Dual Diagnosis is a combination of any mental disorder and addiction. For example, a mood disorder such as depression and a problem with substance abuse, like drug or alcohol abuse.
A person with a dual diagnosis has two separate illnesses and each needs its own treatment plan. Dual Diagnosis is a relatively new concept, which emerged just over 20 years ago. It is sometimes not well understood by the medical establishment, even though as many as half of those with drug or alcohol addiction also have some form of mental illness. Often dual problems, if not treated in an integrated manner can lead to a high incidence of relapse. For example, if the addiction is treated, but not the underlying psychiatric disorder at the same time, it can complicate the process and a relapse may occur. Or, if the two problems are treated by different doctors, they may not have comprehensive picture of the person’s health.
A Dual Diagnosis situation might develop in response to some kind of genetic issue. In other words people often use drugs to deal with the symptoms of their illness, they “self-medicate”. For example, someone with anxiety may drink to calm themselves. The situation may also develop when damage caused by addiction comes into contact with a genetic abnormality that could lead to mental illness. The National Institute on Drug Abuse in the USA, suggests that people with a genetic vulnerability to schizophrenia might see that disorder surface when they use marijuana, it might otherwise never appear if they didn’t use drugs.
Signs and symptoms can vary from case to case, but there are some general warning signs that something is not right with you or with a loved one.
Mental health professsionals recommend looking for the following signs that a disorder may be present:
Not being able to remember a time, before the abuse of drugs and alcohol, when you were satisfied with life. Drugs make you feel normal.
The use of drugs or alcohol to overcome anxiety or stress, or the use of drugs and alcohol to counter the side effects of medications for mental illness.
A traumatic experience in your past. These can trigger both substance abuse and mental illness.
A family history of mental illness or addiction. Both of these disorders can have a strong genetic component.
Struggling to keep down a job or to keep up with studies
Trying to quit a drug or alcohol makes you angry, violent or suicidal.
Experiencing withdrawal symptoms after trying to quit a harmful substance or cutting down the dose.
The only way to know that Dual Diagnosis exists is to be evaluated by a mental health professional with specialised training in Dual Diagnosis. Getting help is the first step in the recovery process.
According to a report in the Journal of the American Medical Association half of people with severe mental health disorders struggle with substance abuse too. Genetic markers, exposure to traumatic events and exposure to medications which cause addiction can all add to the risk of dual diagnosis.
Having a dual diagnosis can have a knock-on effect often creating other problems such as conflict in relationships, financial problems, inability to hold down a job, risky behaviour, isolation, legal problems or an unstable home environment.
Diagnosing a comorbid situation is often difficult as the symptoms of the one can contribute to the cause of the other. The simultaneous nature of the illness and the fact that each illness is complex can make a diagnosis complicated.
Determining which illness came first, can also be problematic. Often a period of detoxification can make it easier to diagnose.
Comorbidities are often difficult to diagnose because the symptoms of one can often contribute to or cause the other. For example, those with depression often may experience more intense side effects as a result of alcohol use. Some drugs like psychedelics may instigate certain symptoms of psychosis or schizophrenia in individuals. So, the nature of these complex and simultaneous illnesses can complicate an accurate diagnosis.
What can help with an accurate diagnosis is determining which illness came first. That can be hard to do sometimes as it requires a person to abstain from drugs or alcohol for a period of time. Once detoxification is complete, clinicians can then look at the symptoms that remain and address them.
Assessing and treating a comorbid condition can be especially difficult due to the co-occurring nature of the disorders. One can often proliferate the other or, in some cases, both the substance abuse and the mental illness can occur separately from one another. Determining which illness is primary to the other can be problematic and troublesome. After a period of detoxification, physicians may have a better chance of diagnosing a patient with one of the above types of substance-related comorbidities. Many substance use disorders have symptoms that will rapidly decline after use discontinues, making a proper diagnosis more feasible.
So what then? After substance use stops, how to physicians know how to diagnose a mental health disorder? For that, a variety of illness-specific models have been established to help doctors, psychiatrists, and physicians better determine what disorders are present within an individual.
