Dual diagnosis

This article is about co-occurring mental disorder and substance abuse. For the general definition of any two diagnoses together, see Comorbidity.

Dual diagnosis (also called co-occurring disorders, COD)[1] is the condition of suffering from a mental illness and a comorbid substance abuse problem. There is considerable debate surrounding the appropriateness of using a single category for a heterogeneous group of individuals with complex needs and a varied range of problems. The concept can be used broadly, for example depression and alcoholism, or it can be restricted to specify severe mental illness (e.g. psychosis, schizophrenia) and substance misuse disorder (e.g. cannabis abuse), or a person who has a milder mental illness and a drug dependency, such as panic disorder or generalized anxiety disorder and is dependent on opioids. Diagnosing a primary psychiatric illness in substance abusers is challenging as drug abuse itself often induces psychiatric symptoms, thus making it necessary to differentiate between substance induced and pre-existing mental illness.

Those with co-occurring disorders face complex challenges. They have increased rates of relapse, hospitalization, homelessness, and HIV and Hepatitis C infection compared to those with either mental or substance use disorders alone.[2] The cause of co-occurring disorders is unknown, although there are several theories.

Differentiating pre-existing and substance induced

Drug abuse, including alcohol and prescription drugs, can induce symptomatology which resembles mental illness, which can make it difficult to differentiate between substance induced psychiatric syndromes and pre-existing mental health problems. More often than not psychiatric disorders among drug or alcohol abusers disappear with prolonged abstinence. Substance induced psychiatric symptoms can occur both in the intoxicated state and also during the withdrawal state. In some cases these substance induced psychiatric disorders can persist long after detoxification, such as prolonged psychosis or depression after amphetamine or cocaine abuse. Abuse of hallucinogens can trigger delusional and other psychotic phenomena long after cessation of use and cannabis may trigger panic attacks during intoxication and with use it may cause a state similar to dysthymia. Severe anxiety and depression are commonly induced by sustained alcohol abuse which in most cases abates with prolonged abstinence. Even moderate sustained use of alcohol may increase anxiety and depression levels in some individuals. In most cases these drug induced psychiatric disorders fade away with prolonged abstinence. A protracted withdrawal syndrome can also occur with psychiatric and other symptoms persisting for months after cessation of use. Benzodiazepines are the most notable drug for inducing prolonged withdrawal effects with symptoms sometimes persisting for years after cessation of use.[3]

Prevalence

The 2011 USA National Survey on Drug Use and Health found that 17.5% of adults with a mental illness had a co-occurring substance use disorder; this works out to 7.98 million people.[4] Estimates of co-occurring disorders in Canada are even higher, with an estimated 40-60% of adults with a severe and persistent mental illness experiencing a substance use disorder in their lifetime.[5]

A study by Kessler et al. in the United States attempting to assess the prevalence of dual diagnosis found that 47% of clients with schizophrenia had a substance misuse disorder at some time in their life, and the chances of developing a substance misuse disorder was significantly higher among patients suffering from a psychotic illness than in the those without a psychotic illness.[6][7]

Another study looked at the extent of substance misuse in a group of 187 chronically mentally ill patients living in the community. According to the clinician's ratings, around a third of the sample used alcohol, street drugs, or both during the six months before evaluation.[8]

Further UK studies have shown slightly more moderate rates of substance misuse among mentally ill individuals. One study found that individuals suffering from schizophrenia showed just a 7% prevalence of problematic drug use in the year prior to being interviewed and 21% reported problematic use some time before that.[9]

Wright and colleagues identified individuals with psychotic illnesses who had been in contact with services in the London borough of Croydon over the previous 6 months. Cases of alcohol or substance misuse and dependence were identified through standardized interviews with clients and keyworkers. Results showed that prevalence rates of dual diagnosis were 33% for the use of any substance, 20% for alcohol misuse only and 5% for drug misuse only. A lifetime history of any illicit drug use was observed in 35% of the sample.[10]

Diagnosis

Substance use disorders can be confused with other psychiatric disorders. There are diagnoses for substance-induced mood disorders and substance-induced anxiety disorders and thus such overlap can be complicated. For this reason, the DSM-IV advises that diagnoses of primary psychiatric disorders not be made in the absence of sobriety (of duration sufficient to allow for any substance-induced post-acute-withdrawal symptoms to dissipate) up to 1 year.

