“All heroin users look bipolar,” my colleague, a psychiatric nurse practitioner, told me as I sat across from him in his office in the largest yard in the prison. Between orange-clad clients, we would discuss the realities of psychiatric diagnosis. This was my first job in mental health, and I was so eager to know everything that there was to be known about psych. Perceiving this psych NP as competent and well-seasoned in his field, I would pump him for information. Luckily for me, he was very willing to share his expertise.

Sometimes, he ranted about the widespread incompetence of psychiatrists. There was fair amount of inmate movement among the yards, and often he inherited patients from different psychiatric providers. Upon assessing these patients, he often found himself in the position of putting a note in the EMR (electronic medical record) that there was “no evidence” for the diagnoses they had been given. He would then dig into the patients’ histories to make more appropriate diagnoses. A particular pet peeve was when other psychiatric providers erroneously diagnosed drug addicts as having schizophrenia, bipolar, or schizoaffective disorder.

Once could conclude that this is an issue limited to a corrections setting, that psychiatry in corrections is generally not very good and that is why addicts are being misdiagnosed with purportedly organically-occurring mental disorders rather than being diagnosed as simply addicts. However, this problem is not exclusive to a correctional setting. It is ubiquitous in the mental health world, and everyone from an unknown inmate to a high status celebrity can be affected.

Misdiagnosis in general is actually a huge problem in psych. This Canadian research study gives an idea of just how bad the situation is, as summed up by this quote:

Of the 840 primary care patients assessed, 27.2%, 11.4%, 12.6%, 31.2%, and 16.5% of patients met criteria for major depressive disorder, bipolar disorder, panic disorder, generalized anxiety disorder, and social anxiety disorder, respectively. Misdiagnosis rates reached 65.9% for major depressive disorder, 92.7% for bipolar disorder, 85.8% for panic disorder, 71.0% for generalized anxiety disorder, and 97.8% for social anxiety disorder.

For these five given diagnoses, the rates of misdiagnosis were far over half, and for two of the diagnoses, close to 100%! The question remains – why is this happening?

In a previous article, I discussed three reasons why a psych professional might misdiagnose patients. To summarize, she or he may do so for insurance reasons, to provide the client with access to perks that are not available with the correct diagnosis, or because of incompetence. Going back to the research article above, I found another telling quote –

Despite the high prevalence of mood and anxiety disorders, few patients are screened and diagnosed appropriately. Indeed, recent studies suggest that a quarter of psychiatrists and half of primary care physicians often do not use Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnostic criteria for major depressive disorder when diagnosing depression. Furthermore, despite the availability of several validated, easy-to-administer scales that can facilitate diagnosis and monitoring of outcomes in patients with mood disorders, they are not routinely used by the majority of clinicians.This is despite guideline recommendations supporting the routine use of validated outcome scales… to assess and monitor patients being treated for depression.

So, basically, a number of these clinicians don’t even bother to use the guidelines established by the mental health industry itself. They just do whatever they want. Little wonder that meth users are getting diagnosed with schizoaffective disorder!

Unfortunately, the attitude a number of psych workers take toward diagnosis can be summed up as follows: “The drug use is not the main issue. It’s the chemical imbalance that makes you use drugs.” Four unfortunate things can happen as a result of such an approach – 1) the client could actually buy into the unproven chemical imbalance theory and become convinced she or her had a defective brain all along; 2) hence, the client may feel hopeless and be less motivated to pursue a change of lifestyle; 3) the client may possibly becomedisinclined to kick the drug habit because psych drugs are now available to alleviate the unpleasant side effects of street drugs; and 4) the mental health industry potentially obtains a client for life to treat a condition that they never even substantiated.

The Drugs Absolutely Can Be the Main Issue

My former colleague had a point when he stated that all heroin addicts look bipolar. Certain side effects of heroin use can present like bipolar, particularly the inability to sleep during withdrawal. If a psychiatric provider who is not particularly scrupulous is approached by a client who claims to have been up for five days, this provider just might jump to the conclusion that the client must be bipolar, without ever asking if substances were involved. Yes, this kind of scenario does happen, unfortunately.

Various substances, both legal and illegal, can have short-term to long-term impact on mental health. Cocaine and methamphetamine can make users look bipolar or schizophrenic. Though often seen as innocuous, marijuana can also cause psychosis, such as in the horrific case of a woman who, after trying marijuana for the first time, became psychotic and stabbed her boyfriend to death, then turned the knife on her dog and herself. Appropriate diagnoses exist for cases of mental illness caused by drugs – cannabis-induced psychosis, substance-induced mood disorder, medication-induced psychosis, and so forth.

When I worked at an addictions clinic, there was a client who started using methamphetamine at age 18. Upon seeking psychiatric help, he received three diagnoses that had nothing to do with his meth use: schizophrenia, schizoaffective disorder, and unspecified psychosis not due to a substance or physiological condition. Look at that again – unspecified psychosis not due to a substance or physiological condition. His symptoms had been paranoia, mood swings, and auditory hallucinations, and these had ceased two years prior to me speaking with him. Interestingly enough, his reported time frame for the cessation of his symptoms coincided exactly with when he stopped meth. Yet, his use of psych drugs got the credit for him feeling better.

Now, the question remains: did he even have a valid reason to continue with those psych drugs, or did the mental health industry dupe him into believing his problem was not the drugs but rather an inborn schizophrenic/schizoaffective/psychotic condition that would never resolve on its own? You be the judge, but it sounds to me that the mental health industry had managed to scam this unsuspecting man into being a perpetual client by convincing him it wasn’t actually the meth that had caused his problems.

Another client, a 25-year old man, was diagnosed with bipolar (manic with psychotic features), marijuana use, cannabis dependence, and nicotine dependence. I uncovered that he had been diagnosed with mental illness at age 19 after smoking marijuana laced with PCP and then coming down with mood issues and psychosis. So, why the bipolar diagnosis? Why wasn’t he just diagnosed with substance-induced mood disorder?

A third client, a 26-year old man, had started smoking marijuana at age 12 and meth at age 14. At 16, he began having hallucinations and was (of course) diagnosed with schizophrenia. He admitted to still smoking 1-5 grams of marijuana weekly and he still did meth, though he was evasive about the last time he had used. This man was on cocktail of psych drugs – Clozapine, Haldol (both oral and injection), and lithium. The antipsychotics probably had a lot to do with his weight of 337 lbs. He continued to display symptoms of auditory and visual hallucinations, mood instability, loss of sleep, and aggression, and he was pending court ordered treatment for assaulting his father. So… why the schizophrenia diagnosis? And what was the point of the psych drugs when he would not quit the street drugs?

Does it appear to you that the mental health industry is intentionally giving addicts erroneous diagnoses in order to keep them as returning customers? Share your opinions in the comments below.

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