More than 50 percent of those with mental illness also have a substance abuse problem. Among the severely mentally ill, the incidence may be as high as 85 percent. Often, the use of alcohol or drugs goes undetected by families and is misdiagnosed by treating professionals. Partly, this is due to similarities in symptoms for both conditions. There may also be "dual denial" -- of both the psychiatric disorder and the addiction.

Dual Diagnosis

The coexistence of mental illness and substance abuse is referred to as dual diagnosis. This condition can occur when alcohol and/or drugs are used to self-medicate symptoms of psychiatric disorders or as a coping mechanism to alleviate symptoms, such as anxiety. Over time, an entrenched addiction can develop. In some instances, individuals may develop depression, agitation and other psychiatric symptoms as their addiction progresses. Many researchers believe that substance abuse may trigger an underlying, previously undiagnosed psychiatric disorder.

The combination of psychiatric illness and substance abuse compounds the person's distress and disability. Using alcohol or other drugs can seriously impair judgment, making those with dual disorders at higher risk for suicide. Special challenges exist for treating those with dual diagnosis.

Unique treatment issues

Coexisting disorders can be difficult to treat due to the complex relationship between addiction and psychiatric illness. Symptoms for both conditions may be similar. For example, a person with an alcohol addiction can develop symptoms seen in psychiatric disorders (depression, anxiety, mood swings, erratic behavior, etc.).

The treatment of psychiatric disorders becomes more complicated when a substance abuse problem is also present. Failure to recognize such a problem can adversely affect treatment. For instance, even minimal use of alcohol and/or drugs can result in recurrent symptoms for one with depression. Conversely, an undiagnosed psychiatric disorder can precipitate a relapse from sobriety. Successful treatment requires that both conditions be treated simultaneously and aggressively.

Identifying substance abuse

Evaluating substance abuse in those with mental illness requires different criteria as compared to the general population. Typically, a person with dual diagnosis may not be drinking or using drugs regularly; however, any use of alcohol or drugs can be detrimental to psychiatric well-being.

In assessing an addiction, the consequences of using drugs or alcohol can be more significant. For example, a person may only drink once or twice a year but each of these occasions precipitated a suicide attempt.

The three levels of substance abuse are --

• Use: any intake of alcohol and/or drugs; experimentation.
• Abuse: continuing to use alcohol and/or drugs despite negative consequences.
• Dependence: substance abuse with greater tolerance.

For example, an adolescent male begins experimenting with alcohol (use). He continues to drink more frequently despite an arrest for driving under the influence (abuse). Over time, he requires greater quantities of alcohol to achieve the desired effect (dependence). When he tries to limit his alcohol intake, withdrawal symptoms (physical and psychological reactions to decreased substance use) begin to occur. Eventually, alcohol dependence affects all aspects of his life -- health, family, work and spiritual.

Assessment

A comprehensive biopsychosocial (physical, psychological and social) assessment is critical in treating dual diagnosis. Evaluating all aspects of an individual's health provides vital information for accurate diagnosis and treatment planning.

Performed by a multidisciplinary team, the assessment involves a psychiatrist, medical physician, clinical social worker, nursing staff and dual diagnosis counselor. Family members are also interviewed. When appropriate, other health care professionals may be consulted, including a psychologist for personality or intelligence testing, a neuropsychologist to assess cognitive functioning, and a dietitian to evaluate nutritional needs. Additional assessments may also be conducted to determine hobbies, exercise and recreational interests.

Throughout the assessment process, clinicians gain an understanding of the individual's overall level of functioning, family history and living situation. This information enables treating professionals to identify individual strengths to build on during the recovery process.

Causes

There is increasing evidence that disturbances in brain neurochemistry form the biological basis for the disease of addiction and psychiatric disorders, such as depression, anxiety and psychosis. This may explain why psychiatric and addictive illnesses often occur in the same individual and why the symptoms overlap. Some psychiatric illnesses are found more frequently in individuals with dual diagnosis.

Treatment

Safety is paramount for dual diagnosis patients, and absolute abstinence may not be the initial goal. Most important is a continued commitment to sobriety and a willingness to be an active participant in the recovery process. Relapse is viewed as part of the recovery process. Individuals and their families must be realistic during treatment -- progress is often slow, setbacks will occur and symptoms may return.

The 12-step approach espoused by Alcoholics Anonymous and Narcotics Anonymous has proven helpful to many individuals with dual diagnosis. A recent study found that 40 percent of AA attendees also suffered from clinical depression.

Medication evaluation and management are integral to the treatment plan. Most medications used to treat psychiatric disorders are not addictive and have proven safe and effective over long-term use. Medications, such as benzodiazepines, valium and librium, are highly addictive and should be avoided for individuals with a history of substance abuse.

The combination of alcohol or drugs with some psychiatric medications can be toxic and even life-threatening. When appropriate, special medications may be prescribed to assist recovery. Some medications produce toxic reactions to alcohol consumption and drug use. Other medications can be used to reduce the feelings of craving and euphoria.

Family involvement

Families are always affected when a loved one has a dual disorder. They may feel frustrated, angry and hopeless. When treatment begins, families often have difficulty. They need educational information and guidance about how best to help their loved one recover. Issues may be further complicated by a family history of psychiatric and/or addiction disorders.

Often, families are unaware that their relative also has a substance abuse problem. This is because many of the behaviors that typically indicate suspected alcohol or drug problems already exist in persons with mental illness (e.g., being detached, rebellious or argumentative).

Family counseling is an essential part of the treatment process. There are also many self-help and support groups for friends and relatives of people with dual diagnosis. Families are encouraged to attend groups like Alanon to achieve greater understanding and support.

Dual Diagnosis & adolescents

Adolescence is a period of many changes -- biological, psychological and social. It is also a time of transitions -- new schools and peers, first love, first job, first drink. For adolescents with dual diagnosis, all of these changes must be considered and factored in the biopsychosocial assessment. Peer pressure makes adolescents more resistant to working on substance abuse issues than adults. Family involvement is even more critical in their successful treatment outcomes.

As with adults, more than half of adolescents with psychiatric disorders also have a substance abuse problem. Usually, they do not have a "drug of choice", and are more likely to use whatever drug is most easily available. This increases the potential for more serious symptoms, such as delirium, delusions, hallucinations and psychotic episodes.

We can help

Help for dual diagnosis begins with excellent diagnosis and treatment. At Dominion Hospital, our mental health professionals have extensive experience in the treatment of dual diagnosis disorders in adolescents and adults. Our team approach supports patients and their families as they identify substance abuse issues in the context of psychiatric illness. Through careful evaluation of medical and psychological history, our experts can determine the most appropriate treatment resources, both at Dominion and in the community.

Dominion offers a complete spectrum of care with varying levels of treatment intensity to meet individual needs. In addition to on-site Alcoholics Anonymous, Narcotics Anonymous and Alateen meetings, Dominion Hospital also conducts an aftercare support group for individuals in dual recovery.