Dual diagnosis patients

[lockian]

I’ve noticed time and again that patients with dual diagnosis or high risk substance use tell me that “if only I got my anxiety/depression/etc under control I would have no problem not using.” Which is an elaborate form of denial, and there are plenty of people with anxiety/depression etc who never even think to turn to substance use when they’re having trouble. (As an attending of mine in residency said, too, people do not drink because they have depression or anxiety but because they like to drink.) Of course, I don’t think I see myself ever saying *that* to a patient, nor do I think that statement is entirely true, but it does illustrate the denial element well. What I do tend to say is something along the lines of if you have both you treat both, and treating anxiety/depression etc before substance use is likely to be less effective and more high risk. But somehow that feels unsatisfying, so I wonder if anyone has another way they approach that conversation.

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[nexus73]

I agree with your post. It's like magical thinking: "now that I'm on Effexor (or Prozac, or Buspar, or etc etc) for my anxiety I'm not going to drink anymore.....so I don't need to go to rehab." It would be nice if things worked that way.

I like to frame my comments by saying the "scientific literature" shows the best results are when people get treatment for both depression and addiction at the same time. You can do one or the other, it's your choice, but it won't be as good as doing both together.

If someone is agreeable to taking psych meds, but hesitant to enter a residential CD or CDIOP program, I'll often imply I'm worried about whether they'll even have room and there could be a very long waitlist even if we can get you in. Then when the person gets in right away I think they feel more motivated because they somehow got lucky to gain admission right away. Making it seem like a rare resource makes it more attractive I think.

 

[erg923]

I’ve noticed time and again that patients with dual diagnosis or high risk substance use tell me that “if only I got my anxiety/depression/etc under control I would have no problem not using.”

This is not an empirically supported statement. Naturally, people like to blame things.... on "other" things. The literature's' take on the question is..."eh.... yea, maybe/possibly."

People can just be addicts...right? We should always be skeptical regarding how our patients attribute "the cause" of their addiction.

Yes, you should treat MH and SUD disorders simultaneously, but that does NOT mean we buy everything they are selling, right?

 

[lockian]

This is not an empirically supported statement. Naturally, people like to blame things.... on "other" things. The literature's' take on the question is..."eh.... yea, maybe/possibly."

People can just be addicts...right? We should always be skeptical regarding how our patients attribute "the cause" of their addiction.

Yes, you should treat MH and SUD disorders simultaneously, but that does NOT mean we buy everything they are selling, right?

Oh, I totally agree. I am just looking for effective ways to counter that statement in the clinical setting when patients try to use it as a justification to refuse substance use treatment and just focus on mood/anxiety/whatever else.

 

[theduderino]

Oh, I totally agree. I am just looking for effective ways to counter that statement in the clinical setting when patients try to use it as a justification to refuse substance use treatment and just focus on mood/anxiety/whatever else.

help them find the particular moments in life when substance use is worsening their anxiety/mood/ issues. help them connect these problematic behavioral patterns w/ the emotional sequlae. help them interrogate why all the work they having been doing on their mood/anxiety hasn't amounted, presumably, to much progress.

 

[Candidate2017]

I’ve noticed time and again that patients with dual diagnosis or high risk substance use tell me that “if only I got my anxiety/depression/etc under control I would have no problem not using.” Which is an elaborate form of denial, and there are plenty of people with anxiety/depression etc who never even think to turn to substance use when they’re having trouble. (As an attending of mine in residency said, too, people do not drink because they have depression or anxiety but because they like to drink.) Of course, I don’t think I see myself ever saying *that* to a patient,

Substance abusers constantly lie to themselves and others. By dancing around the obvious and not pointing out their defense mechanisms, you are also lying to them and just another enabler or SW therapist.

Your job as a psychiatrist is to point out the uncomfortable and get them to confront and tolerate it. To be able to do your job effectively, you must confront and tolerate your own discomfort. It is synergistic. The patient cannot grow unless you grow as well, and vice versa.

 

[aim-agm]

I’ve noticed time and again that patients with dual diagnosis or high risk substance use tell me that “if only I got my anxiety/depression/etc under control I would have no problem not using.” Which is an elaborate form of denial

I might be misunderstanding, but my limited experience thus far is at least some patients comorbid mood and SUD who profess that the latter is being used to control the former are quite legitimate. Of the three patients I inherited like you describe, two of them engaged in treatment of their anxiety (primarily psychotherapy) and in short order eliminated their alcohol use without difficulty.

