Episode 20 – The Reality Of Relapse
Dr. Ashish Bhatt ❘
Relapse is oftentimes part of the recovery process. Dr. Bhatt, MD explains why it happens and what you should do if it does.
Read More ⟶
The podcast and articles by Dr. Bhatt are intended to be strictly informative, and will not provide any diagnosis, treatment recommendation, or directed medical advice. Unfortunately, not all messages can be addressed, and no message is guaranteed a response. Information provided by Dr. Bhatt in articles and podcasts is intended to address common questions of general applicability, and may not apply to your unique situation. As a result, please do not use the advice or conclusions found in any articles and podcasts on this site as a substitute for professional personal medical advice. If you are looking for treatment, please call.
Hayley: Hello, I’m Haley and this is Straight Talk With The Doc, a podcast that breaks down topics on addiction, mental health, and treatment. I’m joined by our expert and medical director Dr. Bhatt, and our content director Jeff. How are you two doing today?
Dr. Bhatt: Doing well Hayley, how about you guys?
Jeff: I’m doing well, it’s a good day today.
Hayley: I’m doing well, too. In previous episodes, we’ve talked about mental health disorders and their connection to addiction. But today we’re going to take some time and break down a pretty common mood disorder, depression. Dr. Bhatt, can you start by telling us, how common is depression?
Dr. Bhatt: When we look at it, depression is one of the most common mental disorders that we have, and it effects woman and men, a variety of ages throughout their life span. It’s a huge topic that you will see when we speak about mental illness as a whole and those who suffer with addiction, and how often depression comes up when we speak about that.
Hayley: Are there different levels of severity for depression?
Dr. Bhatt: Depression is often qualified and classified in a variety of ways. But most people, when we hear about depression, we’re talking about clinical depression. And when we’re speaking about treatment and we’re speaking about addiction, and there are many types. Major depression being one of them, there’s also a thing called persistent depressive disorder- it was known as dysthymia before. There’s depression that occurs in the scope of other mood disorders, like bipolar disorder. And then there are unspecified depressive disorders, and depression can also be secondary to periods of adjustment, grief, periods where we’re using substances, and medical conditions that can cause depression. So, depression exists in many different forms and can occur secondary or as a primary mental health issue.
Hayley: Okay, can you explain what’s going on in the brain of someone with depression, and is that different if it’s primary or if it’s secondary?
Dr. Bhatt: Well, when we look at depression as a primary mental health illness, we’re talking about people who have- the science shows there are neuro biological dysregulation that occurs. We try to see if somebody has a primary depression that often they are treated with psychotherapy. Believe it or not, a lot of therapeutic interventions have proven to actually alter the brains neuro chemistry. The neuro chemical underpinnings and dysregulation has been hypothesized as a major cause of somebody to feel depressed, and that’s really our hallmark of treatment when it comes to medications, it is to re-regulate or rebalance those altered neuro chemicals. That’s the underlying understood cause of depression.
Hayley: Could you break down some of the most common symptoms?
Dr. Bhatt: Depression is again, we talked about just a few moments ago, there’s different severities of depression. It can be mild, moderate, and severe. But according to some of the textbooks that we have and the criteria that’s established under the American Psychiatric Association, the hallmark for depression is persistent sad mood. Sad mood that can accompanied by hopelessness, isolation, changes in energy, sleep patterns, loss of interest, this can become very persistent that somebody stops taking care of themselves in terms of their hygiene. The things that they experience that used to make them happy before they’re no longer feeling pleasure out of them, and it should be causing a functional change. So, a lot of the time I think we toss that word around and say hey, I feel depressed today. Feeling sad momentarily or to a specific situation, yeah that can be a depressed mood for that moment, but that’s not clinical depression. Clinical depression is understood by a general persistent mood change, and that should be evident by the way somebody can observe a functional change in that person. Again, I don’t want to go into too much extent, but the criteria specific to the different kind of depression, sustained sadness, hopelessness, that’s really the hallmark criteria of somebody who suffers from clinical depression.
Hayley: So, are you saying that the symptoms are different in different people, almost?
Dr. Bhatt: Yeah, because how depression is experienced amongst children and adolescents is different than adults for example. Irritability is often a common symptom of depression in children. They might not be able to articulate that they’re feeling sad, or that they don’t have interest in things that used to make them happy before. But it can be evident by their behaviors. They become withdrawn, or they become angry, things that would normally not make them upset will get them to have a temper outburst. So, those are different. And then people who have atypical depression for example, they’re depressed, but then a positive stimuli, a positive situation and environmental condition can break that depression momentarily. There’s so many different symptoms and relationships that can exacerbate symptoms or not, and definitely depression looks different based on the individual.
