Are People Who Take Antidepressants Really Sober?

By Kristen McGuiness 06/30/11

It's time for abstinence extremists to stop spreading the dangerous propaganda that "clean and sober" means no medications for depression, anxiety and other mental health problems. Even Alcoholics Anonymous says so.

Abstinence extremism can be dangerous to your health. Photo via

Does abstinence from booze, coke, heroin and other substances include medications for common mental health problems like depression, anxiety, bipolar disorder, even schizophrenia? Many people in recovery—particularly those in 12-step programs—seem to think so. And some, often out of an excess of conviction, attempt to persuade fellow members that "clean and sober" means no Prozac, no Effexor, no Klonopin, no Abilify.

Yet why should these drugs for medical conditions that are no less biologically based, chronic and debilitating than diabetes or heart disease be banned? Given that many studies have shown that the incidence of mental health problems is vastly more common among addicts, denying them safe and effective treatment seems dangerous, to say the least. A medical doctor who denies treatment to a patient is generally viewed as unfit to practice. Is it time for all these evangelical abstinence adherents to stop playing doctor?

These questions are increasingly being asked not only by addiction specialists but many people who swear by their 12-step programs.

When Paul R. was nine years' sober, he felt he was facing two choices: relapse or suicide. “In early sobriety, I was on [the antidepressant] Wellbutrin, but after a few years I decided I wanted to be entirely abstinent from everything,” the 39-year-old New Orleans medical-office assistant recalls. “But then the anxiety came back. After eight months it got to the point where I had trouble leaving my apartment—and if I was in a large social situation, like an AA meeting, I was just paralyzed.” Paul ended up in the hospital after fearing he might commit suicide. “I realized that it was a new surrender for me,” he says. “I was trying to control something I could not control: my own mind.”

After being hospitalized, Paul got back on Wellbutrin. Two years later, he was married and, not long after that, became a father for the first time. “I had gotten really dogmatic in my program,” he says now. “No alcohol-based products, no antidepressants. I thought that was how my sobriety should look. But it wasn’t realistic and it wasn’t healthy.”

According to Dr. Adi Jaffe, an addiction specialist at UCLA and an expert for The Fix, there is a mountain of evidence that links depression and substance abuse, although the chicken-and-egg aspect remains unresolved. Says Jaffe, “Depression rates are 2.5 to four times higher among substance abusers than the general population, but it is hard to nail that fact down to one specific cause. For some people, the depression was there first and they use the alcohol or drugs to alleviate it—what we call self-medication. For others, the drugs actually induced brain changes that ended up causing depression.”

For Michael S., a Dallas-based publicist who has been sober for eight years, meth and alcohol were part of the problem—but not all of it. “When I got sober, I realized how much I had fucked up my brain because of speed,” he says. “I was still having psychotic episodes and paranoia—and finally went to a good psychiatrist and began therapy. It was recommended that I go on medication." Not long afterward he began taking both an anti-psychotic and an anti-anxiety medication and quickly saw the difference: "I stopped thinking people were going to jump over my fence or break into my house. They say it takes four to five years to heal the brain from speed but I didn’t want to wait that long. After two or three years, I was well enough to stop taking the anti-psychotic.”

Abstinence was not good for Michael's mental health. “Gradually I went back into my old form of depression, which is quiet, miserable rumination,” he says. "And no amount of the third step prayer or the St. Francis prayer or talking to anyone was helping."

Depression can be episodic or it can have more long-term effects, according to Jaffe. “Some people might only need medication for a matter of months, others for some years, and still others might need it lifelong,” he says. “Even if the depression or paranoia is not directly linked to the drug abuse, people who have been abusing drugs or alcohol have typically experienced significant life changes because of their addiction—and those can result in depression. Many times, when people stop the substance, their lives improve, and the depression lifts. Unless it’s biological.”

Dr. Dale Archer, a clinical psychiatrist in New Orleans and New York, agrees. “You could say that most alcoholics and addicts don’t start seeking help until they begin to have problems with family, friends and career,” he says. “Even in terms of the behavioral aspects alone, there are often enough stressors to trigger depression without the addiction." Treat the alcoholism and drug abuse, and you can lift the depression, he says. "But many addicts have real chemical-imbalance problems, and they get sober, do the 12-step program, and are still really depressed. They need either cognitive or experiential therapy—and they may well benefit from medication as well.” 

Addiction itself is at least partly associated with a deficiency of dopamine, a brain chemical that plays a central role in the brain's pleasure and reward centers, while depression is at least partly linked to a lack of the brain chemical serotonin—and the activity of the two neurotransmitters is interconnected, says Archer.

Like many other people in recovery, Michael tried to get off his medication, in keeping with the widespread belief in abstinence. “I didn’t want a crutch, if it is a crutch, or something that might make me sick over time," he says. "With my psychiatrist’s guidance, I went off of my anti-anxiety medication for a year.”

