Essential Mnemonics for Diagnosis on the Addiction Counselor Exam

Welcome to the Addiction Counselor Exam Review. This presentation is part of the Addiction Counselor certification training. Go to HTTPs www.allceus.com certificate tracks to learn more about our specialty. Certificates starting at $149. Hi everybody and welcome to your review of diagnosis. Now this is again going to be a really high level overview of diagnosis for substance abuse and mental health issues. If you're looking for something more in depth, we do have other diagnosis courses@allce.com, but this one is just kind of to hit the highlights. So you're going through and going, yeah, I know that. Yeah, I know that. It's kind of what I'm hoping. We'll review the criteria for substance use disorder, discuss substance induced disorders and learn mnemonics to help you identify signs of intoxication and withdrawal as well as signs of mental health issues. So the DSM is created to facilitate communication between and within professions regarding mental health and substance use disorders. You gotta remember that a DSM diagnosis, like depression, for example, says you have to have a certain number of the symptoms in order to meet diagnostic criteria, but that those symptoms can show up in any one of like 144 different permutations. So it's important to remember that not every person's depression is going to look like every other person's depression, nor is it going to necessarily be caused by the same thing. You can have depression because of not enough serotonin. You can have depression because of not enough, not enough norepinephrine, not enough dopamine. There's a whole bunch of stuff. I mean, we do know that moods are affected by our levels of neurotransmitters. But then you back up a step and you go, what is causing that imbalance in neurotransmitters? Is it organic? The brain just can't make enough? Or is it something like the person isn't getting enough nutrition or is under too much stress or is not sleeping enough? So it's important to recognize that the DSM and diagnoses in general are just shorthand and they're necessary for billing and that kind of stuff. But you don't want to assume you know what's going on with the client. When you read the word depression or substance use disorder, it improves inter rater reliability regarding diagnosis because it says you have to have, for example, six out of the following nine symptoms. So you're not going to have, you know, Jim Bob over here who wants to, you know, find a label of diagnosis for everybody, and Sally over here who says no, you have to have all nine symptoms. You know, the DSM says any six of these nine, so it improves the reliability. So if you see a client and I had this happen a lot of times when I worked in community mental health where clients would come back for another episode of treatment and I would be reassessing them and you know, you really want. If the first therapist diagnosed them with bipolar disorder, for example, the second therapist needs to be able to see those same symptoms and see how that therapist arrived at their diagnosis. So the DSM helps with that and it improves sharing of information about client presentation and needs because it ensures we really look at all of the symptoms, so to speak. And the DSM goes into great detail about differential diagnosis. So it helps us figure out what biopsychosis social needs the client might have in addition to their emotional mental health needs. The ICD10 is the international classification of disease and is used for diagnosis just like the dsm. It's used more in medical settings and some insurance providers require that you use the ICD10 classification. So, you know, if you're getting ready to take your addictions counselor exam or something, you know, it's important to be able to go online and figure out how to look something up in the ICD10 because you can find it online. Let me just see. Do it right here real quick. So the ICD10 code for generalized for anxiety disorder, unspecified F41 9. Let's do for generalized anxiety it's F41.1. So you know, the ICD10 should not be confusing or scary to you at all. And through the use of Google or some other browser, you can usually really easily find the codes that you need. So you don't necessarily have to have the book sitting on your desk. So Diagnosis of substance use disorders. The DSM 5, which is what we're on right now, recognizes 10 separate classes of drugs. Alcohol is in a class by itself. Now that doesn't. Well, inhalants, opioids, sedatives such as hypnotics and barbiturates and anxiolytics, your anti anxiety medications, stimulants, caffeine, tobacco, cannabis, hallucinogens, and then other unknown substances. Now it's important to recognize that sedatives and alcohol, for example, have some similar properties. So you don't want to assume that they're completely distinct. And it's. We'll talk about some of the symptoms of intoxication withdrawal as we go through this presentation. Stimulants are another one, you know, and caffeine is A stimulant, but it's in a class all by itself. So, you know, just being aware that you can have substance intoxication of any of these things, substance withdrawal from any of these things, and you know, the substance use disorder diagnosis, it used to be broken into substance abuse and substance dependence. And when we went to the DSM, DSM 5, they combined it all into substance use disorder. Although how each type of drug acts in the brain differs, they all activate the