Perhaps one of the most widely used interview models for clinical assessment is the PRISM-IV. The PRISM-IV stands for Psychiatric Research Interview for Substance and Mental Disorders, and is a structured set of questions that help the interviewer assess mental illness and its relation to substance abuse. With a structured set of interview questions and measures for illness severity, an interviewer can better identify one or more of many mental illnesses. Over 10 major mental health disorders are targeted in this questionnaire including personality disorders, PTSD, obsessive-compulsive disorder (OCD), panic disorder, social phobias, specific phobias, major depression, manic depression and schizophrenia. Typically, questions relating to substance use precede those relating to mental illness so as to best serve as a benchmark for possible mental health disorders, and to understand how the two relate in an individual.
Other assessment models include the Young Mania Rating Scale (YMRS) for manic disorders and bipolar disorder, the Inventory of Depressive Symptoms (IDS), the Montgomery Asberg Depression Rating Scale (MADRS), the Structured Clinical Interview for DSM-IV for Axis II personality disorders (SCID-II), and the Angst Hypomania Check List (AHCL) that assesses hyperactivity and hypomania (useful for bipolar disorder evaluation).
These targeted assessments, along with detoxification, can dramatically help a physician determine what mental illness or illnesses remain comorbid with a substance use problem. While a 100 percent accurate diagnosis may be difficult all the time, achieving the best diagnosis possible is the goal.
The best treatment for dual diagnosis is integrated intervention, when a person receives care for both their diagnosed mental illness and substance abuse. The idea that “I cannot treat your depression because you are also drinking” is outdated—current thinking requires both issues be addressed.
You and your treatment provider should understand the ways each condition affects the other and how your treatment can be most effective. Treatment planning will not be the same for everyone, but here are the common methods used as part of the treatment plan:
Detoxification. The first major hurdle that people with dual diagnosis will have to pass is detoxification. Inpatient detoxification is generally more effective than outpatient for initial sobriety and safety. During inpatient detoxification, trained medical staff monitor a person 24/7 for up to seven days. The staff may administer tapering amounts of the substance or its medical alternative to wean a person off and lessen the effects of withdrawal.
Inpatient Rehabilitation. A person experiencing a mental illness and dangerous/dependent patterns of substance use may benefit from an inpatient rehabilitation center where they can receive medical and mental health care 24/7. These treatment centers provide therapy, support, medication and health services to treat the substance use disorder and its underlying causes.
Supportive Housing, like group homes or sober houses, are residential treatment centers that may help people who are newly sober or trying to avoid relapse. These centers provide some support and independence. Sober homes have been criticized for offering varying levels of quality care because licensed professionals do not typically run them. Do your research when selecting a treatment setting.
Psychotherapy is usually a large part of an effective dual diagnosis treatment plan. In particular, cognitive behavioral therapy (CBT) helps people with dual diagnosis learn how to cope and change ineffective patterns of thinking, which may increase the risk of substance use.
Medications are useful for treating mental illnesses. Certain medications can also help people experiencing substance use disorders ease withdrawal symptoms during the detoxification process and promote recovery.
Self-Help and Support Groups. Dealing with a dual diagnosis can feel challenging and isolating. Support groups allow members to share frustrations, celebrate successes, find referrals for specialists, find the best community resources and swap recovery tips. They also provide a space for forming healthy friendships filled with encouragement to stay clean. Here are some groups NAMI likes:
- Double Trouble in Recovery is a 12-step fellowship for people managing both a mental illness and substance abuse.
- Alcoholics Anonymous and Narcotics Anonymous are 12-step groups for people recovering from alcohol or drug addiction. Be sure to find a group that understands the role of mental health treatment in recovery.
- Smart Recovery is a sobriety support group for people with a variety of addictions that is not based in faith.
Searching for the right mental health professional or program look for therapists that have specialised training in Dual Diagnosis and well as the ability to be able to provide services for both illnesses in a single centre or place. It is also important to have an individualised treatment with both one-on-one and group counselling sessions.
The best treatment for co-occurring disorders is an integrated approach, where both the substance abuse problem and the mental disorder are treated simultaneously.
Recovery depends on treating both the addiction and the mental health problem. Whether your mental health or substance abuse problem came first, recovery depends on treating both disorders. There is hope. Recovering from co-occurring disorders takes time, commitment and courage. It may take months or even years but people with substance abuse and mental health problems can and do get better. Combined treatment is best. Your best chance of recovery is through integrated treatment for both the substance abuse problem and the mental health problem. This means getting combined mental health and addiction treatment from the same treatment provider or team.
