Dual Diagnosis — Two Ways To Describe One Thing

One of my special shrink magazines had a story headlined: “DUI offenses may signal untreated Bipolar Illness” in the November 2009 issue.

Since you have to sign up for a free account to read the article, and since they prefer you be a mental health professional, I’ll just tell you about it.

I don’t think you have to have twenty years of medical school and psychiatry training to reach the conclusion that anyone who has DUIs — especially a bunch of DUIs — should be screened for bipolar disorder.  This radical conclusion was reached by Dr. Mark J. Albanese of Harvard Medical School and his colleagues report.

This has been known for a while.  The academics in the Publish-Or-Perish situation love to do this kind of research – like “does the sun always rise in the east?”  Any front-line mental-health specialist who has the privilege of seeing whomever-comes-in-the-door knows this fact like they know their name.  I cannot believe it took Harvard this long to get a grant to prove this.  This is the reason why the “town and gown” dichotomy exists.

When I started to build my private, cash-only practice, one of the things I did was call lawyers who defended DUIs and try to explain to them that a lot of people with bipolar disorder did not know they had bipolar disorder.  They did not do anything to treat their bipolar disorder in what we mental health professionals would consider a reasonable way.
They did not walk into their nearest board-certified psychopharmacologist and say “Hello, sir or madam, I seem to be a bit manic, so you think you could prescribe something?”  They did what society still values and sanctions, even though it is a third rate mania treatment at best.  They got drunk.  Although every lawyer I talked to was fascinated by this and seemed to think it was an excellent (if somewhat creative) defense, nobody ever referred me a single patient who got into trouble for being drunk to see if he had an underlying bipolar disorder.

As a matter of fact, when I have seen people with alcohol problems to whom I have suggested they may be bipolar, when there were no DUIs and no lawyers involved, and generally, they get pretty angry at me.  They think that being called bipolar is some kind of an insult, and means they are really crazy.  National Institutes of Mental Health is as good a place as any to start to understand bipolar illness.

I studiously avoid sites that are sponsored by drug companies and will try not to steer you toward any. I had an inordinate amount of non-compliance with prescription drugs when I made attempts to prescribe them to bipolars.  My folks with bipolar illness have always been intelligent, creative, and lovable.  The nature of medications is to have side effects aplenty, and the nature of bipolar illness is episodic, so people do well in between either manic or depressive episodes.  They may be either relatively or totally oblivious to the fact that they can cause trouble for themselves or others when they get either manic or depressed.  That is why, although there have been relatively few publications, my treatment of choice for bipolar illness centers around a supplement called EmPower Plus, made by the folks at Truehope Nutritional Support.

Back to the concept of people who have alcohol problems having underlying bipolar illness, a lot of people call this “dual diagnosis.”  It is a false concept because it is an artifact of our classification system.  I think the same thing that makes people want alcohol to stabilize their mood is the thing that makes them merit the classification “bipolar.”

We know a LOT about brain chemistry.  But we still keep perpetuating classification systems for psychiatric illness that are based on behavioral descriptions.  Behavioral descriptions, like DSM-IV, are used to assess response to medication.  Pharmaceutical companies have the money and fund the research and so we are still using these descriptions of behavior to get people insurance compensation and (ta-da-da-da) to write prescriptions.  Most series that I have seen estimate 60% of known bipolars are first “discovered” with substance abuse problems.  Of course, there is no way of knowing how many substance abusers, especially the ones with recidivism, have underlying psychiatric diagnoses.  It may be a simple depression.  People may be using stimulants to recreate how energetic a manic episode feels.  This gets pretty complicated.

When I was a newly-hatched psychiatrist, they told me that somebody had to be four weeks off any substance of abuse before you could make any kind of a “real” diagnosis.  Now I believe the thing to do is spend more time with these patients, find out what their lives were like during their periods of sobriety, and think in terms of brain chemistry.
Sometimes, looking at how to treat the brain chemistry can actually help someone stop using the substance. This takes time, thinking in depth, and a doctor who really knows what he or she is doing.  Please, do not settle for anything less.