Many people who want to quit drinking are concerned about the after-effects of the withdrawal process. One of the most concerning is the onset of depression. In this article, I explain what alcohol withdrawal is, depression and withdrawal, PAWS, and coping strategies.
Understanding Alcohol Withdrawal
Alcohol withdrawal occurs when a person who has been regularly drinking alcohol excessively stops drinking. Withdrawal symptoms experienced during alcohol detoxification can range from mild to severe. Common symptoms may include:
- Anxiety
- Restlessness
- Tremors
- Sweating
- Nausea
- Insomnia
- Cravings
In more severe cases, hallucinations, seizures, and delirium tremens (DTs) can occur. Medical professionals need to monitor these symptoms closely and provide appropriate interventions to manage discomfort and minimize risks.
Alcohol depresses the central nervous system (CNS). It slows brain function and changes the way your nerves send messages. It works by stimulating GABA, the main inhibitory neurotransmitter which is produced in excess, resulting in sedation. Alcohol changes the balance of GABA signals in the CNS and the excitatory signals (glutamate).
With long-term alcohol consumption, receptors affected by alcohol change to adapt and maintain normal, balanced function. Glutamate is overproduced to balance the excess GABA provided by alcohol. When a person who chronically drinks alcohol stops, the GABA signal is suddenly diminished. This results in an excess of glutamate, which causes the effects of alcohol withdrawal syndrome [1].
Managing withdrawal symptoms usually includes:
- Non-medication approaches, such as therapeutic activities
- Counseling
- Support groups
When necessary, medications are administered to help with symptoms and ensure the person’s comfort and safety.
While alcohol detoxification is a critical step, it’s only the beginning of the recovery journey. To achieve long-term sobriety, a person should participate in comprehensive addiction treatment recovery programs. These address the underlying causes of addiction and provide ongoing support and therapy.
Most people who go through alcohol withdrawal make a full recovery. But death is possible, especially if delirium tremens occurs.
Depression During and After Withdrawal
It’s common for people undergoing alcohol withdrawal to experience depressive symptoms. Up to 15% of alcoholics are at risk of death by suicide, and increased by recent consumption [2]. This may be due to the lowering of behavioral inhibitions when intoxicated or the increase in feelings of depression following the decline from peak consumption during withdrawal.
Additionally, the social, psychological, and physical impact of excessive alcohol use may contribute to the development of depression. Those with alcohol dependence showed, in some studies, a sense of alienation, emotional instability, anxiety, and aggressiveness, reflecting self-uncertainty and loss of self-respect. It’s very likely that depression after withdrawal is an incentive to re-start drinking [3].
There are two types of depression associated with alcohol withdrawal: Short-term and long-term (protracted withdrawal):
Short-term depressive symptoms often subside in a few weeks and include:
- Feeling hopeless
- Having a sense of low self-worth
- Feeling empty without the thrill of getting drunk
- Frequent periods of crying
- Difficulty concentrating
- Inconsistent eating patterns
- Disturbed sleep patterns
Long-term depressive symptoms (Major Depressive Disorder) last for months. According to the American Psychiatric Association’s DSM-5 manual, these must be apparent every day for at least two weeks. They must represent a change from the previous functioning and include either of the first two items:
- Depressed mood most of the day
- Diminished interest in or pleasure in most or all activities
- Significant weight loss or gain, though not dieting or equivalent change in appetite
- Insomnia
- Feeling agitated or slowed down
- Fatigue or loss of energy
- Feeling worthless or excessively guilty
- Reduced ability to think or concentrate
- Repeated thoughts of death or suicide or a suicidal attempt or plan
Post-Acute Withdrawal Syndrome (PAWS)
There are two aspects to withdrawal:
- The acute phase which is what we commonly think of when referring to withdrawal
- The post-acute phase which follows for many people.
Post-acute withdrawal Syndrome (PAWS) is not easy to identify as it is primarily psychological. It only has a few physical symptoms, fatigue being the main one.
PAWS may typically last two years. The first year is more intense, with episodes lasting 2-5 days, followed by a gradual lessening of symptoms. Time is the biggest factor, requiring great patience. The biggest issue with PAWS is that it may trigger a relapse.
Some of the key symptoms of PAWS are:
- Mood swings
- Agitation and irritability, when not previously common
- Sleep disruption, either more or less than before
- Difficulty thinking, focusing, or recalling events
- Loss of energy or enthusiasm
- Loss of joy in previously pleasurable activities
- Cravings, dreams, or intrusive thoughts of drinking
Coping Strategies During Withdrawal
Withdrawal is often a difficult process. It typically includes the following elements:
Medications: Antidepressant medications are prescribed by either your primary care doctor or a psychiatrist. These are effective in managing a number of symptoms of depression, including sleep troubles, problems with appetite, and low mood.
Friends and Family: Maintain your key relationships as they likely understand you best and can empathize most effectively. Make a point of seeing them even if you don’t feel too sociable.
Exercise Routine: Keep up your exercise activities whatever they may be. They stimulate Serotonin which is a “feel good” neurotransmitter.
Experiential Therapy: Experiential therapies are a great way to connect with the senses, boost self-esteem and improve general wellbeing. These may include art therapy, dance, roleplay, yoga and meditation.
Support Groups: If you are feeling isolated or met with a lack of understanding from loved ones, support groups can be a great no-shame zone to connect with others who may have shared similar struggles of depression.
Sources
[1] Canver B. et al. 2024. Alcohol Withdrawal Syndrome. [Updated 2024 Feb 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan.
[2] Trevisan L. et al. 1998. Complications of alcohol withdrawal: pathophysiological insights. Alcohol Health Res World. 1998;22(1):61-6. PMID: 15706735; PMCID: PMC6761825.
[3] Kobayashi T et al. 1999. Mental and physical symptoms in alcoholics after alcohol withdrawal–comparing with involutional melancholia patients. Nihon Arukoru Yakubutsu Igakkai Zasshi. 1999 Dec;34(6):558-67. Japanese. PMID: 10659609.
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