Adverse combination of diagnoses: alcohol dependence and mental illness

Prepared by Dr. Alvyda Pilkauskienė

Introduction
Sometimes it is necessary to diagnose concurrent diseases and record two diagnoses in the medical history - alcohol dependence and mental illness. Some epidemiological studies (Regier, Farmer) show that the prevalence of addictions in the group of patients with mental illnesses is about 30%. This percentage is higher in patients with schizophrenia (47%), bipolar affective disorder (61%), and antisocial personality disorder (84%). Regier and colleagues state that addiction, when it comes to severe mental illnesses, is more of a rule than an exception. When it comes to addictions, alcohol consumption plays a crucial role.
Such a combination of disorders is unfavorable for both the doctor and the patient - it complicates diagnosis and treatment selection, worsens treatment outcomes, and leads to adverse outcomes (Table 1).
Table 1. Adverse associations when addiction and mental illness coexist

Anxiety, Depression, and Alcohol
Psychiatric practice shows that alcohol consumption often accompanies mood and anxiety disorders. One explanation for this is that patients suffering from severe symptoms try to alleviate their condition with alcohol. This self-medication with alcohol eventually turns into addiction. This issue has attracted the attention of researchers. In 2018, Sarah Turner and colleagues published the results of a study they conducted. Researchers searched for articles (published from January 1997 to April 2018) describing prevalence and correlation studies (self-medication with drugs and alcohol in a population of patients with anxiety or mood disorders) in the general population (n=22). They used the Scopus and PsycINFO databases. The results of the study showed that the prevalence ranged from 21.9% to 24.1%. It is also stated that younger individuals, men, divorced or widowed individuals, and Caucasians more frequently used drugs or alcohol for self-medication when suffering from anxiety or depression. Long-term data showed that anxiety or mood disorders manifest first, and self-medication with alcohol is secondary, eventually leading to addiction.
Researchers point out the need to offer patients alternative methods to alcohol, which, as studies confirm, effectively alleviate severe symptoms of anxiety and depression.

Challenges in Diagnosis
It is not easy for a clinician to distinguish whether depressive symptoms are primary or have developed over a long period of alcohol use. It is unclear how depression will manifest if the patient does not consume alcohol, and vice versa. When taking a medical history, patients may be uncooperative, deny alcohol use problems, fail to understand the link between alcohol consumption and the symptoms of mental disorders they experience. It should not be forgotten that patients avoid admitting addictions, seeking secondary benefits that may be hindered by sobriety (e.g., disability benefits, hospital treatment, various forms of social support, subsidized medications, etc.).
Diagnosis is complicated by the fact that both alcohol dependence and mental illness can manifest as insomnia, anxiety, depression, mania, or psychosis. What should be done? How to establish the correct diagnosis?
First, when taking a medical history, it is necessary to focus on the chronology of symptoms of both disorders (addiction and mental illness). Second, objective historical data provided by close relatives (with the patient's consent) and objective data that can be found in the outpatient medical record (e.g., test results, history of trauma, discharge summaries from hospitalizations, consultations with a social worker, etc.) are always very helpful. It is also important to evaluate the previous treatment outcomes for both disorders; for example, if a patient has consistently relapsed while undergoing addiction treatment, it may be inferred that more effective treatment for depression is needed.
According to the DSM-V, a mental illness can be diagnosed when the patient has not used substances causing dependence for at least a month. However, how can one find out if the patient has used alcohol or not? In this case, it is almost always necessary to rely on what the patient says. When we receive patients at the clinic suffering from anxiety, depression, insomnia, without admitting alcohol consumption, we cannot act differently - we can only diagnose based on the clinical picture we have (i.e., based on symptoms - mental illness) and provide treatment.
Unfortunately, practice shows that when alcohol consumption is suspected, despite all the doctor's efforts, the precise diagnosis often remains unclear for a long time. In such cases, clinical observation remains, waiting for data to refine the diagnosis and treat more effectively.