Hayley: Going off of that question, I know you already answered this but it’s just such an important topic that I want to ask you again. What are the signs that someone that you know might be struggling with depression?
Dr. Bhatt: So, I mentioned that you have to see some functional change, again nothing is absolute. In life, we try to identify and classify diagnoses to show the most common presentations. But if you see somebody changing the way that they behave, they become more isolated, they’re withdrawn, you can see they’re being apathetic, they’re no longer taking care of themselves, even the way that they dress or their smell. They’re not bathing or changing their clothes as often, you can see them maybe pursue alternative ways to feel happy – drugs, alcohol, these are often signs that other people can see that this person might be suffering from depression, and that can become even more severe. People start to often harm themselves which is one of the worst things we can see from someone suffering from depression, is if they ultimately end up with self-harm or a suicide attempt, so all of those things- it’s such a broad range of symptoms.
Hayley: I would like to dive into the drug and alcohol addiction and depression a little bit more later, but first can you tell me about the treatment options that are available for someone with depression?
Dr. Bhatt: With many different illnesses, it’s often best to see if we can avoid medication. Obviously depending on the severity of somebody’s presentation, we gage what would be the best and most appropriate intervention based on the presentation. Generally, I think I and many other clinicians would like to try conservative approaches, meaning without medication. See if something in their environment can change. Also, using psychotherapeutic interventions, cognitive behavioral therapies, which help people identify negative thoughts and behaviors that are associated with them and see if that can improve it. And the research shows that therapy works in treatment of depression, but sometimes these therapeutic measures and the behavioral changes don’t work, medications may be indicated. So, we have a wide variety of antidepressant medications that can be used and depending on the class of those medications and the response that the patient may have, we can see improvement with those symptoms. There are some things that maybe people have heard about in the past as even trans-magnetic stimulation, there’s electroconvulsive therapies, those are often reserved for people who have often treatment resistant depression, or depression that hasn’t improved with multiple trials of medications and therapies. Again, just like everything, there’s a wide of range of different therapeutic interventions that we have. Therapy all the way to getting hospitalized and maybe even having, like I said, electroconvulsive therapy.
Hayley: For people that are struggling with depression, I know it can feel hopeless, they can feel like they’re never going to get better. But is it possible to fully recover from depression or is this something that these people are going to just have to deal with for the rest of their lives?
Dr. Bhatt: Many people have episodes of depression, even major depression, and they might not have similar episodes again in the future, then we see other individuals who have major depressive episodes which tend to cycle if left untreated. It really depends on the individual. It’s important though that if you are diagnosed and you are suffering from depression that you do get that treatment because the outcomes in the prevention of relapsing is there if left untreated, the relapse potential, it’s higher. To answer your question, it depends on the individual. Some people can experience a major depressive or depressive episode and not have them again in the future, but often times when people suffer from those major changes in their mood, which ends up classifying them as major depression, we often see that happening again in the future. A prognosis can be better, if people learn from what has worked for them therapeutically. Sometimes people have to remain on medications or stay in therapy for extended periods of time to prevent relapse of their symptomatology, but we do see improvement in symptoms with the proper treatment.
Hayley: I want to talk to you about the medications a little bit, I feel like some people might be hesitant to start the medications because they may assume that they’re going to have to take them forever. So, can someone take medications temporarily and then taper off? Or, for some people, will they have to take medications for their entire life?
Dr. Bhatt: That’s a good question, because like you said, many people are hesitant to take medicine, and understandably. Medications come with side effects, but in the case of what you just mentioned, yeah, many people will take it under the guidance of their physician, and they might only have to take it for a limited time. If the physician sees improvement in symptomatology, and with that therapeutic relationship and understanding the patient and doctor have, some people might have to take it just for a limited time. Then there might be individuals who have demonstrated cycles of depression where we do see that trials of taking them off have not worked and they have persistent depression that tends to re-lap very quickly, and those people may have to stay on antidepressants for their lifetime
Jeff: It is very important to always taper down from anti depression medications, under the supervision of your therapist and your medical team because they can have some side effects that are unpleasant, and you will experience withdrawal-like symptoms with many depression medications.