 

[Mass Effect]

I agree with your post. It's like magical thinking: "now that I'm on Effexor (or Prozac, or Buspar, or etc etc) for my anxiety I'm not going to drink anymore.....

Or Ativan.

 

[Mass Effect]

I might be misunderstanding, but my limited experience thus far is at least some patients comorbid mood and SUD who profess that the latter is being used to control the former are quite legitimate. Of the three patients I inherited like you describe, two of them engaged in treatment of their anxiety (primarily psychotherapy) and in short order eliminated their alcohol use without difficulty.

You are correct. Many people with a SUD are self-medicating due to some other psychiatric illness. This does not apply to all, but a not insignificant number.

 

[splik]

I think sometimes this idea that patients need treatment for their SUD is overplayed. There definitely are patients who when you treat their anxiety, PTSD or whatever else, they don't drink or use whatever anymore. The best epidemiological studies tell us that recovery of some kind is the rule and most patients enter some stage of recovery without any treatment. For example NESARC found that 75% of patients who met criteria alcohol use disorder in the previous year were in some level of recovery, and 75% of those did so without any treatment. In another study, for patients with acute alcoholic hepatitis who receive liver transplantation, a history of no prior psychiatric treatment was a positive prognostic factor (i.e. treating the hitherto untreated psychiatric disorder, had an outsize impact on the course of the alcohol use disorder). Obviously, there are patients that do need to have their SUD addressed along with their psychiatric disorders, but those with milder use disorders, particularly if they have not had any treatment for psychiatric disorders, some will do well.

Substance abusers constantly lie to themselves and others. By dancing around the obvious and not pointing out their defense mechanisms, you are also lying to them and just another enabler or SW therapist.

Your job as a psychiatrist is to point out the uncomfortable and get them to confront and tolerate it. To be able to do your job effectively, you must confront and tolerate your own discomfort. It is synergistic. The patient cannot grow unless you grow as well, and vice versa.

As william miller of MI fame says '“Denial” in addiction treatment is often not so much a client problem as a counselor skill issue.' Self-deception and lying are universal to the human condition and the basis of psychiatry as a specialty. They are in no way special or unique to those with addictive disorders. Our job is absolutely not to point out the uncomfortable, and get patients to "confront and tolerate". Patients already know everything they need to. Our job is simply to help them accept that which they already know. They need to figure it out from themselves. Confronting patients' cherished defenses rarely leads to progress, but instead entrenches the defensiveness and resistance.

 

[clausewitz2]

As william miller of MI fame says '“Denial” in addiction treatment is often not so much a client problem as a counselor skill issue.' Self-deception and lying are universal to the human condition and the basis of psychiatry as a specialty. They are in no way special or unique to those with addictive disorders. Our job is absolutely not to point out the uncomfortable, and get patients to "confront and tolerate". Patients already know everything they need to. Our job is simply to help them accept that which they already know. They need to figure it out from themselves. Confronting patients' cherished defenses rarely leads to progress, but instead entrenches the defensiveness and resistance.

Well-said. Most addicts have enough shame. Piling more on just isn't going to be all that effective. No one really thinks that drinking a case of beer every day is a good life choice, even if they will say something to that effect when you push them about it. Roll with that resistance, don't beat your head against it.

 

[WisNeuro]

By and large, the best dual diagnosis providers and treatment protocols that I have seen have been in the VA system. If you have a local VA with a dual diagnosis program, may be worth a discussion with colleagues there about approaches.

 

[Candidate2017]

Our job is absolutely not to point out the uncomfortable, and get patients to "confront and tolerate". Patients already know everything they need to. Our job is simply to help them accept that which they already know. They need to figure it out from themselves. Confronting patients' cherished defenses rarely leads to progress, but instead entrenches the defensiveness and resistance.

I disagree, but we're probably talking about different things. Confrontation should absolutely be done in most sessions. It can be as subtle as an ophthalmologist's scalpel or blunt as an orthopod's hammer. The patient should leave the session feeling better and hopeful, but with a hint of discomfort that grows. To the point where they question whether the things they presented in session (situations, feelings, responses, viewpoints, solutions etc) may or may not have been the truth or could have been handled better.