Treatment Challenges
These studies of comorbidities' treatment outcomes suggest that the main principle of treatment is integrated (superior to parallel), simultaneous treatment. In simpler terms, a team of specialists works together to treat both disorders at the same time. Evidence-based psychotherapy tailored to addictions, including motivational interviewing, cognitive-behavioral therapy, relapse prevention, contingency management, skills training, case management, is essential and must be rationally combined with pharmacotherapy for treating both addiction and mental illness. The proposed treatments sound promising; however, implementing these evidence-based best practices in practical work is not easy (we will not discuss in the article how this could be implemented not only in the work of a family doctor but also in a psychiatrist's work in Lithuania). Individuals with addictions and mental illness often do not recognize their health problems, are not motivated to make changes, and do not seek help from healthcare professionals. For example, in 2016, the Substance Abuse and Mental Health Services Administration (SAMHSA) of the United States reported that 52% of individuals with addiction and mental illness did not receive any treatment. It is noted that patients who seek medical help are usually treated by a psychiatrist who focuses more on diagnosing and treating mental disorders. Addiction problems are usually suggested to be addressed by the patient themselves. They are advised to seek help from addiction centers, Alcoholics Anonymous groups, or other institutions/organizations that provide assistance to individuals with addictions. Despite individuals dependent on alcohol often requesting relief from anxiety, depression, severe withdrawal symptoms, or even curing psychosis, they do not recognize the problem of alcohol use and refuse to admit that they are dependent on alcohol. Issues with Pharmacotherapy There is a lack of evidence-based treatment recommendations for patients with mental illnesses and addictions (these patients are often not included in studies). Often, it is challenging for doctors to choose appropriate treatment for such patients because medications cannot be used together with substances that cause addiction. Knowing this, patients themselves often poorly adhere to the treatment regimen. A significant portion of such patients is opposed to taking psychotropic drugs (sometimes this attitude is encouraged by self-help groups they attend or non-professional consultants). Disulfiram, naltrexone, and acamprosate are prescribed for treating alcohol addictions, but there are very few studies on individuals with comorbid mental illness. Antidepressants, anti-anxiety medications, and antipsychotics are prescribed for mental disorders, but there is also a lack of research in this area. Studies with Selective Serotonin Reuptake Inhibitors (SSRIs) have sparked various discussions among scientists. Berman et al. in 1999 argued that SSRIs have few side effects and should be the first choice of medication. Other scientists have stated that SSRIs have a direct impact on alcohol consumption - reducing its intake. It was later revealed that this is because SSRIs reduce anxiety and the need to calm down with alcohol for those suffering from depression. This effect was not observed in those without depression. Currently, SSRIs are indicated for various types of depression and anxiety disorders. Benzodiazepines (BZDs) are usually prescribed in short courses to alleviate anxiety. Both theory and clinical practice show that there is a high risk of developing dependence on BZDs in patients addicted to alcohol. Several studies have been conducted with the specific anti-anxiety drug buspirone, but the results are conflicting, so there are no optimistic suggestions for using it to treat this population. There are no controlled studies showing that any antipsychotic drugs are more effective in treating patients with mental illness and alcohol addiction. It is recommended to rely on general treatment principles known to psychiatrists. Considering the possible interaction of the drug with alcohol, antipsychotic drugs are prescribed based on this, and the patient should be warned about it. Conclusion Addictions, usually alcohol addiction, often coexist with mental illness. This leads to worse clinical outcomes and poorer functioning (compared to when these disorders occur separately). This group of patients is less likely to seek medical help, and if they do, it is usually only for symptom relief - anxiety, depression, psychosis. There is very little research on how to treat individuals addicted to alcohol and suffering from mental illness, and the data is conflicting. When treating, it is recommended to rely on general treatment principles known to psychiatrists and consider the possible interaction of the drug with alcohol. Publication "Internistas" No. 7 2018. LITERATURE 1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), 2013. 2. Berman R, Charney D. Models of antidepressant action. Journal of Clinical Psychiatry. 1999;60:16–20. 3. DeVido J, Weiss R. Treatment of the Depressed Alcoholic Patient. Curr Psychiatry Rep. 2012 14(6): 610–618. 4. Pierre J. M. Real-world challenges in managing ‘dual diagnosis’ patients. Curr Psych. 2018, 17(9), p. 24-30. 5. Kelly TM, Daley DC. 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