Drugs or bipolar
Q: Dear Dr. Phelps: In short, I have three children, 18,20,and 23. All have had varying diagnoses from schizoaffective to bipolar. The 20 year old has a hard time accepting and won't take meds. He uses drugs and becomes very violent, and in trouble with the law all the time. He admits to hearing voices. Is there a way to tell if the voices are from the drug use or from a condition like bipolar? He says he hears them "off and on" at times of sobriety as well as when high. For the most part the voices are "insulting". He is also paranoid, I have noticed, and depressed. His personality is nothing like it used to be. I hate to keep paying for psychiatrists in the hope he will eventually keep taking the meds they prescribe, if it is just drugs doing all this. I only make $900/month and this is very difficult. His siblings are compliant, so it is worth it. If it is just the drugs, I know I can't keep him from using or make him want to quit. If it is possibly a condition, I'll keep trying. Thank you for any help you may be able to give. Susan
Dear Susan --
Ouch, tough position to be in. Let's see, though: he's 20, and you have to pay for meds/treatment? I'm sure it would be agony to watch him go without treatment if you could help, but at some point you may have to reinforce his efforts to find his own help (in which case he's probably less likely to waste the money spent on it). Meanwhile though, it doesn't hurt to ask this on-target question of yours. I'll try to answer it:
Yes, you're right to wonder if it might be "just drugs", and it could be. And if it were, trying to treat that with medications may have very limited success. Alcohol craving and binging has been pretty effectively decreased with a medication called naltrexone (U.S. "Revia") that also blocks any "high" from heroin -- but a person has to take the pill every day. There are not a lot of other medication approaches to substance use with obvious effectiveness, besides methadone for heroin addiction and Antabuse for the folks who'll keep taking that one.
However, suppose as you have wondered that the substance use is just riding along with some mental illness such as his siblings have. Here's where there is more hope: quite often the medications that help bipolar disorder (given his siblings' diagnoses, we could start by hoping that's what he has too) also help people stay away from substances. At least Depakote has certainly lessened impulse control problems (substance use, violence). Lithium may have some antiviolence effects (from old prison studies where the half of the prisoners that were given lithium had less violent episodes than the other half of the prison population).
So generally in these circumstances I will treat with mood stabilizers and hope for such an effect, while keeping very close eye on the substance use and being prepared to refer the person for substance use treatment if necessary. I try to reinforce her/his sense of autonomy, that is, this is their choice, to get this treatment; and to mess it up a few times, with substance use, if they choose -- but trying meanwhile to help them recognize the effects of such use on the mood problems they came to see me for! See how that's different (if I read you right) than paying for his treatments, at the "big picture" level?
Good luck with this difficult situation. Maybe you could spend some of that hard earned cash on a therapist for you, to help cope with all this?
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