brain's reward system. Wow, I can't talk this afternoon. Two groups of substance disorders that you need to be aware of. Substance use disorders, which are what we typically think of as addiction, substance intoxication, withdrawal, tolerance, yada yada, and substance induced disorders. Sometimes when you take a substance, it can cause hallucinations, it can cause anxiety, it can cause depression. So, you know, you need to differentiate what's going on. When you're looking at mental health disorders, for example, is the depression simply a side effect of withdrawal from stimulants or is it an ongoing underlying disorder? You can have substance induced depression, or you can have a substance use disorder and major depressive disorder in the same person. So for substance use disorder diagnosis, the person needs to use in larger amounts or for a longer period of time than intended. They have needed to want to cut down or stop, but failed. They need to spend increased time getting using or recovering from use, have cravings and urges, neglect work, school, family, social obligations because of use, continue to use even when it causes problems in relationships, give up important social, occupational, recreational activities because of use. So even if it's not causing problems, if you're giving this stuff up and all you're doing is using, that's a problem. Using in risky situations, continuing to use despite knowing that it's making a physical or psychological problem worse, Those are your big criteria. Then you've also got tolerance, which is the need of more of the substance to get the same high, or the need to combine substances to get the same high or the same effect and withdrawal physiological or psychological symptoms that occur when that substance is leaving your system. So people who have a certain number of criteria meet the criteria for substance use disorder. So if they have two to three symptoms, so that's not many, then they have mild substance use disorder, which is what we may have called substance abuse in the past. Four or five is moderate, and more than five is a severe substance use disorder, which in the the past we would have called substance dependence. So we want to look at is their problem mild, moderate, severe. And then we want to look at, where are they at in terms of their recovery process? Are they in early remission, which means they pretty much just got out of detox or you know, 30 days clean, something like that? Are they in sustained remission? You know, that would be a much longer period of time on maintenance therapy, like methadone maintenance. So you know, you can be not using your drug of choice, but on maintenance therapy or in a controlled environment. So this helps us see how long is the person, has the person been clean or you know, able to refrain from using the drug of choice to a point where it's going to cause them problems? And are there factors that are contributing to that, such as they're on maintenance therapy or they just can't access it because they're in jail or they're an inpatient? Substance induced means that the current presenting symptoms are likely the result of use of a substance and not an underlying pre existing mental disorder. So like I alluded to a little while ago, you can have someone who is experiencing clinical depression as a result of detoxing from excessive stimulant use. You can have somebody have really bad anxiety who is detoxing from benzodiazepine or alcohol use. So that would be substance induced. Now, once the substance is out of their system and you know, they're clean, so to speak, then we start to get a better picture about whether there's an underlying mental health issue in addition to the substance use disorder. Concurrent mental disorders can and often do occur. The rule now is that co occurring disorders are the expectation, not the exception. The results from effects of the use of a substance can include intoxication and withdrawal, anxiety or depressive disorders, bipolar or related symptoms, psychotic issues like hallucinations or delusions, sleep issues, you know, either insomnia or being really, really sleepy. I've worked with clients who've been on, you know, they've been using methamphetamine for a week and haven't slept. And then when they start to detox, they sleep for days. Sexual dysfunction and neurocognitive disorders such as the inability, decreases in memory, inability to concentrate, those sorts of things, the substances, whether they're in your system or whether you're withdrawing from them, you're putting them in, it changes the neurotransmitters when they leave your system. Your brain can't adapt as quickly as the substances leave your symptoms, so you have the withdrawal symptoms. So it's important to recognize that some of these things may happen just because of the action of the substance that was ingested or used. The teeter totter principle helps predict symptoms in the withdrawal period. If somebody's using stimulants, then when they're withdrawing, they're going to probably be depressed. If somebody's using depressants like alcohol, then when they withdraw, they're probably going to be anxious and agitated. So you see the opposite of whatever the drug did. Now if they were using polysubstances such as cocaine and alcohol, or cocaine and benzodiazepines, it complicates the picture a little bit because cocaine, you would typically see them be depressed afterwards, but alcohol, you would typically see them be agitated and anxious. So if they're