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Clinical Focus
Primary Psychiatry. 2005;12(1):41-46
Alcohol and Mental Illness
Laurence M. Westreich, MD
Focus Points
• Alcohol dependence co-occurs with mental illness more often than most
clinicians realize: >20% of those with mental illness also suffer from alcohol
abuse or dependence.
• Alcohol use disorders can cause or exacerbate a wide variety of psychiatric
syndromes, from schizophrenia to the anxiety disorders.
• Alcohol dependence, abuse, or misuse can cause or exacerbate Cluster B
personality disorders, and alcoholism itself can be mistakenly diagnosed as
a personality disorder.
• Treatment of alcohol dependence and a co-occurring mental illness necessitates a coordinated plan which addresses both problems.
Abstract
Alcohol use disorders (AUDs) frequently affect the course of mental illness. Alcohol
can both cause and exacerbate symptoms and must be treated concurrently with
the psychiatric illness. Similar to personality disorders, alcohol can cause or worsen
symptoms, though often in a more hidden manner. Treatment for dually diagnosed
individuals with alcoholism and mental illness consists of an integration of addiction
and mental illness treatment paradigms, use of peer-led support groups, a “coaching”
therapy style, and medication regimens tailored to each patient’s specific syndromes.
Specific psychotherapeutic modalities useful for dually diagnosed patients include
relapse-prevention psychotherapy, motivational interviewing, cognitive-behavioral
psychotherapy, and social skills training groups. The clinician must modify the treatment regimen on an ongoing basis to address symptoms of alcoholism or mental
illness as they appear. Using research data and case examples, this article provides a
model for the treatment of individuals diagnosed with mental illness and AUDs.
Introduction
A common Alcoholics Anonymous
(AA) saying is “There is no problem that
alcohol cannot make worse.” Of all the
problems that alcohol can exacerbate,
mental illness is one of the most common, serious, and frequently missed.
Patients with mental illness, irrespective
of the diagnosis, can face profound consequences when they misuse alcohol.
According to the Diagnostic and
Statistical Manual of Mental Disorders,
Fourth Edition (DSM-IV),1 the diagnosis
of alcohol dependence, abuse, or misuse
is no different in the presence of another
mental illness. However, when dealing
with those suffering from mental illness,
the criteria for diagnosing a patient’s
problem with alcohol should be quite
broad. That is, the depressed individual
who only misuses alcohol occasionally
should be considered to “have a problem” with alcohol, even if he would not
meet strict DSM-IV criteria for alcohol
dependence or even abuse.
So when does alcohol worsen a
mental disorder and when is it merely
incidental? As this review will demonstrate, the answer is that alcohol
always plays a part. Alcohol causes
some depressive and anxiety syndromes, worsens others, always
impairs sleep, and has harmful interactions with psychiatric medications.
Thus, a person who drinks any amount
of alcohol while receiving psychiatric treatment, especially pharmacologic treatment, should be advised to
stop all use of alcohol. Of course, the
addicted individual may not be able to
stop his or her alcohol use and may
need education about the interaction
between addiction and mental illness,
treatment of the addictive substance
use, or even inpatient treatment of the
addiction. Cessation of alcohol use
is an important clinical goal but will
most likely not be achieved overnight.
The cessation of alcohol use does not
guarantee the remission of psychiatric
symptoms. Nonetheless, discontinuing
alcohol use for the psychiatric patient
is often necessary, partly to remove
an impediment to effective treatment.
Mental illnesses often confounds efforts
to stop alcohol use: the profoundly anxious person who experiences a quick,
short-lived, respite from her anxiety will
only reluctantly part with her “medication.” This article reviews the various
psychiatric syndromes most commonly
linked with alcohol, discusses the relevant research, and recommends some
treatment approaches.
Epidemiology
A 1990 epidemiologic survey2 using
estimated nationwide data from a
household sample of 20,291 individuals, found that 22.5% of the United
States population met lifetime criteria
for a non-addiction mental disorder;
13.5% met criteria for alcohol abuse or
dependence; and 6.1% met criteria for
drug abuse or dependence. Of those
who were found to have a mental illness, 22% had a lifetime diagnosis of
alcohol abuse or dependence and 15%
had a lifetime diagnosis of drug abuse
or dependence. Of those with alcohol
dependence, 53% had a co-occurring
mental disorder (Figure 1).2
Dr. Westreich is clinical associate professor of psychiatry in the Division of Alcoholism and Drug Abuse, Department of Psychiatry, at the New York University
School of Medicine in New York City.
