Substance- or drug-induced depressive disorder

Some substances and drugs can induce symptoms similar to those of major depression. Symptoms either:

  • start during exposure to the drug or substance and persist beyond the expected length of intoxication; or
  • start shortly after withdrawal of the drug or substance and persist beyond the withdrawal period.
Check for recent changes in drug regimens of drugs that can affect mood. Some substances and drugs associated with development of depressive symptoms lists some substances and drugs associated with the development of depressive symptoms.

Consider differential diagnoses in patients presenting with depressive symptoms. Thoroughly assess patients with depressive symptoms, including an assessment of suicide risk.

Figure 1. Some substances and drugs associated with development of depressive symptoms.

[NB1]

Analgesics

  • opioids

Anti-infective drugs

  • efavirenz
  • ciprofloxacin
  • mefloquine

Cardiovascular drugs

  • alpha2-receptor agonists (eg clonidine, guanfacine)
  • beta blockers (predominantly high-dose propranolol)
  • digoxin
  • gemfibrozil
  • methyldopa
  • nifedipine

Endocrine drugs

  • anabolic steroids
  • corticosteroids
  • gonadotropin-releasing hormone agonists
  • hormonal contraceptives

Dermatological drugs

  • finasteride
  • isotretinoin

Immunomodulators and antineoplastic drugs

  • alpha interferon
  • tamoxifen

Neurological drugs

  • anticonvulsants (eg phenytoin, vigabatrin)
  • levodopa
  • tetrabenazine
  • triptans (eg sumatriptan)

Psychotropics

  • benzodiazepines
  • bupropion
  • varenicline

Recreational drugs and substances (see also History-taking in screening and assessment of substance use and addictive behaviours)

  • alcohol
  • amfetamines
  • cannabis and synthetic cannabinoids
  • cocaine
  • hallucinogens
  • other stimulants
Note: NB1: There are varying levels of evidence for an association between depressive symptoms and these drugs or substances; a causal link has not always been proven. This list is not exhaustive.

If a substance- or drug-induced depressive disorder is suspected, withdraw the implicated substance or drug if possible. Symptoms are expected to resolve over a period of days to a few weeks after withdrawal of the inducing agent—this would confirm a diagnosis of substance- or drug-induced depressive disorder. If symptoms persist beyond this time, consider another disorder that can cause depressive symptoms.

If it is not possible to withdraw the drug, assess the severity of depressive symptoms and treat accordingly (see Assessing a person with depressive symptoms).