Dual Diagnosis

The term "dual diagnosis" may be new to your life and vocabulary or it may be something you are familiar with and have heard about before today. While not particularly well-known, dual diagnosis is more common than you might imagine. According to a report published by the Journal of the American Medical Association (JAMA), "Thirty seven percent of alcohol abusers and fifty-three percent of drug abusers also have at least one serious mental illness. Of all people diagnosed as mentally ill, 29 percent abuse either alcohol or drugs (NMHA, 2005). "Dual diagnosis" is defined as an individual who has two separate but very interrelated diagnoses. For the purpose of this article, dual diagnosis means a person has both:

1. A psychiatric diagnosis
2. A substance abuse diagnosis which may include drugs (and/or) alcohol

A dual diagnosis occurs when an individual is affected by both chemical dependency and an emotional or psychiatric illness. Both illnesses may affect an individual physically, psychologically, socially and spiritually. Each illness has symptoms that interfere with a person's ability to function effectively and relate to themselves and others. Not only is the individual affected by two separate illnesses, both illnesses interact with one another. The illnesses may exacerbate each other and at times the symptoms can overlap and even mask each other making diagnosis and treatment more difficult (Dual Recovery Anonymous (DRA), 2005).

The following psychiatric problems are common to occur in dual diagnosis, (i.e. in tandem with alcohol or drug dependency).

1. Depressive disorders such as depression and bipolar disorder.
2. Anxiety disorders, including generalized anxiety disorder, panic disorder, obsessive-compulsive disorder, and phobias.
3. Other psychiatric disorders, such as schizophrenia and personality disorders.

The following table based on a National Institute of Mental Health Study (2004), lists seven major psychiatric disorders and shows how much each one increases an individual's risk for substance abuse.

Thus, someone suffering from schizophrenia is at a 10.1 percent higher-than-average risk of abusing drugs and/or alcohol. Someone who is having an episode of major depression is at a 4.1 percent higher-than-average risk of abusing drugs and/or alcohol and so on. The list is not all-inclusive; any mental health issue increases the risk of substance abuse concerns, and vice versa. Roughly 50 percent of individuals with severe mental illness are affected by substance abuse (NAMI, 2005). While this is a scary thought, don't despair: there is hope and there is help for recovery.

Many ask, "What came first, the substance abuse or mental illness?" The answer is often unclear. Most times it is the psychiatric problem that developed first. In an attempt to feel calmer, and more cheerful, a person with emotional symptoms may drink or use drugs: health care professionals call this "self-medicating." Frequent self-medicating can eventually lead to physical or psychological dependency on alcohol or drugs. If it does, the person then suffers from not just one problem, but two. In adolescents, however, drug or alcohol abuse may merge and continue into adulthood, which has the potential to contribute to the development of emotional difficulties or psychiatric disorders.

In other cases, alcohol or drug dependency is the primary (or first) condition. A person whose substance abuse problem has become severe may develop symptoms of a psychiatric disorder: perhaps episodes of depression, fits of rage, hallucinations, or suicide attempts.

For the person dually-diagnosed, the consequences are numerous and harsh. Substance abuse complicates almost every aspect of care for the person with mental illness. Persons with a co-occurring disorder have a statistically greater propensity for violence, medication noncompliance, and failure to respond to treatment than people with just substance abuse or a mental illness. These problems also extend out to the person's families, friends, and co-workers.

From a health perspective, having a simultaneous mental illness and a substance abuse disorder frequently leads to overall poorer functioning and a greater chance of relapse. People may find themselves in and out of hospitals and treatment programs without lasting success.

Other problems and consequences that are associated with dual disorders include (DRA, 2005):

• Family problems or problems in intimate relationships.
• Isolation and social withdrawal.
• Financial problems.
• Employment or school problems.
• High-risk behavior while driving.
• Multiple admission for chemical dependency services due to relapse.
• Multiple admissions for psychiatric care.
• Increased emergency room admissions.
• Increased need for health care services.
• Legal problems and possible incarceration.
• Homelessness.

With all that said, there is a light at the end of the tunnel. Most people with dual disorders are able to achieve recovery. Research has strongly indicated that to reach full recovery, a person with a co-occurring disorder needs treatment for both problems — focusing on one does not ensure the other will go away (EvidenceBasedPractices (EBP), 2005). The chance of recovery improves when people receive integrated dual disorders treatment, which means combined mental health and substance abuse treatment from the same clinician or treatment team — often called the "integrated approach."

This treatment approach helps people develop hope, knowledge, skills, and the support they need to manage their problems and to pursue meaningful life goals. Effective treatment will help reduce the risk for many additional problems such as increased symptoms of a mental illness, hospitalizations, financial problems, family problems, homelessness, suicide, violence, sexual and physical victimization, incarceration, serious medical illnesses (such as HIV and Hepatitis B and C) and sometimes even early death.

It is important to remember that in order for recovery to be successful, it must be the individual's choice. People cannot be "pushed" into giving up substances. Over time they can learn to manage both their illnesses and to get on with their lives in personally meaningful ways. The process of recovery begins as soon as someone becomes committed to managing their illnesses and initiates appropriate treatment. Recovery takes time, hope and courage. For most people, recovery occurs over months or years.

Being able to provide and receive appropriate, integrated services is key for recovery to be possible for the dually diagnosed person. It will not only allow for recovery and improved overall health, but can lessen the affects their disorders have on their family, friends, and society at large. By helping people with dual disorders stay in treatment, find housing and jobs, and develop better social skills and judgment, we can potentially begin to substantially diminish some of the more dire symptoms and consequences of co-occurring disorders.

There is much evidence that integrated treatment can be effective (EBP, 2005). For example:

• Individuals with a substance abuse disorder are more likely to receive treatment if they have a co-occurring mental disorder.
• Research shows that when consumers with dual diagnosis successfully overcome alcohol abuse, their response to treatment improves remarkably.

With continued education on co-occurring disorders, hopefully, more treatments and better understanding are on the way.

References:

About.com. (2005). Dual diagnosis ? The problem. Retrieved May 16, 2005 from http://alcoholism.about.com/cs/dual/a/aa981209.htm

Dual Recovery Anonymous. (2005). Dual diagnosis or co-occurring disorders. Retrieved May 16, 2005 from http://www.draonline.org/dual_diagnosis.html

Evidence-Based Practices. (2005). Co-occuring disorders: Integrated dual disorders treatment. Retrieved May 23, 2005 from http://www.mentalhealthpractices.org/iddt_c.html

Evidence-Based Practices. (2005). Co-occuring disorders: Family and supporter information. Retrieved May 23, 2005 from http://www.mentalhealthpractices.org/iddt_fs.html

Hatfield, A.B. (1993). Dual diagnosis and mental illness (Schizophrenia and drug or alcohol Dependence). Retrieved May 6, 2005 from http://www.schizophrenia.com/dualdiag.html

National Alliance for the Mentally Ill. (2005). Dual diagnosis and integrated treatment of mental Illness and substance abuse disorder. Retrieved May 6, 2005 from http://www.nami.org

National Mental Health Association. (2005). Substance abuse — Dual diagnosis. Retrieved May 6, 2005 from http://www.nmha.org/infoctr/factsheets

Information in this document is taken from the resources cited and developed for use by the general public. It is not intended as medical/clinical advice or treatment. Only a healthcare provider can make a diagnosis or recommend a treatment plan. For more information about your behavioral health benefits, you can call the member services or behavioral health telephone number listed on your healthcare identification card. Any references in this material to other organizations or companies, including their Internet Websites, is not an endorsement or warranty of services, information or products provided by those organizations or companies.