Treatment

Only a small proportion of those with co-occurring disorders actually receive treatment for both disorders. In 2011, it was estimated that only 12.4% of American adults with co-occurring disorders were receiving both mental health and addictions treatment.[4] Clients with co-occurring disorders face challenges accessing treatment, as they may be excluded from mental health services if they admit to a substance abuse problem, and vice versa.[2]

There are multiple approaches to treating concurrent disorders. Partial treatment involves treating only the disorder that is considered primary. Sequential treatment involves treating the primary disorder first, and then treating the secondary disorder after the primary disorder has been stabilized. Parallel treatment involves the client receiving mental health services from one provider, and addictions services from another.[2]

Integrated treatment involves a seamless blending of interventions into a single coherent treatment package developed with a consistent philosophy and approach among care providers.[11] [12] With this approach, both disorders are considered primary.[13] Integrated treatment can improve accessibility, service individualization, engagement in treatment, treatment compliance, mental health symptoms, and overall outcomes.[14][15] The Substance Abuse and Mental Health Services Administration in the United States describes integrated treatment as being in the best interests or clients, programs, funders, and systems.[13] Green suggested that treatment should be integrated, and a collaborative process between the treatment team and the patient.[16] Furthermore, recovery should to be viewed as a marathon rather than a sprint, and methods and outcome goals should be explicit.

Although many patients may reject medications as antithetical to substance-abuse recovery and side effects, they can be useful to reduce paranoia, anxiety, and craving. Medications that have proven effective include opioid replacement therapies, such as lifelong maintenance on methadone or buprenorphine, to minimize risk of relapse, fatality, and legal trouble amongst opioid addicts, as well as helping with cravings, baclofen for alcoholics, opioid addicts, cocaine addicts, and amphetamine addicts, to help eliminate drug cravings, and clozapine, the first atypical antipsychotic, which appears to reduce illicit drug use amongst stimulant addicts. Clozapine can cause respiratory arrest when combined with alcohol, benzodiazepines, or opioids, so it is not recommended to use in these groups.

Theories of dual diagnosis

There are a number of theories that explain the relationship between mental illness and substance abuse.[17]

Causality

The causality theory suggests that certain types of substance abuse may causally lead to mental illness.

There is strong evidence that using cannabis can produce temporary and usually mild psychotic and affective experiences.[18] When it comes to persisting effects, there is a clear increase in incidence of psychotic outcomes in people who had used cannabis, even when they had used it only once. More frequent use of cannabis strongly augmented the risk for psychosis. The evidence for affective outcomes is less strong.[18] However, this connection between cannabis and psychosis does not prove that cannabis causes psychotic disorders.[18] The causality theory for cannabis has been challenged as despite explosive increases in cannabis consumption over the past 40 years in western society, the rate of schizophrenia (and psychosis in general) has remained relatively stable.[19][20][21]

Attention-deficit hyperactivity disorder

One in four people who have a substance use disorder also have attention-deficit hyperactivity disorder,[22] which makes the treatment of both conditions more difficult. ADHD is associated with an increased craving for drugs.[23] Having ADHD makes it more likely that an individual will initiate substance misuse at a younger age than their peers.[24] They are also more likely to have a poorer outcome, such as longer time to remission, and increased psychiatric complications from substance misuse.[23][24] While generally stimulant medications do not seem to worsen substance misuse, they are known to be abused in some cases. Psychosocial therapy and/or nonstimulant medications and extended release stimulants are ADHD treatment options that reduce these risks.[24]

