Perhaps the most common mistake in psychiatric diagnosis is ignoring that a substance problem may be causing the presenting symptoms. Patients who should be diagnosed with a substance-induced psychiatric disorder are all too often treated as if they suffer instead from a primary psychotic, dementing, mood, or anxiety disorder. This always leads to inefficiency, and sometimes, has quite disastrous consequences.
Substance-induced psychiatric symptoms rarely get much better if the patient continues to use the substance, and may get much (even dangerously) worse if the treatment instituted for the secondary psychiatric problem interacts negatively with the substance problem or promotes its continuation.
One typical example:
A teenager, jumpy and irritable because he is surreptitiously using illegal speed, is carelessly misdiagnosed by his doctor as having primary Attention Deficit Disorder. He is paradoxically given a prescription for legal speed that helps to further his addiction (or perhaps that of his friends).
Another typical example:
An elderly woman who becomes agitated on an antidepressant receives an inappropriate benzo prescription meant to treat her secondary agitation. She then becomes confused because of the benzo, falls and breaks her hip, then dies in the operating room.
Substance-induced psychiatric disorders are so very frequently encountered because the use of psychoactive substances is almost ubiquitous in the general population. And because there is a very wide variety of available substances which manage to mimic virtually every conceivable psychiatric presentation. Sometimes, the substance causing the psychiatric symptoms is illegal – e.g., heroin, cocaine, or amphetamines. Frequently, the substance is alcohol. And increasingly, the causal culprit is a legal drug prescribed by a physician – e.g., opioids, benzos, stimulants, antidepressants, or beta blockers.
The magnitude of the problem becomes clear when you consider that at least:
- 20% of the general population takes a prescribed psychoactive medication on a regular basis
- 7% have an alcohol use disorder
- 10% regularly use an illicit drug
Substance and Medication Use
Systematic inquiry about substance and medication use is an absolutely essential part of every psychiatric evaluation. Substance-induced disorders are especially hard to pick up in part because so many different substances are potential contributors, in part because patients are often such bad informants. Sometimes, the patient is forthcoming, but more often he won’t be. People may be ashamed of their substance use, fearful of losing access to the substance if they admit to its misuse, and may not connect the substance to the symptoms it is causing.
I have been fooled dozens of times by seemingly sober and otherwise reliable people who are trustworthy in every other aspect of life, but are desperate enough to lie about or minimize their substance use. Family evaluations are therefor crucial and are often revelatory. Blood and urine testing is sometimes necessary.
Missing the role of substances is especially common in the evaluations of the old and the young, but the clinician must be alert in every evaluation because substance-induced disorders are also common at every age in between.
In the elderly, any late onset of a new psychiatric or cognitive symptom should always be presumed to be a drug side effect until proven otherwise. Seniors on average are prescribed five or more different meds a day, often by different doctors, and with a failure to consider the possible blood level and behavioral consequences of drug/drug interactions. With aging, we also become less efficient at metabolizing and clearing drugs, so that a once ideal dosage now becomes toxic. And seniors are more likely to see doctors, and are therefore more likely to be prescribed meds than can cause or exacerbate psychiatric or cognitive problems. As mentioned in a previous blog, the benzos are the biggest culprit, ridiculously overprescribed in the elderly and particularly toxic to them.
New symptoms in teenagers and young adults may represent the onset of a primary psychiatric disorder, but just as likely as not may be due to a pattern of substance use that the patient will usually not bring up spontaneously. A systematic, non-judgmental review of drug use is absolutely necessary to rule in or rule out substance-induced, secondary psychiatry disorder. The correct diagnosis of first episodes as either primary or substance-induced has enormously significant consequences for the rest of the patient’s life, because the treatments and prognoses will be so very different.
- Any use of substances by people presenting with psychiatric symptoms makes diagnosis more difficult and treatment less likely to be effective. Take time and be cautious about making any definitive long term diagnosis of a primary psychiatric diagnosis based on observations made while the person is still taking, or is withdrawing, from a substance.
- It is often unclear whether the substance use is causing the psychiatric problem, or is a form of secondary self medication, or is independent. Connecting the dots is also difficult because many patients are on many different substances, and may be intoxicated by some, while withdrawing from others.
- You must evaluate the chronology of onsets, the prominence of the substance use in the clinical picture, and whether the psychiatric symptoms are the ones characteristically caused by that specific substance. This usually requires painstaking interviewing of both the patient and family and careful evaluation of the prevailing symptoms in relation to the drugs used.
- The best tool in determining a definitive diagnosis is also the best tool in treating the patient – i.e., get him off the drug, through the withdrawal period, and then see what happens. Of course that is far easier said than done.
What to focus on depends a great deal on the relative severity, urgency, and treatability of the substance problem and of the psychiatric symptoms. All things being equal, it is far preferable to treat the primary substance problem first with the hope and expectation that the secondary psychiatric symptoms will improve as the impact of substance use or withdrawal is reduced.
It is impossible and irresponsible to ignore psychosis, mania, deep depression, suicidal urges, or panic attacks while waiting for the eventual beneficial effects of substance treatment, even when these symptoms are likely to be secondary to the substance intoxication or withdrawal.-Allen FrancesBut often enough, all things are not equal. The secondary psychiatric symptoms may have taken on a life of their own or be so severe or so dangerous that they require independent (but always coordinated) attention. It is impossible and irresponsible to ignore psychosis, mania, deep depression, suicidal urges, or panic attacks while waiting for the eventual beneficial effects of substance treatment, even when these symptoms are likely to be secondary to the substance intoxication or withdrawal. Combined substance and psychiatric treatment is also necessary for dual diagnosis patients who present with the co-morbidity of a substance problem and an independent psychiatric disorder.
It is almost always tougher to treat the complexity of two problems than it would be to tackle either the addiction or the psychiatric symptoms if either presented alone. Very often substance programs are poorly equipped to deal with psychiatric symptoms and psychiatric programs are poorly equipped to deal with substance problems. The ideal set-up is a dual diagnosis program, with both inpatient and outpatient capacity, that can deal with both.
But these are often unavailable or over-booked. The frequent co-occurrence of addiction and psychiatric problems requires that everyone working in the substance field also have psychiatric skills and that those dealing primarily with psychiatric problems also have skills in diagnosing and treating addiction. In my experience, many clinicians and programs are too specialized in either substance or psychiatric problems to adequately meet the needs of patients who so often present with both.
Substances can cause or amplify virtually all of the psychiatric disorders. Substances are widely used and often under reported – a hidden source of a significant proportion of all the psychiatric problems that need to be diagnosed. It is always crucial to inquire about substance use and consider its role in the presentation. Substance-induced disorders are frequently missed in every clinical setting- primary care, psychiatric practice, psychotherapy, and even in substance programs where it should obviously always be the very first thought.
There is only one way to improve clinician recognition in all of these sites: Make it routine to assume a potential role of substances in every psychiatric presentation and to systematically ask the questions that will help rule it out. And patients also have a responsibility to themselves to become informed about the possible behavioral effects of any prescribed medications, street drugs, and alcohol they may be using and to be honest reporters about their use.
The best, and often the only, way to deal with a substance-induced psychiatric disorder is to successfully treat the substance problem, and this can be done only if the substance problem is brought out into the open.
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