A dual diagnosis of mental illness and substance abuse is a very common and often underestimated problem. According to the National Alliance on Mental Illness(NAMI), as many as half of all patients with a mental health disorder also have a substance abuse problem. Mental illnesses that are mostly likely to occur with substance abuse include mood disorders, anxiety disorders, personality disordersandeating disorders. Many substances can also produce the symptoms of mental disorders, especially anxiety, depression, psychosis or loss of touch with reality, The dual diagnosis of mental illness and substance abuse leads to more problems for the patient, including physical illness, failure to respond to treatment and relapse than with either condition alone.
The precise reasons why mental disorders and substance abuse problems frequently occur together are not known, but many factors may be involved. Many patients with mental illnesses abuse substances in an attempt to self-medicate. Social factors (e.g., stress, trauma) that impact mental health patients may predispose them to substance abuse. Further, substance abuse is frequently a risk factor for mental illness in itself.
Patients with both mental illness and substance abuse problems are frequently under-diagnosed. In many cases, only one of the conditions is identified. When the full dual-diagnosis is recognized, treatment may be difficult to receive. Many services available to patients with either mental illness or substance abuse problems are not ideally suited to handle both conditions. Because of this, patients are frequently required to move between separate mental health services and substance abuse programs. In many cases, these patients are refused treatment at one facility due to the other condition. Effective programs for the treatment of the combination of mental illness and substance abuse address both conditions together. Treatment is viewed as long-term. Instead of punishing patients for slips or mistakes, effective therapists acknowledge accomplishments. Comprehensive treatment including job and housing assistance may be needed. Since programs may not be available in all communities, families of patients with mental illness and substance abuse problems may have to actively advocate for effective programs in their area.
About substance abuse & mental illness
Substance abuse and another mental illness are often diagnosed together. Typically referred to as a dual diagnosis, the combination of these conditions requires unique care that addresses both issues simultaneously. This problem has been overlooked extensively. It has only recently been recognized. However, in many cases, apparent symptoms of another mental illness actually result from the substance abuse.
According to the National Alliance on Mental Illness (NAMI), as many as 50 percent of patients with a mental health disorder also have a substance abuse problem. Alcohol is the most commonly abused substance. Further, approximately 37 percent of patients who abuse alcohol and 53 percent of drug abusers have a serious mental illness. The stigma placed on patients with both of these conditions tends to be greater than the stigma placed on patients with a single illness.
It should also be noted that it can be very difficult to diagnose another mental illness in a substance abuser who is actively using substances. As a result, patients are often misdiagnosed with other mental disorders and do not receive appropriate treatment for their substance abuse. In addition, many of these patients prefer being diagnosed with a mental disorder rather than a substance abuse problem since they may be eligible to receive financial benefits (e.g., disability payments, worker’s compensation, insurance coverage) for their treatment that they would not receive if they were diagnosed with substance abuse.
Certain mental illnesses are more likely than others to occur with substance abuse, including:
- Mood disorders, especially bipolar disorder
- Personality disorders (e.g., antisocial personality disorder)
- Anxiety disorders (e.g., generalized anxiety disorder[GAD], panic disorder, obsessive compulsive disorder[OCD], post-traumatic stress disorder[PTSD], phobias)
- Eating disorders (e.g., bulimia nervosa, anorexia nervosa)
In young people, conduct disorder and substance abuse frequently occur together.
The dual diagnosis of mental illness and substance abuse leads to more social problems than either condition alone. About 72 percent of incarcerated patients with mental illness also have a substance abuse problem, according to NAMI.
Because substance abuse is not usually a permissible reason in the U.S. legal system for breaking the law, but other mental disorders sometimes are, people facing criminal charges may try to attribute their substance abuse or illegal activity to another mental disorder to obtain a lesser punishment.
About 50 percent of the adult homeless population with mental illness has problems with substance abuse as well.
Other problems that are typically more common in patients who have been dually diagnosed include:
- Disruptive behavior, violence and suicide attempts
- Failure to take medications as directed
- Failure to respond to treatment and relapse following treatment
- Development of physical illness and worsening of psychiatric symptoms
- Poor social and overall functioning
Risk factors for substance abuse/mental illness
The precise reasons why mental health disorders and substance abuse problems frequently occur together are not completely known, but many factors may be involved. Some professionals speculate that there may be a genetic factor that increases the risk of both mental illness and substance abuse. For example, both bipolar disorder and alcoholism may have a genetic component. The combination of mental illness and substance abuse is generally more common in women and among patients between the ages of 18 and 44 years. There is the possibility that the frequency may also reflect the misdiagnosis of symptoms of substance abuse as being those of another mental disorder.
Mental health conditions may be risk factors for substance abuse. Patients with mental illnesses may self-medicate in an attempt to treat the symptoms of their illness. This may occur both before and after diagnosis, regardless of whether the mental illness is being treated. Many substances (e.g., sedatives) can reduce a patient’s level of anxiety for at least a short while. Certain drugs (e.g., cocaine, amphetamines) may help to restrict food intake, effects that may be desirable for people with eating disorders. These patients may also use other substances (e.g., alcohol, other sedatives) to help counter the feelings of guilt or shame that may accompany the condition. When mental illness develops before a substance abuse problem, it may precede substance abuse by five to 10 years.
Problems adhering to certain social standards (e.g., behavior issues, keeping a steady job) occur in patients with mental illnesses. As a result, patients may end up living in areas with prevalent drug cultures. They may also find more acceptance of their behavior in social groups that revolve around drug use. This is known as “downward drift.”