Dr. Bhatt: Yeah Jeff, again you raise good point that anything, any medication if you’re prescribed something by a physician, it’s important that you speak with them. Coming off medications without the proper guidance, without the proper titration as you mentioned Jeff, yeah you can have negative side effects. If you speak with your doctor, you ask the right questions, you become aware, hopefully that doctor provides you with that information when you provide informed consent when you start medications in the first place. You can see which ones might have increased propensity to develop those withdrawal symptoms or side effects, but nothing should be done without speaking to your physician first. Again, sometimes people do stop when side effects initially start to come out, of course if the side effects are extremely unpleasant, I wouldn’t want somebody to muscle through without considering stopping at that time. Medications can have negative effects, but that’s why we look at the risk versus benefits of any sort of therapeutic intervention for any sort of illness.
Hayley: While we’re on this topic, I wanted to ask Dr. Bhatt, do you often see people with depression self-medicating?
Dr. Bhatt: As it relates to addiction, and other maybe physical illnesses or other things that are going on in your life, yeah, people medicate themselves just to feel better. And often it’s self-medication where we speak about that, we’re talking about using alcohol or illicit substances. I wish people self-medicated with exercise and healthy things, which people do, those people who have good coping mechanisms or those people who have the support system and the will to do it. But unfortunately, we are human, we often don’t make the right choices, and sometimes, depending on our lives and our exposures to different things, we do self-medicate with the wrong thing. And being that I know you’re not asking specifically just asking about substances of abuse, but being that when you use a substance it’s such a powerful influence in changing your state of mind, that’s a huge risk factor for developing or using substances further. If I’m depressed and I take something and it makes me feel better, well that’s a recipe for self-medicating and using something again, often to my detriment.
Hayley: You mentioned substances of abuse. Are some substances more commonly abused in those with depression than others?
Dr. Bhatt: We see the whole gambit. I think just having depression in itself, it is known as a risk factor to develop substance use disorders if you are genetically predisposed or have other additional circumstances in your life. But, I think when it comes to the substances with depression, we often see a wide variety. Anything from alcohol to Cocaine to Benzodiazepines to Opiates, we see it all with those susceptible to depression.
Hayley: Are those with depression at an increased risk to develop an addiction?
Dr. Bhatt: When we look at the risk of developing addiction, scientifically we’ve understood that genetics- our make-up, our underlying framework, that placed about a 50% chance of a risk of us developing- it’s based on who we are, how we’re made up. We don’t know in advance. I know that there are family histories and there’s certain genes that are identified with susceptibility to develop a substance use disorder. But this unknown variable that’s there, we don’t know in advance what’s going to increase our chances right away once alcohol or substances are introduced to us. We don’t know what relationship will ultimately develop. So, that underlying framework is there. But that other 50% is everything else. The presence or absence of mental health conditions or physical conditions is a huge risk factor for developing further substance use disorder, and depression being one of them.
Hayley: So, going back to what you said earlier, we were talking about self-medicating and it would obviously be great if people self-medicated with exercise and healthy diet, but unfortunately that’s not always the reality. For somebody who is self-medicating, how do different substances interact with someone with depression? If somebody is drinking a lot, is that going to worsen their symptoms?
Dr. Bhatt: Different substances of abuse have different characteristics, and some can tend to worsen depression, and some can tend to have a tendency to temporarily alleviate them. When we talk about self-medicating, at some point in the range of substance abuse somebody is feeling better when they’re using. So, when we look at how addictive substances work or illicit substances or even alcohol, they tend to make people feel good or at least that’s the intention when somebody is using it. And that’s often when the substance is introduced, neurochemicals like dopamine and other pleasure chemicals that are there, they’re increased in our body. Depending on the substance, we do feel a pleasurable, rewarding sensation. But then beyond that, there are substances that are more classified as depressants in terms of the fact that they sedate you. They slow down the central nervous system. And these are substances like alcohol, or benzodiazepines, and even opiates to a degree. I know many people who use heroin or opioid products, they feel good initially, but the more we use them there is that depressive effect. On the other side, we have elevating, Stimulant type classes of substances like Cocaine or Methamphetamines and those aren’t classified as depressants because they tend to boost you up, increase your energy, but with that you can become more paranoid or you can become psychotic. As a class, the alcohol, the Benzodiazepines, the sedative hypnotics, those things tend to be more depressive in terms of slowing down our central nervous system. Somebody who is suffering from depression might end up feeling more depressed quicker with those substances, although the initial feeling might be one of feeling more calm or euphoric. In the endgame, I always say for every substance that we use, for every action that is has, our body will provide an equal and opposite reaction. If these drugs are abused to make us feel good, once the drugs are removed, we’re all going to feel bad.
