Diagnosing bipolar disorder in an alcoholic

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What can be done for a mood disorder (specifically bipolar I and II) secondary to alcohol abuse when the patient has failed all treatments (i.e., court-ordered Alcoholics Anonymous, disulfiram [Antabuse], acamprosate [Campral], naltrexone [Vivitrol], and psychiatric evaluation)? According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, diagnosis cannot be made in the presence of substance abuse.—ANTHONY CERULLO, PA-C, Sedahia, Colo.

While a history of past or ongoing substance abuse often confounds the establishment of a clear psychiatric diagnosis, that common reality should not interfere with the treatment of obvious psychiatric symptoms. Whether or not it is associated with cocaine use, mania is mania and can be treated (at least acutely) with standard anti­psychotics. Similarly, depression or suicidal ideation should be treated regardless of cause; there is no reason to withhold an antidepressant until a patient is clean. Perhaps the only caveat is that benzodiazepines should be avoided in treating a substance-abusing patient. For a more detailed analysis, see Buckley P. Dual diagnosis: severe mental illness and substance use disorders. In: UpToDate, Rose, BD, ed. UpToDate. Wellesley, Mass.: UpToDate; 2010.—Reuben W. Zimmerman, PA-C (137-4)
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