Why Can’t Antidepressants and Recovery Go Together?

originally posted on Rehabs.com

Natalie,* a 21-year-old recovering alcoholic, had been sober for six months when her therapist suggested she see a psychiatrist for a consultation about antidepressants. “I was in a 12-step program,” Natalie explains. “Thanks to the program, my obsession with drinking had lifted. But I was still miserable.”

Feeling miserable isn’t uncommon in early sobriety. Withdrawing from any substance to which you are addicted may produce symptoms of depression, such as changes in sleep patterns, feelings of helplessness, and appetite or weight changes. For Natalie, however, like many others, symptoms of depression appeared long before she began drinking alcohol or using drugs. Worse, they didn’t go away, or improve, as she stayed sober month after month.

The psychiatrist gave Natalie a dual diagnosis. This means being diagnosed with both addiction and a mental illness—in Natalie’s case, Major Depressive Disorder (MDD). Natalie began taking a low dose of antidepressant in a class known as SSRIs (Selective Serotonin Reuptake Inhibitors).**

Natalie and her fellow dual-diagnosed are hardly anomalies in the recovery community. In his comprehensive study of depression, The Noonday Demon: An Atlas of Depression, Andrew Solomon notes that, “while it’s impossible to find exact statistics, it’s been estimated that one-third of all substance abusers suffer from some kind of depressive disorder.”

How Addiction and Depression Interact

In trying to picture the relationship between addiction and depression, it’s important to understand four things:

  • Not everyone with addiction has a depressive disorder.
  • Not everyone with a depressive disorder has an addiction.
  • People with a dual diagnosis have two separate conditions, each requiring different treatments.
  • Despite this, the state of your recovery from one frequently impacts your recovery from the other.

People who are in addiction recovery are far more likely to relapse if they are depressed. And according to one disturbing estimate, “suicide is the cause of death for an estimated 25 percent of treated alcoholics.”

So what’s the best course of action in treating an individual with MDD who is also in addiction recovery? John H. Krystal, M.D., chair of the Department of Psychiatry at Yale University School of Medicine, says that while therapy alone can be a successful treatment for depression, “studies suggest that for individuals with repeated depressive episodes, a combination of therapy and antidepressants are the most effective course of treatment.”

Many people in recovery, however, hesitate to take antidepressants. If ingesting chemicals resulted in their devastating addiction, why should they resume ingesting chemicals now that they’ve gotten sober? Some don’t need to. But for the benefit of those whose depression would benefit from antidepressants, it’s important to separate myth from fact when we ask what antidepressants are and what impact they can have on someone with a dual diagnosis.

Why Antidepressants Have a Bad Rap in Recovery

Most recovery programs cite abstinence from drugs and alcohol as the best—indeed the only—way to overcome addiction. As a result, stigma often surrounds the use of medication to help with MDD.

“At first, I didn’t want anyone in my 12-step program to know that I was on antidepressants,” says John, a recovering alcoholic of four years who has MDD. “People [in my 12-step program] would say, ‘being sober means not taking mood altering drugs’ and I just assumed that meant antidepressants because, yeah, eventually taking them altered my mood.”

While John’s description of the prevailing attitude at 12-step meetings might be accurate, the attitude itself is based on two significant fallacies: first, that a condemnation of the use of medications is inherent to any 12-step program and second, that antidepressants alter your mood in the same way as opioids, benzodiazepines and other addictive medications.

Alcoholics Anonymous (AA) provides literature to warn against the attitude John found in his 12-step group. It reads, “Because of the difficulties that many alcoholics have with drugs, some members have taken the position that no one in AA should take any medication. While this position has undoubtedly prevented relapses for some, it has meant disaster for others.”

Addressing the use of medication to treat depressive disorders, and the dangers of those disorders if left untreated, the AA literature continues: “AA members and many of their physicians have described situations in which depressed patients have been told by [members of AA] to throw away the pills, only to have depression return with all its difficulties, sometimes resulting in suicide.”

Addictive drugs such as opioids and benzodiazepines have a few things in common. The user feels the effect of the drug soon after taking it and feels high for a period of time. When someone who is addicted “comes down,” they want more. Eventually, the same amount of a drug produces a less effective high, and more of the drug will be required to achieve the desired effect.

Antidepressants, on the other hand, take weeks, and sometimes months to take effect. Further, Dr. Krystal explains, “They do not really make people feel ‘high,’ they are not abused in a pattern of escalating doses and they have little black-market value.” The bottom line? “In general, antidepressants do not pose substantial risk to people in recovery.”

