Dr Jonathan Avery on the Dangers of Misdiagnosing or Mistreating Concurrent Psychiatric and Substance Use Disorders

Jonathan Avery, MD, director of addiction psychiatry, New York-Presbyterian Hospital, Weill Cornell Medical Center, explained why it’s important to diagnose and treat concurrent substance use disorders and mental illnesses at the same time.

What can happen if a psychological disorder is treated but substance use is left undiagnosed or vice versa?

The big problem, I think, in American psychiatry or in medicine in general is that we tend to only treat 1 condition at a time, and often it’s the psychiatric condition and not the substance use disorder condition that gets treated. We think in an ideal world both should be treated at the same time, and if not, if you just treat the psychiatric condition and not the substance use, things aren’t going to get better, and similarly if you address the substance use without addressing the reason why they’re using, it sets the person up for failure. So you really have to address both at the same time if you want the person to get on the right track.

What are the dangers of misdiagnosing a psychiatric disorder when a substance use disorder is present?

Diagnosis can be very challenging when people are using substances. It’s unclear, as we were discussing, if the substance use leads to the mental illness, if the mental illness symptoms wouldn’t be there if they weren’t using a substance. These days, though, we sort of argue that things should be just kept simple, that if it looks like they have depressive symptoms, we don’t have to completely figure out if the substance use was related but they should all be addressed. So if it’s, say, someone who’s depressed and drinking a lot, it might be hard to tease out what started first—if the depression started first or the drinking started first—and our goal would be to recommend that you treat both. You give them medications for the substance, for the alcohol use, or the psychosocial treatment, and you give them meds and therapy if needed for the depression.
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