THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE

2017, VOL. 43, NO. 4, 402–415

http://dx.doi.org/10.1080/00952990.2016.1199697

Cognitive-behavioral therapies for depression and substance use disorders: An

overview of traditional, third-wave, and transdiagnostic approaches
Anka A. Vujanovic, PhDa,b, Thomas D. Meyer, PhDb, Angela M. Heads, PhDb, Angela L. Stotts, PhDb,
Yolanda R. Villarreal, PhDb, and Joy M. Schmitz, PhDb
a
Department of Psychology, University of Houston, Houston, TX, USA; bDepartment of Psychiatry and Behavioral Sciences, McGovern Medical
School, University of Texas Health Science Center at Houston, Houston, TX, USA

ABSTRACT ARTICLE HISTORY

Background: The co-occurrence of depression and substance use disorders (SUD) is highly pre- Received 9 March 2016
valent and associated with poor treatment outcomes for both disorders. As compared to indivi- Revised 5 May 2016
duals suffering from either disorder alone, individuals with both conditions are likely to endure a Accepted 6 June 2016
more severe and chronic clinical course with worse treatment outcomes. Thus, current practice KEYWORDS
guidelines recommend treating these co-occurring disorders simultaneously. Objectives: The over- Depression; substance use;
arching aims of this narrative are two-fold: (1) to provide an updated review of the current comorbidity; treatment;
empirical status of integrated psychotherapy approaches for SUD and depression comorbidity, intervention; cognitive
based on models of traditional cognitive-behavioral therapy (CBT) and newer third-wave CBT behavioral therapy; review
approaches, including acceptance- and mindfulness-based interventions and behavioral activation
(BA); and (2) to propose a novel theoretical framework for transdiagnostic CBT for SUD-depression,
based upon empirically grounded psychological mechanisms underlying this highly prevalent
comorbidity. Results: Traditional CBT approaches for the treatment of SUD-depression are well-
studied. Despite advances in the development and evaluation of various third-wave psychothera-
pies, more work needs to be done to evaluate the efficacy of such approaches for SUD-depression.
Conclusion: Informed by this summary of the evidence, we propose a transdiagnostic therapy
approach that aims to integrate treatment elements found in empirically supported CBT-based
interventions for SUD and depression. By targeting shared cognitive-affective processes under-
lying SUD-depression, transdiagnostic treatment models have the potential to offer a novel
clinical approach to treating this difficult-to-treat comorbidity and relevant, co-occurring psychia-
tric disturbances, such as posttraumatic stress.

Substance use disorders (SUD) frequently co-occur with
depression and are associated with adverse clinical conse-
quences. Indeed, National Comorbidity Survey studies
report strong and positive associations between SUD and
depression (1). According to a recent systematic review and
meta-analysis of epidemiological studies over the last 25
years (1990–2014), the strongest documented associations
were between illicit SUD and major depressive disorder
(MDD), followed closely by alcohol use disorders (AUD)
and MDD, with pooled odds of 3.80 and 2.42, respectively,
as compared to individuals without SUD/AUD (2). It is
estimated that approximately one-third of individuals with
MDD also have SUD or AUD (3). Among treatment-
seeking samples with SUD, the rates of MDD comorbidity
are even higher, up to 67%, depending on the substance
class studied (4,5).
Individuals with this dual diagnosis typically experi-
ence a more severe and chronic course, with worse treat-
ment outcomes than those with a single disorder (6,7).
This comorbidity is also associated with greater psycho-
social impairment and higher suicide risk (8,9).
Therefore, current practice guidelines recommend treat-
ing the co-occurring disorders simultaneously (10,11).
Given the widespread use and well-established efficacy
of cognitive-behavioral therapy (CBT) as a treatment for
each individual disorder (5), integrated CBT approaches
targeting co-occurring disorders have been developed and
evaluated in recent years.
The overarching aims of this review are thus two-fold:
(1) to summarize the current empirical evidence of inte-
grated psychotherapy approaches for SUD-depression
comorbidity, based on models of traditional CBT and
newer third-wave CBT approaches, including acceptance-
and mindfulness-based interventions and behavioral acti-
vation (BA); and (2) to propose a novel theoretical frame-
work for transdiagnostic CBT for SUD-depression, based
upon empirically grounded psychological mechanisms
underlying this highly prevalent comorbidity. Selected