Disclosure: Dr. Westreich is on the speaker’s bureaus for Odyssey and Pfizer.
Please direct all correspondence to: Laurence M. Westreich, MD, Division of Alcoholism and Drug Abuse, Department of Psychiatry, New York University
School of Medicine, 550 First Ave, New York, NY 10016.
Primary Psychiatry © MBL Communications, January 2005
41
L.M. Westreich
In a study focusing on the correlation
between addiction and mental illness,
Helzer and Pryzbeck3 found that every
psychiatric diagnosis they screened for
was more prevalent in the alcoholic
respondents while using the same data.
The highest associations with alcoholism were mania, antisocial personality
disorder, and other substance abuse.
Importantly for psychiatrists, approximately one third of general psychiatry
patients and up to 50% of emergency
room (ER) patients have presenting
problems directly related to addiction.4
Given the high community prevalence
of dual diagnosis and the even higher
prevalence in treatment populations,
psychiatrists should evaluate all of their
psychiatric patients for latent or manifest alcohol use disorders (AUDs).
Depression
The classic stigma of clinical depression, such as mood impairment, hopelessness, and insomnia, are mimicked by
the effects of alcohol use. The diagnosis
of an alcohol-induced mood disorder,
anxiety disorder, or psychotic disorder5
should be considered a presumptive
diagnosis until proven by symptom resolution after the patient ceases alcohol
use. The fact that alcohol causes depression and anxiety is not particularly surprising, given that alcohol is pharmacologically categorized as a central nervous
system depressant.6
In a study on depressed individuals
who also drink alcohol, Schuckit and
colleagues7 delineated two groups: those
with independent depression and those
with substance-induced major depression. Those with an independent, non
alcohol-related, depressive condition
were more likely to have a close family
member with depression, and to be marFigure 1
Addiction in the Mentally Ill2
30
Percentage
25
20
15
10
5
0
Addiction
Alcohol
Drugs
Lifetime Prevalence
Westreich LM. Primary Psychiatry. Vol 12, No 1. 2005.
42
ried, caucasian, and female. In a study
of 50 alcoholics, Dorus and colleagues8
found that 66% had Beck Depression
Inventory (BDI) scores of >17 within 24
hours of their last drink. However, when
reassessed a little more than 3 weeks
later, only 16% had a BDI >17, demonstrating a “spontaneous” remission of
depressive symptoms as the effects of
alcohol wore off. Of course, this spontaneous remission may have been due to
the treatment for alcoholism.
Although it is important to distinguish major depression from depression
due to alcohol consumption, clinicians
rarely have the opportunity to wait 3
weeks to delineate the two disorders.
Allowing a patient to suffer depressive
symptoms any longer than necessary
while waiting for a firm diagnosis is
unnecessary. Rather than waiting for
depressive symptoms to resolve, clinicians should treat both alcoholism and
depression simultaneously and in an
integrated manner. For example, the cessation of drinking should be treated as
an essential component of recovery from
depression. The clinician should provide
clear instruction on how to avoid drinking. This instructive style often involves
a paradigm shift for the therapist more
attuned to the mental illness alone.
Rather than remain neutral or give interpersonal or instructional interpretations,
the addiction treater assumes a coaching role, where direct suggestions are
made and behavioral change is strongly
supported and encouraged. This psychotherapeutic stance is well-described in
the motivational interviewing literature.9
Painful depressive symptoms should not
be minimized but regarded as possibly
related to the consumption of alcohol.
Case Study
Jane, a 29-year-old female lawyer,
was referred by her therapist for “postpartum depression.” History taken from
both Jane and her husband revealed that
up until the eighth month of pregnancy,
she had never experienced diagnosable
depressive symptoms. In fact, she had
never seen a therapist until 6 months
after her son was born, when she realized that her sadness had not dissipated
and that she was feeling increasingly
anxious every day. The couple originally attributed Jane’s sleeplessness to
the effects of staying awake with the
baby, but even when Jane’s mother
came to help Jane could not fall asleep
Primary Psychiatry © MBL Communications, January 2005
despite the exhaustion that she felt 24
hours a day. Jane also noticed that she
rarely felt hungry and worried that her
difficulties breastfeeding made her a
“horrible mother.”