using both of them, you're not really sure what's gonna, what it's gonna look like in the detox period. So depressants, you know, let's talk about how do you know somebody's been on this? Because diagnostics are important and I've put together some mnemonics that can help you identify, you know, what you're looking at. So for alcohol, which is a depressant, general sedatives like your and your anti anxiety medications, your barbiturates, what you're looking at is Sam's gin. This is espine, Mnemonic slurred speech attention impairment, you know, they're not focusing on much of anything. Memory impairment, can't remember what you said 5 minutes ago. Stupa or stupor or coma or death. So they may be just bleh and kind of unresponsive. Now, obviously that is heavy intoxication. Their gait may be unsteady, so they have difficulty walking. They may be uncoordinated, have difficulty signing papers, carrying things, not just walking, but uncoordination in other areas. And they may have nystigmus, which is when the eyes go side to side or up and down in terms of alcohol, side to side, involuntarily. So their pupils, their irises are kind of jumping around all over the place. Now every person who's intoxicated is not going to have every single one of these symptoms, just like, you know, when we're making a mental health diagnosis. But these are the things that you're going to look at most people who are under alcohol, under the influence of alcohol, you're also going to smell it on them. But if they're using Xanax or Valium or one of those, there's nothing to smell. So you're going to have to look for some of these sorts of things. Withdrawal from your sedatives you're going to have psychomotor agitation. Remember that teeter totter principle. So instead of stupor and coma, you're going to have somebody who's restless, irritable, jittery, anxiety seizures can happen as the person, as the drug gets out of the system. The person's blood pressure can go up with any of these, which can cause grand mal seizures. Detoxification from your alcohol, sedative hypnotic anti anxiety medications can be life threatening. This is not something we want to advise people to do on their own. They need to be medically supervised. Transient hallucinations can happen. Nausea or vomiting, insomnia, hand tremors, excitability, increased heart rate and blood pressure. So they might feel like they're going to crawl out of their own skin as they detox. And sweating, which is the clinical term, is diaphoresis. But if they start sweating profusely, that's also a symptom. And if you've worked in a detox unit, you've seen this, you recognize this. The acronym that we're talking about here is past nights. And you can download this presentation from the class so you can learn all these different acronyms and you have them in handy when you're doing diagnostics or you know, so you can memorize them for the test. Amphetamine, cocaine intoxication, the mnemonic is a code blue. So the person is agitated or slowed down. So when we say agitation or psychomotor retardation, that means they're either, you know, really jittery and kind of all over the place or they're really slow. Sloth like and slow. Cardiac. You can have tachycardia, which is the heart rate beating too fast or sometimes bradycardia which is the heart rate beating too slow. So you want to look for that normal heart rate. Opening of the pupils. When they're on amphetamines, their pupils will be blown. Just like when you're really dark room, your pupils get really big to let more light in. Well, the pupils are not going to be as reactive to light. When somebody's under the influence of amphetamines, diaphoresis or sweating and chills, then you have encephal, encephalopathic like changes. So brain type changes, including seizures, confusion or coma. Blood pressure can be elevated or lowered, loss of stomach content. See people puke a lot of times when they're on intoxicated with stimulants. Unstable muscle associated changes can include muscle weakness, slowing or increasing of respiration and heart arrhythmias. So it's not even, you know, we said it's too fast, too slow or not regular. You want to hear bump, bump, bump, bump, bump, bump, bump. Not bump, bump, bump, bump, bump, bump, bump, bump, bump, bump. That, that's not a heart rate. That's something you dance to. And evidence of weight loss, people who are taking amphetamines. I mean, amphetamines are prescribed for weight loss. It's a system. What's the word I'm looking for? It makes you so you're not hungry and so amphetamines are going to do that naturally, but they also speed up your heart rate and your metabolism and stuff. So people may lose a lot of weight if they're using stimulants. When they withdraw from stimulants, it's much shorter list de pants Depression is really prominent for a lot of people withdrawing from cocaine and amphetamines. Just lots of depressed thoughts, sense of hopelessness, apathy, often suicidal ideation, not always there, but sometimes psychomotor agitation or retardation. Sometimes. A lot of times people slow way down. Their appetite increases because they don't have that appetite suppressant in their system anymore. They may have nightmares, vivid unpleasant dreams. They may be really tired. Well, you know, if you've been running on full bore for three days and haven't slept, you're probably going to be tired. And they may have sleep problems. And it can be hypersomnia, sleeping too much, which would make sense, but it can also be insomnia. They