CONTACT Dr. Joy M. Schmitz, PhD Joy.M.Schmitz@uth.tmc.edu Center for Neurobehavioral Research on Addiction, Department of Psychiatry & Behavioral
Sciences, McGovern Medical School, University of Texas Health Science Center – Houston, 1941 East Road, Houston, TX 77054, USA.
© 2017 Taylor & Francis
 THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 403

publications were identified from PubMed, MEDLINE,
and PsycInfo databases, using various combinations of
key terms, including “depression,” “substance use/abuse/
dependence,” “alcohol,” “cognitive behavioral therapy,”
“acceptance and commitment therapy,” “mindfulness,”
and “behavioral activation.” Since most studies in this
domain have not distinguished between unipolar and
bipolar depression, and the acute depressive states of
either disorder are phenomenologically similar (12), this
overview focuses on SUD-depression, broadly. Notably,
despite the organizational structure adopted for purposes
of this overview, the treatment approaches discussed all
putatively fall under the overarching CBT umbrella and
are often utilized together in practice as well as in research
(e.g., (19)).
Traditional CBT approaches: Summary of the
evidence
The traditional CBT approach focuses upon the
development of disorder-specific, manual-based treat-
ment protocols to achieve cognitive and behavioral
change. These interventions derive from assumptions
based on the cognitive mediational model, i.e., cog-
nitive appraisal of events can affect response to those
events, and by modifying the content of these apprai-
sals, desired behavior change may be effected (13). In
the case of depression, negative or dysfunctional
thinking in reaction to specific situations increases
the likelihood of depressive symptoms; correspond-
ingly, in the case of addiction, thoughts about sub-
stance use may give rise to use. For each disorder,
therapy begins with a functional analysis of the pro-
blem, followed by learning cognitive and behavioral
coping skills to reduce the substance use and/or
depressive symptoms (see Figure 1). There is strong
empirical support for the efficacy of CBT when
applied to either depression (14) or SUD (15).
The evidence-base supporting CBT when applied to
co-occurring SUD-depression has been subject to sev-
eral recent systematic and meta-analytic reviews (16–
18). In their 2012 review of randomized controlled
trials (RCTs) for co-occurring depression and alcohol
misuse, Baker and colleagues (18) identified two studies
demonstrating effectiveness (19,20). In one study (20),
integrated CBT, delivered via either therapist or com-
puter, showed a beneficial effect on depression and
alcohol use problems, with both delivery formats super-
ior to brief intervention only. In another study, argu-
ably the most rigorous RCT to date, Baker and
colleagues (19) evaluated integrated versus single-
focused (depression or alcohol) CBT, which included
mindfulness training, in a sample of 284 patients with
co-occurring depression and AUD. The psychotherapy
conditions were manualized and matched for time and
duration (nine weekly 1-hour sessions), using the same
structure and techniques, varying only in targeted pro-
blem (i.e., depression-focus, alcohol-focus, or both).
Integrated CBT addressed depression and alcohol use
in parallel, emphasizing the way in which the condi-
tions impacted each other. The results suggested greater
reduction in drinking days and level of depression for
the integrated CBT compared with single-focused CBT.
The most recent meta-analytic review was performed

Treatment Treatment Elements Theoretical Mechanisms of Change Outcome

CBT • Functional analysis of • Increase awareness of Reduce substance use

for SUD situations for substance antecedents and
use consequences of
• Cognitive skills training to substance use
challenge and modify • Change problematic
maladaptive thoughts thoughts associated with
leading to substance use substance use
• Behavioral coping skills to • Increase adaptive coping
reduce craving and resist with craving and urges to
substance use use substances

CBT • Functional analysis of • Increase awareness of Reduce depressive

for Depression situations related to antecedents and symptoms
depressive symptoms consequences of
• Cognitive skills training to depressive symptoms
challenge and modify • Change problematic
maladaptive thoughts thoughts associated with
leading to negative depressed mood
emotions • Increase adaptive coping
• Behavioral coping skills to to improve mood
manage mood and
increase pleasant events

