Dr. David Sack - PsychCentral.com
February 16, 2010
Double Trouble: Mental Illness and Addiction
In the past few years, more and more states as well as the federal government have begun to examine the complex relationship between substance abuse and mental illness. Having been involved in both addiction and mental health treatment for over two decades, I can attest to the fact that though plenty of people struggle with both issues simultaneously, many of them don’t get correctly diagnosed. Frequently, patients are diagnosed with either a mental health problem or an addiction. This means that an important part of their treatment is missing.
Dr. David Sack, a psychiatrist who is certified in psychiatry, addiction psychiatry, and addiction medicine and is the CEO of Promises Treatment Centers,
a California-based treatment program, has generously agreed to discuss
co-occurring mental illness and addiction, also known as dual-diagnosis.
Richard Zwolinski (RZ): Thank you for joining us, Dr. Sack. Your treatment program, Promises, is considered to be one of the best in the country. We know that peer pressure/recreation, family-of-origin dysfunction, and family-of-creation dysfunction can be contributing factors to substance use. Critical to understanding substance use, abuse, addiction, and recovery is the understanding of the emotional or feeling-based components of addiction. It would be helpful if you could begin by explaining the primary mental and emotional states that might lead a person to use, abuse, and even become addicted to drugs or alcohol.
Dr. David Sack (DS): People start using or experimenting with drugs and alcohol for a number of different reasons. These include the desire to experience intense pleasure, wanting to suppress bad feelings, curiosity (wanting to know what the big deal is), and [in order to] enhance performance. Once someone uses drugs regularly their motivations shift. It is harder to experience the same level of intense pleasure due to tolerance. Bad feelings increase as a direct effect of the drugs on the brain and also as a consequence of the behaviors the drug user engages in. As the user becomes physically dependent on a drug, the goal of preventing symptoms of withdrawal replaces pleasure as a main reason to use. Finally, as a person’s life is taken over by drugs or alcohol, the only people they socialize with are other drug users, so social reinforcement becomes an additional motivator for drug use.
RZ: Can you explain how people with various specific mental illnesses might be impelled to try and abuse drugs or alcohol? For example, depression?
DS: Patients with depression and anxiety disorders
are much more likely to become dependent on alcohol and drugs than the
general population. The majority of these clients experiences
psychiatric symptoms first and attribute their drug use to trying to
reduce or eliminate their negative emotions. Once a person with
depression or anxiety starts using drugs or alcohol regularly their
problems multiply. Antidepressant and anti-anxiety medications become
less effective. Psychiatric hospitalization becomes more likely and the
risk of attempting suicide escalates. Patients with depressive or
anxiety disorder in addition to drug dependency are more than three
times more likely to relapse to drug use in the year following
treatment than individuals with drug dependency alone.
RZ: Are there particular mental illnesses that make people even more prone to abuse substances?
DS: Every major psychiatric disorder is associated with an increased risk for alcohol and/or drug abuse but the patterns of abuse differ. While alcohol is the most widely abused drug across all groups we see some specific preference within certain diagnoses. For example, in anxiety patients, we are seeing a lot of prescription opiate and heroin abuse. In depression, we see poly drug abuse, with alcohol, cocaine and benzodiazepines a common combination. With most disorders (as I already noted), the psychiatric problems come first. In bipolar disorder patients who also have substance abuse problems, a majority exhibit problems with drug use first.
Double Trouble: Mental Illness and Addiction - PART 2
RZ: Today, more and more addiction and mental health treatment providers are recognizing that co-occurring disorders are quite common. It used to be that addiction treatment programs didn’t always recognize that large percentages of their clients were mentally ill chemical abusers (MICAs), unless their mental illness was very apparent. Now mental health care providers are getting on the bandwagon and beginning to recognize that many of their patients are medicating themselves with everything from wine to prescription pain killers to illicit drugs—leading to potentially serious chemical abuse problems. Do you have any suggestions about how to motivate mental health care patients to be more upfront about substance abuse?
DS: Mental health patients share the biases of the rest of our society. They experience shame and stigma from their mental disorder and this is amplified when it comes to drug abuse. In the U.S., 90% of individual with drug abuse or drug dependency do not seek treatment. We should not be surprised that MICAs face similar issues.
RZ: That’s so true. Also, many MICA patients who are in an outpatient or continuing day treatment program know that if they admit they are using, they will be referred to coordinated substance abuse treatment or face discharge. I find that many are fearful of this reality. One way to motivate people in outpatient mental health treatment is to educate them. First, the mental health professional must understand that most patients really don’t want to have a mental illness — they want to recover (or be symptom free). I believe it’s important for therapists, whether in private practice or in a clinic, to present information to patients about the consequences of using substances or alcohol, that is, how it can hurt their mental health recovery. I really like working with MICAs because they understand suffering in a unique way and they really want to be relieved of that suffering. My experience has been that MICA patients respond better to gentle, non-judgmental support, encouragement, and also, very importantly, education. Also of importance for therapists is if they suspect substance abuse they need to act like a persistent, but gentle detective because as you pointed out, their patients are experiencing shame and stigma and might not share the facts about their chemical dependence openly.
RZ: What should people who have been diagnosed with a mental illness and addiction look for in a treatment program?
DS: First and foremost they need to know that mental health assessment and treatment is integrated into the program. Evaluation by a psychiatrist is critical as is therapy with a licensed mental health professional who is knowledgeable about their disorder. Many of these clients do poorly in psychiatric hospital and mental health center settings, whose staff may believe that since the drug use was ’caused’ by their psychiatric problems that the drug use will stop if their symptoms are controlled. We have found that MICA [patients] need specific drug education treatment and that if their use goes unmodified it is unlikely that that their other mental health treatment will be successful.
RZ: Exactly. Also, they need to know they can get support with special AA/NA groups for people with mental illness with different names in each state. Google “support groups for dual diagnosis” plus your state for more information.
RZ: Can you tell us a bit about Promises Treatment Centers? How long is the typical stay at your program? What kinds of care do you offer? How do you measure success?
DS: Promises is one of the oldest free standing drug and alcohol treatment programs. We evaluate and treat clients with primary drug or alcohol problems and co-occurring disorders. We focus on meeting each individual’s needs through a range of treatments that include psychiatry, individual psychotherapy, neurofeedback, acupuncture, yoga, and meditation, in the context of a spiritual program that supports abstinence and recovery through twelve-step programs.
We look at success in a number of ways:
First, did the client complete treatment, since we know that nearly all of the clients who leave treatment early, relapse.
Second, were the client’s specific needs and the needs of their family addressed?
Finally, after clients leave the program, we monitor their progress through alumni support groups, telephone contacts, and surveys to evaluate whether they are sober and if there are improvements in their quality of life.
RZ: That is so important. If someone reading this is considering entering addiction treatment they should ask how the program follows up with patients and determines its successful outcome rate. It sounds like Promises’ model is very comprehensive in this regard.
Thank you so much, Dr. Sack. The information you shared was extremely detailed and important. It has been an honor to have you join us.
- http://blogs.psychcentral.com/therapy-soup/2010/02/double-trouble-mental-illness-and-addiction/ - PART 1
- http://blogs.psychcentral.com/therapy-soup/2010/02/double-trouble-mental-illness-and-addiction-2/ - PART 2