Q:  Dual Diagnosis & VA

Dear Dr. Phelps,
How do I go about determining that drug addiction/alcoholism was secondary to (or a symptom of) Bipolar I. I know that up to 50% of BPD patients have addictions in their lifetime.  I am dealing with the VA and was treated in service for alcohol/substance abuse in the '70s but never heard of Bipolar until diagnosed by VA in '97.  Their position is drug/alcohol is willful misconduct unless secondary to (or a symptom of)a service connected illness.

My VA doctor has opined that I was most likely BP in service but what do I do about my Dual Diagnosis ? How do I connect the dots?  The VA may suggest I became Bipolar as a result of drug/alcohol misconduct.

Please advise a course of action concerning establishment of symptomology.  My VA doctor is supportive of my claim and is aware of my past and has agreed with a prior Dual diagnosis.

Thank You

 
Dear Mr. R' -- 
Perhaps we should split this into two aspects of the same question: first, the therapeutic issues; then the VA bureaucracy issues. 

Therapeutically, it's pretty straightforward: treat the bipolar part and see how much the substance use problem remains, then treat that as you need to (including aggressively if necessary). That's how I do it, and haven't had too much of things falling apart while I focused on the bipolar disorder.  However, some of my colleagues think that I underdiagnose substance use and underemphasize it's treatment.  In some folks, that could be true. 

As for the VA, at least you could cite the fact that there is no clear evidence that drug/alcohol misconduct causes bipolar disorder.  Bipolar Disorder is very strongly genetic.  Stresses, probably including substance use but probably also including military service and even just military training from what I know, are also recognized as "causing" bipolar disorder. 

Dr. Phelps