Figure 1. Traditional CBT for the treatment of co-occurring SUD and depression.
404 A. A. VUJANOVIC ET AL.
by Riper and colleagues (16) and evaluated combined
CBT and motivational interviewing (MI) for treatment
of comorbid AUD and depression. Six of the 12 studies
reviewed met the four predefined quality criteria (ade-
quate sequence generation; concealment of the alloca-
tion to conditions; blinding of outcome assessors;
intention-to-treat analysis). Small but clinically signifi-
cant effect sizes were found for CBT+MI in terms of
decreased depression symptoms and alcohol consump-
tion at posttreatment (Hedges’s g = 0.27 and g = 0.27,
respectively).
In summary, there is mounting evidence supporting
the broad question of whether integrated CBT is effec-
tive for the treatment of co-occurring SUD-depression;
however, the small number of well-controlled studies
precludes robust conclusions. To date, only one RCT
compared integrated CBT with matched CBT condi-
tions targeting a single disorder only (19). Most trials
have compared integrated CBT with other psychosocial
interventions targeting comorbidity. The RCTs also are
diverse in terms of population studied (e.g., alcohol
and/or other SUD), treatment setting (e.g., outpatient,
residential), format (e.g., individual, group), and dura-
tion (number of sessions), with too few studies provid-
ing sufficient data to explore the effect of these
potential moderator variables. In this area of psy-
chotherapy research, like other areas, there is a lack of
replication studies. Also lacking are studies that directly
test theoretical mediators of depression and SUD out-
comes in the context of traditional CBT. In other
words, does response to integrated CBT indeed occur
via change in cognition and coping ability? In studies
comparing CBT to other psychotherapy approaches not
based on modifying cognitions, treatment effects have
been small or comparable, calling into question the
primary mechanism of change in CBT (21). Taken
together, integrated CBT treatments for SUD-depres-
sion have accumulated evidence in support of their
efficacy. However, populations with co-occurring
SUD-depression present an especially difficult-to-treat
population, and there remains significant room for
development of novel intervention approaches.
“Third wave” therapy approaches: Summary of
the evidence
Acceptance- and mindfulness-based interventions as
well as BA are three third-wave CBT approaches
recognized as research-supported for the treatment
and prevention of depression. Acceptance- and mind-
fulness-based interventions, while not incompatible
with traditional CBT interventions, seek instead to
alter the function of problematic thoughts and
emotions by teaching individuals new ways of relat-
ing to them. Similarly, BA is primarily focused upon
understanding contingencies maintaining depressive
behavior and increasing engagement in behaviors
that are related to improvements in mood (22,23).
The following sections define and distinguish the
clinical focus of Acceptance and Commitment
Therapy (ACT), mindfulness-based interventions,
and BA, along with accruing evidence for each
approach as a treatment for individuals with co-
occurring SUD-depression.
Acceptance and commitment therapy
Traditional CBT has been criticized as a set of techni-
ques and tools based, theoretically, on patterns of cog-
nitions thought to underlie specific forms of
psychopathology (e.g., (24)). As a result, a host of
therapy manuals proliferated, each targeting topogra-
phically distinct disorders (e.g., CBT for depression,
CBT for panic disorder). ACT and other third-wave
CBTs have taken a different approach by identifying
empirically based core principles and processes by
which the majority of psychopathologies can be com-
monly explained. ACT is based on a contextual theory
of language and cognition, known as the relational
frame theory (RFT; (25)). Undoubtedly, the ACT
model will be refined over time, but it is an attempt
to bring psychology back to its behavioral roots, in
particular, emphasizing the contextual factors that
influence behavior.
ACT can be viewed as an intervention “grounded in
an empirical, principle-focused approach. . .that is par-
ticularly sensitive to the context and functions of psy-
chological phenomena, not just their form” (p. 658;
(26)). Thus, ACT uniquely emphasizes contextual and
experiential change strategies in addition to more direct
and didactic ones. Broad, flexible, and effective beha-
vioral repertoires are targeted versus attempting to
eliminate or change narrowly defined problems.
Psychological inflexibility—the overarching process
underlying psychopathology—comprises multiple pro-
cesses that vary in level, such as experiential avoidance,
fusion with unhelpful thoughts and emotions, lack of
present moment focus, attachment to rigid ideas about
oneself, and detachment from values that preclude
effective action (see Figure 2). Behavior driven by
these processes is often described as dysfunctional or
disordered (i.e., preventing individuals from living a life
based on what they value most), resulting in clinical
distress and impairment across social and occupational
domains.

