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Dual Diagnosis

Dual Diagnosis

When a patient receives a dual diagnosis, it means he or she has both a mental health disorder and a drug and/or alcohol addiction at the same time. The patient may have multiple mental health disorders or the patient may have multiple substance addictions.

What is Dual Diagnosis?

According to the National Institute on Mental Illness (NAMI), a dual diagnosis occurs when a person is identified as having both a mental health condition and a substance use disorder at the same time.​​​1 For instance, a person diagnosed with both an opiate use disorder and post-traumatic stress disorder would be identified as having a dual diagnosis or co-occurring disorder.

For example, an alcoholic with depression, anxiety and antisocial disorder suffers a dual diagnosis. The patient may only suffer from one of each type of disorder, for example a paranoid schizophrenic with a cocaine addiction also suffers a dual diagnosis. Because of the wide range of possibility within dual diagnosis, and because sometimes one disorder can worsen another, dual diagnosis should be taken very seriously. Here we discuss dual diagnosis itself, the scale of the problem, and some options for combatting dual diagnosis.

The Chicken or the Egg?

The qualifications for dual diagnosis are broad. Obviously struggling with depression and alcohol use disorder is a far cry in many ways from a schizophrenia diagnosis with a heroin addiction. However, both are dual diagnoses. Determining which disorder came first, and whether or not it caused  the other, can be a tricky situation. Either substance abuse or mental illness can develop first. Someone with a mental health disorder may abuse drugs and/or alcohol as a self-medication for the initial mental problem. Drug and/or alcohol abuse only makes the symptoms of mental health disorders worse.

Although in most dual diagnosis cases it may be impossible to accurately determine which of the diagnoses came first, one thing is for sure: long-term substance abuse causes mental health issues. It is common knowledge that drug and/or alcohol abuse can cause depression, anxiety, paranoia, and even memory loss. These are just a few non-physical examples.

History of Dual Diagnosis

Although services are available to treat a dual diagnosis, the behavioral health community has not always recognized individuals with a dual diagnosis. According to researchers writing for Psychiatric Services, during the early 1980s, mental health experts were aware of chronically mentally ill young adults who abused drugs and alcohol to manage the symptoms of mental illness, but dual diagnosis did not become a recognized condition until the later 1980s. In the early days, individuals with a dual diagnosis were described using terms such as “mentally ill chemical abusers”. 3

As of 1989, dual diagnosis was an officially recognized term in the behavioral health literature, and research was conducted to determine how to assess and provide treatment to dually diagnosed clients. Behavioral health experts grappled with finding ways to overcome treatment barriers and to connect services for mental health and substance abuse. 3

As the understanding of dual diagnosis has progressed since 1990, research has demonstrated that integrated treatment is the best option for treating dually diagnosed clients, as separate programs for mental health and substance abuse tend to be ineffective.

Addiction and Mental Illness

Alcoholics That Have a Mental Illness
37%
Those Addicted to Drugs That Have a Mental Illness
53%

Is Dual Diagnosis Common?

The National Alliance on Mental Illness reports 37% of alcoholics and 53% of those addicted to drugs have a mental disorder as well. This means well over a third of substance abusers qualify for a dual diagnosis. The groups at highest risk of developing a dual diagnosis are those of lower economic status, military veterans, and those predisposed to mental illness.

NAMI’s research has also reported that nearly 8 million Americans have a dual diagnosis; slightly over half of them are male.1  Additional statistics include:

Approximately 25 percent of people with an SMI meet diagnostic criteria for a substance use disorder.

25%

About 10 percent of those with a substance use disorder also have an SMI.

10%

Among people in treatment for prescription painkiller abuse, 43 percent have a mental illness or symptoms of one, with anxiety and depression being especially common among this group.2

43%

Common Co-Occurring Mental Health Conditions

The National Institute on Drug Abuse (NIDA) reports that the research shows that the following mental health conditions are likely to be dually diagnosed with a substance use disorder:

  • Generalized Anxiety Disorder 
  • Panic Disorder 
  • Post-Traumatic Stress Disorder (PTSD)
  • Depression 
  • Bipolar Disorder 
  • Attention-Deficit Hyperactivity Disorder 
  • Borderline Personality Disorder 
  • Antisocial Personality Disorder 
  • Schizophrenia 

Dual Diagnosis Risk Factors

Researchers have conducted studies concerning dual diagnosis to clarify the nature and causes of this condition and to overcome some of the common misconceptions surrounding it.

According to NIDA, there are shared risk factors, such as genetic contributions, brain abnormalities, and exposure to trauma and stressors that can lead to both addiction and mental illness. For example, the research shows that the brain chemical dopamine is involved in both addiction and certain mental illnesses, and it could therefore be a contributor to a dual diagnosis.​​​4

Age

Dual diagnosis can occur as early as the teenage years due to brain changes that take place during this time. The flood of hormones and body changes people more susceptible to both addiction and mental illness. Using drugs during adolescence can be especially hazardous, as it increases the risk for addiction and mental illness later in life.