may still be a little revved. They may have some underlying anxiety, you know, so we want to look for sleep changes in these clients. The biggest thing to watch out with with amphetamine and cocaine withdrawal is the suicidal ideation. So hallucinogens and cannabis hallucinogens. The mnemonic is distort. They may have distorted vision, kind of blurred, hazy, wavy. They may be uncoordinated, sweating, have a fast heart rate, which is tachycardia. Again, their pupils may be wide open and really not responsive to light. They may have racing heart or heart palpitations where it feels like their heart's gonna beat out of their chest. And it may even be at a semi normal rate, but it feels like it's gonna beat out of their chest. And they may have tremor, hand tremors when they're on intoxicated with hallucinogens, when they're intoxicated with cannabis. And I'm not sure why they came up with mnemonic meat, but they did. Their mouth is dry, their eyes are Red, which is erythematous conjunctiva is the Latin term for red eyes, mouth dry, red eyes, increased appetite and tachycardia, racing heart rate. So you see that tachycardia comes up quite a bit, as does sweating and in coordination. So being aware of the different range. So you can figure out again, the presentation is going to be very, very complicated. If you have a client who says, yeah, I was out partying all night and I was doing PCP and cocaine and alcohol and anything and everything, you're not going to know exactly what kind of symptoms you're going to have during the detox period. But you're also not sure whether the intoxication period is completely peaked yet. If somebody eats a marijuana cookie or brownie or something, those effects don't kick in for a lot longer than if they smoked it, for example. So you may still have some increasing symptomatology even after they get to wherever you're seeing them at the jail, receiving facility or emergency room or whatever. So let's talk about opiates. Opiates are the word on everybody's tongue right now. Opiate intoxication, and the mnemonic is spared slurred speech, pinpoint pupils. So up until now, we've been talking about blown pupils. They've been wide open and not responsive. Somebody who's under the influence of opiates, you look at them and their pupils, the black part of their eye is teeny, teeny, teeny, teeny tiny. And it won't open up if you go into a dark room. It's not reactive to light either attention or memory impairment. A lot of people who are on opiates are just kind of lala land place respiratory depression. Opiates are sedatives. So it does slow down heart rate, breathing, that kind of thing. Too much opiate slows it down completely. Person dies, euphoria. Now, this is something a lot of people don't think of with opiates, but many opiates. And one of my clients referred to opiates as his effort drug or screw it drug. We'll clean it up a little bit. Because when he took it, he didn't have a care in the world. He was just like, oh my gosh, it's so liberating. So he had this sense of euphoria when he was taking it. He wasn't manic. He felt relieved. He felt his uber self. So some people, and for some people, this is the most addicting part of the opiates. Other people get really drowsy so, you know, you want to look and don't want to assume that somebody on opiates is going to be drowsy. They can be euphoric and drowsy at the same time. Pinpoint pupils is one of the things that's going to give them away. When we talk about withdrawal, you're going to have. The pupils will dilate more, they start to get itchy. You know, if people are talking to you and they're scratching like this, like they've got bugs on them or something. A lot of times people who are abusing opiates itch a lot. So pay attention to that. Aches. Okay. Withdrawal. The mnemonic is army finds. And this has nothing to do with the army, it's just the way the acronym panned out. Muscular aches, rhinorrhea, which is nose running or lacrimation, which is eyes tearing and kind of running. So somebody kind of oozing their mood is dysphoric, so they're probably going to be depressed. Some people may also have some underlying anxiety issues. I've seen a lot of people self medicate their anxiety with opiates. So when they're withdrawing from the opiates, the anxiety stuff comes back out. Yawning, fever, insomnia, nausea and vomiting, diarrhea and sweating. A lot of people say that withdrawing from opiates looks a lot like the flu. It does. It's really unpleasant in 99% of the cases. Well, even more than that, it's not life threatening. It is severely unpleasant. But as long as the person doesn't get too dehydrated most of the time. Opiate withdrawal can be managed on an outpatient basis, but you do need to be aware of these different things that are happening. You can also get goosebumps, and they call it piloerection, but it's when the hairs stand up on end. So looking for that in your clients. And I had a client who would go to the bathroom during class, during group, and he would use and he would come back and, you know, 20, 30 minutes later, those pupils would be pinpoint and he'd be itching at himself. And I knew exactly what was up. Pcp map stand. You're looking for muscle rigidity, an acute sense of hearing, like they think they can hear the mice walking in the walls. Pain, numbness, just oblivious to pain. And I've had associates, classmates who had a bad trip on PCP who just, he kept banging his head into the wall until it got bloody. And he was just oblivious to the