Treatment Treatment Elements
• Acceptance of internal experiences rather
than avoidance
• Cognitive de-fusion to increase meta-
cognitive awareness of beliefs and thought
Acceptance and patterns related to maladaptive behaviors
Commitment • Committed action to achieve goals in the
Therapy direction of what is valued most.
• Mindfulness exercises to enhance present-
centered focus
• Self-as-context to increase awareness of
the self as the ”vessel” in which internal
experiences reside
• Meditation to enhance present-centered
awareness and intentional regulation of
Mindfulness- attention to the present moment
based
• Meditation to cultivate nonjudgmental
Interventions acceptance of the ongoing flow of
sensations, thoughts, and emotional states
• Engagement in rewarding or values-driven
activities
• Relaxation skills
Behavioral • Social and problem-solving skills training
Activation • Functional analysis of contingencies
maintaining depressive or substance-using
behaviors
• Self-instructional training
• Rumination-cued activation
Figure 2. Mindfulness- and acceptance-based treatments for co-occurring SUD and depression.
Depressive disorders and SUD are two examples of
such psychopathology.
ACT is in its infancy with regard to treatment outcome
research, with few studies targeting dual disorders (27).
There is growing evidence, however, supporting the effi-
cacy of ACT for the single disorders of depression and
SUD (28,29). The first ACT study ever reported was a
small comparative outcome study of ACT versus cogni-
tive therapy (CT) for MDD. Outcomes were similar post-
treatment but ACT participants were judged to be less
depressed compared to CT at follow-up. Posttreatment
process assessments indicated ACT participants were less
cognitively “fused,” or less likely to believe their depres-
sive thoughts than CT participants. Thus, the frequency of
depressive thoughts did not differ, but the extent to which
they believed the thoughts was lower in the ACT group. A
later reanalysis of the process data confirmed that
decreases in fusion (believability of depressive thoughts)
mediated reductions in depressive symptoms (27).
Multiple meta-analyses of ACT studies for depression
have documented its relative efficacy or potential efficacy.
For example, A-Tjak et al. (30) reported ACT was super-
ior to control conditions in an analysis that included eight
studies of ACT targeting depression and anxiety. Ost et al.
(31) in their conservative analysis concluded ACT to be
“possibly efficacious” in the treatment of depression.
More studies are needed, including process analyses, to
determine the relative efficacy and mechanism of action
for ACT.
THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 405
Theoretical Mechanisms of Change Outcome
• Increase meta-cognitive awareness
• Decrease experiential avoidance
• Increase psychological flexibility
• Increase values-driven behaviors
• Increase present-centered awareness
• Increase nonjudgmental acceptance
of internal and external events
Reduce substance use
• Increase meta-cognitive awareness
• Decrease experiential avoidance
• Increase present-centered awareness
• Increase nonjudgmental acceptance
of internal and external events
• Enhance reinforcing environmental Reduce depressive symptoms
contingencies and evoke
corresponding improvements in
cognitions, mood, and quality of life
• Decrease experiential avoidance
• Increase functional understanding of
behavior and behavior change
Similarly, in the area of addiction, ACT has com-
pared favorably in the treatment of SUD (29). ACT has
been compared to both active and passive control treat-
ments specifically for smoking cessation, methadone
detoxification, polysubstance abuse, opioid use, as well
as the general treatment of SUD in a residential treat-
ment setting (32–36). Meta-analysis results of eight
studies reported by A-Tjak et al. (30) supported the
superiority of ACT over control conditions, and again
Ost (31) concluded that ACT is “possibly efficacious” in
the treatment of addiction. A recent meta-analysis on
ACT studies of SUD determined ACT to be relatively
more efficacious than control conditions (37).
With regard to co-occurring disorders, two small-
scale RCTs have been conducted with regard to ACT in
the treatment of MDD and AUD (38,39). While both
studies were small, positive results were found and
suggest strong potential for ACT in this population.
ACT’s emphasis on common core processes and prin-
ciples makes it ideal for integrated treatments for co-
occurring disorders, particularly targeting experiential
avoidance. For example, in both MDD and SUD, the
goal of treatment would not be to change or eliminate
depressive feelings or cravings and associated thoughts
but to weaken their link with behavior. ACT empowers
clients to have unpleasant thoughts and feelings and
pursue meaningful values-based activities and goals.
Allowing inevitable dysphoria ubiquitous to human
life to occur without attempting to change its form or
406 A. A. VUJANOVIC ET AL.
function, via substance use, while persisting in activities
that are personally identified as important and mean-
ingful, would be the ultimate goal of an integrated ACT
treatment for co-occurring SUD-depression.
Mindfulness-based interventions
Similar to ACT, mindfulness-based interventions
focus primarily on the process of thinking and feel-
ing, rather than on the content of specific thoughts
and beliefs. Unlike ACT, the origins of mindfulness
practices in modern psychotherapy are deeply rooted
in Buddhist philosophy and practice of specific med-
itation techniques. As shown in Figure 2, mindful-
ness most commonly involves meditation as the key
treatment element to: (1) enhance intentional regula-
tion of attention to and awareness of the present
moment, and (2) cultivate nonjudgmental acceptance
of the ongoing flow of sensations, thoughts, and/or
emotional states (40,41).
Kabat-Zinn (42) describes several key processes inte-
gral to mindfulness: adopting a nonjudgmental, accept-
ing, and non-striving attitude, and a “beginner’s mind”
(i.e., seeing everything as if it were for the very first
time), with a stance of patience, trust, and the will-
ingness “to let go” of thoughts and emotional states.
Based on this idea, Kabat-Zinn developed Mindfulness
Based Stress Reduction (MBSR; (42)) to address a vari-
ety of health problems (e.g., chronic pain, anxiety).
Given the efficacy of MBSR for the treatment of anxiety
disorders (43) and depressive rumination (44), Segal,
Williams and Teasdale (45) created Mindfulness-Based
Cognitive Therapy (MBCT) as a maintenance therapy
for depression aimed at the prevention of depression
relapse. In fact, MBCT is adapted from the principles of
MBSR. Both mindfulness-based interventions heavily
rely on the experiential practice of mindfulness medita-
tion inside and outside of therapy sessions. MBCT
originally focused on stress reduction and especially
on the prevention of depressive relapse (45,46), but its
application has since spread widely to other psycholo-
gical and physical health problems. Recent meta-ana-
lyses of MBCT demonstrate good and stable effects
across studies, including studies with symptomatic
depressed patients (47,48). Mindfulness interventions
have demonstrated the most compelling evidence for
individuals with recurrent depression who have had at
least three previous episodes of depression (46).
Given the original focus on relapse prevention in
mood disorders, it is not surprising that the link
between mindfulness and SUD has been increasingly
studied (49,50). Mindfulness-Based Relapse Prevention
(MBRP) for SUD (51) was developed as an intervention
to facilitate coping with urges to use substances follow-
ing treatment for SUD. Skills include “urge surfing,” or
observing urges to use substances as they occur, accept-
ing them nonjudgmentally, and “riding the waves”
without giving in to the urges. Indeed, mindfulness
has been underscored as a potential therapy mechanism
for SUD treatment (52–54). Several pilot studies show
the feasibility and preliminary evidence for MBRP for
SUD (55–58). Furthermore, a recent comparative trial
showed that a mindfulness-based intervention might
outperform traditional CBT relapse prevention on
long-term outcome measures of abstinence or heavy
drinking (55).
While the clinical utility of mindfulness interven-
tions for patients diagnosed with both SUD and
depression has been discussed (52,59), we could not
identify any controlled studies that targeted indivi-
duals with dual diagnoses. A post hoc analysis of an
RCT comparing MBRP with treatment as usual
(TAU) in a SUD sample showed a clear association
between posttreatment depression and craving, which
predicted substance use (60). However, this associa-
tion was only evident in the TAU group. Participants
receiving MBRP, in contrast, showed greater
decreases in craving and significantly lower rates of
post-intervention relapse to substance use, suggesting
improved responding to negative emotional situa-
tions. Thus, mindfulness-based interventions for co-
occurring SUD-depression may help by teaching
patients how to notice their negative thoughts, feel-
ings, and cravings as passing events in the present
moment, rather than “automatically” responding in
maladaptive ways. More work is needed to better
understand the process-level changes that occur in
the context of these treatments. Furthermore, the
extent to which these preliminary findings may gen-
eralize to dually diagnosed patients with SUD-depres-
sion remains an open question.
Behavioral activation
BA, considered a third-wave behavioral therapy with
roots in traditional behavioral models of depression
(61,62), is considered an evidence-based treatment for
depression with strong evidence supporting its efficacy
(63,64). The traditional behavioral model of depression,
upon which BA is based, posited that depression
resulted from decreased response-contingent reinforce-
ments for nondepressive behaviors. This model of
depression underscored the number, type, and function
of reinforcing events, the availability of such events in
the environment/context, and an individual’s instru-
mental behaviors as the factors relevant to response

