Comorbidity of substance use with depression and other mental disorders: from Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) to DSM-V

By: Edward V. Nunes & Bruce J. Rounsaville

From: Addiction. Sep2006 Supplement, Vol. 101, p89-96. 8p. (ISSN: 0965-2140)

DOI: 10.1111/j.1360-0443.2006.01585.x

Keywords: comorbidity, depression, diagnostic criteria, DSM-IV, DSM-V, mental disorder, substance use disorder


The American Psychiatric Association’s panel creating the DSM-V.


“To arrive at recommendations for addressing co-ocurring psychiatric and substance use disorders in the development of the Diagnostic and Statistical Manual of Mental Disorders fifth edition (DSM-V) criteria.” (page 89)

In other words, to help improve the DSM-V’s diagnostics and definitions for psychiatric disorders related to, or happening at the same time as, substance use.

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Because some mental disorders (particularly depression) are linked to substance (i.e. “drug”) use, it can be difficult for the psychiatrist to distinguish a disorder that exists without the substances (i.e. a “primary” or “independent” disorder) and one that is caused by the substance (i.e. a “substance-induced” disorder). This paper covers problems with terminology as well as the methodology used to diagnose disorders that occur at the same time in someone who uses substances.

A large portion of this paper recounts changes in terminology and diagnostics from the DSM-I to the DSM-IV.

In fact, their whole argument can be broken down into five different suggestions for the DSM-V:

  1. For independent disorders, specify whether a past independent episode counts toward an overall independent diagnosis if the current episode would otherwise be considered substance-induced, or whether a past independent episode should be noted separately but not influence the diagnosis of the current episode; the latter preserves more information and encourages a careful lifetime history, and is thus perhaps preferable.

  2. For substance-induced disorders, (a) require that the full criteria for a syndrome, such as major depression, to be met; (b) require that each of the component symptoms entering into a diagnosis be shown to exceed the usual effects of the substances involved; and (c) suggest guidelines for making those distinctions.

  3. Consider a more neutral terminology, such as ‘substance- associated’ or ‘substance-related’, that does not carry the causal implication of ‘substance-induced’. […]

  4. Identify both substance-induced syndromes otherwise meeting full syndromal criteria (e.g. ‘substance-induced major depression’), and subsyndromal disorders (e.g. ‘substance-induced subsyndromal depression’).

  5. Consider features of substance-induced syndrome criteria that may be specific to particular substances or syndromes, particularly the more common depressive or anxiety syndromes as opposed to psychosis.

(pg. 93)

Their recommendations want to make sure that, if someone is diagnosed with a disorder, they meet all of the criteria for that disorder, and that terminology does not imply a causal relationship when it doesn’t exist.

Potential Uses

Understanding “Addiction”

This paper was originally collected among a selection of papers about addiction and video game addiction. Basically, the DSM-V (which came out in 2013) changed what many know as “addiction” to “substance use disorder”. This new term discounts any “addictive” activity that doesn’t include ingesting foreign substances, such as gambling. However, the reasons for this change has many other uses, and this paper gives a background of the changes in terminology from the DSM-I all the way to the DSM-IV, which should help students better understand the differences.

featured image “Addiction” by Kaushik Narasimham

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