When she told her husband that she
felt that there was no hope that she
would ever be a decent mother and
that she thought she was better off
dead, he called her obstetrics/gynecologist for the name of a therapist. The
therapist was a cognitive-behavioral
specialist and assessed Jane as severely
depressed, but in no danger of actually
harming herself or her infant. When
the therapist asked about the use of
drugs and alcohol, Jane answered that
she is a “social drinker.”
Over several weeks of therapy sessions (2/week), the therapist helped
Jane reframe some of her inaccurate
beliefs about her mothering skills,
ignore some of the negative thoughts
about herself, and accept the help from
her family that Jane had previously
rejected. Although Jane felt less alone
and beleaguered by her depression,
both she and her therapist worried that
her anxiety had not abated because her
insomnia and low appetite remained.
Jane reluctantly accepted referral to
a psychiatrist for a medication evaluation. Jane informed the psychiatrist
that she was a social drinker but the
psychiatrist probed more and the interview revealed that Jane’s definition of a
social drinker was someone who never
drank alone. In fact, Jane shared a full
bottle of wine every evening during and
after dinner with her husband. On most
evenings she drank “a couple of shots”
of vodka before bedtime. Although Jane
had always enjoyed fine wines, she
acknowledged that her use of wine had
increased markedly after she had delivered: “It really takes the edge off and
lets me sleep,” she said.
After the psychiatrist explained the
depressant and anxiogenic effects of
alcohol, Jane immediately agreed to stop
drinking alcohol. They decided on the
use of the selective serotonin reuptake
inhibitor (SSRI) sertraline, titrating the
dosage up to 150 mg/day, for the treatment of her anxious depression, and
agreed to follow up 3 weeks later. At
follow-up, Jane’s anxiety and insomnia
were unchanged, despite her taking a
therapeutic dosage of the SSRI. When
asked about her use of alcohol, she
became tearful and acknowledged that
Alcohol and Mental Illness
she had cut down for a few days, but was
now drinking at about the same rate. “It’s
the only thing that makes me feel better…and plus it’s the only way I can relax
enough to have sex with my husband. He
wants me to drink,” she said.
At this juncture the psychiatrist
referred the patient to AA and a therapist skilled in dual-diagnosis treatment
and the relapse-prevention model.
Such a therapist should be knowledgable about the abundant literature
guiding clinician working with dual
disorders.10 Several weeks later, the
patient was hospitalized for a 3-day
detoxification period, after which she
continued with an intensive outpatient program, AA, and sertraline. Two
weeks after discharge from the hospital, her psychiatric symptoms improved
markedly: “Since I don’t need the relief
from alcohol, I no longer get depressed
and anxious the next day. I’m not hurting anymore, just tired!” she said.
Anxiety
Anxiety spectrum disorders and
AUDs often co-occur. For example,
even though panic disorder with agoraphobia occurs in the general population at approximately 6.1%,11 alcoholics suffer from panic disorder at a rate
of up to 21%.12 The similarity of panic
symptoms to alcohol withdrawal has
led some to hypothesize a causal link
between the two, even to the point of
suggesting that repeated episodes of
alcohol withdrawal may cause panic
disorder.13 Posttraumatic stress disorder, although inadequately assessed
in the Epidemiologic Catchment Area
study,2 shows significant comorbidity
with substance use disorders14 and,
therefore, should be assessed and
treated as necessary.15
The problem for the anxious alcoholic remains that alcohol initially treats
anxiety, which worsens it later on. The
immediate-term relief of medicating
alcohol withdrawal with a drink in the
morning or the reduction of painful
anxiety with a few drinks overwhelms
the intellectual understanding that
alcohol will only make matters worse
down the line. At a deeper level, the use
of alcohol may function as a medication, as well as a way for the sufferer to
assert control over her emotions.
As Khantzian noted16:
Rather than just relieving painful affects when
they are overwhelming, drugs and alcohol and the
buspirone, which may account for its
poor efficacy among addicted people.