contingent positive reinforcement. Indeed, studies have
demonstrated that depressed mood is related to
decreased positive reinforcement for adaptive behaviors
and greater decreases in pleasurable activities (65).
Depressed mood also may lead to an increased fre-
quency or intensity of negative life events or experi-
ences (66); for example, the social behaviors of
depressed individuals, as compared to nondepressed
individuals, are less likely to yield positive reinforcing
outcomes (67). Thus, traditional approaches focused
upon enhancing response-contingent positive reinfor-
cement via increasing pleasant events and decreasing
frequency and intensity of negative events and
consequences.
Both Behavioral Activation (68) and Brief Behavioral
Activation Treatment for Depression (BATD; (69);
BATD-R; (70)) build upon the original behavioral
models but emphasize a greater idiographic approach,
with more attention to unique environmental contin-
gences and an individualized assessment of life areas
and values (BATD). In addition to incorporating more
basic behavioral therapy approaches (see Figure 2),
such as pleasant events scheduling, teaching relaxation
and social/problem-solving skills, and decreasing avoid-
ance and managing contingencies, these newer
approaches also emphasize understanding the func-
tional aspects of behavior change. These interventions
move away from solely targeting pleasant events to a
detailed assessment and understanding of the contin-
gencies maintaining depressive behavior, individualized
assessment of goals and values, and increasing beha-
viors most likely to decrease depressive symptoms and
increase functioning. Thus, these newer BA approaches
do not focus principally on changing maladaptive beha-
viors but rather upon the underlying factors relevant to
behavior change, including the more contextual and
experiential change strategies (e.g., values, relation-
ships) and not exclusively upon the didactic and more
direct or immediate targets. These approaches are
based upon an acceptance-change model (71), wherein
the focus is upon action with the understanding that
changes in behaviors will elicit changes in thoughts and
moods, rather than that changes in thoughts/moods are
required for behavioral changes to occur. Although BA
and BATD are similar in terms of core treatment pro-
cesses, several distinctions should be noted. While BA
includes mental rehearsal, mindfulness training, skills
training, and periodic distraction, BATD implements a
values hierarchy to orient individuals to life values to
achieve value-consistent living and secondarily empha-
sizes functional analysis.
A growing literature suggests that individuals with
SUD and/or depression tend to reside in environmental
THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 407
contexts lacking positive reinforcements (72). Both pre-
clinical animal studies and human research have estab-
lished a strong association between substance use and the
limited availability of alternative reinforcements (73,74).
Therefore, it is not surprising that, in recent years, the
principles of BATD have been modified for the treatment
of SUD-depression. Although this literature is in a nas-
cent stage, emergent findings hold promise for the utility
of integrating BA or BATD principles in the treatment of
SUD-depression. Treatment programs, such as Life
Enhancement Treatment for Substance Use (LETS ACT;
(75,76)), have demonstrated preliminary support for fea-
sibility and efficacy in terms of decreased depression
severity, greater retention in SUD residential treatment,
and greater increases in activation in residential SUD
patients, as compared to a contact-time matched control
treatment. Similarly, Behavioral Activation Treatment for
Smoking (BATS) has been evaluated among smokers with
mildly elevated depressive symptoms (77); smokers ran-
domized to BATS reported greater smoking abstinence
and reduction in depressive symptoms as compared to
those in standard treatment smoking cessation. Several
clinical trials are currently under way to advance our
understanding of the efficacy of BA-based interventions
for SUD-depression, including web-based interventions.
Despite a promising start, more work is needed to evalu-
ate the efficacy of BA-based approaches for SUD-depres-
sion and to examine the mechanisms of change in process
analyses. Reinforcement-based approaches may be espe-
cially useful for this difficult-to-treat comorbidity, but
more empirical investigation is necessary.
Novel transdiagnostic treatment model for
depression and SUD
Tracing the evolution of traditional to newer-generation
CBT approaches, it is clear that the concept of “inte-
grated” CBT has shifted from using a combination of
disorder-specific therapy protocols to developing “trans-
diagnostic” protocols that focus on common processes
underlying multiple disorders. As discussed, ACT and
mindfulness-based interventions can be conceptualized
as transdiagnostic approaches, targeting processes that
underlie multiple forms of psychopathology. Relatedly,
for example, transdiagnostic treatment approaches for
emotional disorders (78) and anxiety disorders (79) have
been developed, targeting core cognitive-affective pro-
cesses underlying mood and anxiety disorders and
emphasizing various facets of emotion regulation (e.g.,
emotional awareness and tolerance). The movement
toward a transdiagnostic focus on underlying etiological
and maintenance factors for emotional symptoms and
disorders and their comorbidities integrates well with
408 A. A. VUJANOVIC ET AL.