Fact that, that he was giving himself a concussion. Concussion, seizures or coma are possible. Tachycardia, which is again racing heart, or hypertension, which is high blood pressure. You don't have to have. They don't both go together necessarily. You can have both. You can have one or the other. Ataxia, which is loss of control of your bodily movements. You don't feel like you have control over your arms or your legs anymore. Nystigmus, like we talked about before, the eyes are kind of jumping around. With pcp, it can be horizontal or vertical. And dysarthria, which is problems with articulating. So, you know, that's basically slurring your words and having difficulty getting your words out. When we're talking about differentially diagnosing mood disorders, you know, you may have clients, you probably will have clients that have concurrent mood disorders. So let's learn some mnemonics. For the big ones, a sad face is the mnemonic you use for depression. Appetite changes, sleep disturbances, and hedonia, which means you just don't find pleasure in much of anything. Dysphoria, a sense of being depressed, hopeless, helpless, guilty. Agitation. You know, some people when they get depressed have difficulty sitting still and they feel kind of restless. Other people can hardly move. Concentration difficulties, when you're depressed, it's hard to concentrate and low self esteem. Remember, not every symptom is required for a diagnosis of depression, but these are the most common symptoms that you'll see. For mania, the mnemonic is dig fast. Now, if you're diagnosing bipolar disorder, the person is going to have an episode or episodes of depression or persistent depressive disorder and either mania or hypomania. So, you know, you have to have those. And bipolar I or bipolar 2 are different in terms of bipolar I, you have a full blown manic episode. Bipolar two, it's only hypomanic. But I digress. So for mania, you know, how can we tell if this person is manic or not? Now the first thing I want to tell you is when people come out of a depressive episode, they have a period where they feel pretty good and they feel almost euphoric. That's okay. That's not mania. That's them. That's the clouds lifting. That's them being able to breathe again. Mania is distractibility, extreme distractibility. Indiscretion in what they do. You know, doing things that are dangerous. They're taking chances. They're things you wouldn't normally do. Grandiosity, thinking that you're 10 foot tall and Bulletproof or you're all that in a bag of chips and you're going to tell everybody about it. Grandiose ideas can get people into a lot of trouble when they're manic because they tend to think that they can do things that they can't or think that they can convince people to do things and they can't. Flight of ideas. They're all over the place. They may be talking about one thing now and then they'll change directions and start talking about something completely different. And then 15 seconds later, they're talking about something just completely different than that. And a lot of times their speech is really, really fast and it all kind of runs together and you're just going, please take a breath. Flight of ideas. Activity increase. People who are manic are wired, so they are going around and it's often goal directed activity. They're seeking pleasure, they're seeking something that's stimulating. Sleep deficit. You know, they're wide open, they are not sleepy at all, or if they fall asleep, it's like for an hour or two and they feel completely rested. Talkativeness. They talk a lot when they're in a manic episode and they talk about a lot of things because their brain is going really, really fast and there's no filter between their brain and their mouth sometimes. So they're just kind of talking about everything that they think. One thing that I found helpful with clients who are in a manic or hypomanic episode is to use a whiteboard and write down the themes or general issues that they're talking about during the assessment. So then I can say, all right, you know, let's take these one at a time because I'm going a little slower than you are. Let's talk about this and then, you know, work through it a little bit. Now, the difference between mania and hypomania is degree. People who are in a manic episode can have psychotic features. People who are in a hypomanic episode won't. People who are in a manic episode have significant impairment in daily functioning. People who are hypomanic may not. They may actually seem like they're more driven, like they're driven by a motor, like they finally had this burst of energy, but it's, you know, more so. The other thing to remember is with bipolar disorder, people usually don't go from being depressed to being manic. You know, they don't swing like a pendulum. They may have a depressive episode and then have a remission and then have a manic episode or maybe even another depressive episode. You know, they may have four or five depressive episodes and then finally a manic episode. So you don't want to assume that somebody's going to swing like a pendulum back and forth. There are long periods of remission and you know, you. Somebody may only have one manic episode ever, but multiple depressive episodes. So just because they've only had one manic episode or only one depressive episode doesn't mean that it's not bipolar. So you want to really look at what's going on. Anxiety disorder. Most commonly you're going to see generalized anxiety disorder. So