Why the Continuing Fear Factor?

So if there’s no “high” from antidepressants—and thus no reason to fear a potential relapse—and if AA’s only official opinion on the matter is to suggest following medical advice, why are so many depressed recovering alcoholics still unconvinced that antidepressants can help?

One answer has less to do with the medications and more to do with how those medications are prescribed. “When I told my doctor I got sober, he just kind of assumed I would need antidepressants or that I was depressed,” says Nick, a 27-year-old recovering addict of three years. “It was along the lines of, ‘well, you’ll need these.’”

Nick took the antidepressants, but stopped after a few weeks. “They made me feel kind of slow and out of it. Besides, I wasn’t sure I really needed them.” Unlike Natalie, Nick hadn’t struggled with depression prior to his addiction. His mood fluctuated during early sobriety but he never described himself as depressed. As we noted previously, having an addiction doesn’t mean that you also have a depressive disorder.

It’s imperative that the medical community understand this.

Dr. Krystal also attributes some of the negative perceptions of antidepressants to recent news stories fueling “concerns that doctors might inappropriately prescribe medications due to inducements from pharmaceutical companies.” While Dr. Krystal expresses concern about such unethical behavior, he also stresses that, “these concerns do not apply to the typical doctor treating the typical patient.” Unfortunately, he says, “the inappropriate actions of a few people may stigmatize, for some people, an entire profession.”

One can acknowledge cases of the misdiagnosis and the misprescribing of drugs, however, and still accept that for many people, antidepressants are potentially lifesaving.

It often takes a patient 3 to 6 weeks to exhibit signs of response to an antidepressant—and that’s only once the correct dose is administered.

Another reason for reluctance to use antidepressants in the recovery community (and beyond) is frustration with how the drugs themselves work. It often takes a patient 3 to 6 weeks to exhibit signs of response to an antidepressant—and that’s only once the correct dose is administered. Most people begin with the smallest dose and work their way up. Each one of those trial periods takes six weeks. What’s more, only 30 to 40 percent of patients respond to the first medication they receive; after 3 to 4 trials of various medications over one year, about 60 to 70 percent of patients will respond. This process can be lengthy and frustrating, leading to the belief that antidepressants “just don’t work.” But studies show that antidepressants do very often work—it may just require some patience.

The Risks of Stigma

People in recovery know how dangerous stigma can be. Many have to dispel misperceptions about addiction and recovery on a daily basis. Often, fear of the stigma of being seen as an alcoholic or addict is a barrier to getting help.

The stigma around antidepressants can be just as lethal.tablet-428328_640

“It would be tragic were antidepressant medications to become sufficiently stigmatized so that people avoided taking them, as exemplified by the treatment of adolescent depression,” says Dr. Krystal. He explains that after a “black box warning” was introduced into the labeling of antidepressants related to a possible increased risk for suicide in adolescents treated with these medications, prescribing of antidepressants to adolescents decreased. Afterwards, the rate of adolescent suicide increased.

Relief is Possible

“Even before I started drinking, I felt like something was wrong with me,” says Natalie. “I didn’t find joy in things the way my classmates did. I hid it fairly well, but there was always this heaviness to my feelings. Drinking took that away for a little while, but then I got addicted and everything got much worse.”

I still have good days and bad days. But on the bad days, I don’t think about drinking and I don’t think about killing myself. That’s a life I’m grateful to have.-Natalie

Natalie credits her sobriety to working her 12-step program, time in therapy and her antidepressants. “People who don’t take them think antidepressants make you high,” she says. “That’s just not true. I still have good days and bad days. But on the bad days, I don’t think about drinking and I don’t think about killing myself. That’s a life I’m grateful to have.”

Drugs are not the solution to addiction. But for people who struggle with addiction as well as a depressive disorder, antidepressants can be a key ingredient of lifelong recovery.

*Names and identifying details have been changed.
**There are a number of different classes of antidepressants. According to Dr. Krystal, SSRIs (Prozac, Paxil, Zoloft, to name a few) are the most commonly prescribed. None of the classes of antidepressants elicit the feeling of being “high” the way opiates and benzodiazepines do.

Author’s note: For those who think they might be clinically depressed, the single most important thing they can do is talk to a doctor, therapist or both. This article is not a substitute for medical information or advice; I am simply seeking to examine the stigma around the use of antidepressants in recovery and dispel popular myths about antidepressants.

Aurora Photos: Michael Winokur, Jeff Jacobson, Christopher Cumming

 

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