Dual diagnosis is a term used to describe individuals who have a drug or alcohol problem and also have a mental health disorder, like depression or anxiety.
The two issues often go hand in hand; according to the National Institute on Mental Illness (2013), about one-third of people with mental illness also experience substance abuse. More than 23.5 million Americans — or one in 10 Americans over age 12 — struggle with addiction to drugs or alcohol (Partnership at Drugfree.org, 2014).
As many as one in four adults experience a diagnosable mental disorder; of these, about 45 percent struggle with multiple diagnoses, according to the National Institutes of Mental Health (2011).
Overall, research indicates that 70 percent of substance-abusing individuals also experience mental health problems, also known as dual diagnoses (Wynn, 2002).
“As many as one in four adults experience a mental disorder.”
The relationship between mental health and substance abuse may be a common occurrence, but it’s also complex. Learning more about dual diagnosis can help those who have it– and the people who care about them — when making the decision to seek treatment.
What is Dual Diagnosis?
Also known as co-morbidity, the term dual diagnosis simply means two — or more — illnesses or disorders experienced by the same individual. These may occur at once or at different times, but dual diagnosis usually means that the illnesses interact, making the symptoms of each more pronounced, says the National Institute on Drug Abuse (2010).
The disease of addiction is commonly accompanied by mental health issues, and vice versa. Research indicates that:
- 53 percent of individuals who experience the disease of drug addiction also experience at least one mental illness
- 37 percent of those who abuse alcohol experience at least one mental illness
- 50 percent of individuals with severe mental illness also experience substance abuse issues
- 27 percent of all individuals diagnosed with a mental illness also experience substance abuse issues (National Alliance on Mental Illness, 2003)
Who is Affected by Dual Diagnoses?
Certain factors and characteristics have been found to increase the risk of a dual diagnosis that includes substance abuse, says the National Alliance on Mental Illness (2003). These include:
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A diagnosis of bipolar disorder:
67 percent of those diagnosed as bipolar — five times the rate of the general population — also have a diagnosis of substance abuse
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A diagnosis of schizophrenia:
47 percent of diagnosed schizophrenics also have a substance abuse diagnosis, a rate that’s four times higher than that of the general population
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A diagnosis of anxiety or mood disorders:
Individuals with these diagnoses are twice as likely to suffer from substance addiction
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Socioeconomic status:
Individuals with lower socioeconomic status, which includes factors such as income, education level and occupation, tend to have a higher risk of dual diagnosis
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Veterans:
Individuals who have served in the armed forces tend to have a higher risk of dual diagnosis, which commonly includes PTSD (Post-Traumatic Stress Disorder)
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Gender:
Males are more likely than females to experience a dual diagnosis
Conversely, individuals with substance abuse disorders are almost twice as likely to be diagnosed with anxiety or mood disorders
People who have been diagnosed with antisocial personality or other conduct disorders are more likely to experience substance abuse; males are more likely to be diagnosed with antisocial syndrome than females
According to the National Institute on Drug Abuse (2007), other factors that may affect comorbidity include the following:
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Genetic factors:
Research indicates that genetics may predispose some individuals to both mental health and substance abuse disorders, or increase their risk of developing another disorder once one manifests.
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Environmental factors:
Certain external events in an individual’s life, such as stress, abuse and trauma, may increase risk of dual diagnosis, especially among individuals who have a genetic disposition toward these disorders.
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Developmental factors:
When an individual is exposed to addictive substances at a young age — while the brain is still developing — it may result in physiological changes within the brain that increase the risk of developing both substance abuse and mental health disorders.
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Brain structure:
Some of the same parts of the brain — including those that deal with stress and rewards — are affected by drug use and show physiological differences in individuals with mental health diagnoses, indicating possible links between the two.
How are Mental Illness and Substance Abuse Connected?
The connections between mental health and addiction are complex. One of the difficulties associated with dual diagnoses lies in the fact that it’s difficult, if not impossible, to determine if one causes the other or even which issue comes first (National Institute on Drug Abuse, 2010).
Studies suggest that, in most cases, dual diagnoses follow one of two patterns.
First, individuals experiencing mental health disorders may turn to drugs or alcohol to reduce their symptoms, using substances as a form of self-medication. For instance, smoking cigarettes has been found to ease the symptoms of schizophrenia. Studies indicate that about 88 percent of those diagnosed with schizophrenia smoke, a rate that’s almost three times that of the general population (Kelly and McCreadie, 2000).
Second, substance use or abuse may trigger symptoms of another mental health disorder. For instance, research indicates that marijuana use by adolescents triggers physiological changes in the brain. Specifically, when some adolescents use cannabis, the drug interacts with certain genes known as COMT that help regulate the neurotransmitter dopamine in the brain’s pleasure and reward centers.
“Individuals experiencing mental health disorders may turn to drugs or alcohol to reduce their symptoms.”
When cannabis interacts with the COMT genes, the combination can lead to physical changes in brain structure that are linked to an increased risk of schizophrenia (Royal College of Surgeons in Ireland, 2012).
Research suggests that the genetic link in dual diagnoses may account for 40 to 60 percent of an individual’s vulnerability to developing substance addiction (National Institute on Drug Abuse, 2013). Whether genes act directly to spark these issues, in tandem with other genes or in combination with environmental influences, isn’t clear.
