Factsheet: Dual Diagnosis
The term 'dual diagnosis' or 'dual disorders' has in recent years come to be used in the alcohol, drug and mental health fields to describe a particular group of people who have both a diagnosed mental health problem together with problems of alcohol and/or drug use.
Usually this focus has more often referred to a diagnosis of severe mental illness, for example psychotic disorders such as schizophrenia rather than mood disorders such as anxiety and depression, and the combination of alcohol or drug problems.
There is however a wide range of mental health problems, including mood disorders, which in combination with alcohol and drug use can result in many varied problems, which now more commonly is referred to by the name "co-morbidity" (the presentation of two or more problems at the same time in the same person).
This more accurately reflects the tremendous variety of problems people can experience, which in addition to medical problems can also include a wide variety of social and on occasions, legal problems.
The terms 'dual diagnosis', 'dual disorders' and 'co-morbidity' are often used interchangeably.
The focus of this fact sheet will be on severe mental health problems and substance abuse.
Extent of co-morbidity
There are different views on how many people have co-morbidity and are likely to present to treatment agencies. Most studies that originate from North America report very high rates and suggest that people with mental illness have double the possibility of having an alcohol or drug problem compared to the general population.
In some of these North American studies it is reported that people with a severe mental illness have a rate of alcohol or drug use as high as 50%.
It is further reported that people with an alcohol problem have a lifetime rate of experiencing any mental health problem of 37% and, with a drug problem, of 53%.
In Britain reports have indicated an average 30% of people with serious mental illness also misusing alcohol or drugs.
From the research findings to date, it can be generally assumed that a significant umber of people with mental illness will also experience problems with alcohol or drug use.
In addition, many people with alcohol or drug problems are likely to have other forms of mental illness and both these groups are likely to present to alcohol and drug agencies.
The relationship between alcohol, drugs and mental health
Given the variety of mental health problems that can interact with alcohol and drug use and vice-versa it is obvious that no single explanation exists for the development of these relationships.
Mental illness with developing substance misuse
People mainly present with a mental illness, but because of the symptoms of the illness or their attempts to cope with the effects of medication this can lead to the use of substances.
This self-medication theory has been very popular in explaining the increase use of substances in the mentally ill.
However, rather than use specific substances for the relief of particular symptoms, it is considered that people will use any substance for general relief of distress.
The substances used by the mentally ill for the relief of tension would thus be determined more by availability and culture. Indeed some studies suggest that people with severe mental illness are attracted to the use of substances because of social and environmental factors, for example social acceptance.
People with mental health problems such as anxiety and depression are more likely to be influenced to use
substances for the relief of symptoms.
Substance use with developing mental illness
This suggests mental illness can be a consequence of people's alcohol/ drug use. This would include transient mental illness due to either intoxication or withdrawal from substances.
Alcohol withdrawal can display hallucinations, paranoia, anxiety, depression and delirium. Heroin withdrawal can often result in depression, apathy and irritability.
Withdrawal from stimulants can cause depression and suicidal intentions.
There are some studies that suggest that intoxication or short-term use of alcohol or drugs can cause lasting and enduring mental illness in some people vulnerable to mental illness.
A first presentation of mental illness can follow the use of a variety of substances. It is known that amphetamines and cocaine can cause psychotic symptoms like paranoia, if a large dose of the drug is taken on a single occasion.
Cannabis, LSD and ecstasy are thought to precipitate mental illness in some vulnerable people and can also greatly increase the symptoms of an existent mental health problem.
It is also relevant to note that long-term permanent mental illness such as Korsakoff's syndrome (dementia type syndrome linked to heavy drinking and low levels of thiamine B) and alcoholic dementia are both due to chronic alcohol use.
The long-term use of other substances can also result in enduring mental illness such as depression and anxiety.
There is a complex interaction between both problem areas where deteriorating mental illness can increase substance abuse and continued substance misuse can exacerbate mental illness.
If alcohol or drugs are taken in combination with prescribed medication for the treatment of mental health problems, this can result in the prescribed medication being ineffective or having an increased impotency.
Substance abuse in people with severe mental illness is associated with a number of severe problems, some of which are listed below but this list is by no means exhaustive:
* Increased crimes of violence, with a recent report indicating that substance abuse by the mentally ill was a major factor in a number of homicides.
* Increased rates of attempted suicide, especially with people having alcohol problems and depression.
* Poor medication compliance, which results in a worsening of mental illness.
* Poor response to substance misuse treatment.
* Homelessness and having problems such as neighbour disputes.
* High relapse rate in both conditions, resulting in longer periods of hospitalisation.
