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In Search of a Diagnosis

I met Mary[1] in my office one afternoon on a referral from a colleague who was not an addiction specialist. He was concerned about Mary's drinking and felt that her complaints of depression and irritability stemmed largely from her drinking.

In our initial session, Mary reported that she had been having more frequent periods of alcohol use that met criteria for an alcohol use disorder. As we started to discuss her understanding of triggers for her alcohol use she admitted she was confused because she could maintain stretches of sobriety for a number of months but would eventually start to feel more "restless" and irritable. She found that the only thing that calmed this down was to drink, which would start with only a few drinks in the evening but always resulted in daily drinking that affected her job performance and relationships.

Mary was in her late 20s when she came to see me and estimated she had seen 6-7 psychiatrists before me, starting when she was in college for similar complaints. She reported that her periods of restlessness and irritability were relatively short and that she was more concerned with her longer periods of depression in which she struggled to get out of bed and had suicidal thoughts.

Mary was surprised that I was so interested in her periods of restlessness and irritability since she had generally been told that these were likely due to cravings for alcohol, especially since they usually only lasted a few days. Upon further questioning, however, she indicated that these periods usually lasted 4-5 days with less need to sleep though she attributed this to feeling restless rather than not wanting to sleep. She did admit, however, that she felt more energetic and wouldn't have to nap during the day if she did not sleep much the previous night. She also became more focused on details at her work and felt more productive though she would get upset with coworkers if they tried to interrupt her. She would start new projects at work that seemed like great ideas but could not make enough of a plan to carry them through and, since she would usually become depressed a few days after these periods in addition to drinking, she never finished any of the projects.

Mary said these episodes had started in college during a finals week her junior year and she attributed them to the stress of this time. As she started drinking her restlessness would improve but her mood would worsen. She had been diagnosed with Major Depressive Disorder in college and had been tried on various antidepressants without much success. She also mentioned that she felt a little more irritable when she started the antidepressants.

Mary’s case is an example of the difficulty of managing patients with "dual disorders", that is, both a substance use disorder and a mood disorder. Unfortunately, the comorbidity is high and teasing out whether symptoms are due to substance use, mood disorders or both is difficult and requires advanced training in both addiction and mood disorders. In Mary's case, I diagnosed her with bipolar disorder, type II because of her description of periods of changes in mood that included irritability, increased energy, decreased need for sleep, increased rate of speech and goal directed activity.

Mary's symptoms were not classic because she did not feel the usual elevated mood that come with hypomanic episodes, rather, her mood was more irritable. Epidemiological studies have shown that 48% of patients with bipolar II disorder have a substance use disorder in contrast to the 20% of patients without bipolar disorder who have a substance use disorder. More disturbingly, some studies have shown that 48% of patients with bipolar disorder had seen 5 or more health care professionals before they were accurately diagnosed with the disorder and 35% of bipolar disorder patients spend 10 years between the onset of their symptoms and an accurate diagnosis. With the added complication of a substance use disorder, accurate diagnosis and treatment can take even longer.

Despite these grim statistics, treatment of dual disorders exists and is effective. I recently received a text from Mary telling me she was 3 years sober and that her mood symptoms, while still present, were much more manageable with a combination of sobriety, medications and outpatient psychotherapy.

At Sunspire Health, each of our facilities has a physician that is board certified in both addiction and psychiatry, making the likelihood of an accurate diagnosis much higher than seeing a physician without these specialty board certifications. Our clinical staff is also highly trained to recognize and collaborate with our physicians in making these difficult diagnoses. We treat mental illnesses like we treat addictive illnesses: as chronic diseases that require consistent management just as other illnesses like hypertension and diabetes.

Mental Health Facts