The four correlates of long term sobriety are: constitutionally capable of being honest with yourself; goes to 12 step meetings; does a thorough 5th step followed by a 9th step; and, if you have a concurrent psychiatric disorder you take non-addictive medication to manage it. The focus of this article is on the 4th correlate of long-term sobriety: the diagnosis and treatment of concurrent psychiatric disorders.

Large studies of the alcoholic/addict population have confirmed that 37% of alcoholics and 53% of opiate addicts have concurrent and often undiagnosed psychiatric disorders. Relapse is incredibly common in those patients who fall through the cracks and fail to have these disorders treated. I have personally seen countless patients who have worked impressive 12 step programs only to relapse because they failed to address these illnesses.

Why does this occur? The answer lies in our cultural attitudes toward these illnesses. Lets face it, we live in the culture of John Wayne–where everyone is rough, tough, individualistic, and pulls themselves up by their bootstraps. In this culture to have alcoholism, addiction, anxiety or depression is not socially acceptable. Having these illnesses means that you have: a weakness of character, an inability to deal with life, a lack of willpower, a case of chronic wimphood, or–worse yet–a moral failing. This is complete nonsense.

These illnesses have a genetic and neurobiological basis. In the case of alcoholism, we know that 60 % of alcoholics are genetic alcoholics–the other 40 % drink themselves into the illness (please see the accompanying article on this page entitled: “The Disease Concept of Alcoholism and Drug Addiction). There are also strong genetic and biochemical determinants of depression, anxiety, bipolar, and ADHD. These are not weaknesses of character or a moral failing–they are neurochemical imbalances in the brain that can be triggered by viral infections, general anesthesia, or stressful life circumstances. In other words, they are medical illnesses. There is a target organ that is affected–in this case the brain–we give you the medicine and the rehab and, if you take it, you get better. What’s the catch? You have to take the medicine and do the work!!!

Why is compliance with medication and treatment such a big deal? Well, as it turns out, this is a really common problem in any field of medicine. No one likes to take medicine and most people have trouble taking medications if they have to take it more than once a day. However, in the field of addiction medicine there is an additional impediment to compliance and that is known as “denial” or “ego defenses.” This is a problem because the treatment is focused on the brain, also known as your survival tool, also known as “the onboard computer.” Anytime anybody is going to do anything with the onboard computer–look out–the so-called ego defenses leap into action to rescue the unwitting victim!!!

What am I talking about and what does this look like in real life? Here’s a great example right out of my own experience. I was working as an attending physician at an inpatient drug rehab when I met and admitted a 24 year-old man who had just spent 10 days in the ICU after overdosing on a liter of Vodka a day plus “speedballs” (i.e. heroin and cocaine mixed together and injected iv–this is what killed John Belushi). I was admitting him to rehab and at the end of the interview I told him that I thought that he had signs and symptoms consistent with depression and that he could benefit from Prozac. His response was: “Oh Nooo Dude, I don’t want any drugs!!!” Here’s a guy who would shoot-up God knows what that he could get off the street and then chase it with Vodka who’s telling me that he’s scared to take Prozac!!! This medication is effective, extensively researched, FDA approved, pharmacologically pure, cheap (because its generic and off-patent), and it is not a drug of abuse. What’s wrong with this picture!!! I actually laughed out loud at the absurdity of his response.

Unfortunately, the aforementioned scenario is not unusual or atypical. It reflects several mistaken notions that are harbored by the lay public, the media, and those who suffer from “contempt prior to examination.” The prescription drugs that get patients into trouble are the benzodiazepines (a.k.a. alcohol in pill form like Xanax, Klonopin, Ativan, Valium, Librium, etc.) and narcotics (e.g. Vicodin, Percocet, Morphine, Heroin, etc.). Anti-depressants, mood stabilizers, and anti-psychotics are not drugs of abuse. You don’t get high from them. In fact, in the case of anti-depressants, they are not immediately effective. You have to take them consistently and at therapeutic doses for 2 to 6 weeks before you get maximum therapeutic benefit. Once the anti-depressant kicks in the patient will notice the following: sleep improves, energy level rises, appetite normalizes, sex drive returns, and their short-term memory and concentration improves. All this for $4 a month at Wal-Mart!!!

As it turns out, the young man in the example above fell prey to “black and white thinking”, faulty assessment of risk versus benefit, and “contempt prior to investigation.” Since booze and drugs landed him in the ICU, any drug that might mess with the onboard computer must be bad. Then he relied on the media and the internet to tell him that if he took Prozac he would automatically commit suicide. This was a headline some years back, but when an 8 year retrospective study was conducted it showed that it wasn’t the Prozac that caused suicides–it was the disease of depression that it was designed to treat. Unfortunately, that’s a headline that doesn’t sell newspapers and therefore is not “news worthy”. Finally, he thought that his addiction and depression were conditions that would yield to his willpower–in other words, he would be able to think himself into sobriety and wellness. He did not understand the neurobiologic basis of these disease states. His faulty reasoning in this case is the equivalent of a patient with a bad case of Montezuma’s revenge deciding that he will use willpower to control his diarrhea. It will work for a little while, but in the end, Montezuma’s revenge will have its way with him and he will have diarrhea, vomiting, abdominal cramping, etc.

The point is that these so-called psychiatric conditions are really medical conditions. There is a target organ that is affected and the idea is to give the patient the treatment to correct the neurochemical imbalance. Does this mean that pills are the answers to all your ills? Of course not. Relying solely on “better living through chemistry” will not succeed. The patient needs to learn how to live life on life’s terms. This means doing the very real work of rehab. It’s just like when you get a hip replacement. Doing the surgery is only a small part of the recovery. The patient must have extensive physical therapy in order to get back to normal. It’s no different in psychiatry or addiction—the same rules apply.