Needless to say, it can be difficult recognising co-morbidity as often the signs, symptoms and presenting problems can be mis-attributed to either substance misuse or mental illness. There can be difficulty in establishing which comes first.
Symptoms of mental illness such as hallucinations may present in alcohol abuse as part of a withdrawal state and this can be difficult to differentiate from hallucinations as expressed in a psychotic illness. Similarly, depression as a consequence of excessive alcohol use may be indistinguishable from mental
The important point however is to address the person and their needs rather than attempting to dissect problem areas.
There is however a number of indicators which, research suggests, are particularly pertinent to the person with co-morbidity:
* History of violence
* History of attempted suicide
* High contact with criminal justice system
* High relapse rate from psychiatric and substance abuse treatment
* Poor response to substance abuse treatment
* High rate of homelessness
In assessing a person considered to have symptoms of both mental illness and substance misuse, the following points are important to note:
* Limited insight into the nature of their problems. People with mental illness may lack understanding of the effects of substances and may attribute them to mental illness or vice-versa
* Memory difficulties can be common and present in both mental illness and substance abuse
* If presenting in an acute mental state a client's concentration and understanding of their condition will be poor. Remember, people in acute mental distress can find interviews difficult to cope with.
* People can have poor motivation as a consequence of mental illness or as a side effect of medication
* It is necessary to take a very careful history of recent alcohol/drug use to differentiate between symptoms of substance misuse and mental illness.
* Corroborative information is very important from relatives or other agencies. Do not rely on a single interview in making an assessment.
Implications for services/treatment
People with co-morbidity problems can present to agencies with a wide range of needs. The effect of substances on mental health can exacerbate acute mental health symptoms like paranoia, hallucinations, poor concentration.
This can be overwhelming to workers and, with the possible poor treatment contact and outcomes, this group can sometimes be viewed as 'no hopers' or just too difficult.
Needless to say, these are factors that mitigate against successful treatment. However a number of studies have indicated some core principles that are effective in working with this group of clients.
A number of points are important to remember in the management of co-morbidity:
* A method of intervention that reflects the cycle of change model, namely a staged approach, is considered effective with this client group.
* Initially engaging the client involves sustaining contact by not making too many demands. It may require not insisting on an immediate goal of abstinence although that would remain the ultimate goal. Offering help with practical needs such as housing, finances and benefits can lead to maintenance of close contact.
* Very close contact and inter-agency working is vital when working with this group. They can easily lose contact with services and ideally an integrated service that addresses both mental illness and substance abuse issues is considered the most promising approach.
All areas of this complex problem need to be addressed.
* There is no quick fix solution with this client group and the contact with this group is likely to be over a long period rather than a few months. It is therefore necessary to have a long-term view of treatment.
* A non-confrontational and empathic approach with this client group is considered the best intervention. Motivational Interviewing type techniques have shown promise in some studies.
However these methods require being adapted to meet the needs of clients that have many symptoms of
mental health problems such as poor concentration and short-term memory.
* Both mental illness and substance abuse are known for high relapse rates. Remember, the co-morbidity client group are especially prone to high relapse rates, yet various research studies indicate that good contact with services results in a good outcome. Relapse prevention strategies applied to substance misuse is also very relevant for this client group.
* Allan C.A. (1995) Alcohol Problems and Anxiety Disorders - A Critical Review, Alcohol and Alcoholism, 30, p145-151
* Institute for the Study of Drug Dependence (1999) Drug Abuse Briefing, Seventh Edition
* MIND (1998) Understanding Dual Diagnosis, MIND Publications
* Osher F and Kofoed L (1989) Treatment of Patients with Psychiatric and Psychoactive Substance Abuse Disorders, Hospital and Community Psychiatry, 40, p 1025-1030
* Rorstad P. and Checinski K. (1996) Dual Diagnosis: Facing the Challenge, Wynne Howard Books
* Sokya M. (2000) Alcohol and Schizophrenia, Addictions 95.11, p1613-1618
* Ward M. and Applin C. (1998) The Unlearned Lesson - The Role of Alcohol and Drug Misuse in Homicides Perpetrated by People with Mental Health Problems, London, Wynne Howard Books
Institute for the Study of Drug Dependence www.isdd.co.uk
MIND (National Association for Mental Health) www.mind.org.uk
Scottish Association for Mental Health (SAMH) www.samh.org.uk
Alcohol Focus Scotland, 166 Buchanan Street Glasgow G1 2LW
Tel: 0141 572 6700
This handout is jointly owned by Alcohol Focus Scotland and the authors. Many thanks to Mary Girvan and Archie Fulton.