However, there are some cases where a
potentially addictive substance such as
benzodiazepine, must be used to treat
an anxiety syndrome in an addicted
person. In this circumstance, the treating clinician must carefully weigh the
risk-benefit profile of the particular
medication for a particular patient,
and closely monitor the patient for
side effects and addictive behaviors.
Opinions on whether benzodiazepines should ever be used in the
addicted patient vary widely in the
field, and few studies examine this
question.18 There is scant data-based
evidence to support any clear perspective, so each clinician is obliged to
make an individual decision based on
the patient’s best interests.
distress they entail may also be adopted as way of
being in control especially when they feel out of control because affects are vague, elusive and nameless.
Due to the numerous potential
interactions between alcohol and
anxiety, the clinician must focus on
treatments that ensure patient safety
and bring quick symptom relief. This
rapid symptom relief strategy ensures
patient compliance with the long-term
treatment plan. As always, less potentially harmful treatments are preferred
initially, including supportive psychotherapy, cognitive-behavioral psychotherapy, hypnosis, and acupuncture.
The Table explains the four classes
of anti-anxiety medications that are
appropriate for the treatment of anxiety17; their use must be considered
on an individual patient basis. For
example, for the patient addicted
to alcohol or another addictive substance, non-addictive medications are
preferred. Patients expecting the rapid
effect for a benzodiazepine will be
disappointed if they are prescribed
Bipolar Disorder
Bipolar disorder co-occurs with alcohol dependence more than any other
mental illness.19 In a study of patients
Table
Treating the Anxious Alcoholic17
Treatment
Benefit(s)
Prominent Risk(s)
Buspirone
Non-addictive
Sedation
Benzodiazepines
Immediate
symptom relief
Sedation, addiction
SSRIs
Long-lasting
symptom relief
Side effects: agitation, sleep
disturbance, impaired libido
MAOIs
Long-lasting
symptom relief
Tyramine-free diet
TCAs
Long-lasting
symptom relief
Side effects: sedation, constipation
Low LD50
Hypnosis/
relaxation
Immediate
symptom relief
Long-lasting
symptom relief
No biological side effects
Acupuncture
Immediate
symptom relief
Long-lasting
symptom relief
No biological side effects
Cognitivebehavioral
psychotherapy
Symptom relief
No biological side effects
Supportive
psychotherapy
Symptom relief
No biological side effects
Expressive
(psychoanalytic
psychotherapy)
Symptom relief
No biological side effects
Potential for provoking addictive
behavior
SSRIs=selective serotonin reuptake inhibitors; MAOIs=monoamine oxidase inhibitors; TCAs=tricyclic
antidepressants; LD50=the dose of a medication at which half the test animals die.
Westreich LM. Primary Psychiatry. Vol 12, No 1. 2005.
Primary Psychiatry © MBL Communications, January 2005
43
L.M. Westreich
44
Primary Psychiatry © MBL Communications, January 2005
tion, Bill reported that he was living in
a shelter, going to night school classes,
and following up with his psychiatric
appointments and AA meetings. He had
not had a drink in 2 months.
Schizophrenia
Patients with schizophrenia frequently use and misuse alcohol: a study27 of
168 individuals presenting with a first
episode of psychosis had an alcohol
misuse rate of 11.7% as compared to
a drug misuse rate of 19.5%. Another
study28 found that among patients with
schizophrenia, the lifetime prevalence
of alcohol use disorder was in the 50%
range. First psychotic breaks are difficult to diagnose and treat, and the addition of alcohol or any other mood-altering substance confuses the issue even
further. Avoiding premature diagnostic
closure in this scenario is even more
important than with other psychiatric
illnesses: the person misdiagnosed with
schizophrenia because of intervening
intoxicant use will face a lifetime of
attempting to shed the diagnosis and
receive the proper treatment.
Regarding patients who have suffered from a long-term psychotic disorder, Miles and colleagues29 found alcohol to be the most common substance
of abuse (Figure 2). In addition, Miles
and colleagues found that alcohol users
were more likely than stimulant users
to be older, white, and less likely to have
a history of violent behavior.