Hayley: So, the class of drugs does effect symptoms differently?
Dr. Bhatt: Definitely, yeah. You can be more quickly synergized with sedatives on top of depression, but again, the more you use a stimulant, once the stimulant starts to get removed, the opposite reaction of depression will set in.
Hayley: Can you get treatment for depression while you’re still dealing with an addiction?
Dr. Bhatt: Yeah, in many treatment centers, if not most, we know they are going to help somebody understand the presentations that they’re facing- the depression, or the substance abuse, or whatever other psychiatric condition that they might be going through. They should be or would offer treatment for both. And it’s important that we identify this. A lot of times it could be the depression that’s causing someone to pursue substances, or the substances are causing the depression. A proper psychiatric evaluation and assessment through a clinician, through a psychiatrist, it is important. And then, of course, the treatment has to be done. Often times when the depression is secondary, once the substance is removed and people enter recovery, they notice that their moods starts to improve. But with a good evaluation, a good history taking, good collateral information, we often can recognize that the substance use is because someone is having an underlying depression that needs to be treated. If somebody is going through acute withdrawal, then the detoxification period sometimes we want to make sure that the person is washed out of all other substances before we start any medications. But once that’s done, if there is a primary depression, medication or treatment therapies should be started very soon.
Hayley: So, as somebody in your field, how could friends or family convince someone, like a loved one in their life, to get treatment who is struggling with depression, addiction, maybe both or just one or the either?
Dr. Bhatt: For the family members, they probably have tried many times to talk to somebody. And especially if you’re suffering from an addiction, you’re not in the right state of mind. Your mind, your brain, and your body, it’s hijacked with the substance of abuse. To try to talk rationally and convince them, it’s very difficult. Often our suggestion is trying to catch them when they’re not intoxicated, and then try to have a clear conversation at that time. Sometimes it’s not that easy, because we bring a lot of feelings with us when we’re family members and we often have to solicit the help of professionals. Often there’s an interventionist, trained individuals, or even through their own experience. They will try to get involved and help, speak to a loved one to help them get help and find help. And then sometimes unfortunately we have to bring the law, and get the law involved. There are different states, statutes that exist in different states that help loved ones who do see their family members who are suffering from addiction and mental illness, who might be to the point where they’re in innominate danger. There are involuntary processes that can help people, unfortunately against their will, get into treatment. But it’s better to do that and have them be safe than unfortunately have the negative consequences of potentially dying. It’s a tough question that you’re asking because it’s hard to convince anybody that doesn’t want help themselves, but there are stages in trying to talk to them where they’re often in a moment of sobriety is the best option. I think we tend to react when somebody’s using and acting out, and trying to talk to them then, but that’s usually not going to work. Those are some of the steps that we can use.
Hayley: Dr. Bhatt, is there anything else on this topic that you think is important for people to know?
Dr. Bhatt: Depression is a major issue for us and individuals around the world. It’s something that is quite a prevalent mental health condition. Substances of abuse unfortunately, as I mentioned before, that’s a temporary fix. People do end up trying to use and self-medicate, or they have underlying depression, and it gets so blurry that we don’t know if depression was the cause or if depression was the consequence. But at the end of the day, that treatment and professional help, it’s warranted, it’s needed. So, for those individuals out there who are listening who are suffering, if you want to get rid of that suffering, seeking professional help is the proper route. You don’t have to go at it alone. There are people and there are centers and there are a wide variety of options to get help. And it’s similar for family members, help is there and help is available. It can look very difficult and hard, but with resources that might be available like addictioncenter.com, help and recovery is there, and is available.
Hayley: Absolutely. I really want to reiterate that. For anyone whose listening, who’s struggling with depression or addiction, there is help out there. You don’t have to go through it alone. I know it can feel like things won’t get better, but there are a lot of resources and people who are waiting to help you. For help with drug or alcohol abuse, addictioncenter.com has resources, and is also just a great place to learn more. You can check out more podcast episodes on Addiction Center, Spotify, and Apple Podcasts, and we hope to have you again for another episode of Straight Talk With The Doc.
Dr. Ashish Bhatt
Addiction Center’s Medical Content Director, Dr. Ashish Bhatt, MD, MRO is an accomplished physician, addiction medicine specialist, and psychiatrist with over 20 years of medical and administrative leadership.