The Devastating Combination of Psychiatric Illness and Drug Addiction

The Devastating Combination of Psychiatric Illness and Drug Addiction

Posted Apr 21, 2010

Severe psychiatric illnesses can be challenging to manage effectively, but patients can be helped substantially by available treatments. However, when the primary psychiatric disorder is complicated by alcoholism or abuse of drugs such as cocaine or heroin, successful treatment becomes markedly more difficult, if not impossible. Unfortunately, persons with severe psychiatric disorders are more prone to try addictive drugs. Often drug addiction follows. Why? Here are a few reasons:

  • Illnesses such as schizophrenias, bipolar disorders, and severe depressions are associated with poor insight and poor judgment. This may make it more difficult for patients with these disorders to understand the dangers of using alcohol or "hard" drugs.
  • Addictive disorders lead to rewiring of motivational, emotional, and cognitive brain circuits so that a person's primary goal becomes obtaining the next drink, snort, or injection of the abused substance. Most, if not all, abused drugs hijack the brain circuitry underlying motivation. In effect, these drugs become major drivers in a person's life and usurp the ability to follow through with other obligations, including recommendations for treatment. Eventually, taking the abused drug doesn't give the person pleasure; it just allows him or her to avoid the physical and mental pain of withdrawal (the body's reaction to the sudden absence of the needed drug). Because of poor insight or because of biological or psychosocial changes due to severe psychiatric illnesses, it is often more difficult for a person with such illnesses to avoid repeated use of such drugs if the drugs are available.
  • A person with such illness might be attempting to "self medicate" with the abused drug. Initial use of an abused drug may feel good and reverse some of the symptoms of the psychiatric illness such as low energy, poor concentration, and altered mood.
  • Severe psychiatric illnesses often lead to changes in social networks, and such changes may include increased contacts with other persons who are using drugs. Easy availability, peer pressure, and a drug-using environment make it difficult for a person with diminished insight to say no to drugs.

When a person with a severe psychiatric disorder becomes addicted to a drug such as alcohol, cocaine, or heroin, why does that make it much more difficult to treat their psychiatric disorder? Some reasons include:

  • The person becomes pre-occupied with obtaining and using the addictive drug and isn't able to take advantage of psychosocial interventions to help stabilize the psychiatric illness.
  • A person addicted to a drug lacks the motivation to comply with medications for either psychiatric or medical illnesses.
  • The addictive drugs themselves can lead to various and, at times, severe psychiatric symptoms including mood disturbances, agitation, and even psychotic symptoms (delusions, hallucinations, and bizarre behavior) that confuse the clinical picture and confuse the individual and those around him or her.
  • As a result of the unfortunate state of our health care system, it is difficult to treat the psychiatric illness and the addictive disorder simultaneously. If a person is stabilized in the hospital and then is discharged, he or she frequently returns to using the addictive drug, often because it is hard to escape drug-using friends and environment.
  • Even if a person enters a drug treatment program following stabilization of the psychiatric disorder, relapse of the addictive disorder is very common. The waxing and waning course of substance abuse disorders complicates the treatments of any other psychiatric or medical condition.

If not already complicated enough, most persons with severe psychiatric disorders smoke cigarettes. In addition, the majority of people who are addicted to drugs also smoke marijuana. Both cigarettes and marijuana can have bad long term health effects. In fact, cigarette smoking is enemy #1 in terms of public health. Cigarette addiction leads to heart disease, cancers, strokes, and respiratory illnesses. Marijuana is also far from benign, and, like other abused drugs, it usurps motivation and adversely impacts mood and cognition. Some evidence suggests that regular marijuana use also worsens psychotic symptoms and can be a precursor to the development of psychotic illnesses.

The cost: Not surprisingly, the combination of severe psychiatric illnesses with drug addictions costs patients, their families, and society dearly in both emotional and financial terms. The combination of severe psychiatric disorders and addictive disorders leads to repeated hospitalizations, ER visits, homelessness, and crime.

What to do: Unfortunately, there are no simple solutions. Nevertheless, some things can be done. Prevention is key. If you have friends or relatives with a psychiatric disorder, encourage them to:

  • Stop drinking alcohol if they are prone to heavy bouts of drinking.
  • Avoid marijuana completely.
  • Stay away from "friends" who might be using illicit drugs and/or abusing alcohol.
  • Avoid the use of cigarettes. Simply put, cigarette use has no redeeming qualities.
  • Find good medical and mental healthcare teams that can treat the psychiatric disorder before drugs complicate the picture or that can deal with severe psychiatric illnesses in the context of substance abuse. It is also crucial that patients, families, and friends are honest with the treatment team and let them know about all drugs being taken, including both illicit and prescribed medications.

Avoiding the use of potentially addictive drugs greatly improves the chances of a successful outcome in the treatment of severe psychiatric disorders. In fact, avoiding addictive drugs improves the chances of a successful outcome in the treatment of milder psychiatric disorders also.

In addition, it is important to support and advocate for research directed toward psychiatric illnesses, including addictive illnesses. Although abused drugs reset the brain in a manner that lasts for years or decades after the abused drug is stopped, scientists are beginning to learn a lot about the ways the brain is rewired as a result of abused drugs. With more research, we eventually should be able to learn more effective strategies for reversing the abnormal wiring. These strategies are likely to involve a combination of medications and psychosocial and cognitive interventions.

Finally, doctors, mental health professionals, families, and friends should understand that substance abuse often goes hand-in-hand with severe psychiatric disorders. Thus, it is important to avoid blaming the individual for being ill and to resist giving up on him or her. Sometimes, people get better despite extended periods of chronic illnesses, even when addictive drugs are complicating matters. It is appropriate, however, to encourage and expect individuals to follow through with treatment recommendations and to participate actively in strategies to curtail their substance use.

This column was co-written by Eugene Rubin MD, PhD and Charles Zorumski MD.