Major depression among methamphetamine users entering drug treatment programs

Rebecca McKetin, Daniel I Lubman, Nicole M Lee, Joanne E Ross and Tim N Slade
Med J Aust 2011; 195 (3): S51. || doi: 10.5694/j.1326-5377.2011.tb03266.x
Published online: 1 August 2011


Objective: To determine the prevalence of major depression among people entering treatment for methamphetamine use.

Design, setting and participants: The study was a cross-sectional survey involving 41 specialised drug and alcohol treatment agencies in Brisbane and Sydney. Services provided by these agencies included residential rehabilitation, detoxification and counselling. Participants were 400 people entering treatment for methamphetamine use who were recruited from participating treatment agencies between January 2006 and November 2007. Participants underwent a structured, face-to-face, 1.5-hour interview. Assessment instruments included the Composite International Diagnostic Interview and the Short Form 12.

Main outcome measure: Diagnosis of a major depressive episode in the year prior to the study.

Results: The prevalence of major depression in the year prior to the study was 40% (95% CI, 35%–44%). A noteworthy post-hoc observation was that a further 44% of participants met the symptom criteria for major depression but were excluded from a diagnosis because their symptoms were better accounted for by psychoactive substance use. Both major depression and these latter cases of “substance-induced depression” were associated with severe symptoms of depression, high levels of disability and suicidal ideation.

Conclusion: Most people entering treatment programs for methamphetamine use have levels of depression that require clinical management. Making a diagnosis of major depression in the context of heavy methamphetamine use is problematic because of substance-induced symptoms of depression.

Psychotic phenomena are often considered to be the hallmark psychiatric sequelae of methamphetamine use, but depressive symptoms are far more common and can be severe and debilitating among heavy users of the drug.1,2 Although depression is not an uncommon phenomenon in drug-dependent populations,3 methamphetamine directly affects monoamine regulation within the brain, producing a pseudodepressive state that encompasses many of the features of major depression (ie, low mood, anhedonia, fatigue, sleep disturbance, appetite changes, lack of motivation, restlessness, irritability and poor concentration).4,5

If left untreated, depression can reduce adherence to drug treatment, increase the risk of relapse to stimulant use and elevate the risk of suicide.6,7 Despite this, there are no available estimates for the prevalence of major depression among methamphetamine users who enter treatment programs. Previous research has reported high levels of depressive symptoms among dependent methamphetamine users,7 and one study screened for major depression,6 but no studies have assessed the prevalence of major depression using a validated psychiatric assessment instrument. This makes it hard to determine the extent to which depression among methamphetamine users requires clinical management.

The aim of our study was to determine the prevalence of major depression over the previous 12 months in a population of dependent methamphetamine users. We used data from the baseline phase of the Australian Methamphetamine Treatment Evaluation Study, which assessed psychiatric comorbidity in a cohort of methamphetamine users entering specialised drug and alcohol services within the community.

Participants and recruitment

Participants (n = 400) were recruited on entry to participating drug treatment agencies, which were selected from agencies contributing data to the Alcohol and Other Drug Treatment Services National Minimum Data Set. This includes all publicly funded government and non-government agencies that provide specialist treatment services to people with alcohol and other drug problems. Agencies providing counselling, residential rehabilitation and detoxification were included, but those providing assessment only, case management only or other services (eg, education) were excluded. Forty-one agencies were included in the recruitment pool — 26 in the Sydney region and 15 in the Brisbane region. These agencies included 15 outpatient counselling services, 13 residential rehabilitation facilities, 11 detoxification units and two services that provided both detoxification and residential rehabilitation.

Participants were eligible if they were entering treatment with methamphetamine or amphetamine use as a primary or secondary drug problem (78% reported it to be their primary drug problem). Participants had to be at least 16 years of age, willing to do follow-up interviews, and able to understand English. They were excluded if, in the previous month, they had been incarcerated, had received treatment for their methamphetamine use, or had received any form of inpatient drug treatment. This exclusion criterion was necessary to obtain a naturalistic baseline measure of pretreatment methamphetamine use.

Participants were recruited between January 2006 and November 2007. A further 195 prospective participants were screened but found ineligible, mainly because they had been in treatment (58%) or incarcerated (28%) during the previous month, or had declined participation in the study (10%).

The main treatment modalities received by participants in the final sample were residential rehabilitation (n = 211), withdrawal management (n = 149) and counselling (n = 40).

