Drugs, Alcohol and Mental Illness

Great Debates
1

Inspired by this thread.

http://boards.straightdope.com/sdmb/showthread.php?t=360700

Posting this in GD although as although I am looking for factual information, I am sure there will be something of a debate about the subject.

Where is the peer reviewed research evidence that alcohol and non-prescription drugs hinder effective response to Mental Health problems such as Depression and Psychosis.

I am more than aware that abuse of alcohol and drugs can be seen as a Mental Health problem in themselves, but what evidence is there for insisting on excluding people from therapeutic responses if they are using alcohol or drugs?

In your opinion, are drugs and alcohol necessarily counter productive for people with Mental health problems. What is the source for your beliefs in this matter?

2

Your link doesn’t go to a thread.

To answer a few things you appear to be asking:

Alcohol is in itself a depressant drug. Its abuse often leads to anxiety and depression.
It interacts negatively with a number of drugs prescribed to help these conditions.
Non-prescription drugs (are you referring to recreational drugs, “dietary supplements” or what?) have a variety of effects, including interactions with precription meds for psychiatric disorders that may hinder the action of those meds or cause toxic effects.

What is this “excluding people from therapeutic responses” of which you speak?

3

I think Pjen is referring to mental health professionals’ insistence on a patient’s dealing with any substance-abuse problems as a condition of treatment. This article explains it a little: http://www.healthyplace.com/communities/Addictions/Site/depression/dual_diagnosis.htm

As to the OP, I don’t think mental health care providers are doing this to enforce some personal moral code. I think it’s more analogous to (for example) postponing an operation until after an infection clears up. Sometimes it may be advantageous to pursue two separate courses of treatment simultaneously, but often one must precede the other. I’ll bet there’s sometimes conflict between one specialist who thinks it would be a whole lot easier to treat a depressed patient after he quit the booze and pills, and another specialist who is sure she could take care of the substance abuse much faster if some of the underlying emotional issues were competently addressed. Does this result in poorer care for those with competing problems? Probably.

4

[QUOTE=Jackmannii]
Your link doesn’t go to a thread.?
[/QUOTE]

Sorry, the link was to the MPSIMS post I smashed my son’s bong.

C&P the link to get to it- I must have miscoded.

[QUOTE=Jackmannii]
To answer a few things you appear to be asking:
Alcohol is in itself a depressant drug. Its abuse often leads to anxiety and depression.
It interacts negatively with a number of drugs prescribed to help these conditions.

[/QUOTE]

I understand that alcohol depresses the CNS, but these effects are not necessarily linked to the causes and symptoms of depressive or psychotic illnesses. Severe abuse may lead to anxiety and depression, but does not do so necessarily. I am interested to see good research on the real effects of alcohol on prescription drugs- not just supposed inter-reactions placed as a means of avoiding law suits. Where is the research which demonstrates such inter-action?

[QUOTE=Jackmannii]
Non-prescription drugs (are you referring to recreational drugs, “dietary supplements” or what?) have a variety of effects, including interactions with precription meds for psychiatric disorders that may hinder the action of those meds or cause toxic effects.
[/QUOTE]

By non-prescription drugs I meant any drug used outside of a clinical regimen- from heroin and crack cocaine, through marijuana and benzodiaepines to hypnotics etc.

[QUOTE=Jackmannii]
What is this “excluding people from therapeutic responses” of which you speak?
[/QUOTE]

As noted above by The King of Soup there is a tendency to use drug/alcohol abuse as a means of excluding people from normal responses to depression, anxiety and psychosis. I am looking to see if there is any research based evidence to support this.

5

[QUOTE=Pjen]
I understand that alcohol depresses the CNS, but these effects are not necessarily linked to the causes and symptoms of depressive or psychotic illnesses. Severe abuse may lead to anxiety and depression, but does not do so necessarily. I am interested to see good research on the real effects of alcohol on prescription drugs- not just supposed inter-reactions placed as a means of avoiding law suits. Where is the research which demonstrates such inter-action?
[/QUOTE]
Here’s a good introduction to interactions between alcohol and prescription drugs, including psychoactive medications.

You’ll find research citations that make it clear that these interactions pose quite real hazards, and that the warnings relate to good patient care rather than solely “a means of avoiding law suits”.

To look up more on specific medications (Paxil is just one commonly prescribed drug for depression and anxiety that is not recommended for use while drinking), I suggest a PubMed search.

6

[QUOTE=Jackmannii]
Here’s a good introduction to interactions between alcohol and prescription drugs, including psychoactive medications.

You’ll find research citations that make it clear that these interactions pose quite real hazards, and that the warnings relate to good patient care rather than solely “a means of avoiding law suits”.

To look up more on specific medications (Paxil is just one commonly prescribed drug for depression and anxiety that is not recommended for use while drinking), I suggest a PubMed search.
[/QUOTE]

I am aware of these generalities- I am trying to dig deeper.