This is not so different from OP questioning whether they could have done something better when confronted by patients' BS and coming here to explore it.

 

[meow1985]

Substance abusers constantly lie to themselves and others. By dancing around the obvious and not pointing out their defense mechanisms, you are also lying to them and just another enabler or SW therapist.

Your job as a psychiatrist is to point out the uncomfortable and get them to confront and tolerate it. To be able to do your job effectively, you must confront and tolerate your own discomfort. It is synergistic. The patient cannot grow unless you grow as well, and vice versa.

There's got to be a middle ground, though. If you confront someone with the weight of a sledgehammer the first visit, you may never see them again, which is one way of solving the problem, but not the most constructive one. If you're not direct enough, however, the risk is that they simply don't "hear" the confrontation.

Once I've built up a few sessions' worth of rapport with patients, I've had "come to Jesus" real talk discussions with them, and it's turned out well. I've even said a softer version of that attending's statement: "people don't just drink because they're depressed or anxious, but also because they have an addiction." (DBT reconciliation of opposites for the win!) Sometimes I leave out the just and the also. I also find framing it as "having an addiction" makes it sound like less of an attack on the person's character, because our society is already saturated with enough misinformation about addiction as moral weakness. In earlier sessions, I make note of anything they say that sounds like insight into the problems of their use, and keep bringing it back up to them, using *their own words* for best results.

 

[Stagg737]

I disagree, but we're probably talking about different things. Confrontation should absolutely be done in most sessions. It can be as subtle as an ophthalmologist's scalpel or blunt as an orthopod's hammer. The patient should leave the session feeling better and hopeful, but with a hint of discomfort that grows. To the point where they question whether the things they presented in session (situations, feelings, responses, viewpoints, solutions etc) may or may not have been the truth or could have been handled better.

This is not so different from OP questioning whether they could have done something better when confronted by patients' BS and coming here to explore it.

I think people are using different definitions of confrontation. You seem to be suggesting the psychoanalytic technique of confrontation, where as I feel others are using the layman's definition of the word which is far more blunt, direct, and often seen as at least somewhat condescending. I agree that the former is essential with most patients, including those with SUD, to help them build insight and move forward in treatment. However, the I agree with others that the latter form of confrontation is less likely to be helpful and more likely to harm rapport with the patient.

 

[deleted1100659]

As someone who treats a population where if you see a clean UDS its a miracle (everyone in my clinic gets standard labs before i see them), I always ask them a simple question when I first see them. "Why did you decide to come today? Why not a month ago? Why not a week? Or why not wait for a bit? Why today?". Their answer often tells me everything I need to know and how likely they will be receptive to anything I tell them.

Heres a patient case that just recently happened. Pt with long term alcohol use d/o. Six days sober. Mother and sister brought him to the appt, they want him to get help. I ask them "What kind of help do they want?". They don't want any medications to decrease cravings. Ok no worries. So I start talking to the pt about AA and NA its clear he has zero interest in those. We even offer substance abuse groups at the facility which are great, the woman that runs them will come down and talk to the potential person about it. Pt has zero interest in even hearing her out. So I ask the family, ok so what exactly do you guys want for help? "He needs to go to a facility involuntarily to remain sober". Like ma'am, we can't arrest people for having an alcohol problem...It was clear the patient was only their because his family made him go (he still lived with his mom..). That detail alone told me the likely outcome, and the more the story unraveled it was clear the family was going to leave disappointed, and the pt would likely relapse at some point, since he was largely indifferent.

Short version: I assess how receptive the patient is. If the answer is zero, I may make some statements but no point in being overly aggressive as that often does not work. There has to be some desire and/or reason to change, and that isn't there then I offer f/u for when it does come along and state that I will be there when they are ready to go to the next step.

 

[calvnandhobbs68]

As someone who treats a population where if you see a clean UDS its a miracle (everyone in my clinic gets standard labs before i see them), I always ask them a simple question when I first see them. "Why did you decide to come today? Why not a month ago? Why not a week? Or why not wait for a bit? Why today?". Their answer often tells me everything I need to know and how likely they will be receptive to anything I tell them.

