Dual diagnosis is when a person with a substance abuse problem has a diagnosable underlying psychological or psychiatric issue that may be contributing to the substance abuse problem.
Alcohol abuse and drug addiction rarely occur in a vacuum. Most people who have addiction problems also have an underling psychiatric issue such as depression, anxiety, post-traumatic stress disorder, or ADHD. Some have even more serious psychiatric issues such as psychosis and schizophrenia. Often these people are self-medicating - meaning they are using alcohol or drugs to alleviate the symptoms of their underlying disorder.
The prevalence of individuals with co-occurring mental or psychiatric disorders and substance abuse has reached alarming levels in the last decade. In particular, substance abuse among schizophrenics has reached epidemic proportions. According to some estimates, persons with schizophrenia who develop a substance abuse disorder have prevalence rates of up to 65 percent. Antisocial personality disorder has also been associated with very high rates of substance use disorders and mental illness.
According to other sources, people with psychiatric disorders abuse alcohol and illicit substances twice as frequently as the general population. The problem is even greater in the early years of psychiatric disorders. According to various studies, the prevalence of substance abuse ranges from 35 to 65 percent during the first psychotic episode.
The National Alliance on Mental Illness cites statistics from the Journal of the American Medical Association (JAMA) that:
• About 50 percent of persons with severe mental disorders are affected by substance abuse
• 53 percent of substance abusers and 37 percent of alcohol abusers have at least one serious mental illness
• Of all people diagnosed as mentally ill, 29 percent abuse either alcohol or drugs
Considerable attention has been devoted to developing effective treatment for persons with co-occurring psychiatric disorders and substance abuse since the 2003 President’s New Freedom Commission Report on Mental Health and numerous publications from the Substance Abuse and Mental Health Services Administration (SAMHSA). Integrated treatment is the new standard for treating individuals with co-occurring psychiatric disorders and substance abuse.
Theories on Causes
Why do substance abuse and psychiatric disorders co-occur so frequently? While there is no single model that explains it, there are several theoretical models that may account for the increasing prevalence of the dual diagnoses:
• A common factor may account for both
• Primary psychiatric disorder causing secondary substance abuse
• Primary substance abuse leading to secondary psychiatric disorder
• A bidirectional problem, where each contributes to the other
While genetic research and family studies could explain such a common factor, no common gene has yet been identified. Common neurobiology – specifically dopamine-releasing neurons in the mesolimbic system – may be involved in mental illness. Self-medication could explain secondary substance abuse, as patients with mental disorders may believe the substance helps their symptoms, a specific substance may be used by specific psychiatric disorders, or severe symptomatic patients are more likely to abuse substances than those with only mild symptoms. Neuronal kindling from a substance-induced disorder may explain subsequent psychiatric disorder. Patients who develop a psychiatric disorder after substance abuse have a course of illness that’s like that of patients with a psychiatric disorder alone – but not with a substance abuse disorder. Bidirectional is consistent with disturbed teenagers associating with friends using drugs and alcohol, but research studies need to test this model rigorously.
What Is Integrated Treatment?
With so many different models, behavior intervention requires a multi-component program, and integrated treatment plan that generates a problem list and creates interventions to respond to each problem on the list. This necessitates a multi-disciplinary team to assess and deliver treatment to fit the patient’s tolerance and abilities.
Integrated treatment includes:
• Providing specific recommendations for screening patients with substance abuse disorders and psychiatric disorders
• Assessing the individual’s motivation to change
• Managing any medical conditions that co-occur with dual diagnoses patients (such as liver complications, lung cancer, cardiovascular disease, HIV and hepatitis B or C infections) and selecting appropriate medications to manage those medical conditions
• Psychosocial interventions for dual-diagnosed patients (dual recovery therapy, modified cognitive behavioral therapy, modified motivational enhancement therapy, management of substance abuse model and others, as appropriate).
• Pharmacotherapy for treating psychiatric disorder and co-occurring substance abuse, as well as depression, anxiety and sleep problems.
• Family therapy
• Vocational rehabilitation
Data from numerous studies have shown that the second-generation antipsychotics (aripiprazole, clozapine, olanzapine, quietiapine and risperidone) may be superior to conventional antidepressants in treating individuals with schizophrenia and co-occurring substance abuse. Substance abuse disorder is the most common co-morbid psychiatric disorder in patients with schizophrenia.
In some studies, patients who received treatment with the second-generation antipsychotics demonstrated a reduced craving and increased reduction in substance abuse. In addition, tricyclic antidepressants, when added to the antipsychotic maintenance therapy, showed success in reducing substance abuse and cravings. In a few studies, naltrexone and disulfiram, both anti-craving medications, led to a decrease in drug intake.