From the cite you give I can quote and commentate:

*Antidepressants. Alcoholism and depression are frequently associated (14), leading to a high potential for alcohol-antidepressant interactions. Alcohol increases the sedative effect of tricyclic antidepressants such as amitriptyline (Elavil and others), impairing mental skills required for driving (15). Acute alcohol consumption increases the availability of some tricyclics, potentially increasing their sedative effects (16); chronic alcohol consumption appears to increase the availability of some tricyclics and to decrease the availability of others (17,18). The significance of these interactions is unclear. These chronic effects persist in recovering alcoholics (17). *

Increases sedative effect, impairs skills, increases/decreases availability. No evidence that it works against the primary use of the Rx drug. Many other Rx drugs interreact similarly with anti-depressants and doctors can factor this in to their Rx regimen.
*Antipsychotic medications. Drugs such as chlorpromazine (Thorazine) are used to diminish psychotic symptoms such as delusions and hallucinations. Acute alcohol consumption increases the sedative effect of these drugs (20), resulting in impaired coordination and potentially fatal breathing difficulties (7). The combination of chronic alcohol ingestion and antipsychotic drugs may result in liver damage (21). *

Increases sedative effect, impairs coordination, can lead to breathing difficulties or liver damage. Many other Rx drugs interreact similarly with anti-psychotics and doctors can factor this in to their Rx regimen.
*Sedatives and hypnotics (“sleeping pills”). Benzodiazepines such as diazepam (Valium) are generally prescribed to treat anxiety and insomnia. Because of their greater safety margin, they have largely replaced the barbiturates, now used mostly in the emergency treatment of convulsions (2).

Doses of benzodiazepines that are excessively sedating may cause severe drowsiness in the presence of alcohol (35), increasing the risk of household and automotive accidents (15,36). This may be especially true in older people, who demonstrate an increased response to these drugs (5,19). Low doses of flurazepam (Dalmane) interact with low doses of alcohol to impair driving ability, even when alcohol is ingested the morning after taking Dalmane. Since alcoholics often suffer from anxiety and insomnia, and since many of them take morning drinks, this interaction may be dangerous (37).

The benzodiazepine lorazepam (Ativan) is being increasingly used for its antianxiety and sedative effects. The combination of alcohol and lorazepam may result in depressed heart and breathing functions; therefore, lorazepam should not be administered to intoxicated patients (38).

Acute alcohol consumption increases the availability of barbiturates, prolonging their sedative effect. Chronic alcohol consumption decreases barbiturate availability through enzyme activation (2). In addition, acute or chronic alcohol consumption enhances the sedative effect of barbiturates at their site of action in the brain, sometimes leading to coma or fatal respiratory depression (39). *

Drowsiness and increased risk of accidents. Breathing difficulties. Many other Rx drugs interreact similarly with sedatives and hypnotics and doctors can factor this in to their Rx regimen.

I accept the counter reaction and severe respiratory depression in barbiturates- it is this type of inter-reaction I am looking for in the other psychotropic drugs that would give a rational reason for excluding alcohol users from medication and other treatment programs.

7

It is difficult to understand what you’re getting at.

This has been answered with a readily available cite that includes research citations, but your principal response seems to be (to paraphrase): “Well, other (prescription) drugs can interfere with treatment too.”

A good treatment program will take into account all medications (including drugs of abuse and supplements) in devising an effective and safe course of therapy. If a recreational drug or alcohol abuser with a mental health problem refuses to take steps to address his/her dependency, any plan to treat the psychiatric disorder is likely to be compromised and potentially hazardous to the patient. That doesn’t mean “give up booze or we won’t treat you”, but it does highlight the need for a comprehensive approach.

To consider a somewhat analogous situation: if a depressed patient has a disabling problem due to a chronic illness (such as inflammatory bowel disease or arthritis, for example), it makes sense to assure that a chronic disease that is likely to contribute to depression is being properly addressed at the same time you’re treating the depression itself.

Does it make sense to you that an interaction that heightens the symptoms of depression and may result in a subtherapeutic dosage (or overdosage) of antidepressant being received by the patient isn’t “working against the primary use of the Rx drug”? Of course it is.

What is the source of your apparent belief that drug and alcohol abuse aren’t major factors to be taken into account when treating depression and psychosis? Can you cite research published in peer-reviewed journals supporting this position?

8

[QUOTE=Jackmannii]

A good treatment program will take into account all medications (including drugs of abuse and supplements) in devising an effective and safe course of therapy. If a recreational drug or alcohol abuser with a mental health problem refuses to take steps to address his/her dependency, any plan to treat the psychiatric disorder is likely to be compromised and potentially hazardous to the patient. That doesn’t mean “give up booze or we won’t treat you”, but it does highlight the need for a comprehensive approach.?
[/QUOTE]

Unfortunately that is often the reaction to drug and alcohol abusers- refusal of treatment for the depression/psychosis until the alcohol/drug problem can be treated. Yet there is no clear evidence that such treatment is not possible while the person is still using- it just changes the person’s reaction to the medication, and psychiatrists manage to work around other such interactions where they are not drug/alcohol abuse related. Your quotes did not show that ‘any plan to treat the psychiatric disorder is likely to be compromised and potentially hazardous to the patient’, only that ‘workarounds’ would be necessary. Instead a tendency has built up to refer these people for substance-use treatment primarily and relegate the psychiatric problems to a lesser urgency.