Patients
with schizophrenia use alco30
hol25for a number of reasons. First, alcohol20 is an easily available, fast-acting
15
agent
that quells the fears and pain of
10
becoming
psychotic, especially during
5
a first
break. Second, alcohol use can
0
be one
of the
few easy
social experiAddiction
Alcohol
Drugs
Lifetime Prevalence
ences available
to long-term schizophrenics with few friends and impaired
social skills. The rituals of drinking,
Percentage
Case Study
Bill, a 54-year-old homeless Vietnam
veteran with bipolar disorder, frequently ended up in the ER of a public
city hospital. On each occasion he was
intoxicated, but joked and teased the
physicians on call in a pleasant manner, regaling them with long, hilarious
tales of his misadventures. In fact, he
became quite friendly with some of
the ER staff, to the point that they welcomed him into the ER and asked him
if he wanted his “regular room” on the
alcohol detoxification ward. However,
after four such admissions in a 2-week
period, the director of the ER asked
for a psychiatric assessment of Bill in
order to determine the root cause of
his recidivism. A brief symptom review
revealed that Bill had a clear pattern of
2–3-day depressions followed by an irritated, insomniac state which Bill called
“the nasties.” His military service had
been cut short by his first manic episode upon his return from a 6-month
tour of duty in Vietnam. Although he
had been diagnosed as bipolar by a
military physician, Bill had ultimately
rejected the diagnosis, saying that he
had “freaked out” during his Vietnam
tour, and he subsequently went to the
Veterans Administration Hospitals only
for alcohol detoxification.
Bill refused admission to the DualDiagnosis Ward, saying “I’m not crazy,
just drunk.” He consented to speaking
with a psychiatrist in the detoxification
ward. During that interview it became
clear that Bill’s mother had been diagnosed and successfully treated for bipolar disorder and that his younger brother
had symptoms suggestive of bipolar disorder. Bill’s professed satisfaction with
his life confounded any attempt to offer
him treatment: he said that other than
the “nasties,” he felt that the camaraderie of the street was a fine tradeoff for
the stability he might achieve elsewhere.
Bill and the psychiatrist agreed that they
would talk again in 2 days, just prior to
Bill’s scheduled discharge.
At that second interview Bill presented in a very different way. Although
he was sober, normotensive, and wellgroomed, he appeared lethargic and his
mood was morose to the point of saying
that he saw “no reason to go on.” As Bill
talked about his plans for the future,
both he and the psychiatrist realized
Bill’s only coherent plan was to get a
bottle as soon as possible to “drown his
sorrows.” The psychiatrist offered Bill a
better way to improve the way he was
feeling, and Bill reluctantly agreed to follow up in the clinic that afternoon after
leaving the Detoxification Ward. At the
clinic visit, the outpatient psychiatrist
(having been briefed by the detoxification ward psychiatrist) started Bill on a
medication regimen including lithium
and, subsequently, the antidepressant
bupropion. After much discussion, they
decided not to use disulfiram, since
Bill was “not sure” if he would drink
even if he did take disulfiram. They
also arranged for an AA meeting that
Bill could attend, escorted by another
patient in the clinic who attended the
same meeting. To his own surprise,
Bill enjoyed the AA meeting and was
able to engage with several AA members there. Although he experienced
numerous short slips over the next several weeks, the medications quelled the
mood swings which had interfered with
his functioning. When seen in the ER=
several months later for a hand lacera-
Figure 2
Substance Use in Psychotic Illness2
35
30
Percentage
with bipolar disorder and alcoholism,20
patients who had primary alcoholism
(unrelated to their bipolar disorder)
were less likely to experience remission
from their alcoholism. Bipolar patients
with alcoholism have been shown to
suffer more cognitive dysfunction21 and
attempt suicide more often.22
The high prevalence and serious
consequences of bipolar disorder combined with alcoholism necessitate
aggressive treatment for this combination of illnesses. Since impaired
judgment, grandiosity, and irritability
all promote excessive alcohol use, the
clinician must address the mania and
alcohol use together. Psychoeducation
often serves as a useful warning
about the dangers of further alcohol
use. Psychotherapeutic methods can
include group therapies with others
who suffer from bipolar disorder,23 and
relapse-prevention teaching.
Medications such as valproic acid24
and carbamazepine25 are often used
as mood stabilizers and can also serve
as detoxification agents from alcohol.
Although naltrexone can be used as an
anti-craving agent, patients should be
aware of the potential for a hepatotoxic
interaction with valproic acid, and an
apparent opiate withdrawal syndrome
which may be precipitated by the high
endorphine state of acute mania.26
25
20
15
10
5
0
ETOH
ETOH/MJ
MJ
Stim.