But abstinence was not good for Michael's mental health. “Gradually I went back into my old form of depression, which is quiet, miserable rumination,” he says. “I was still going to meetings, working with my sponsor and sponsees, but I couldn’t change my perspective that life could be good. And no amount of the third step prayer or the St. Francis prayer or talking to anyone was helping." Michael learned the hard lesson that biology is destiny. "I finally realized that I was going to live negative, upset, annoyed, irritated, and hopeless, or I could call my therapist and say, ‘Hey, I think I need to go back onto medication.’”

Archer explains that there is a big difference between standard antidepressants, such as the Prozac category of drugs that increase serotonin levels or dopamine-lifting Wellbutrin, which are nonaddictive, and anti-anxiety drugs, such as Klonopin and other benzodiazepines, which can easily give rise to abuse. In a January 2011 Harper’s article, a writer and recovering alcoholic described the difficulty he faced in controlling his Xanax prescription, unsure how to balance sobriety and his use of the mood-enhancing molecule. “Antidepressants are generally very safe and effective for alcoholics," Archer says. "Where you run into problems is with the benzodiazepines, which have addiction potential. A lot of people who treat addicts, myself included, believe that the best thing to do is not to use them. But there are always cases where you have no choice and then the medication needs to be closely monitored.”

What it all comes down to, says Jaffe, is that if an addict in recovery has depression independent of their drug use, they need to treat that depression by methods independent of their recovery. The best recommendation if you are grappling with this quandary is to educate yourself about the different treatment options. “You need to be honest with your doctor,” Jaffe says. “For people in the 12-step programs who have pursued the other treatments for depression, I strongly encourage them to look at what Prozac, Wellbutrin and other standard antidepressants can do for you and your brain, and then decide whether using medication would threaten their abstinence.”

Unfortunately, there are some folks in the 12-step world who attach stigma to the use of SSRIs and other psych meds. That was LA executive assistant Mary T.’s biggest fear. With large blue eyes and a nervous air, she has suffered from lifelong depression and knew that getting sober didn’t equal getting sane. “It’s hard to hear people say you’re not sober if you’re on antidepressants,” she says. “I have been horribly depressed in sobriety, and without the medication I wouldn’t be able to get out of bed on a regular basis." Mary attempted suicide at 15 and was hospitalized for six weeks for depression a year later. "I didn’t start drinking until 18 and I don’t think I was an alcoholic until I was 25, but I would have killed myself long before I got around to drinking without the antidepressants. They have kept me alive.”

“In my home group, a speaker shared that he didn’t believe that alcoholics should use antidepressants," Michael says. "To me, that’s an outside issue, and to bring in your opinion like that from the podium is inappropriate and dogmatic. This isn’t Scientology or Christian Science." 

Michael has encountered similar anti-medication prosthelytizing. “In my home group recently, a speaker shared that he didn’t believe that addicts or alcoholics should use antidepressants as a way to treat their symptoms," he says. "To me, that’s an outside issue, and to bring in your opinion like that from the podium is inappropriate and dogmatic. This isn’t Scientology or Christian Science. When these people look at someone who is on an antidepressant, do they see a 'stoned' person or someone who used to be depressed and is now hopeful?”

Archer agrees. “I have a problem with the notion that someone isn’t sober because they take antidepressants. That’s a very dangerous idea," he says. "The reality is that some people have true major depressive episodes and after being sober for six months or a year, they realize that those aren’t going away. If people tell them that they can’t take anything, they’ll think they need to be depressed for the rest of their lives.”

Archer recommends that you start with a recovery program and then move through the treatment options from there. “I always suggest that people try AA, and hopefully the depression will clear,” he says. “They’ll view life from a different lens. But if they still have the depression, then look at therapy, which is where the decision about medication should be made. In general, Americans are overmedicated and overdiagnosed. But if medication is needed, it needs to be looked at.”

Mary has found that a combination of all three—AA, therapy and meds—has been the best solution for her. “Sobriety and recovery helped shift my perception but I wouldn’t be able to do them if I wasn’t on medication,” she says. "With the medication and therapy, I can work the 12 steps and participate in all the other parts of AA: sponsorship, service, spirituality, and fellowship. With all those things, including the medication, I have been able to maintain my sobriety—and also my sanity.”

It may come as a surprise to some abstinence fundamentalists that Alcoholics Anonymous has an official position of this issue—and it is most emphatically not their own. In the pamphlet titled "The AA Member: Medications and Other Drugs," the organization articulates its policy that "No AA Member Plays Doctor." As for taking medication,"it becomes clear that just as it is wrong to enable or support any alcoholic to become readdicted to any drug, it's equally wrong to deprive any alcoholic of medication which can alleviate or control other disabling physical and/or emotional problems." This plain edict should put an end to the quiet but dangerous campaign against these lifesaving drugs. Why it has not is a question that is not so plainly answered.

Kristen McGuiness is a freelance writer and regular contributor to The Fix who wrote previously about the 13th step and dreaming about drinking, among many other topics. She is the author of 51/50: The Magical Adventures of a Single Life

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