Both short- and long-term substance abuse (e.g., stimulants, hallucinogens) may produce symptoms similar to many mental illnesses. Many symptoms of substance intoxication are often associated with what appear to be symptoms of other mental disorders (e.g., anxiety, paranoia, delusions). In some cases, these symptoms persist long after use of the substance has been halted. For example, the hallucinogen LSD may cause “flashbacks” years after the patient last abused the drug. The symptoms of these mental conditions are typically described as “substance-induced”. Certain consequences of lifestyles associated with substance abuse (e.g., failure at school or work, relationship problems, criminal involvement) may also lead to the development of mental health problems (e.g., depression).Factors that increase the risk of either mental illness or substance abuse are often the same. For example, children who are physically or sexually abused may be at increased risk for both mental illness and substance abuse problems in adulthood. The risk of developing a mental illness or substance abuse problem may also be increased for adults who have experienced abuse or assault.
Recognizing substance abuse & mental illness
The combination of mental illness and substance abuse can be difficult to diagnose. Many of the signs and symptoms of substance abuse, including rebellious or argumentative behavior, also commonly occur in patients with mental health disorders who do not abuse substances. In addition, many signs and symptoms of substance abuse (e.g., paranoia) may be similar to those of certain mental illnesses.
It can be difficult and time-consuming for mental health professionals to determine which symptoms are due to substance abuse, which occur because of mental illness, and which are the result of the interaction between the two. Signs that may indicate that a patient with a mental disorder is abusing a substance may include:
- Sudden money problems
- Sudden change in friends
- Disappearance of valuables
- Appearance of drug-related items
- Extended periods in private, such as in the bathroom
- Dilated or pinpoint pupils
- Needle marks on the body
Treatment for substance abuse & mental illness
It is important to recognize the risks and prevalence of a dual diagnosis with mental illness and substance abuse. Problems with substance abuse complicate nearly all areas of mental health care. Mental illness likewise complicates substance abuse treatment.
Those who abuse substances tend to have more relapses of their mental illness and require more hospitalizations. In addition, such substances can interfere with the effects of medications commonly used to help control symptoms of mental illnesses.
Because both mental illness and substance abuse may be accompanied by denial (refusal to admit truth or reality), some patients refuse to seek treatment. Others seek treatment only after friends, family members, coworkers or others have urged them to do so. Some patients enter treatment only after it is ordered by a judge or other means.
There are often problems with the medical treatment of dually diagnosed patients. Treatment therapies for one condition are not designed for the other. Because of this, treatment for dual diagnosis of mental illness and substance abuse often requires a patient to move back and forth between facilities. However, patients with mental illness may not be welcomed in residential and rehabilitation programs for substance abuse and patients with substance abuse problems may not be welcomed in therapies for mental illness. In addition, a person with a mental illness and a substance addiction requires treatment from professionals in both fields.
Because treatment for non-substance abuse mental illnesses are more likely to be covered by insurance plans than substance abuse treatment, it appears that the substance abuse issues may be downplayed by both patients and health care professionals when treatment is sought.
According to the National Alliance on Mental Illness (NAMI), traditional substance abuse programs are not typically recommended for mentally ill patients. NAMI emphasizes that the standard techniques of many substance abuse programs frequently result in high degrees of stress that can exacerbate psychiatric symptoms or cause relapse of a mental disorder. In addition, the confrontive and coercive techniques associated with these programs, as well as the common tendency to discourage the use of all medications, can be detrimental to the treatment of these patients. Substance abusers who are placed in treatment programs that do not focus on their abuse usually receive little benefit from them.
Effective programs for the treatment of the combination of mental illness and substance abuse must address both conditions together in an integrated fashion. This treatment needs to take a gradual approach. It must be viewed as long-term. In some cases, it may take years to treat the conditions and develop abstinence from substances of abuse and remission of mental illness.
Both conditions must be recognized as illnesses, not character flaws. Instead of punishing patients for slips or mistakes, effective therapists acknowledge accomplishments. Social networks that can reinforce positive behavior are important. However, in substance abuse programs, treatment often begins with patients taking responsibility for their behavior. This is in contrast to programs for the treatment of other mental illnesses.
Since mental illness and substance abuse drastically affect all aspects of the patient’s life, assistance will likely be comprehensive. It may need to include job and housing assistance, family counseling and money and relationship management.Proper facilities and programs for the treatment of dually diagnosed patients may not be available in all communities. Families of patients with mental illness and substance abuse problems may have to actively advocate for these programs in their area.
Questions for your doctor
Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions about substance abuse and mental illness:
- What makes you think that I may have both a mental illness and a substance abuse problem?
- How much experience do you have in treating people with both of my conditions?
- What symptoms can I expect from my mental illness?
- What symptoms can I expect from my substance abuse problem?
- Can you suggest any effective programs in this community to treat both of my conditions together?
- Given my conditions, how long is treatment likely to last?
- Am I likely to experience substance withdrawal during treatment? How can I prevent or lessen the symptoms of withdrawal?
- What medications, if any, will be used in my treatment program?
- What forms of counseling may I expect to attend?
- Can you suggest any support groups for people with my conditions?
- Once both of my conditions are treated, how likely am I to relapse?
- If a relapse occurs in one of my conditions, how likely is a relapse of the other?
- How do you know that my symptoms are not just due to my substance abuse, but also indicate the presence of another mental disorder?