Unknown
ETOH=alcohol; MJ=marijuana; Stim.=stimulant.
Westreich LM. Primary Psychiatry. Vol 12, No 1. 2005.
Alcohol and Mental Illness
whether in a bar or on a street corner, fosters an easy acceptance among
“drinking buddies.” Finally, alcohol is
legal, easily obtainable, and relatively
inexpensive, making it an attractive
intoxicant for the schizophrenic, who
may not be able to muster the skills or
cash to obtain other substances.
Patients with schizophrenia and
other psychotic illnesses must be carefully monitored for their alcohol usage,
since alcohol can worsen or even cause
psychotic illnesses. Alcohol withdrawal can mimic the hallucinations of
schizophrenia, as can the longer term
alcohol-induced psychotic disorder
with delusions or hallucinations. Since
all antipsychotics are metabolized by
the liver, patients with schizophrenia may need vigilant monitoring of
their liver functioning and a dosage
adjustment if they are in liver failure.
A period of abstinence from alcohol is
important in making definite diagnoses in forming a treatment plan.
Treatment for a schizophrenic
using alcohol should focus on avoiding alcohol while maximizing the use
of antipsychotics and psychosocial
treatments (such as dual diagnosis
or addiction-knowledgeable day treatment programs) and assertive case
management techniques. Assertive
case management techniques involve
a clinician engaging with the patient in
securing work or education, housing,
and structured follow-up with mental
health and social services. Although
peer-led self-help groups may be useful, a better option for this population
is the “Double Trouble” AA groups
which cater to individuals taking psychotropic medications.
Personality Disorders
Although all of the personality disorders are affected by the use of alcohol
or drugs, borderline personality disorder (BPD)30 is the only disorder which
mentions substance abuse per se as
one diagnostic criterion. In fact, all the
cluster B, or “dramatic” personality
disorders (ie, antisocial, BPD, histrionic, and narcissistic) are often mixed
with alcohol or other drugs. Each
of these personality styles involves
uncomfortable affective studies and/
or maladaptive thought and behavior
patterns make the individual vulnerable to self-medication with alcohol.
Perversely, these desperate attempts at
relief from psychotic suffering lead to
a worsening of the patient’s well-being.
Research suggests that a manualized
form of dialectical behavior therapy is
effective in treating BPD and comorbid substance abuse.31
Schuckit32 wrote that alcoholism
may be a symptom of antisocial personality disorder (ASPD), may cause
behaviors which look like ASPD, or
may be caused by the same genetic
factors that cause ASPD. Others have
suggested that alcoholism, or at least
alcohol consumption, conveys an evolutionary advantage for sociopaths by
enhancing a “cheating reproductive
strategy,” thereby conveying an evolutionary advantage.33 Whatever the
connection, ASPD is highly prevalent
among alcoholics34 and correlates with
a more rapid progression of alcoholism and its sequelae.
The clinician treating an alcoholic
with a personality disorder must carefully distinguish between psychiatric
phenomena caused by alcohol use,
versus chronic characterological traits
and symptoms independent of alcohol
use. Most addicts, irrespective of sociopathic traits, lie and cheat in order to
maintain their addiction; however, if
the addiction is treated and remits, so
does the dishonest behavior.
ASPD and other Cluster B personality
disorders evoke strong negative counter
transference in therapists because of
the patient’s often dramatic and selfdestructive behaviors. Alcohol intensifies these self destructive or deceptive behaviors often leading to greater
alienation between the patient and
others, including therapists. However,
aggressive treatment of the AUD, can
significantly ameliorate these adverse
behaviors. Since the patient is unavailable for intervention on the chararacterologic issues when alcohol is in the
picture, the clinician must first focus
on helping the patient abstain from
alcohol. Although addicted, personality
disordered patients are among the most
difficult to treat, their often-astonishing
gains when they become sober serve as
a reward for the persistent therapist.
Treatment
Treatment of the alcohol dependent
mentally ill patient should strive toward
an integrated approach. The treatment
should address both diagnoses simultaneously, and “…appear seamless to
patients with respect to philosophical
underpinning, treatment approach, and
psychoeducational content.”35 By definition, an integrated approach avoids
excluding either the addiction or the
mental illness from monitoring and similarly avoids mistaken emphasis by the
treatment team on non-essential issues.
