Studies have clearly shown that misuse of alcohol and drugs can generate psychiatric symptoms that resolve with abstinence and specific treatment of the addiction. Acute and chronic use of stimulant drugs and withdrawal from depressant drugs (alcohol, opiates, benzodiazepines) can cause many symptoms of anxiety disorders that mimic phobic, obsessive-compulsive, panic, and generalised anxiety disorders. Acute and chronic use of depressants or withdrawal from stimulants can cause a severe and incapacitating depression similar in quality to major depression. Psychotic symptoms may be produced as a result of stimulant use and depressant withdrawal (uncommon with opiate withdrawal).
The co-occurrence of psychiatric illness and substance misuse is greater than would be expected by chance alone. Research has largely failed to demonstrate that psychiatric symptoms or underlying psychiatric disorders cause addiction to alcohol and drugs. Rather, the relationship is more likely to be the reverse, where the use of substances can cause or precipitate the development of psychiatric illness.
Severe mental illness and/or severe substance misuse problems should always be referred to the appropriate specialist team for advice and/or management. However co-occurring relatively minor mental illness and substance misuse disorders may be adequately dealt with in primary care. The mainstay of treatment in such cases will be the provision of advice. Such advice should clarify the following for the patient:
- Symptoms of anxiety and depression occurring in the context of substance misuse are usually due to the effect of the substances used.
- Abstinence from the substances used will result in the resolution of psychiatric symptoms within 2 to 4 weeks in many cases.
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- The co-occurrence of psychiatric illness and substance misuse is greater than would be expected by chance alone. In most cases the use of substances is responsible for the generation of psychiatric symptoms, rather than the reverse.
- Co-occurring relatively minor mental illness and substance misuse disorders may be adequately dealt with in primary care. The mainstay of treatment in such cases will be the provision of advice to cease or reduce the use of substances.
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- In people with chronic dependent substance misuse, feelings of anxiety and insomnia may last for up to 6 months following cessation of substance misuse, but should resolve in due course.
- Prescription of antidepressants and/or sedativehypnotics is unlikely to help while the patient continues to use substances.
When giving advice, this is likely to be most effective if delivered using a 'FRAMES' approach, as outlined in Section A3, page 11.
If the patient's symptoms fail to resolve despite a period of abstinence, then prescription of the appropriate psychotropic medication may be indicated. Note that the prescription of sedative-hypnotics should in general be avoided. If the patient is assessed as being at acute risk of suicide, violence or neglect, or if there is no improvement in the presentation over the next period, a referral to specialist services is most likely indicated (see Section D1, page 52 for referral pathway).
Next page .. THE MANAGEMENT OF 'DUAL DIAGNOSIS' 2
The above information is copyright of Dr Bruce Trathen MBBS MRCPsych (2006). ISBN 0-9545164-0-0. The author grants permission for these guidelines to be downloaded, copied and distributed freely, but does not grant permission for their sale.
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