results get trickier. For example, both experimenting and heavy-use of drugs and/or sex among girls led to depression. But among boys, it was only heavy using that increased depression a year later—for some reason, these boys were more resilient to experimentation than girls. And in drug-abstaining girls, depression made them even less likely to experiment a year later, but in girls who were already experimenting, depression made them more likely to transition into heavy use—as if depression further insulated abstainers from temptation and tipped experimenters over a self-destructive cliff.
Of course there are people who buck the trend. There are many individuals who are depressed first and find substance abuse or risky sex second. And there are people with at-risk or even heavy-use behaviors who never become depressed.
The truth is, despite what science shows is usually the case we can rarely know with certainty at the onset of treatment what triggers depression, substance abuse, and risky sexual behavior. And it’s not worth guessing which is the chicken and which is the egg—the consequences are too extreme. Instead, when presented with co-occurring disorders, we find it’s best to treat each as a cause, and treat each psychological and psychiatric disorder concurrently with addiction. Only by peeling back the layers of symptoms until discovering the causes of risky, destructive and terrifying behaviors, can we treat these issues in a way that is truly long-lasting.
Richard Taite is founder and CEO of Cliffside Malibu, offering evidence-based, individualized addiction treatment based on the Stages of Change model. He is also coauthor with Constance Scharff of the book Ending Addiction for Good.