Genetics

Genetic factors can make teenage drug use even more dangerous; for example, heavy marijuana use during adolescence is associated with psychotic symptoms later in life among a subgroup of people with a variation in a specific gene. Finally, just as early initiation of drug use can be associated with a dual diagnosis later in life, having a mental health condition as a teenager can also increase this risk.​​​4

Self-Medication or the Cause?

With multiple risk factors being associated with a dual diagnosis, it appears that the causes of this condition are complex. On the one hand, a person with a mental illness may use drugs and alcohol to attempt to alleviate their mental health symptoms, and then later develop an addiction with repeated use of drugs and alcohol. 

On the other hand, someone may begin using drugs and alcohol, which can over time harm the brain in a way that leads to the development of a mental health condition. Furthermore, because certain genes are associated with both addiction and mental illness, people with these genes could be at increased risk of a dual diagnosis.  

Misconceptions

Despite the fact that dual diagnosis is now recognized in the behavioral health field, there are still misconceptions surrounding people with comorbid substance use disorders and mental health diagnoses. 

Dual Diagnosis Can't Be Treated

One common misconception about a dual diagnosis is that it is impossible to treat individuals who are dually diagnosed. While substance abuse can exacerbate mental health symptoms and increase functional impairment in individuals with a dual diagnosis, treatment is certainly possible. In fact, NAMI reports that the belief that a mental health condition cannot be treated when someone suffers from addiction is simply archaic.​​​1

Dual Diagnosis Conditions Must Be Treated Separately

Similarly, some people might believe that a mental health condition and substance use disorder must be treated separately in individuals with a dual diagnosis. On the contrary, NAMI recommends that treatment should be integrated, with both conditions being treated at once and the treatment plan considering how the substance use disorder impacts the mental illness, and vice versa.

Its not Mental Health, it's Substance Abuse

Another misunderstanding associated with a dual diagnosis is that people who are dually diagnosed don’t actually have a mental illness and are simply experiencing symptoms associated with their substance abuse. This is an incorrect assumption. NAMI has stipulated that a dual diagnosis can occur regardless of whether the mental illness or the substance use disorder presents first. In addition, the Diagnostic and Statistical Manual of Mental Disorders- Fifth Edition, indicates that certain conditions, such as major depressive disorder, cannot be diagnosed if the symptoms can be explained by the effects of drugs or alcohol. That being said, it is possible that a person may first develop a substance use disorder and then be diagnosed with a mental illness, but the mental illness will involve more than the temporary symptoms that occur with drug or alcohol intoxication or withdrawal.

Treating a Dual Diagnosis

Individuals with a dual diagnosis may find a treatment program that suits their unique needs from the following types of providers:
  • Community mental health clinics
  • Inpatient rehabilitation centers
  • Hospitals offering psychiatric services
  • Non-profits
  • Private mental health agencies or counseling centers
  • Medication-Assisted Treatment (MAT) Clinics
  • Offices of Psychiatrists or Physicians Specializing in Behavioral Health
  • Religious Organizations
Professionals from these types of organizations can provide the services needed to treat co-occurring addiction and mental illness. Treatment services may involve:
  • Group Counseling
  • Individual Therapy
  • Educational Groups
  • Family Counseling
  • Detoxification Services
  • Case Management
  • Medication
  • Inpatient Treatment
NIDA reports that the following treatment modalities may be effective for treating a dual diagnosis:​​​4
  • Therapeutic Communities
  • Assertive Community Treatment
  • Exposure Therapy
  • Integrated Group Treatment
  • Dialectical Behavioral Therapy
  • Cognitive Behavioral Therapy

In order to properly treat a patient with dual diagnosis, each disorder must be accurately diagnosed and treated separately.

Specific services will vary based upon a client’s unique needs. Clients who are in a state of severe intoxication or withdrawal may need to complete an inpatient detoxification program before beginning ongoing services, such as counseling, case management, and pharmacotherapy. 

Other clients may be able to enter outpatient treatment, perhaps using medications to assist with detoxification. A behavioral health professional can complete an assessment to determine what level of care is necessary to treat a dual diagnosis.

If you feel like you may have a dual diagnosis, there is help available. Contact Arrow Passage Recovery today to learn about your options.


Resources

  1. https://www.nami.org/learn-more/mental-health-conditions/related-conditions/dual-diagnosis
  2. https://www.drugabuse.gov/publications/research-reports/common-comorbidities-substance-use-disorders/part-1-connection-between-substance-use-disorders-mental-illness
  3. https://ps.psychiatryonline.org/doi/full/10.1176/appi.ps.51.9.1126
  4. https://www.drugabuse.gov/sites/default/files/rrcomorbidity.pdf