Mentally ill substance abusers represent a largely unmet challenge in primary care, mental health, and drug and alcohol treatment settings. Although dually diagnosed patients seek services in a variety of places, they remain treatment misfits. Effects on symptoms, social functioning, legal consequences and health are significant in this population, however, those with severe mental illnesses may not have a personal goal of abstinence and may feel uncomfortable and unable to relate in addictions treatment.
Prevalence
Kim Muesser, Ph.D. and co-authors Noordsy, Drake, and Fox in their guide to clinical practice, "Integrated Treatment for Dual Disorders" estimates the prevalence of substance abuse among those with mental illness to range from 40 to 60 percent. Although some who suffer from dual diagnosis may have periods when they are clean and sober, they remain at risk. The reasons for substance abuse among the mentally ill proves complex. Movement of these individuals to poor inner city areas may increase the availability of drugs and alcohol. Substance abusers may find acceptance in a subculture, thereby decreasing the social isolation of mental illness. Opiates, marijuana, or alcohol may decrease agitation and anxiety while stimulants may relieve depression and unwanted side effects of medications. A common genetic susceptibility to mental illness and addiction may also exist.
Younger individuals prove more likely than older people to abuse drugs such as marijuana, cocaine, methamphetamine or opiates. Substance abuse commonly begins at an early age and may predate the onset of psychiatric symptoms. Muesser indicates that substance abuse may also precipitate an earlier onset of mental illness.
Assessment
Dual diagnosis can prove a difficult problem to assess. Muesser and colleagues suggest four basic classifications: primary mental illness that leads to substance abuse, substance abuse with associated psychiatric events, unrelated co-existing mental illness and drug dependence, and predispositions to mental illness and substance abuse due to common underlying factors, such as homelessness, depression and alcoholism.
Treatment Gaps
A survey of 249 drug and alcohol services and 493 mental health services was conducted by researchers in England. While respondents estimated that 32 percent of clients met the criteria for dual diagnosis, less than half of those providers assessed for both disorders and only one fourth had dual diagnosis specialists on staff. Most collaborated with other agencies to provide care but no comprehensive, continuous, integrated systems of care met the needs of these clients.
G. Hussein Rassool, editor of "Dual Diagnosis", points out that chemical dependency is under-diagnosed by psychiatrists, who misunderstand the effects of substance abuse. In the addiction recovery field, ineffective or inappropriate treatments such as interpersonal confrontation may actually increase the frequency of relapse and contribute to poor outcomes.
Denial
Addicts and alcoholics typically minimize the negative effects that substance abuse has on multiple areas of their lives. Similarly, those with schizophrenia or bipolar disorder frequently deny that they have an illness and minimize the extent of their disability. Rather than confronting denial, Rassool advocates the long term goal of an open, honest dialogue and trusting relationships between clients and counselors, and the use of alternate sources of information.
References
- "Integrated Treatment for Dual Disorders"; Kim Mueser, Ph.D., Douglas Noordsy, Robert Drake, Lindy Fox, 2003
- "Dual Diagnosis"; G. Hussein Rassool, 2002
- "Drug and Alcohol Review", Treatment approaches for dual diagnosis clients in England, Schulte SJ, November, 2008, 27(6)