the National Institute of Mental Health’s Research Negative affect

Domain Criteria (RDoC), National Institute on Alcohol
Abuse and Alcoholism’s Alcohol Addiction RDoC, and
the National Institute on Drug Abuse’s Strategic Plan
(80), which underscore that common traits and biological
pathways account for the manifestation of various psy-
chiatric presentations (81).
Notably, transdiagnostic treatment programs have
not yet sufficiently incorporated addiction, although
emerging conceptual work is suggesting the promise
of transdiagnostic approaches to inform comorbidities
between emotional disorders and cigarette smoking, for
example (82). Given the high rates of co-occurrence
between depression and SUD, and the prevalence of
trauma exposure and posttraumatic stress among these
populations ((83,84)), a transdiagnostic CBT approach
has the potential to meaningfully change the treatment
landscape. Notably, a transdiagnostic framework would
not necessarily be limited to depression-SUD comor-
bidity, exclusively, but could be applicable to a wider
range of psychiatric disturbances, including posttrau-
matic stress, multiple types of SUD, or other mood or
anxiety conditions. Therefore, in this concluding sec-
tion, we put forth a theoretical framework for trans-
diagnostic treatments that incorporate SUD. First, we
present a core set of malleable (i.e., targetable via inter-
vention) cognitive-affective processes that cut across
SUD-depression, and then describe how transdiagnos-
tic treatment programs may offer a more efficient and
parsimonious treatment option for co-occurring disor-
ders (see Figure 3).
Negative affect is defined as a subjective experience of
emotional distress, which includes a variety of aversive
mood states, such as sadness, anxiety, and anger (85).
Negative affect has been identified as one of the stron-
gest risk factors for relapse when treating both SUD
and depression (54,86,87). Self-reported depression has
been shown to predict treatment outcomes for sub-
stance users, and negative affect has repeatedly been
shown to be related to craving and relapse in indivi-
duals with SUD (54,86). The negative reinforcement
model has provided a theoretical basis for understand-
ing initiation and continued substance use. According
to this model, reduction or avoidance of negative affect
is a primary motive for substance use (87).
Anhedonia
Anhedonia, a symptom of depression (88) but com-
mon to most psychiatric disturbances (89,90), man-
ifests as a significant loss in appetitive functioning
and decreased enjoyment and pleasure from and
interest in otherwise rewarding stimuli (91). In addi-
tion to its core relevance to depression, anhedonia
has been conceptualized as an etiological factor of
relevance to addiction onset, maintenance, and
relapse (92). Heightened anhedonia is associated
with the use and dependence of various substance
classes (93–95) and intensity of craving and with-
drawal symptoms (96,97). Both animal and human

Treatment Treatment Elements1 Targeted Processes underlying Outcome

depression and SUD
• Functional analysis of situations for
substance use and depression to decrease
maladaptive patterns of behavior
• Cognitive skills training to challenge and
modify maladaptive thoughts related to
depression and substance use; or
cognitive de-fusion exercises to increase • Negative affect
Transdiagnostic meta-cognitive awareness of beliefs and • Anhedonia Reduce substance use
Treatment for thought patterns related to maladaptive • Rumination
SUD-depression behaviors • Experiential avoidance
• Emotion regulation Reduce depressive symptoms
• Emotion regulation skills to increase
awareness and acceptance of emotional • Distress tolerance
states and decrease maladaptive coping
(e.g., substance use, isolation)
• Behavioral distress tolerance skills to
increase ability to withstand negative
emotional states and uncomfortable
physical sensations (e.g., withdrawal)
• Behavioral activation to increase
engagement in values-driven behaviors,
decrease anhedonia, and decrease
avoidance

