I left the teenage psych ward with a folder full of handouts about substance abuse, pamphlets on suicide prevention, and a prescription for a new antidepressant called Effexor. It was a double-barreled shotgun of a drug, working on both serotonin and norepinephrine, one of the first of its kind. Like all antidepressants, it came with a warning: DO NOT DRINK ALCOHOLIC BEVERAGES WHILE ON THIS MEDICATION.
Problem is, I was drinking alcoholic beverages. Often. And the doctor knew it, or at least knew I drank. Sure, I filled out their surveys with lies, filling in bubbles that said I drank “a few times a month,” took illegal drugs “a few times a year,” and used tobacco “a few times a week.” More accurate responses would have been “often,” “regularly,” and “every goddamn day.” Maybe psychiatric doctors have a rubric for getting the real answers out of a sullen, suicidal teen: take the survey scores, double them, and subtract four. Or maybe the reduced usage I reported was alarming enough. Either way, I was stamped with a dual-diagnosis of substance abuse disorder and unspecified mood disorder, and I was prescribed medications to treat the latter that came with warning labels about the former.
The Diagnostic and Statistical Manual for Mental Disorders, or DSM, is the Bible of labels in psychiatry. It says, clearly, that diagnoses don’t count if the patient is under the influence of drugs or alcohol or is in withdrawal at the time of diagnosis. This is a problem, because I was both diagnosed and prescribed medications while I was drinking and using drugs. If I wasn’t under the influence, I was withdrawing. According to the Mayo Clinic, drinking, drug abuse, and withdrawal can cancel out the benefits of antidepressants, mask the symptoms of a mood disorder, or make that disorder worse. How could anyone give me a diagnosis and feel sure of it? They couldn’t have. The folks who wrote my prescriptions knew I was a drinker and a drugger. They saw my daily vital signs in the psych ward, with the elevated heart rate and body temperature that indicates withdrawal. I was treated in the same way as the teenagers down the hall, in the non-dual-diagnosis unit, but my dual-diagnosis really required a different level of care. It required sobriety.
To be fair, my doctors did recommend that I avoid alcohol and drugs as they scrawled prescriptions. They did their due diligence, but I think they should have refused to prescribe unless I sobered up. Sadly, sobering up isn’t so easy. At seventeen, I didn’t want to stop drinking, smoking pot, and snorting coke. I liked it. I felt the most like myself when I was high and had a drink in my hand — why would I want to quit? It doesn’t help that alcohol and drugs are, of course, highly addictive, both physically and mentally. The physical addiction is easier to spot. It can cause tremors, jaundice, delirium, and seizures, but also some less-obvious symptoms that I had, like anemia, dry skin, chronic diarrhea, and vitamin B deficiency. The mental addiction is more slippery. It shows up as depression, anxiety, low self-esteem, poor impulse control, and mania. Throughout my years of addiction, I experienced every single one of those states, sometimes rapid-cycling through them or dealing with all of them at once.
My dual-diagnosis really required a different level of care. It required sobriety.
That’s how I wound up in the psych ward in the first place. I was too sad to do anything but cry, get high, and sleep, and I was anxious about facing everyday tasks, like school or driving a car. Then I felt bad about myself for being so dysfunctional. Then came the impulsive idea to try suicide. A manic push into action followed. I wrote an eloquent note, called my family and friends to say goodbye, and then drove my car, fast, too fast, through the snow on the sharp curves of 501 that led to the Blue Ridge Mountains, only to be found wandering the woods with a noose an hour later. It wasn’t the first time I attempted suicide while I was in active addiction, and it wouldn’t be the last.
Teens who binge drink have a higher rate of depression during their adolescence, but also later on, in their twenties—about 38% more. They’re more than twice as likely to abuse or get addicted to drugs. Young women are especially prone to depression, especially if they engage in binge drinking and promiscuous sex. This makes sense, thanks to the double standard of sex that congratulates men and shames women. I got called names—“easy,” “slut,” “whore”—while my guy friends who slept around received high-fives. Once, I watched my best friend’s older sister throw away the carton of ice cream I’d been eating out of. She didn’t know I was listening, but I heard her whisper to my friend, “I don’t want to eat after her. Who knows where her mouth has been!”
No wonder I was depressed. No wonder I had low self-esteem. No wonder I was anxious and impulsive. Between the slut-shaming and the vicious circle of addiction, I didn’t stand a chance. My mental health issues were alarming enough to demand treatment of their own, so I understand why I was prescribed medication for them, but if those issues were actually symptoms of substance abuse, then they needed to be treated differently. I’ll never know for sure, but it’s possible that all my mental health gymnastics were symptoms of my addiction, and what I really needed was sobriety, not medication.
Does the addiction cause the mental illness, or does the mental illness cause the addiction? It’s a chicken/egg question, and there’s no clear answer. I told my doctors that I would stop drinking and using drugs so much if they could cure my melancholy and self-loathing. They tried. They diagnosed me using the most sophisticated tests available. They treated me with the latest medication. They sent me to therapy. They suggested twelve-step programs. They were doing the best they could.
My experience may not be universal, but I didn’t get better until I walked into a meeting, said “Hi, I’m Emma, and I’m an alcoholic,” and got sober. Unfortunately, that didn’t happen until I was well into my 20s, almost ten years after my first suicide attempt. Because I was in active addiction every time I was diagnosed, it’s possible that all my diagnoses were crap, and I was improperly medicated for a decade, leaving me to fight mental illness with one hand tied behind my back.
It wasn’t the first time I attempted suicide while I was in active addiction, and it wouldn’t be the last.
I’m not suggesting that my unspecified mood disorder (or whatever flavor of crazy I am) improved as soon as I put down the bottle, pipe, and powder, because it didn’t. It took months, maybe years, of sobriety for my brain chemistry to find its new normal. I’m still on antidepressants today, after seven years without a drink or a drug, and I don’t plan on getting off of them anytime soon. While I don’t think my addiction created my mental illness, I believe it masked it, twisted it, and made it explode. I don’t know for sure, but I have a hunch that using alcohol and drugs while I was on all those different antidepressants and anti-anxiety medications, spanning the alphabet from Abilify to Zoloft, created a brand-new tornado that roared through my life and left behind an unrecognizable wreck of hair dye, bong hits, whiskey, and self-destruction. While I was on Effexor, for example, I got arrested twice, attempted suicide once, dropped out of high school, and ran away from home. Three years after getting sober, I was prescribed Pristiq, the second generation of Effexor, and I experienced the first long-term wave of relief from mental illness.
How and when to medicate dually-diagnosed patients is a controversial topic, and I don’t know what the right answer is. I’m not a doctor, pharmacist, or therapist. I understand that not medicating a suicidal patient is a dangerous prospect — who wants to tempt death, or worse, see a patient die and wonder if meds could have prevented suicide? All I know is that my adolescence was hellish, more hellish than most, and it didn’t have to be — or maybe it did. I’ll never know. What I do know is that when I was released from the psych ward, I still had six years of suffering to go. If I had known then that I wasn’t even halfway through my trip to hell, I may not have made it.
Image: Flickr/Steve Snodgrass
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