Dual Diagnosis: Substance Abuse And Mental Illness

Families who have mentally ill relatives whose problems are compounded by substance abuse face problems of enormous proportions. Mental health services are not well prepared to deal with patients having both afflictions. Often only one of the two problems is identified. If both are recognized, the individual may be bounced back and forth between services for mental illness and those for substance abuse, or they may be refused treatment by each of them.

While the picture regarding dual diagnosis has not been very positive at this point, there are now signs that the problem is being recognized and there is an increasing number of programs trying to address the treatment needs of people with both problems. Research studies are beginning to help us understand the scope of the problem. It is now generally agreed that as much as 50 percent of the mentally ill population also has a substance abuse problem. The drug most commonly used is alcohol, followed by marijuana and cocaine. Prescription drugs such as tranquilizers and sleeping medicines may also be abused.

The incidence of abuse is greater among males and those in the age bracket of 18 to 44. People with mental illnesses may abuse drugs covertly without their families knowing it. It is now reported that both families of mentally ill relatives and mental health professionals underestimate the amount of drug dependency among people in their care. There may be several reasons for this. It may be difficult to separate the behaviors due to mental illness from those due to drugs. There may be a degree of denial of the problem because we have had so little to offer people with the combined illnesses. Care givers might prefer not to acknowledge such a frightening problem when so little hope has been offered.

Substance abuse complicates almost every aspect of care for the person with mental illness. First of all, of course, these individuals are very difficult to engage in treatment. Diagnosis is difficult because it takes time to unravel the interacting effects of substance abuse and the mental illness. They may have difficulty being accommodated at home and may not be tolerated in community residences of rehabilitation programs. They lose their support systems and suffer frequent relapses and hospitalizations.

Violence is more prevalent among the dually diagnosed population. Both domestic violence and suicide attempts are more common, and of the mentally ill who wind up in jails and prisons, there is a high percentage of drug abusers. Given severe consequences of drug abuse for the mentally ill, it is reasonable to ask: "Why do they do it?" Some of them may begin to use drugs or alcohol for recreational use, the same as many other people do. Various factors may account for their continued use. Probably many people continue their use as a misguided attempt to treat symptoms of the illness or the side effects of their medications. They find that they can reduce the level of anxiety or depression -- at least for the short term. Some professionals speculate that there may be some underlying vulnerability of the individual that precipitates both mental illness and substance abuse. They believe that these individuals may be at risk with even mild drug use.

Social factors may also play a part in continued use. People with mental illnesses suffer from what has been called "downward drift." This means that as a consequence of their illness they may find themselves living in marginal neighborhoods where drug use prevails. Having great difficulty developing social relationships, some people find themselves more easily accepted by groups whose social activity is based on drug use. Some may believe that an identity based on drug addiction is more acceptable than one based on mental illness.

We realize that this overview of the problem of drugs and mental illness is not a very positive one. However, we believe there are some encouraging signs that better understanding of the problem and potential treatments are on the way. Just as families have faced other very troublesome problems in the past and developed adequate responses to them, we believe that they can learn to deal with this one in a way that their lives become less troubled and their relatives begin receiving better treatment.

Copyright 1993 National Alliance for the Mentally Ill
By Agnes B. Hatfield, Ph.D.

"Dual Diagnosis" refers to those who have been diagnosed with major mental health disorders and alcohol or substance addictions at the same time.

At least 50 percent of the 2 million Americans with severe mental illness abuse illicit drugs or alcohol, compared to 15 percent of the general population, according to the Alcohol, Drug Abuse, and Mental Health Administration.

The problem for professional counselors and mental health care providers in trying to help these patients is making an accurate diagnosis. According to Patrick Smith, M.A., of PacifiCare Behavioral Health, "A substance abuse problem can mimic, mask, or aggravate various mental health disorders.

Drug and alcohol problems and mental illnesses often go hand-in-hand. Among alcoholics, nearly half have an overlapping mental illness or other substance dependence problem. Substance dependence can cover up a serious psychiatric illness, while depression can disguise a substance-use disorder.

Compound Factors

The "double troubled" patient can be extremely difficult to recognize. Often only one of the two problems is identified. The patient diagnosed with a mental disorder may be in denial about the drinking or substance abuse, while the obvious substance abuse of others can disguise the mental disorder.

With teens the diagnosis can be extremely difficult. As one counselor says, "How can (we) separate the normal mood variations of a fifteen year old teenager from certain Bi-polar disorders? When substance use or abuse is present, with resulting mood fluctuation, the variables become staggering."

"It is not uncommon," according to Harold E. Doweiko's Concepts of Chemical Dependency, "for dual diagnosed clients to use one disorder to shield for another disorder." One client may admit to mental health issues in order to avoid his substance abuse and, once the psychiatric issues are resolved, drop out of treatment.

Another client may deny her disorder because "it is less threatening to be a junkie" than to accept a diagnosis of paranoid schizophrenia, Doweiko says. Frustration and depression may hinder one client's ability to recognize and ask for help, while another client may become confused by a lack of knowledge of the processes and goals of treatment services.

Crises for Families

Families who have mentally ill relatives whose problems are compounded by substance abuse face problems of enormous proportions. Mental health services are not well prepared to deal with patients having both afflictions or supporting their families.

Violence is more prevalent among the dually diagnosed. Domestic violence and suicide attempts are more common, and of the mentally ill who wind up in jails and prisons, there is a high percentage of drug abusers.

It is also known that sexual abuse has been a problem for many who are dually diagnosed. One report says that an estimated 40 percent of those attending Dual Diagnosis meetings, have had experiences with sexual abuse also.

Copyright 1993 National Alliance for the Mentally Ill
(used with permission of NAMI 2003)