When Psychiatrists Fail to Diagnose Addictions

A recent report tells a troubling story of missed opportunities.

Posted Jan 21, 2018

According to the National Survey on Drug Use and Health (2016), in 2015 substance use disorders affected an estimated 7.8 percent of the U.S. population, representing 20.8 million people. Alcohol use disorders affected 15.7 million, and 2.7 million people had both an alcohol use disorder as well as a substance use disorder related to illicit drugs.

SAMHSA, 2015 National Survey on Drug Use and Health
Number of people 12 and older in 2015 with a substance use disorder
Source: SAMHSA, 2015 National Survey on Drug Use and Health

Substance use disorders often co-occur with mental illness. According to the same national survey, of the 43.5 million people with a mental illness, 20 percent of people suffer with both substance use disorders and mental illness, representing over 8 million people with co-occurring substance use and mental illness.

SAMHSA, 2015 National Survey on Drug Use and Health
Overlap among Substance Use Disorders and Mental Illness
Source: SAMHSA, 2015 National Survey on Drug Use and Health

The current study

In order to better understand how psychiatry addresses co-occurring mental health and substance use, study authors Mark and Meinhofer (2018) analyzed data on office-based psychiatric visits from the 2012-2015 National Ambulatory Medical Care Survey to determine how care was being provided. They looked at diagnostic information and medication prescription to find out what conditions were being treated, and how they were being treated.

They found that psychiatrists diagnosed a substance use disorder on only 9 percent of office visits total. Mark and Meinhofer point out that this means that of the estimated 20 percent of patients with co-occurring mental illness and substance use disorder, less than half are receiving care when seen by outpatient psychiatry.

Further considerations

So, psychiatrists—who receive instruction in diagnosing and treating substance use disorders as part of general psychiatry training but not as extensively as those who complete addiction medicine fellowships—can improve the treatment of co-occurring conditions by looking more carefully for substance use disorders among their patients. The same is true for primary care providers, both for mental illness as well as substance use disorders, both of which are under-recognized in primary care settings (Petterson et al., 2014).

In order to better understand this situation, it is important to understand why millions of patients with substance use disorders presenting to outpatient psychiatrists aren’t being fully evaluated. Putative reasons include: lack of attention to signs and symptoms of substance use disorders; non-disclosure by patients who do not report substance-related problems when evaluated; and under-diagnosis and lack of treatment when a substance use disorder is known to be present.

This last possibility is concerning because it may arise from conscious and unconscious collusive influences—for example, physicians may be avoiding addressing substance use problems for patients who are reluctant to acknowledge such issues, or may downplay problems when they are discussed and fail to follow through. The reasons for these kinds of omissions can be individual and interpersonal, as well as systemic.

Alcohol use disorders are often hard to accept because alcohol is legal and part of social fabric for many, including doctors. Substance use disorders are often associated with stigma and shame, and this may make discussing them difficult without an adequate treatment alliance. Developing a good alliance requires time, and given problems with healthcare delivery, visits are shorter and doctors are more harried, allowing many problems to be neglected. Furthermore, family members who are aware of substance use problems may hesitate to notify their loved ones' healthcare providers.

In addition, patients may avoid doctors who are more likely to ask about difficult subjects, leading to economically-driven pressures to steer clear of bringing up such issues. Patients may preferentially look for physicians who don’t address substance-related issues in depth, and physicians may be reluctant to alienate patients—perhaps more nowadays as consumer reviews become a driving force in the healthcare marketplace.

Future research identifying obstacles to diagnosis and treatment can identify interventions to help doctors and patients do a better job of identifying and addressing both mental illness as well as substance use disorders. Such interventions are likely to be on the level of individual practitioners, both in terms of initial medical training as well as professional development efforts for seasoned providers, and on the level of public education and reduction of stigma and concrete barriers to care (socioeconomic factors, under-supply of providers, lack of geographic access, entrenched complicity). Regardless, it is troubling that half of patients with substance use disorders and mental illness seeking care from psychiatrists in the community may not be receiving necessary services.


Key Substance Use and Mental Health Indicators in the United States: Results From the 2016 National Survey on Drug Use and Health. HHS pub no SMA 17-5044, NSDUH Series H-52. Rockville, MD, Substance Abuse and Mental Health Services Administration Center for Behavioral Health Statistics and Quality, 2017. https:// www.samhsa.gov/data    https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2015/NSDUH-FFR1-2015/NSDUH-FFR1-2015.pdf

Petterson, S., Miller, B. F., Payne-Murphy, J. C., & Phillips, R. L., Jr. (2014). Mental health treatment in the primary care setting: Patterns and pathways. Families, Systems, & Health, 32(2), 157-166.

Center for Behavioral Health Statistics and Quality. (2016). Key substance use and mental health indicators in the United States: Results from the 2015 National Survey on Drug Use and Health (HHS Publication No. SMA 16-4984, NSDUH Series H-51). Retrieved from http://www.samhsa.gov/data/ 

Mark TL, Meinhofer A. (2018). The Extent to Which Psychiatrists Diagnose and Treat Substance Use Disorders.Psychiatric Services 2018; 00:1; doi: 10.1176/appi.ps.201700457