Figure 3. Transdiagnostic CBT applied to the treatment of co-occurring SUD and depression. Note: 1Treatment would be idiogra-
phically tailored to include any or all of these treatment elements based upon the individual’s unique cognitive-affective and
behavioral profile, values, and environmental context.

studies indicate that frequent use of substances con-
tributes to heightened anhedonia (98–100), while
periods of successful abstinence are associated with
reduced anhedonia (101,102). Furthermore, anhedo-
nia is a prospective predictor of abstinence-related
cravings (95,96,103–105), suggesting that anhedonic
individuals may be more likely to use substances to
facilitate positive affective states. Several studies sug-
gest that specifically targeting anhedonia in the treat-
ment of SUD has the potential to significantly
improve treatment outcomes.
Rumination
Rumination, a specific type of maladaptive cognition
commonly manifested both in individuals with
depression and in SUD, is described as repetitively
focusing on distressing symptoms, causes, and con-
sequences of those symptoms without engaging in
active problem solving to cope with these thoughts
(106). Dysfunctional (or maladaptive) beliefs and
thinking influence depressive symptoms and sub-
stance use (107). Individuals who engage in rumina-
tion are more likely to exhibit depressive symptoms
and are prone to experiencing those symptoms more
severely and for longer periods of time. Temporary
distraction from ruminative thinking is related to
decreases in negative affect (108). According to
Nolen-Hoeksema, a tendency to ruminate is asso-
ciated with a greater tendency to use alcohol or
other substances (109). Substance use may provide
temporary relief from negative emotions and the
added aversive effects of ruminative thinking.
Experiential avoidance
Experiential avoidance, or the tendency to suppress
unpleasant internal states (e.g., emotions, thoughts,
bodily sensations), has been postulated as a leading
risk and maintenance factor for emotional disorders,
including depression (110,111) and SUD (112,113).
Avoidance prevents individuals from engaging with
and reacting to emotional stimuli, which paradoxi-
cally increases the avoided material, perpetuating dis-
tress in the form of depressive symptoms or other
negative emotional states (33,114). Furthermore,
experiential avoidance has been associated with a
greater likelihood of using substances for coping rea-
sons (e.g., 115) so as to escape negative emotional
experiences. Individuals with heightened levels of
avoidance tend to use substances to decrease or elim-
inate contact with negative affect and other unplea-
sant internal experiences. In turn, chronic substance
THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 409
use may decrease or weaken an individual’s willing-
ness or ability to effectively manage internal experi-
ences. Theoretically, experiential avoidance may
underlie the development and maintenance of SUD-
depression comorbidity, as individuals with an
increased tendency to suppress unpleasant states
may be especially likely to seek out and maintain
the use of substances to facilitate acute relief from
negative emotional states. Over time, these indivi-
duals may maintain substance use to escape the
experience of unpleasant physical sensations asso-
ciated with withdrawal symptoms or craving.
Emotion regulation
Emotion regulation is defined as the set of strategies
(e.g., suppression, cognitive reappraisal) used by
individuals to manage their experience of emotions
(116). Mounting evidence indicates that emotion
regulation difficulties may underlie various psycho-
logical difficulties, including depression (117) and
SUD (118). Individuals with difficulties in emotion
regulation may be more likely to rely on maladap-
tive strategies such as substance use to cope with
negative emotions (119) given the more immediate
relief offered by substance use, as compared to the
psychological effort required of cognitive-behavior
emotion regulation strategies (e.g., deep breathing,
cognitive restructuring). Thus, during periods of
heightened dysphoria or distress, such as in MDD,
when adaptive emotion regulatory resources may be
more difficult to access, an individual with emotion
regulatory deficits may be especially likely to seek or
maintain more immediate and pleasurable mechan-
isms, such as substance use (120,121). Studies show
a clear, prospective link between problems with
emotion regulation and both depression and sub-
stance use (122,123). Abstinence in treatment-seek-
ing individuals with AUD has been found to be
associated with more adaptive emotion regulation
strategies, while maladaptive emotion regulation
strategies have been linked to craving and continued
use. Therefore, focusing on emotion regulation stra-
tegies in transdiagnostic treatment programs for
SUD-depression has the promise of positively influ-
encing outcomes for both conditions.
They also suggest that (1) abstinence is associated
with a shift toward more adap-tive emotion regulation
patterns and that (2) inefficient regulation strategies
may lead to craving and the maintenance of alcohol
use. If these findings are confirmed through longitudi-
nal and mediation designs, they will have important
clinical implications.
410 A. A. VUJANOVIC ET AL.
Distress tolerance
Distress tolerance, defined as the perceived or actual
ability to tolerate negative or aversive emotional or
physical states (124), is a malleable factor (125) with
relevance to both depressive symptoms and SUD.
Lower levels of distress tolerance have been asso-
ciated with depressive symptoms (126–131); among
depressed individuals, low levels of distress tolerance
have been associated with greater depressive sympto-
matology (126–130). Lower distress tolerance also has