For example, the treatment team inexperienced with mental illness might wrongly minimize an alcoholic’s profound dysphoria as an “expected consequence”
of heavy drinking. A more experienced
treatment team would probe for, and if
necessary, treat an underlying depression or suicidal thoughts.
Individual therapy for the alcoholic
mentally ill individual should start at the
supportive rather than the expressive
(psychoanalytic) end of the spectrum
because the powerful affects generated
in expressive therapy can precipitate a
slip or full-blown relapse. Using more
of a “coaching” model, the therapist
helps the patient initiate and stabilize
his sobriety, while at the same time
addressing psychiatric problems. The
individual therapy should coordinate
peer-led support groups, motivational
interviewing approaches, individual
psychotherapy, medications, and any
necessary group psychotherapy.
AA can play a pivotal role in the treatment of many alcoholic, mentally ill
individuals. AA, as a peer-led community,
does not treat mental illness, but can
support the alcoholic in her search for
sobriety. Although AA proscribes the use
of any mind-altering substance as a substitute for alcohol, AA does not officially
comment in any way on appropriate
medical or psychiatric treatment, including medication usage. However, some
members may believe that psychiatric
medications are unhelpful and express
this during AA meetings. The treating
clinician should explore with their dually
diagnosed patients what the AA group
had to say, if anything, about necessary
psychotropics. Although the vast majority of AA members adhere to the official
AA policy of not commenting on appropriate medications, some do not. Since
many mentally ill individuals experience
these and other difficulties with AA,36 the
dually diagnosed patient should probably transfer to a “Double Trouble” AA
meeting, which is specifically designated
for the dually diagnosed and, therefore,
will be supportive of medications which
are correctly prescribed.
Primary Psychiatry © MBL Communications, January 2005
45
L.M. Westreich
Medications tailored for the treatment of alcoholism can be of significant use in the mentally ill population.
Psychiatric medications rarely have
interactions with anti-alcoholism medications. Medications such as benzodiazepines and barbiturates may be used
in the acute phase of detoxification.
A mood stabilizer can simultaneously
effectively treat withdrawal and bipolar
mania.37 Naltrexone may be used with
the mentally ill patient, as with other
patients, with the hope that it will act as
an anticraving agent which also increases time to first drink and amount that
the relapsing patient drinks.38
Disulfiram, while arguably more effective than naltrexone, does present some
problems for the mentally ill alcoholic.
Patients prescribed disulfiram must
understand that alcohol combined with
disulfiram will cause an uncomfortable
reaction. The patient must be motivated
to avoid that reaction. If the depressed
patient is so cognitively impaired that
he cannot understand the risk/benefit
profile of disulfiram, the medication
should not be prescribed. A special consideration for the schizophrenic patient
is that disulfiram inhibits aldehyde
dehydrogenase activity,39 which might
cause an increase in synaptic dopamine
and a worsened psychosis. Similarly,
if the treating physician believes that
the patient exhibits self-destructive traits
and might provoke a disulfiram reaction
intentionally, the medication should not
be prescribed. These problematic scenarios are extremely rare: most mentally
ill alcoholics are candidates for a discussion about disulfiram.
Mueser and colleagues40 found that,
out of 33 severely mentally ill patients
administered disulfiram, 64% experienced remission for at least 1 year. The
medication was also associated with a
decrease in days hospitalized. However,
28% of schizophrenic subjects experienced disulfiram reactions, and there
was no change in work status. The benefits shown in the study demonstrated that
although disulfiram must be carefully
considered for the mentally ill individual,
it has a place in the pharmacopoeia.
Conclusion
Integrated treatment of the dually
diagnosed patients and comorbid AUDs,
although challenging, can yield great
rewards. Since alcohol exacerbates mental illness, abstinence from alcohol or
46
use reduction significantly improves the
patient’s overall level of functioning, and
leads to marked, sometimes astonishing
improvement. These benefits, once seen
by the clinician and the patient, can be
used to promote the behaviors necessary to avoid alcohol, achieve a stable
abstinence, and obtain the best possible
outcome for the mental illness. PP
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