All participants were volunteers who provided informed consent and were reimbursed $30 for their time and travel expenses.

Major depression

The CIDI was used to establish a diagnosis of a major depressive episode in the preceding 12 months, based on criteria specified in the Diagnostic and statistical manual of mental disorders, 4th edition (DSM-IV).9 The CIDI is a fully structured, lay-administered interview schedule that has been validated against clinician-administered psychiatric interview schedules and is widely used in epidemiological studies.10 In order to meet the DSM-IV criteria for a major depressive episode, five or more symptoms of depression must have been present during the same 2-week period and represent a change in functioning, and one of the symptoms must be either depressed mood or loss of interest/pleasure (Criterion A); the symptoms must not meet criteria for a mixed episode (Criterion B); the symptoms must cause clinically significant distress or impairment (Criterion C); the symptoms must not be due to the direct physiological effects of a substance or medical condition (Criterion D); and the symptoms must not be better accounted for by bereavement (Criterion E).

The CIDI also flagged instances in which respondents’ symptoms met criteria for major depression but diagnostic criteria were not met because the symptoms were considered to be the result of direct physiological effects of using a substance (Criterion D). For conciseness, we have referred to this condition as “substance-induced depression”. Criterion D was not met if participants endorsed that depressive symptoms were “always the result of taking medication, drugs or alcohol” or if they told a medical doctor about their depressive symptoms and the doctor said that the symptoms were caused by medication, drugs or alcohol. We were unable to assess DSM-IV Criterion B, so participants with a mixed episode may have been included in the major depression group.

The severity of major depression was coded as mild (5–6 symptoms), moderate (7 symptoms) or severe (≥ 8 symptoms).

Substance use

Methamphetamine dependence was diagnosed using the CIDI.8

The number of days of drug use in the previous month was measured using the OTI11 (daily substance use was defined as having used 20 or more days in the previous month).

Drug use in the previous year was also assessed for all major drug classes. For each drug, participants were asked whether they had used the drug in the previous 12 months, and if so, how often, with possible response categories being: no use, less than weekly, weekly, 2 days per week, 3–4 days per week, or ≥ 5 days per week.

A polydrug-use score was calculated based on the number of other drug classes used in the previous year (drug classes included cannabis, heroin, cocaine, ecstasy, hallucinogens, inhalants, alcohol, tobacco and benzodiazepines).

Demographic and drug-use characteristics

Demographic and drug-use characteristics of participants are summarised in Box 1. Participants were typical of methamphetamine users entering treatment in Australia,13 with a predominance of single unemployed males, most of whom (83%) had injected methamphetamine. The median age was 31 years (range, 16–54 years). Almost all participants (97%) met DSM-IV criteria for methamphetamine dependence.

The reported frequency of methamphetamine use over the previous year was typically 3–4 days per week (39%) or more often (38%).

Participants had used a median of five other drug classes in the previous year (range, 1–9), the most common being tobacco (96%), alcohol (87%) and cannabis (87%). Almost half the sample (47%) reported smoking cannabis on a daily basis over the previous year, and 21% reported drinking alcohol at this level. The use of other drugs in the previous year was also common (ecstasy [63%], cocaine [48%], heroin [35%] and inhalants [19%]), but less than 5% of the sample reported using them daily.

Impact of polydrug use

Specific polydrug patterns that were associated with depression were cannabis and benzodiazepine use. After adjustment for severe methamphetamine dependence and other demographic factors associated with depression (Box 1), both cannabis and benzodiazepine use remained significantly associated with major depression (cannabis: odds ratio [OR], 2.3 [95% CI, 1.2–4.4]; P = 0.013; benzodiazepines: OR, 2.1 [95% CI, 1.1–4.2]; P = 0.032) and substance-induced depression (cannabis: OR, 2.4 [95% CI, 1.2–4.6]; P = 0.010; benzodiazepines: OR, 2.0 [95% CI, 1.0–4.0]; P = 0.049). The prevalence of major depression among participants who had used cannabis and/or benzodiazepines in the previous month was 42%, compared with 26% among those who had used neither drug.