Heres a patient case that just recently happened. Pt with long term alcohol use d/o. Six days sober. Mother and sister brought him to the appt, they want him to get help. I ask them "What kind of help do they want?". They don't want any medications to decrease cravings. Ok no worries. So I start talking to the pt about AA and NA its clear he has zero interest in those. We even offer substance abuse groups at the facility which are great, the woman that runs them will come down and talk to the potential person about it. Pt has zero interest in even hearing her out. So I ask the family, ok so what exactly do you guys want for help? "He needs to go to a facility involuntarily to remain sober". Like ma'am, we can't arrest people for having an alcohol problem...It was clear the patient was only their because his family made him go (he still lived with his mom..). That detail alone told me the likely outcome, and the more the story unraveled it was clear the family was going to leave disappointed, and the pt would likely relapse at some point, since he was largely indifferent.

Short version: I assess how receptive the patient is. If the answer is zero, I may make some statements but no point in being overly aggressive as that often does not work. There has to be some desire and/or reason to change, and that isn't there then I offer f/u for when it does come along and state that I will be there when they are ready to go to the next step.

Just to piggyback on this though there ARE some states where a person can be deemed incompetent due to a severe substance use disorder and a guardian is appointed. That isnt this case above of course but weirdly enough adults can be involuntarily admitted in those states since their parent or whoever else is their legal guardian and so they’ll be technically “voluntary” admissions.

 

[hallowmann]

As someone who treats a population where if you see a clean UDS its a miracle (everyone in my clinic gets standard labs before i see them), I always ask them a simple question when I first see them. "Why did you decide to come today? Why not a month ago? Why not a week? Or why not wait for a bit? Why today?". Their answer often tells me everything I need to know and how likely they will be receptive to anything I tell them.

Heres a patient case that just recently happened. Pt with long term alcohol use d/o. Six days sober. Mother and sister brought him to the appt, they want him to get help. I ask them "What kind of help do they want?". They don't want any medications to decrease cravings. Ok no worries. So I start talking to the pt about AA and NA its clear he has zero interest in those. We even offer substance abuse groups at the facility which are great, the woman that runs them will come down and talk to the potential person about it. Pt has zero interest in even hearing her out. So I ask the family, ok so what exactly do you guys want for help? "He needs to go to a facility involuntarily to remain sober". Like ma'am, we can't arrest people for having an alcohol problem...It was clear the patient was only their because his family made him go (he still lived with his mom..). That detail alone told me the likely outcome, and the more the story unraveled it was clear the family was going to leave disappointed, and the pt would likely relapse at some point, since he was largely indifferent.

Short version: I assess how receptive the patient is. If the answer is zero, I may make some statements but no point in being overly aggressive as that often does not work. There has to be some desire and/or reason to change, and that isn't there then I offer f/u for when it does come along and state that I will be there when they are ready to go to the next step.

I absolutely agree with what you said. I just want to emphasize that what's offered to patients doesn't really change for me based on how receptive I perceive them to be. I describe all options and provide recommendations based on what seems to have the most evidence and what might work for their goals.

I've had plenty of people that came into MAT because they were pressured and then end up being happy in treatment because a lot of other problems in their lives have gotten better as a result. Is it the majority that come in that type of situation, no, but its enough and enough people I would have bet on not returning that I know I can't predict with great accuracy, who will succeed in treatment.

I will admit that my threshold for success is based on the harm reduction model. If someone is now drinking 10 beers a night instead of 20, that's success. If it means that they have a few months a year sober or the length of relapses get shorter, that's also success, etc.

 

[LimpSpatula]

I’ve noticed time and again that patients with dual diagnosis or high risk substance use tell me that “if only I got my anxiety/depression/etc under control I would have no problem not using.” Which is an elaborate form of denial, and there are plenty of people with anxiety/depression etc who never even think to turn to substance use when they’re having trouble. (As an attending of mine in residency said, too, people do not drink because they have depression or anxiety but because they like to drink.) Of course, I don’t think I see myself ever saying *that* to a patient, nor do I think that statement is entirely true, but it does illustrate the denial element well. What I do tend to say is something along the lines of if you have both you treat both, and treating anxiety/depression etc before substance use is likely to be less effective and more high risk. But somehow that feels unsatisfying, so I wonder if anyone has another way they approach that conversation.

In my experience, 99% patients who say this sort of thing are trying to use us as their society sanctioned, dollar discount drug dealer, or they’re being forced to see us. My opinion is that we place an overabdunance of burden for addiction on the healthcare system which leads to false hopes and expectations for both patients and providers. The same could be said for depression and anxiety.