Relapses are part of the recovery process. Don’t get too discouraged if you relapse. Slips and setbacks happen, but, with hard work, most people can recover from their relapses and move on with recovery. Peer support can help. You may benefit from joining a self-help support group like Alcoholics Anonymous or Narcotics Anonymous. They give you a chance to lean on others who know what you’re going through and learn from their experiences.
Why is it important to treat both the mood disorder and the alcohol/drug use? When neither illness is treated, one illness can make the other worse. When only one illness is treated, treatment is less likely to be effective. When both illnesses are treated, the chances for a full and lasting recovery are greatly improved, and it is easier to return to a full and productive life. Why is it important to stay clean and sober when getting treatment? Mixing alcohol or drugs with medication can have serious and dangerous effects. Many medications, including over-the-counter medications, interact with alcohol or drugs in harmful ways. It is also unlikely that you will benefit from talk therapy if you are under the influence.
You may need to go to more than one doctor and attend more than one support group. All of your treatment providers should be aware that you have a dual diagnosis. Treatment for your mood disorder may include counselling or psychotherapy, medication and DBSA support groups where you can share your experience living with depression or bipolar disorder. Treatment for your alcohol and/or drug use may include some type of recovery group. If you are drinking or using every day, you and your doctor may decide that you need to check into a hospital or treatment center so you can be treated for physical withdrawal symptoms. After treating the withdrawal, you will need to treat the addiction. This may include a residential or outpatient alcohol/drug treatment center, a 12-step group or another group that focuses on living without substances. In these groups, you will learn how others stopped drinking or using, how to cope with cravings and urges to drink or use, and how to live comfortably without the use of alcohol or drugs.
Talk therapy (psychotherapy) can help you learn to cope with symptoms of depression and/or mania, and change the patterns of thinking that may be making them worse. Therapy can also help you look at your drinking/using habits and work on staying clean and sober. You may get therapy from a psychiatrist, a psychologist, a social worker, a therapist, a counsellor, a nurse or another health professional.
Medication to help with symptoms of depression and mania may be prescribed by a physician or psychiatrist. You and your doctor will work together to find the right medication(s) for you. Different people have different responses to medication, and many people need to try several before they find the best one(s). Though it may not be easy, be patient when starting new medications and wait for them to work. Don’t lose hope. Some can take four to eight weeks before you feel their full effects.
Keep your own records of treatment—how you feel each day, what medications and dosages you take and how they affect you, and any alcohol or drug use.
Medications that affect the brain may also affect other systems of the body, and cause side effects such as dry mouth, constipation, sleepiness, blurred vision, weight gain, weight loss, dizziness or sexual problems. You might feel the side effects before you feel the helpful effects of your medication. Many times, these side effects will go away in a few weeks. If they don’t go away immediately, don’t be discouraged. There are ways to reduce or get rid of them.
Change the time you take your medication to help with sleepiness or sleeplessness.
Take it with food to help with nausea.
Your doctor may change your dosage or prescribe another medication.
Tell your doctor about any side effects you are having. You and your doctor should work together to make decisions about medication.
Never stop taking your medication or change your dosage without talking to your doctor first.
Absolutely. Taking medication as prescribed by a doctor is not the same as using alcohol or street drugs to feel better. Medications affect the same brain chemicals that alcohol and street drugs do. But medication balances the levels of these chemicals instead of making them rise and fall. Medications help keep your brain chemicals, and your moods, more predictable and stable. They can help you to be yourself.
Medications do not impair your judgment. They do not give you a false sense of courage. They do not cause you to crave another pill soon after you’ve taken the first. They are not mixed or “cut” with other dangerous chemicals. They have been tested and found to be safe and effective.
The goal of medication treatment is to help you become stable and healthy. Medications manage your symptoms, rather than masking them. They help you take control and work toward positive changes in your life. Your doctor also monitors your medications, and if you have any problems, s/he can help you decide what changes need to be made. Some drug and alcohol recovery groups may believe that you can’t be clean and sober if you take medications prescribed by a doctor. This belief is just plain wrong. Medication for your mood disorder is no different than medication for another illness such as asthma, high blood pressure or diabetes. If your recovery group challenges your use of medication, it is probably best for you to become part of another group that understands the concept of dual diagnosis. The good news is there are many different recovery groups to choose from. Don’t give up hope. If you keep looking, you will find other people who are dually diagnosed and receive treatment for both illnesses.