Unraveling the Question of Substance Abuse and Mental Illness
(September 2003)
Keynoter: Marc A. Schuckit, MD
The NASW-NYC 35th Annual Addictions Institute, held on May 21 st , was an opportunity for social workers and substance abuse counselors to network, to expand their skills and knowledge, and to share with one another. Over 500 participants attended this event that featured keynote presentations, 37 workshops, and numerous exhibits.
The morning keynote address was given by Marc A. Schuckit, M.D., Professor of Psychiatry at the University of California at San Diego and Director of the Alcohol and Drug Treatment Program; Director of the Alcohol Research Center at the San Diego Veterans Administrations Facility; and Chair of the Substance Related Disorders Work Group in the Task Force on the Diagnostic and Statistical Manuel of Mental Disorders; 4 th edition DSM IV.
Dr. Schuckit focused his remarks on the challenge of establishing a diagnosis with the clients who might be either abusing drugs or mentally ill, or both. “The real world is much more complicated than the text books,” Dr. Schuckit said. “Substances can change brain function, which leads to a confusing pattern of behaviors and symptoms. Establishing whether or not a person has a mood or thought disorder, independent of their substance abuse is extremely difficult but crucial to determining a correct course of treatment.” Dr. Schuckit explained that a misdiagnosis could be very harmful, aggravating symptoms and causing problems to become worse and even precipitating a fatality.
There are many cases where substance abuse induced symptoms present similarly to the bipolar disorders or schizophrenia, but in reality are caused by substances. For example, alcohol and abuse of controlled substances, such as valium, can cause depression. Amphetamines and cocaine can induce psychosis, mania, and paranoia. However, these symptoms are fundamentally different from major depression or schizophrenia or mania. With substance abuse induced symptoms, it is often best not to medicate as such symptoms will clear on their own if the client remains clean and sober. These clients do well if monitored closely, for example on a rehabilitation unit. However, when these symptoms are caused by an underlying major mental illness, such as a mood or thought disorder, clients will need to be medicated and put on a different treatment regime.
The key to an accurate diagnosis is to take a careful and complete psychosocial history. This includes getting a psychiatric history, noting when symptoms first began to appear. In addition, it is important to focus on when the person began to abuse substances and when they were last sober for a period of at least 3 months.
Major developmental milestones should be charted on a timeline that includes all mental symptoms and periods of substance abuse. A careful assessment and history is very helpful in diagnosis and treatment planning, said Dr. Schuckit. It is critical in avoiding a misdiagnosis that can be dangerous.
For example, Dr. Schuckit said that antidepressants, when prescribed for some people with bipolar disorders, could precipitate a manic episode and/or a suicide attempt.
For more information on this and related topics, visit www.alcoholmedicalscholars.org.