[QUOTE=Jackmannii]
To consider a somewhat analogous situation: if a depressed patient has a disabling problem due to a chronic illness (such as inflammatory bowel disease or arthritis, for example), it makes sense to assure that a chronic disease that is likely to contribute to depression is being properly addressed at the same time you’re treating the depression itself.Does it make sense to you that an interaction that heightens the symptoms of depression and may result in a subtherapeutic dosage (or overdosage) of antidepressant being received by the patient isn’t “working against the primary use of the Rx drug”? Of course it is.
[/QUOTE]

This assumes the disease hypothesis of drug/alcohol misuse. A counter example might be to suppose that the Mental health Industry should say- bulimia is a serious problem which it is extremely difficult to address medically (as with alcohol/drug abuse). It is even debatable whether it is in fact a ‘mental illness’ (as with alcohol drug abuse). The vomiting involved affects the balance of electrolytes and may result in the expulsion of tablets. This makes it difficult to treat depression/psychosis, therefore we will insist that this person copes with their bulimia in a manner acceptable to the profession before they may access normal therapeutic treatment for depression/psychosis.

What I am arguing is that there is a case for saying that the co-existing depression/psychosis should be treated as best as possible, accepting that the person is likely to continue to use and abuse, in order to achieve the best mental state for the person to consider removing themselves from the use/abuse problem. Unfortunately the usual method is to concentrate on the use/abuse problem and to ignore the co-existing mental health problem.

[QUOTE=Jackmannii]

What is the source of your apparent belief that drug and alcohol abuse aren’t major factors to be taken into account when treating depression and psychosis? Can you cite research published in peer-reviewed journals supporting this position?
[/QUOTE]

I do believe that they are major factors to be taken into account. However I am concerned that instead of being seen as ‘factors’ they are seen as exclusion criteria.

9

[QUOTE=Pjen]
Unfortunately that is often the reaction to drug and alcohol abusers- refusal of treatment for the depression/psychosis until the alcohol/drug problem can be treated.
[/quote]
What is your evidence that this “often” occurs?

This is a strawman, as impossibility of treatment is not being alleged.

Why this dogged refusal to recognize that a drug (alcohol) that a) is a central nervous system depressant whose abuse is commonly linked to mental depression, and b) damages the liver, affecting metabolism of a host of other drugs is not the same as other medications which psychiatrists “manage to work around”.

It doesn’t help to minimize the seriousness of having a drug of abuse dependency problem on top of a mental disorder. The link supplied by The King Of Soup emphasizes that as well.

10

[QUOTE=Jackmannii]
What is your evidence that this “often” occurs?

[/QUOTE]

25 years as a mental health practitioner.

[QUOTE=Jackmannii]
This is a strawman, as impossibility of treatment is not being alleged.Why this dogged refusal to recognize that a drug (alcohol) that a) is a central nervous system depressant whose abuse is commonly linked to mental depression, and b) damages the liver, affecting metabolism of a host of other drugs is not the same as other medications which psychiatrists “manage to work around”.
[/QUOTE]

There is a difference between being a CNS depression and being a causative factor in depression. Liver damage is only apparent in longer term alcohol use. Physicians/Psychiatrists have no problem working with damaged livers by using LFTs and titrating when the liver damage is not alcohol related.

[QUOTE=Jackmannii]

It doesn’t help to minimize the seriousness of having a drug of abuse dependency problem on top of a mental disorder. The link supplied by The King Of Soup emphasizes that as well.

[/QUOTE]

I am not minimizing dependency, only questioning its use as a reason to exclude dependent persons from the treatment offered to the non-dependent. There is a non-clinical element to the psychiatrist’s decison making process in treating substance abusers similar to their use of ‘Personality Disorder’ to exclude those people from treatment.

11

[QUOTE=Pjen]
25 years as a mental health practitioner.

There is a difference between being a CNS depression and being a causative factor in depression. Liver damage is only apparent in longer term alcohol use.
[/quote]
I am stunned by the lack of correlation between your first statement, and your apparently being completely unaware of the liver’s role in breakdown of various drugs. It does not take long-term alcohol use and demonstrable damage for alcohol-drug interactions to occur. One could be a light to moderate drinker, have no alterations in liver function tests and still have severe effects from interactions between psychoactive medications and alcohol. I refer you to the link I previously supplied on alcohol-drug interactions for explanations as to why these interactions occur.
It is also amazing that you appear to be questioning alcohol’s documented role as a factor in clinical depression. Have you studied this at all?

Whatever your experience is, it does not substitute for objective evidence that mental health practitioners are preventing drug and alcohol abusers from receiving mental health care on a wholesale basis. When it is extremely difficult or impossible to separate signs and symptoms of mental disease from the effects of drugs and withdrawal from same, it only makes sense to be insistent that the patient seek help in treating his/her alcohol or drug addiction, rather than pretending that the addiction is no different than taking a prescription drug for asthma or inflammatory bowel disease.

Rather than accepting your opinion on faith, it would be good to have citations backing these blanket allegations of unprofessional behavior.