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Dual Diagnosis: mental health and drug use
Dual diagnosis is one of several terms used to indicate that a person has both a mental disorder and an alcohol or drug problem. Other common terms include comorbidity, dual disorder and co-occurring disorders. These conditions frequently occur together. In particular, alcohol and drug problems tend to occur with depression, anxiety disorders, schizophrenia, bipolar disorder and personality disorders. In this Intel, the terms will be used interchangeably, but “dual disorders” is preferred, because these problems are often overlooked and a formal diagnosis is not made; in other cases, the level of mental disorder or drug use has a significant impact on the persons’ life, or interferes with treatment, yet fails to reach the levels necessary to make a formal diagnosis. More than a third of people seeking help with alcohol problems and more than half of people attending drug treatment services also have at least one serious mental illness. Likewise, between 30% and 50% of all people diagnosed as mentally ill, misuse alcohol and other drugs. In each case, this is twice the rate as the general population. In almost all cases, the indications of mental illness or its prodrome are evident before the drug problems develop, although there are times when substance abuse occurs first, since over time, either as a direct result of the drugs, or more often as a result of the life style associated with drug dependence, emotional and mental problems develop. By the time a dual disorder is evident, which came first is no longer relevant: both need to be a focus of treatment.
Most major mental health problems develop in childhood but don’t manifest until adolescence. Depression certainly occurs in childhood as does anxiety, but few children have access to drugs at the time childhood disorders are diagnosed. Rather, childhood depression, Oppositional Defiance Disorder (the most commonly diagnosed mental illness in childhood) and childhood anxiety problems are common predictors of later drug abuse and dual disorder.
The most serious mental illnesses are generally diagnoses in late teens an early adulthood. Schizophrenia is usually diagnosed at about 18 years of age in men, a little later in women. Bipolar disorder is usually first seen in early 20s in men and mid 20s in women. However, both disorders are present from birth, and so precede any drug disorders. Importantly, at the time these problems are first diagnosed, the rate of drug and alcohol dependence is about the same as the rest of the population: about 8 people in 100. However, 12 months later, the likelihood of addiction for someone with bipolar disorder has increased 5 fold, and people with schizophrenia are by then twice as likely to have become drug dependent as other people. These changes can be explained in large part by the impact of stigma, isolation, social withdrawal, restricted social outlets, loss of vocational and educational opportunities. Alcohol and other drugs fill many of these gaps, help people structure time, help replace lost social networks and dull the despair of having a degrading, chronic, incurable illness. Many of the same issues can by experienced by people with other mental illnesses but in addition, the several of the medications used as first-line treatment for psychoses also induce high levels of the enzymes that metabolise alcohol and other addictive drugs. One of the results of this is to increase the person’s tolerance: they require more to experience the pleasant effects and relief they seek. As a result, they drink more and quickly become dependent. This is clearly not the whole story: Dual disorders do not occur only in people undergoing treatment, although this is where the highest rates are found. Self-medication is believed to account for a proportion of cases. However, people with mental problems do not drink primarily to relieve symptoms; the drugs which people use actually make symptoms worse, increase the rate of relapse and hospitalisation. In reality, people with mental problems use drugs for the same reasons as anyone else: to feel good, to socialise, to structure time, to be like their peers... unfortunately, and for a number of reasons, they suffer negative impacts from drug use at a far greater rate than other people. Two factors particularly influence their drug choice: availability and reinforcement. Availability needs little explanation: people use what they can get. Within the range of what is available, reinforcement tends to determine the drug of choice. Reinforcement in this context refers to the internalised world-view of the user. People suffering depression live in a bleak, pessimistic universe, a view that is reinforced by heavy use of depressant drugs. Speed, ICE and cocaine are stimulants; these and steroids offer the user a sense of power, superiority and invulnerability that mimics the self-image of people who are hypomanic or suffering delusions of grandeur. Hallucinogenic drugs (mushrooms, LSD, cannabis, for instance) help to sustain the fantasy worlds of many people with personality disorders.... As far as there is any relationship between particular mental disorders or coping styles, reinforcement is a better explanation than self-medication.
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This intel was contributed by David Rich
David Rich
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May, 2012
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