this is watchers. The person has a lot of worry about a lot of different things and it feels uncontrollable. They have a lot of anxiety. You know, they worry about their worry and they're anxious, they feel threatened. Tension in their muscles, Concentration difficulty. And think about when you're stressed. Let's go back to tension and muscles for a second. Makes sense, right? When you're worried. A lot of us tend to carry tension. I know I grind my teeth and I carry tension in my upper back and my neck. Well, people who have generalized anxiety disorder, they have that same tension in their muscles. So concentration difficulties. If you're worried about something, you probably have difficulty concentrating on other things and getting through the day because you're focused on this other thing over here. Hyperarousal, being kind of wound up or irritability, being, being more irritable, moody than normal. People who are anxious. Now remember, anger and anxiety fight or flee. Both of them represent the emotional responses to a threat or a perception of a threat. So if somebody is anxious, then their brain somewhere in there is telling them there's a threat. Something bad's gonna happen. When you are feeling threatened, we tend to be more irritable. We tend to be a little bit more short tempered. We tend to be a little bit more like a cat that's backed into a corner. Get away from me. Energy loss. Yeah, anxiety can result in that because when you're wound up for so long, eventually your body's just like, I can't do it, I got no more to give. You're not sleeping, you're not eating well, you're just thinking all the time, I need a break, I'm tired. So the energy goes down. Because you've been so wound up. Restlessness, part of you may still be kind of on edge, looking around, you know, hyper vigilant, so to speak. Restless, difficulty sitting still. You know, you can't do anything, but you can't sleep and you're just kind of in this limbo land. And sleep disturbances, most of the time, people with generalized anxiety have difficulty sleeping. They may be able to get to sleep, but they may wake up 3, 4, 5, 7 times during the night worrying about things or even may wake up with panic attacks. So sleep disturbance doesn't necessarily mean they don't want to sleep or they're not sleepy. It may mean they can't stay asleep. And ptsd, the mnemonic I chose, there are multiple out there is trauma, traumatic event has to have happened. Yeah, go figure. They need to be re experiencing the event either through flashbacks or intrusive dreams and nightmares. They need to be avoiding reminders of the event or their feelings about the event. Emotional numbing kind of goes in that avoidance too, where people just, they're like, I don't feel anymore. I can't feel. It's not safe. They're unable to function. They have difficulty going to work and doing things. The symptoms last for a month or more. They have increased arousal and obviously that should go up a little bit higher. But in order to make the mnemonic work, you know, it had to go at the bottom. But their arousal is increased. So they're constantly scanning for signs of threat. They're hyper vigilant. Their startle response is a lot stronger to things that may happen. They may be. A little bit and not pathologically so, but they may seem to others to be a little bit paranoid or over concerned about things. So being aware of the arousal, it's important, and I will say this, and it's true for all of the disorders and all of the symptoms, not just ptsd, to help normalize the symptoms, help the client see, see how this symptom makes sense in terms of the body's desire to survive. You know, if you've been through a trauma, then it makes sense you're going to be a little bit more sensitive and aware and maybe aroused to your environment to prevent being traumatized again. Now we can deal with those symptoms so they can reduce their level of arousal, because that's exhausting. But it's important to help clients see that these symptoms make sense. They're not pathological. They are basically creative ways that your body has tried to help you survive something that most people shouldn't have to experience. So some conditions are substance induced. That means, you know, like depression that's caused when you're withdrawing from stimulants. Once the body has the stimulants, added out of its system and has, you know, a couple of days to get back in order that depressiveness, those depressive symptoms may go away. Now you may have depressive symptoms that continue because the brain chemistry is out of whack for some other reason. So we have substance induced symptoms. We have substance use disorder, which is using more than intended and continuing to use despite knowing it's causing you problems in multiple areas of life. And then you have mental health issues that would have existed with or without the substance. Now, sometimes the substance can trigger schizophrenia, you know, the stress from everything that's going on. But it's important to recognize that depression needs to be treated. You know, if somebody is in your treatment program and they're sobering up and they're clinically depressed, if they don't get some help for that, if you just assume, well, you know, once they get through that post acute area, they'll be fine. They need to have treatment to help them deal with their depressive symptoms or they ain't going to stay clean and sober for long. I hope this review was helpful and I will see you on the next video.