Anxiety, depression, mania, schizophrenia and other mental health disorders and substance use disorder are tightly interwoven, with 9.2 million adults in the U.S. living with co-occurring mental health and substance use disorders. But for the average psychiatrist or healthcare provider, it can be difficult to discern whether a particular symptom stems from a mental health disorder or from substance use, leading to the prescribing of unnecessary medications.
There are several contributing factors to the frequency of this problem. For starters, many patients do not disclose or under disclose substance use when talking to a healthcare professional about emotional distress. They may not believe their use is related or relevant to their emotional distress. They may be ashamed about how much alcohol they are drinking or what drugs they’re using. The provider may also exhibit gender bias or operate under other assumptions. Equally important, individuals may protect their substance use because it serves them in some way – either consciously or subconsciously.
Unfortunately, there are a lot of practitioners who do not ask patients about their substance use. They may not dig deeper for a host of reasons – known patient resistance, family members present, lack of time in the appointment or their own misunderstanding about substance use disorders. As a result, they end up treating psychiatric symptoms because the patient presents with significant anguish. But symptoms of substance use disorder can mimic mental health disorders. For example:
- Alcohol use often manifests as depression
- Marijuana use can manifest as depression, anxiety, mania, psychosis or ADHD. It is common for marijuana use disorder to be misdiagnosed as bipolar disorder or even schizophrenia.
- Cocaine, methamphetamine, and prescription psycho stimulants like Adderall or Ritalin can precipitate mania or psychosis and also result in an inaccurate bipolar or schizophrenia diagnosis.
For this reason, it’s essential for a patient entering residential treatment for a substance use disorder to undergo a multidisciplinary assessment, because there’s a good chance he or she is not on the most optimal medication regimen. An extensive assessment includes paying close attention to the patient’s personal and family history, trying to determine the extent of the substance use – its onset, its duration – and when the mental health symptoms first arose.
Through those patterns, professionals tease out whether there is a co-occurring mental health disorder or whether the substance use was simply mimicking symptoms of a mental health condition. By undertaking this process, the clinical team can determine an accurate diagnosis and therefore what medication is appropriate for the individual.
This multi-disciplinary assessment includes:
- Establish a sense of safety for the patient. It is difficult to move forward if a person does not feel safe. Oftentimes, that doesn't happen until they leave their home environment and are no longer actively using. Once in treatment, it’s critical to gather an accurate and complete patient history. Once a rapport is established, patients feel more comfortable disclosing their vulnerabilities, including adverse childhood experiences, substance use and other traumatic experiences.
- Abstinence. After a period of time without any substances in their system, we can begin to get a much clearer picture of how patients truly look and act. This does not mean we will not return the patient to an appropriate medication, such as an SSRI. But it is important to first peel back the layers and see what is really going on without medication.
- Toxicology. We use toxicology tests to tell at least part of the story. They are not perfect, but it can give us a sense of the extent of the substance use.
- Pharmacogenomic testing. One of the newer tools at our disposal is pharmacogenomic testing, where we look at how a person’s genes might be interacting with medications.
There is a misconception, even among healthcare professionals, that pharmacogenomic testing will reveal what treatment will definitively work for a patient. Unfortunately, such testing is not currently commercially available as a diagnostic tool. What it can help with is identifying drug-gene interactions, revealing why a patient might not have responded favorably to one class of medication, to SSRIs for example. It can direct treatment toward medications or classes of medications that are less likely to have drug-gene interactions and therefore increase the likelihood of a favorable result for that patient.
Pharmacogenomic testing also does not help tease out “the chicken or the egg” phenomenon with substances and mental health symptoms. That takes thorough clinical investigation. Here is where the multidisciplinary team approach benefits patients the most. Regardless of what frequency a therapist sees a patient, they are only getting a 25- to 90-minute snapshot of the patient. In a residential treatment center, the patient interfaces with a lot of different team members over the course of a day, including peers, who are attuned to the patient’s behaviors. Holding intermittent team meetings and case consults can give a more complete picture of how the patient is progressing or regressing.
At the heart of it, if the substance is removed and the mania or the psychosis spontaneously resolves, then we can surmise we are dealing with a substance-induced phenomenon. Treatment can focus on the substance use disorder itself.
If the substances are removed and the symptoms persist, then we're left with two questions: Were symptoms triggered by the substance use, or was the patient using substances to seek relief from an underlying mental health disorder? In either case, treatment for the substance use disorder must be done in concert with treatment for the co-occurring mental health issue.
One of the biggest challenges in addressing substance use disorders and co-occurring conditions is the tendency to focus exclusively on the mental health side of the picture, or exclusively on the substance use side. We must raise awareness that an integrated approach works best, in which both elements are addressed together. If you only treat substance use disorder without dealing with the underlying mental health issue, then relapse becomes much more likely, because people will continue to seek relief from their pain. Likewise, treating only the mental health symptoms without addressing the substance use disorder will likely impede sustained recovery.
I do predict we are moving towards more sophisticated testing to provide a more accurate diagnosis earlier, which in turn supports better treatment outcomes. In the meantime, it’s important for providers to take a comprehensive look at the patient before reaching for their prescription pad.