Our findings suggest that clinical levels of depression are almost ubiquitous among people entering treatment for methamphetamine use, indicating a need for clinical protocols to manage depression in this context. Four in 10 methamphetamine treatment entrants in the current sample met DSM-IV criteria for a major depressive episode in the previous year, and a further 44% had substance-induced depressive symptoms that were similarly severe and disabling. These levels of depression are high, even when compared with levels in other drug-dependent populations.3

Distinguishing between major depression and substance-induced symptoms of depression was problematic. Whether existing structured psychiatric assessment instruments can accurately make this distinction remains controversial.14-16 The differential diagnosis of independent and substance-induced disorders relies on respondents having insight into the temporal relationship between their substance use and their depressive symptoms, which, in turn, requires periods of abstinence from drug use. Long periods of abstinence are a rarity in populations of heavily dependent drug users, who, by definition, find it hard to abstain, and typically engage in almost daily patterns of polydrug use, oscillating between intoxication and withdrawal. Making a diagnosis of depression in the context of methamphetamine use is particularly problematic, as many of the drug’s acute effects (such as reduced appetite and insomnia) and withdrawal symptoms (such as anhedonia, depressed mood, hypersomnolence and increased appetite) overlap with the symptoms of depression.17 Participants in our study may have misattributed depressive symptoms to drug use, or vice versa.

GPs were the most common source of help for depression among methamphetamine users, but even so, a large proportion of methamphetamine users did not receive help for depression from their GP (or via other avenues), or did not receive as much help as they thought they needed. This finding indicates that there is a substantial gap in mental health service provision for dependent methamphetamine users and that GPs are well placed to provide treatment and referral for this population. The use of antidepressant medication was common in this sample of methamphetamine users, and GPs need to consider the potential interactions between antidepressant medication and the range of illicit drugs that are concurrently consumed by methamphetamine users. Particular consideration should be given to the role of psychosocial interventions for depression (eg, cognitive behaviour therapy) as an alternative to medication.2,7

There is undoubtedly a range of factors that contribute to depression among methamphetamine users. Illicit drug use is associated with various social and individual risk factors for depression (eg, social stressors, poverty, and physical illness such as hepatitis C). In our study, concurrent polydrug use (in particular, use of cannabis and benzodiazepines) was significantly associated with depression, a finding that is consistent with previous research in this area.1 The relationship between drug use and depression is likely to be bidirectional, with heavy drug dependence leading to mood changes and life stressors that increase the risk of depression, and people with depression self-medicating with drugs to relieve their depression. This is particularly likely in the context of methamphetamine use, because acute intoxication with the drug has a potent short-term antidepressant effect.18

In conclusion, the clinical management of depression and related suicide risk is imperative within settings that provide treatment for methamphetamine use, because of the high rates of depression seen in this context. Further research is needed to understand whether methamphetamine use increases the risk for major depression or whether the high rates of depression in this population are a consequence of transient drug-related depressive symptoms. Finally, caution is needed when diagnosing major depression in the context of methamphetamine dependence.

  • Rebecca McKetin1,2
  • Daniel I Lubman3,4
  • Nicole M Lee5
  • Joanne E Ross2
  • Tim N Slade2

  • 1 Centre for Mental Health Research, Australian National University, Canberra, ACT.
  • 2 National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW.
  • 3 Turning Point Alcohol and Drug Centre, Melbourne, VIC.
  • 4 Monash University, Melbourne, VIC.
  • 5 National Centre for Education and Training on Addiction, Flinders University, Adelaide, SA.



The data reported here were collected through the Methamphetamine Treatment Evaluation Study (MATES). The study was conducted by the National Drug and Alcohol Research Centre, University of New South Wales, and was funded by the National Health and Medical Research Council and the Australian Government Department of Health and Ageing. We acknowledge the contribution of the following MATES investigators: Robert Ali, Amanda Baker, Sharon Dawe, Richard Mattick, Abdullah Mamun and Jake Najman. We also thank the research officers who assisted with data collection (Shelley Cogger, Erin Kelly, Kate Hetherington, Grace Ho, Julia Rosenfeld, Cathie Sammut, Sagari Sarkar, Rachel Sutherland and Miriam Wyzenbeek), the participating treatment agencies, and the research participants.

Competing interests:

Rebecca McKetin has received consultancy fees from the United Nations Office on Drugs and Crime. Daniel Lubman has received speakers fees from Bristol-Myers Squibb (2007) and conference travel support from AstraZeneca and Janssen (2008). Nicole Lee has done paid consultancy work for St John of God Health Care.

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