Medications such as these, or others, may be suggested for the treatment of psychiatric disorders and substance abuse. For co-occurring schizophrenia and substance abuse, however, administration of second-generation antipsychotics, coupled with anti-craving medications and tricyclic antidepressants may be recommended.
Why Integrated Treatment Is So Important
Individuals suffering from mental disorders and substance abuse have enormous problems to overcome. Existing mental health services are not well equipped to handle clients with both disorders (mental disorder and substance abuse). Often, only one disorder is identified and treated. The client may, therefore, bounce back and forth between treatments for each type of disorder, or they may be refused treatment for either. For clients with co-occurring disorders, this fragmented treatment approach and services that are uncoordinated causes a serious gap.
Integrated treatment helps not only the dual disorder client, but also their families, friends, and others. Evidence shows the effectiveness of integrated treatment. Individuals with a substance abuse disorder are more likely to receive treatment if they have a co-occurring mental disorder. According to research, when individuals with dual diagnosis overcome alcohol abuse, their response to treatment rapidly improves.
As more research and education are devoted to co-occurring disorders, better treatment and more understanding will hopefully be on the horizon.
Key Factors in Effective Integrated Treatment
There are several key factors that should be included in any integrated treatment program for clients with mental disorders and substance abuse in order to be successful:
• Treatment must be in stages – The first requirement is to establish trust between the client and the caregiver. Trust is important to motivate the individual to learn the skills to control their illnesses and to focus on goals. Keeping the client on track helps to prevent relapse. Individualized treatment can begin at any of these stages.
• Assertive outreach – Effective assertive outreach programs, using intensive case management, engage and retain clients at a high rate. Such outreach includes meeting at the client’s residence, developing a dependable relationship, and ensuring that the client is consistently monitored and counseled.
• Motivational interventions – Effective treatment also requires motivational interventions, including counseling, support and education. This helps clients who are deeply demoralized to better be able to recognize how important it is for them to develop goals and to self-manage their illnesses.
• Counseling – Fundamental to any treatment of dual diagnosis, counseling helps clients develop positive coping patterns, as well as learn cognitive and behavioral skills. Individual, group, family therapy or a combination of all of these is recommended.
• Social support – Persons with dual diagnosis need help to strengthen positive relationships and get rid of any that encourage negative or self-destructive behavior. The clients’ immediate environment has a direct effect on their moods and subsequent choices.
• Comprehensive – Treatment for the substance abuse and mental disorder client also must be comprehensive, taking into account various aspects of the client’s life: stress management, jobs, housing, activities and social networks. The treatment considers both disorders (substance abuse and mental illness) as intertwined, not separate. Solutions to both are provided at the same time.
• Cultural sensitivity – Integrated treatment programs can also benefit from being sensitive to the needs and competent in treating clients with services tailored to their particular cultural and racial needs.
Outlook For The Future
A research breakthrough in the study of schizophrenia, reported in July 2009 by the National Institute of Mental Health (NIMH), part of the National Institutes of Health, shows that schizophrenia and bipolar disorder share genetic roots. In part, they may share the same chromosomal neighborhoods. Three schizophrenia genetics research consortia, each partially funded by the NIMH, have pinpointed genetic variations that may collectively account for at least one-third of the genetic risk for schizophrenia.
Specifically, the researchers identified an area of Chromosome 6, which harbors genes involved in immunity and how/when genes are tuned off and on. This may help explain how environmental factors affect an individual’s risk for schizophrenia. Autoimmune involvement is also indicated. Evidence shows that offspring of mothers with influenza while pregnant are at higher risk for developing schizophrenia.
Variation on Chromosomes 11 and 18 could account for schizophrenic thinking and memory deficits. One of the three studies found an association between schizophrenia and a genetic variation on Chromosome 1, which has been implicated in multiple sclerosis, an autoimmune disorder.
The three studies showcase the importance of genes as well as the DNA sequences between them that control their expression. What does this portend for the future? In the case of schizophrenia and bipolar disorder, these new findings could eventually lead to biomarkers or multi-gene signatures for severe mental disorders. As researchers learn more about the genetic pathways, it may be possible to differentiate what each shares or is unique to each mental disorder. Thus, additional medications and treatment for specific psychiatric disorders can be developed and applied to the integrated treatment plan for co-occurring psychiatric disorders and substance abuse.
In the area of substance abuse, research continues unabated in developing medications that can help reduce cravings, minimize symptoms of withdrawal, aid in relapse prevention – even cure substance abuse. One point is certain – national attention is focused on alleviating this growing problem of co-occurring mental disorder and substance abuse. With the best scientific minds devoted to unraveling the secrets inherent in both psychiatric disorders and preventing, eliminating and curing substance abuse, expect even more breakthroughs in years to come.