However, studies indicate that certain behaviors linked to pleasure, reward, stress-response, novelty-seeking and risk-taking are correlated with genetics, leading researchers to suggest genetic links to both substance abuse and mental health disorders.
Adding even more complexity to the links between mental health and addiction, certain substance abuse issues actually mirror the effects of some mental health problems, making a proper diagnosis difficult (Wynn, 2002).
What are the Implications of Dual Diagnosis for Those Affected by Substance Abuse?
For those struggling with dual diagnoses — as well as those who care about and for them — the combination of mental illness and addiction presents many challenges. The National Alliance for Mental Illness (2003) states that individuals who experience both diagnoses are statistically at higher risk of experiencing or committing violent acts and of noncompliance with medications. 
In addition, those with a dual diagnosis are less likely to follow a treatment plan and less likely to receive adequate medical care, leading to a greater risk of hospitalization and crisis.
Those with a dual diagnosis face a number of serious health consequences. Because they are unable to adhere to a treatment plan, keep their medical appointments and take therapeutic medications as prescribed, a dual diagnosis often leads to poor overall health, more severe complications and death at an earlier age (National Alliance for Mental Illness, 2013).
“Individuals who experience both diagnoses are statistically at higher risk of experiencing or committing violent acts and of noncompliance with medications.”
Individuals with a dual diagnosis are also more likely to tangle with law enforcement; an estimated 16 percent of jailed inmates experience both substance abuse and mental illness, and of those with diagnosed mental disorders, more than 70 percent also have substance abuse disorders (National Alliance for Mental Illness, 2003).
These statistics are similar among homeless populations, as well. It’s estimated that 50 percent of homeless adults who have mental illness also have substance abuse problems.
Other statistically notable risks related to dual diagnosis may include the following:
- Basing social connections around drug use
- Increased incidence of psychosis
- Contracting HIV/AIDS
- Suicide
Commonly Used Drugs and Mental Health Disorders
Though each case of dual diagnosis is different, certain substances are often associated with certain mental health disorders.
Often, individuals who are intoxicated or experiencing withdrawal exhibit symptoms of mood disorders, such as confusion, memory problems, depression or emotional swings. Commonly used drugs for those with mood disorders include stimulants, such as amphetamines or cocaine; opioids and alcohol (Wynn, 2002).
The highest percentage of substance abuse dual diagnoses is found in those with personality disorders (Wynn, 2002). This population often uses a range of substances, including alcohol, marijuana, methamphetamine, cocaine and heroin; often, individuals with this diagnosis combine alcohol or marijuana with stimulants in an attempt to reduce stress and anxiety.
Schizophrenia is distinguished by psychotic breaks, hallucinations, paranoia and abnormal emotional response — all of which are also symptoms of those experiencing alcohol withdrawal or amphetamine or hallucinogenic intoxication. Often, those with schizophrenia use alcohol and marijuana in an attempt to alleviate their symptoms.
How is Comorbidity Diagnosed?
Reaching a dual diagnosis may be complicated by a range of factors. Notably, many symptoms of substance abuse — or withdrawal related to substance abuse — mimic symptoms of mental illness, making it difficult to obtain an accurate diagnosis. In addition, individuals with both mental illness and substance abuse disorder tend to display symptoms that are more intense than would be seen with just one diagnosis.
According to Wynn (2002), these symptoms may include:
- Disorientation
- Delirium
- Agitation
- Tremors
Those making the decision to seek treatment should be carefully monitored for possible mixed symptoms of substance abuse and mental health issues in order to come to an accurate diagnosis.
How is Dual Diagnosis Treated?
The complex nature of the connections between substance abuse and mental illness can make an accurate dual diagnosis hard to come by. Often, just one of the disorders is diagnosed and treated, while the other condition is left ignored or inadequately treated, only to cause more problems later. 
These realizations have led to a trend in recent years toward concurrent treatment methods. Many advocate a treatment plan that utilizes both medications and behavioral therapy (National Institute on Drug Abuse 2010).
Most treatment programs for dual diagnosis begin with a detoxification process; studies indicate that treatments are more effective for those who have been through detox and aren’t actively abusing substances (National Alliance on Mental Illness, 2013).
Many programs include pharmaceutical treatments, such as disulfiram, acamprostate and naltrexone for alcohol addiction; methadone and buprenorphine for those using opiates; and buprorion for depression, nicotine and methamphetamine addiction.
Behavioral therapies have been found to offer an effective path to recovery for those with dual diagnoses. These may include:
- Assertive community treatment (ACT) — for those with schizophrenia
- Brief strategic family therapy (BSFT) — for antisocial personality disorder
- Cognitive behavioral therapy (CBT) — for anxiety and mood disorders
- Dialectical behavioral therapy (DBT) — for borderline personality disorder
- Exposure therapy — for anxiety disorders
- Integrated group therapy (IGT) — for bipolar disorder
- Multi-systemic therapy (MST) — for antisocial personality disorders
Therapies vary based on factors such as age and drugs used. For those with dual diagnosis, integrated treatment represents the first step on the road to recovery.
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