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Mental Illness and Addiction Part I: An Interview with Dr. Sack of Promises

Richard Zwolinski, LMHC, CASAC talked with Dr. David Sack, CEO of Promises Treatment Centers and addiction psychiatrist, about dual diagnosis, or people who suffer from mental illness and substance-abuse disorders. Following is the article, published on

In the past few years, more and more states as well as the federal government have begun to examine the complex relationship between substance abuse and mental illness. Having been involved in both addiction and mental health treatment for over two decades, I can attest to the fact that though plenty of people struggle with both issues simultaneously, many of them don’t get correctly diagnosed. Frequently, patients are diagnosed with either a mental health problem or an addiction. This means that an important part of their treatment is missing.

Dr. David Sack, a psychiatrist who is certified in psychiatry, addiction psychiatry, and addiction medicine and is the CEO of Promises Treatment Centers, a California-based treatment program, has generously agreed to discuss co-occurring mental illness and addiction, also known as dual-diagnosis.

Richard Zwolinski (RZ): Thank you for joining us, Dr. Sack. Your treatment program, Promises, is considered to be one of the best in the country. We know that peer pressure/recreation, family-of-origin dysfunction, and family-of-creation dysfunction can be contributing factors to substance use. Critical to understanding substance use, abuse, addiction, and recovery is the understanding of the emotional or feeling-based components of addiction. It would be helpful if you could begin by explaining the primary mental and emotional states that might lead a person to use, abuse, and even become addicted to drugs or alcohol.

Dr. David Sack (DS): People start using or experimenting with drugs and alcohol for a number of different reasons. These include the desire to experience intense pleasure, wanting to suppress bad feelings, curiosity (wanting to know what the big deal is), and [in order to] enhance performance. Once someone uses drugs regularly their motivations shift. It is harder to experience the same level of intense pleasure due to tolerance. Bad feelings increase as a direct effect of the drugs on the brain and also as a consequence of the behaviors the drug user engages in. As the user becomes physically dependent on a drug, the goal of preventing symptoms of withdrawal replaces pleasure as a main reason to use. Finally, as a person’s life is taken over by drugs or alcohol, the only people they socialize with are other drug users, so social reinforcement becomes an additional motivator for drug use.

RZ: Can you explain how people with various specific mental illnesses might be impelled to try and abuse drugs or alcohol? For example, depression?

DS: Patients with depression and anxiety disorders are much more likely to become dependent on alcohol and drugs than the general population. The majority of these clients experiences psychiatric symptoms first and attribute their drug use to trying to reduce or eliminate their negative emotions. Once a person with depression or anxiety starts using drugs or alcohol regularly their problems multiply. Antidepressant and anti-anxiety medications become less effective. Psychiatric hospitalization becomes more likely and the risk of attempting suicide escalates. Patients with depressive or anxiety disorder in addition to drug dependency are more than three times more likely to relapse to drug use in the year following treatment than individuals with drug dependency alone.

RZ: Are there particular mental illnesses that make people even more prone to abuse substances?

DS: Every major psychiatric disorder is associated with an increased risk for alcohol and/or drug abuse but the patterns of abuse differ. While alcohol is the most widely abused drug across all groups we see some specific preference within certain diagnoses. For example, in anxiety patients, we are seeing a lot of prescription opiate and heroin abuse. In depression, we see poly drug abuse, with alcohol, cocaine and benzodiazepines a common combination. With most disorders (as I already noted), the psychiatric problems come first. In bipolar disorder patients who also have substance abuse problems, a majority exhibit problems with drug use first.

Posted on February 18, 2010 and modified on April 28, 2019

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