Dual diagnosis is a term that refers to patients who have both a mental health disorder and substance use disorder. It may be used interchangeably with "co-occurring disorders" or "comorbidity." According to the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA), an estimated 10 million people in the United States will have a combination of at least one mental health and one substance abuse disorder in any twelve-month period. Substance abuse is the most common and significant co-occurring disorder among adults with such severe mental illnesses as schizophrenia or bipolar disorder. It may also be observed in individuals with mental health diagnoses that include depression, anxiety, post-traumatic stress disorder, or eating disorders. The term "substance abuse" refers to substance use disorders that range along a continuum from abuse to dependence or addiction.
The term "dual diagnosis" is considered to be misleading by some professionals because most people with this diagnosis actually have many problems rather than just two discrete illnesses. Occasionally, the term is used to describe a person with developmental disabilities and/or a mental health disorder or substance abuse disorder. More commonly, dual diagnosis refers to those with severe mental illness and a drug or alcohol abuse disorder, and who receive therapy in the public treatment systems.
The prevalence of people with dual diagnoses became fully apparent to clinicians in the early 1980s. Initially, dual diagnoses were thought to be most likely in young adults with schizophrenia or bipolar disorder who also had extensive histories of drug or alcohol abuse. There was a widespread belief, often shared by family members of affected patients, that a young person's initiation into illegal drug use actually caused a subsequent mental illness. It is now more commonly thought that symptoms of the mental disorder generally appear first, and that the abuse of drugs or alcohol may represent the patient's attempt to self-medicate and alleviate the troublesome symptoms that accompany mental health disorders.
Today it is clear that the co-occurrence of mental illness and substance abuse is common: about 50% of individuals with severe mental illnesses are affected by substance abuse. A dual diagnosis is also associated with a host of negative outcomes that may include higher rates of relapse, hospitalization, incarceration, violence, homelessness, and exposure to such serious infections as HIV and hepatitis.
Despite almost twenty years of evidence regarding the prevalence and serious illnesses of people with dual diagnoses, the United States mental health and substance abuse systems continue to operate on parallel tracks, causing additional confusion to those with concurrent disorders. Refusal to combine services to provide better coordinated treatment has meant unnecessary suffering and expense for thousands of patients and their families.
For many people with dual diagnoses, the criminal justice system—juvenile as well as adult— becomes their de facto treatment system. Nearly two-thirds of incarcerated youth with substance abuse disorders have at least one other mental health disorder. The common association between conduct disorder or attention-deficit/hyperactivity disorder and substance abuse are two examples of combinations of serious and disabling disorders. A person in need of treatment for dual diagnoses who is in the current criminal justice system may not be evaluated or assessed, let alone provided with appropriate treatment.
Children of alcohol or other drug-addicted parents are at increased risk for developing substance abuse and mental health problems. Disruptive behavior disorders coexist with adolescent substance abuse problems more often than not. Other special groups that may be affected include older adults with mood or anxiety disorders, especially those who are grieving numerous losses. They may drink or misuse or abuse prescription drugs to cope with their lowered quality of life. These factors can often complicate treatment of hypertension, diabetes, arthritis, and other health-related problems that affect the elderly as well.
Abuse of alcohol or other drugs may occur in persons with eating disorders in an effort to deal with guilt, shame, anxiety, or feelings of self-loathing as a result of bingeing and purging food. Many military veterans suffer from anxiety, depression or post-traumatic stress disorder and have histories of substance abuse. Services for veterans are woefully inadequate, adding to the chronic nature of dual diagnosis among them.
One of the difficulties in treating patients with dual diagnoses is that most treatments for mental illness are usually developed for and validated by studies of patients with single diagnoses; therefore, many cases of comorbidity may not be well treated by these approaches. Recent research on services provided to people with dual diagnoses, however, indicates that treatment can be successful, provided certain specific components are included in the treatment process. The critical elements identified as part of treatment programs with the most successful outcomes are:
- • Staged interventions that begin with engaging the client; persuading him or her to become involved in recovery-focused activities; acquiring skills and support to control the illnesses; and then helping the patient with relapse prevention.
- • Assertive outreach that may involve intensive case management and meetings in the person's home.
- • Motivational interventions to help the client become committed to self-management of their illnesses.
- • Counseling that includes cognitive and behavioral skills.
- • Social network support and/or family interventions.
- • An understanding of the long-term nature of recovery.
- • Comprehensive scope to treatment that includes personal habits, stress management, friendship networks, housing, and many other aspects of a person's life.
- • Cultural sensitivity and competence.
The success of 12-step programs in the treatment of substance abuse is well-established. Nevertheless, the level of confrontation sometimes found in a traditional 12-step group may feel overwhelming to people with mental illnesses. In addition, the use of psychotropic (mood- or behavior-altering) medications is controversial in some areas of the substance abuse recovery community. As a result, other models of consumer-led support groups specifically for people with concurrent disorders, such as Dual Recovery Anonymous and Double Trouble, are being developed.
Kranzler, H. R., and B. J. Rounsaville, eds. Dual Diagnosis and Treatment: Substance Abuse and Comorbid Medical and Psychiatric Disorders. New York: Marcel Dekker, Inc., 1998.
Pepper, Bert, and E. L. Hendrickson. Developing a Cross Training Project for Substance Abuse, Mental Health and Criminal Justice Professionals Working with Offenders with Co-Existing Disorders (Substance Abuse/Mental Illness). New York City: The Information Exchange, 1998.
Drake, Robert E., M.D., PhD., Susan M. Essock, PhD., and others. "Implementing Dual Diagnosis Services for Clients with Severe Mental Illness." Psychiatric Services 52: (April 2001): 469-476.
Rach Beisel, Jill, M.D., Jack Scott, Sc.D. and Lisa Dixon, M.D., M.P.H. "Co-occuring Severe Mental Illness and Substance Use Disorders: A Review of Recent Research." Psychiatric Services 50: (November 1999) 1427-1434.
National Alliance for the Mentally Ill (NAMI). 2107 Wilson Blvd., Suite 300, Arlington, VA 22201. <http://www.nami.org>.
National Mental Health Association. 1021 Prince St., Alexandria, VA 22314 <http://www.nmha.org>.
National Mental Health Consumers' Self-Help Clearinghouse. 1211 Chestnut St, Suite 1207, Philadelphia, PA 19107. <http://www.mhselfhelp.org>.
Judy Leaver, M.A.