been associated with both alcohol and substance use
(132–135) (127,131,136–139). Notably, an initial RCT
of a distress tolerance treatment for SUD, Skills for
Improving Distress Intolerance (SIDI), demonstrated
feasibility and initial promise with regard to yielding
clinically significant improvement, as compared to
treatment-as-usual (125); however, more work needs
to be carried out to conclusively determine the utility
of SIDI and similar treatment programs with regard
to SUD. Theoretically, an individual’s impaired capa-
city to withstand negative emotional states or phy-
siological symptoms of acute withdrawal or craving
can increase the risk for substance use to alleviate
aversive internal states. The mounting empirical evi-
dence for the role of distress tolerance in the etiology
and maintenance of both depressive symptoms and
SUD underscores its theoretical relevance and poten-
tial clinical utility as a transdiagnostic treatment tar-
get for co-occurring depression and SUD.
Transdiagnostic treatment model: overview
A transdiagnostic model for the treatment of SUD-
depression could address each of the cognitive-affective
processes that underlie depression and SUD, including
negative affect, anhedonia, rumination, experiential
avoidance, emotion regulation, and distress tolerance
(see Figure 3). Such a treatment approach might be
flexibly implemented over 12–16 sessions and idiogra-
phically tailored to the specific needs of the individual
and his/her unique cognitive-affective and behavioral
profile. Certain cognitive-affective processes would be
targeted in advance of others based upon the unique
needs of each individual, as determined via pretreat-
ment assessment.
First, the transdiagnostic approach would focus
upon setting substance use reduction goals in order to
improve substance-related outcomes (e.g., (19)).
Second, treatment would shift to directly ameliorating
negative affect and anhedonia via cognitive skills train-
ing and/or BA, increasing meta-cognitive awareness of
beliefs and thought patterns related to maladaptive
behaviors, and increasing engagement in values-driven
behaviors to decrease avoidance and anhedonia. Third,
this model would build emotion regulation skills via
increasing awareness and acceptance of unpleasant
emotional or physical states through mindfulness or
cognitive de-fusion exercises, for example. Similarly,
distress tolerance skills training through physical exer-
cise or mindfulness practice, for example, would be
used to improve the capacity to withstand negative
emotional or physical states. Each of these skills
would directly impact experiential avoidance, as aware-
ness and acceptance would be emphasized along with
engagement in values-driven activities. Through an
emphasis on core etiological and maintenance process
relevant to SUD-depression and possibly other co-
occurring disturbances, such as posttraumatic stress or
anxiety disorders, the transdiagnostic model would
incorporate elements of each of the third-wave thera-
pies with more traditional CBT approaches, such as
functional analysis and behavioral coping skills, to
offer a novel treatment avenue for the difficult-to-
treat comorbidity of SUD-depression. It is important
for future research to empirically examine the duration,
feasibility, and limitations of a transdiagnostic treat-
ment, generally, and its applicability to various sub-
stance classes, specifically.
Conclusions and future directions
Various psychotherapeutic approaches are available for
the treatment of co-occurring SUD-depression. Extant
treatment avenues can be conceptualized as either tra-
ditional CBT or third-wave psychotherapy, but these
approaches are conceptually similar and often used
together in practice. To date, CBT approaches are the
most well-established and well-investigated, offering
the most effective psychotherapies available for SUD-
depression. However, a growing body of literature has
delineated the limitations of such approaches and
underscored the need for treatment advances. Third-
wave behavioral therapies, such as ACT, mindfulness-
based interventions, and BA, are less widely studied for
SUD-depression, but initial findings are promising.
Finally, although transdiagnostic treatment approaches
have been developed for emotional disorders and anxi-
ety disorders, such programs have not been developed
for SUD-depression or for addiction-relevant comor-
bidities. Given a host of shared cognitive-affective fac-
tors empirically documented to underlie both SUD and
depression, a transdiagnostic treatment approach is
theoretically compelling and potentially clinically
important. Furthermore, the degree of applicability of
such a transdiagnostic approach to populations with

psychiatric disturbances related to and co-occurring
with depression-SUD, such as posttraumatic stress
and anxiety disorders, is an empirical question of
great clinical value.
Given the psychotherapeutic focus of this review, phar-
macotherapies and other neurobiological approaches
(e.g., neurostimulation) of relevance to SUD-depression
treatment were outside the scope. Similarly, issues of
dissemination and implementation of evidence-based
treatments as well as limited access to services for sub-
populations with SUD-depression were not discussed, but
remain significant and important issues. Nevertheless, it is
worthy of mention that, given the complexity of SUD-
depression comorbidity, the most effective treatment
approaches likely will need to address not only the psy-
chosocial and biological elements of human behavior but
also the sociocultural contexts within which such beha-
viors are manifested.
Conflicts of interest
The authors report no relevant financial conflicts.
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