A person with a dual diagnosis has both a psychiatric disorder and a substance abuse problem.
Dual diagnosis is not a rare phenomenon. Some studies indicate that as many as half of those with a drug or alcohol addiction also have some form of mental illness.
Any combination of mental illness (including depression, anxiety disorder, schizophrenia, etc.) and addiction (alcohol, drugs, gambling, etc.) can qualify an individual as a dual diagnosis patient, making the contingencies almost endless.
The severity of the Problem
Patients with psychiatric disorders compounded by complications from addiction run a greater risk of succumbing to suicide and violent tendencies. Hence, comorbid psychiatric and substance abuse disorders present with significant clinical challenges,
A negative impact on treatment adherence,
Unsatisfactory treatment response and outcome
Increased service utilization,
Increased morbidity and mortality.
Although efforts at improving treatment interventions are ongoing, the treatment need for this population remains largely unmet.
Moreover, tobacco smoking and nicotine dependence, which is a major comorbid substance use disorder among individuals with a psychiatric disorder, has received a dearth of attention from the mental health and substance use treatment communities.
Assessment and diagnosis of co-occurring illnesses
Owing to the co-occurring nature of these disorders, assessing and subsequently treating comorbid conditions can be difficult.
While one condition can contribute to and proliferate the other, in some cases, the substance abuse and the mental condition can occur separately from one another. Clinicians are tasked with the problematic and troublesome charge of determining which illness is primary to the other.
Substance-induced psychiatric illness
This type of diagnosis can be hard to pinpoint as it requires the individual to be abstinent for a certain length of time. Since many drugs can project symptoms that appear to mimic those of mental illnesses, abstinence for a period is key.
As defined by the DSM-IV, substance-induced disorders are "the direct physiological consequence of substance intoxication or withdrawal, medication use or toxin exposure.”
To further understand the underlying mental illness and substance problem, physicians must scrutinize the patient's history with drugs and/or mental illness, laboratory reports including blood tests and urinalysis along with performing a physical examination.
It's not necessary for all criteria of a substance-induced disorder to be met for it to be considered valid or legitimate. For instance, if a person with alcohol-induced depression exhibited signs of fatigue and overwhelming sadness but did not seem to have a low sense of self-worth, a diagnosis could still be made.
Substance use secondary to psychiatric illness
An individual may self-medicate with drugs and alcohol to alleviate the symptoms of a mental illness if the symptoms are difficult to manage and cause the patient significant distress. In this case, mental illness may be considered the primary disorder as opposed to substance abuse.
This scenario is more common in individuals who maybe be unable to afford the high costs of prescription drugs and other treatment. According to studies, approximately 20 percent of those suffering from post-traumatic stress disorder (PTSD) self-medicated by using drugs or alcohol as a coping mechanism to relieve the anxiety and panic associated with the illness.
Another, seemingly counter-intuitive, method of "self-medication" is when patients use drugs to enhance the symptoms of the mental illness. This might be evident in people with manic disorders using stimulants to "increase alertness or focus" for example.
Independent psychiatric illness and substance abuse
In this situation both mental illness and drug or alcohol use develop separately from one another. After abstinence from drugs for an adequate time period, a mental illness may be deemed independent of substance use if the symptoms still persist and the individual meets the criteria for the mental health condition.
Physicians may have a better chance of diagnosing a patient with one of the above types of substance-related comorbidities following a period of detoxification. A proper diagnosis is made more feasible by the fact that many substance use disorders have symptoms that will rapidly decline after use is discontinued. Following the cessation of substance abuse, the psychiatric disorder within the individual has to be determined.
One of the most widely used interview models for clinical assessment is the PRISM-IV, which stands for Psychiatric Research Interview for Substance and Mental Disorders. It is a structured set of questions that assist the interviewer in evaluating mental illness and its relation to substance abuse. Using this compilation of questions and measures for illness severity, an interviewer is able to better identify one or more of many mental disorders.
Over 10 major psychiatric health disorders are targeted in this questionnaire,
including personality disorders
Obsessive-compulsive disorder (OCD)
Such targeted assessments, in combination with detoxification, can drastically assist a physician in deciphering what psychiatric illnesses or illnesses remain comorbid with a substance abuse issue.
Although a definitive diagnosis is difficult to be achieved at all times, coming to the best diagnosis possible is the objective.
Treatment of Dual Diagnosis patients
Dual Diagnosis or Psychiatric disorders augmented by substance abuse problems place a double burden on both patient and clinician. Complete recovery takes time and there may be multiple challenges along the way.
Dual diagnosis patients present with a wide array of conditions that are likely to begin in adolescence and co-occur over the life span. A key concern among the numerous issues faced by clinicians, is the selection of effective treatment, as an evidence-based treatment for dual diagnosis patients is a developing field and the options to guide treatment selections are limited.
Treatment of these patients requires combined attention to both psychiatric and substance use disorders. Attending only one disorder typically results in treatment failures, poor response, non-compliance and treatment dropout, leading to worsened prognosis.
Furthermore, treatment generally requires a well-tailored, combined regimen of counseling and pharmacotherapy.
Among the non-pharmacologic interventions that may be used are
Motivational enhancement therapy
Integrative case management
The Living in Balance model for addiction treatment.
"ASV programs and services provide affordable, evidence-based drug and alcohol rehab options across Melbourne, Victoria. The core program is delivered in the persons home where they feel safe and their privacy is protected". - Jase Bowman - ASV CEO Drug Rehabilitation Center, Melbourne & Geelong 2020.