Mental Illness and Substance Abuse
Mental health problems are frequently complicated by substance abuse, putting patients in need of special care.
By Colette Bouchez
Reviewed By Brunilda Nazario, MD
on Monday, June 02, 2003WebMD Feature
Mental health problems can take many forms: The Fortune 500 executive with mood swings who drinks martinis to get through the day; the college senior struggling with depression who snorts cocaine to get through the semester; the housewife riddled with fear who needs a carton of cigarettes and bottle of tranquilizers just to leave her house.
Although the problems -- and the people -- are vastly different, they share a common bond: They all suffer from both a mental health problem and substance abuse.
And it's a combination that doctors are increasingly noting in people from all walks of life. Today, experts estimate that at least 60% of those battling one of these conditions are battling both.
"Mental health problems and substance abuse are often seen together because one makes you more vulnerable to the other," says Alan Manevitz, MD, a psychiatrist with New York-Presbyterian Hospital, Cornell University campus, in New York.
Mental health problems are common in the U.S. An estimated 1 in 5 adults in the U.S. suffers from a diagnosable mental disorder, according to the National institute of Metal Health.
When there is a biological or genetic vulnerability to any type of mental health problem, regardless of how big or small, Manevitz says, substance use often triggers the onset of that problem.
"The substance is not really causing the mental health problem, but it can be a precipitating factor that causes the condition to manifest," Manevitz tells WebMD.
Likewise, he says, the brain chemistry involved in many types of mental health problems can, in some respects, appear to be neutralized by certain addictive substances. This, he says, can cause many folks to "self-medicate" problems they don't even know they have, often beginning years before obvious symptoms appear.
"In this respect, the mental health condition is already actively present when the substance abuse begins, but the patient just doesn't know it -- the problem is driving the addiction, it just hasn't yet been recognized or diagnosed," Manevitz tells WebMD.
It is, in fact, the increasing awareness of this dual diagnosis that has opened the door to a whole new line of thinking about both substance abuse and mental health problems. Indeed, some researchers contend that certain forms of mental illness and some addictions may, in fact, be a single disease.
Among the areas where this research is most prominent is a condition known as bipolar disorder -- a disease characterized by cycles of extreme mood swings between deep depression and high elation, or mania. During periods of mania, patients show extreme irritability, racing thoughts, little need for sleep, poor judgment, distractibility, abuse of drugs, and denial that anything is wrong. Depressive periods are associated with feelings of hopelessness, guilt, too much sleep, and thoughts of death or suicide.
"What we have found is that people with bipolar disorder, particularly women, have an enormously high rate of alcoholism -- up to seven times that of the general population," says Mark Frye, MD, director of the UCLA Bipolar Disorder Research Program in Los Angeles.
This is also true, says Frye, when both male and female bipolar patients are compared to those with other forms of mental illness.
And while the reason remains unclear, Frye tells WebMD that there is at least some evidence that the two conditions may really be one and same -- emanating from the same area of the brain and controlled by somewhat the same brain chemistry.
Indeed, as the age of "brain science" continues to mature, a number of researchers have begun to note some startling similarities within the brain chemistry patterns of various types of mental health problems and substance abuse. Some of the more interesting discoveries had to do with animal models of addiction.
"Research on rats showed us that there were certain pleasure centers of the brain that, when stimulated, elicited such a powerful response, the animal would opt for stimulation over food," says Francis Hayden, MD, associate director of the division of Alcohol and Substance Abuse at Bellvue Hospital in New York.
This discovery, he says, led many researchers to question whether there was something different about the brains of substance abusers that "causes them to kind of feel not quite right -- so that when they happen upon a substance, it kind of normalizes them in a way," says Hayden.
That feeling of "not quite right," he says, may be the mental health problem at work.
Another indication that they may be one disease: Studies that show that when one condition worsens, the other is soon to follow suit.
"In someone who has both a mental illness and a substance abuse problem, almost without exception, an addiction relapse will worsen the mental health problem, and when the mental health problem goes untreated, or declines, it makes them more susceptible to renewing addictive behaviors," says Kenneth Skodnek, MD, chairman of the department of psychiatry and psychology and director of the addiction service at Nassau University Medical Center in East Meadow, N.Y.
In addition, says Skodnek, it's very clear that activation of one problem frequently activates the other in those who are susceptible.
Finding the Treatment That Works
Whether the mental health problem -- or the drug use -- came first, or they are, in fact, one in the same disease, doctors say that good mental health can't prevail until both problems are treated. The best way to accomplish this, however, remains a matter of some debate.
"When the two disorders coexist, you frequently have to address the substance abuse issue right away because if someone is intoxicated, they need to be detoxed," Frye tells WebMD. Without that component in place, he says, starting therapy can be very difficult.
Though this approach looks good on paper, he says, the reality isn't always easy to achieve. The very process of detoxification, says Frye, can often leave an addict feeling so raw and vulnerable, their mental health situation rapidly declines -- which in turn can easily cause the substance abuse problem to quickly recur as well.
"There is a relatively small window of opportunity in which to get the mental health problem under control before the patient ends up right back into substance abuse," says Frye.
As such, many doctors are now turning to a dual treatment approach -- a program that integrates detoxification of addictive substances with simultaneous identification and treatment of any coexisting mental health problems.
"This approach can be particularly effective because even if you get a clear history of a patient, even if you are certain that the substance abuse led to the mental illness, or vice versa, treating the first problem doesn't necessarily lead to the cessation of the second problem, " says Hayden.
Unfortunately, the dual approach is still considered somewhat specialized, and frequently only available in pricey private hospitals. The next best thing, say experts, is to integrate patient care among the professionals dealing with each part of the illness.
"If one doctor or clinic is treating the mental illness and another is treating the addiction, there has to be some kind of coordinated effort in order to get both problems under good control," says Manevitz.
When the patient isn't able to coordinate that care on their own, experts say family members should intercede to make certain all the doctors involved work together.
But what if there is a relapse -- of either the addiction or the mental health problem?
Doctors say that a slip up in one area frequently leads to a decline in the other area as well -- but this doesn't mean the patient is doomed to repeat their destructive behaviors indefinitely. The answer, says Hayden is the development of a doctor-patient alliance that both can trust.
"The goal is to engage in a true therapeutic alliance between doctor and patient, to establish a rapport that is strong and honest enough so that the patient tells the doctor what they are really up to," says Hayden.
When this is the case, experts say relapses of both the mental health problem and the substance abuse can often be circumvented in the earliest, most easily treated stages -- or some cases, even prevented from occurring at all.
Published June 2, 2003.
SOURCES: Alan Manevitz, MD, psychiatrist, New York - Presbyterian Hospital, Cornell University Campus, New York. Mark Frye, MD, director, UCLA Bipolar Disorder Research Program, Los Angeles. Kenneth Skodnek, MD, chairman, department of psychiatry; director, addiction service, Nassau University Medical Center, East Meadow, N.Y.; Francis Hayden, MD, associate director, Division of Alcohol and Substance Abuse, Bellvue Medical Center; clinical professor of psychiatry, NYU School of Medicine, New York.