Autism spectrum disorder

Unlike ADHD, which significantly increases the risk of substance use disorder, autism spectrum disorder has the opposite effect of significantly reducing the risk of substance abuse. This is because introversion, inhibition and lack of sensation seeking personality traits, which are typical of autism spectrum disorder, protect against substance abuse and thus substance abuse levels are low in individuals who are on the autism spectrum.[25] However, certain forms of substance abuse, especially alcohol abuse, can cause or worsen certain neuropsychological symptoms which are common to autism spectrum disorder, such as impaired social skills due to the neurotoxic effects of alcohol on the brain, especially the prefrontal cortex area of the brain. The social skills that are impaired by alcohol abuse include impairments in perceiving facial emotions, prosody perception problems and theory of mind deficits; the ability to understand humour is also impaired in alcohol abusers.[26]

Past exposure to psychiatric medications theory

The past exposure theory suggests that exposure to psychiatric medication alters neural synapses, introducing an imbalance that was not previously present. Discontinuation of the drug is expected to result in symptoms of psychiatric illness which resolve once the drug is restarted.[27] This theory suggests that while it may appear that the medication is working, it is only treating a disorder caused by the medication itself.[27] New exposure to psychiatric medication may lead to heightened sensitivity to the effects of drugs and alcohol, which has a deteriorating effect on the patient.[28][29][30][31]

Self-medication theory

The self-medication theory suggests that people with severe mental illnesses misuse substances in order to relieve a specific set of symptoms and counter the negative side-effects of antipsychotic medication.[32]

Khantizan proposes that substances are not randomly chosen, but are specifically selected for their effects. For example, using stimulants such as nicotine or amphetamines can be used to combat the sedation that can be caused by higher doses of certain types of (usually typical) antipsychotic medication.[32] Conversely, some people taking medications with a stimulant effect such as the SNRI antidepressants Effexor (venlafaxine) or Wellbutrin (bupropion) may seek out benzodiazepines or opioid narcotics to counter the anxiety and insomnia that such medications sometimes evoke.

Some studies show that nicotine administration can be effective for reducing motor side-effects of antipsychotics, with both bradykinesia[33] (stiff muscles) and dyskinesia[34](involuntary movement) being prevented.

Alleviation of dysphoria theory

The alleviation of dysphoria theory suggests that people with severe mental illness commonly have a negative self-image, which makes them vulnerable to using psychoactive substances to alleviate these feelings. Despite the existence of a wide range of dysphoric feelings (anxiety, depression, boredom, and loneliness), the literature on self-reported reasons for use seems to lend support for the experience of these feelings being the primary motivator for drug and alcohol misuse.[35]

Multiple risk factor theory

Another theory is that there may be shared risk factors that can lead to both substance abuse and mental illness. Mueser hypothesizes that these may include factors such as social isolation, poverty, lack of structured daily activity, lack of adult role responsibility, living in areas with high drug availability, and association with people who already misuse drugs.[36][37]

Other evidence suggests that traumatic life events, such as sexual abuse, are associated with the development of psychiatric problems and substance abuse.[38]

The supersensitivity theory

The supersensitivity theory[39] proposes that certain individuals who have severe mental illness also have biological and psychological vulnerabilities, caused by genetic and early environmental life events. These interact with stressful life events and can result in either a psychiatric disorder or trigger a relapse into an existing illness. The theory states that although anti-psychotic medication can reduce the vulnerability, substance abuse may increase it, causing the individual to be more likely to experience negative consequences from using relatively small amounts of substances. These individuals, therefore, are "supersensitive" to the effects of certain substances, and individuals with psychotic illness such as schizophrenia may be less capable of sustaining moderate substance use over time without experiencing negative symptoms.

Although there are limitations in the research studies conducted in this area, namely that most have focused primarily on schizophrenia, this theory provides an explanation of why relatively low levels of substance misuse often result in negative consequences for individuals with severe mental illness.[39]

History

The traditional method for treating patients suffering from dual diagnosis was a parallel treatment program.[40] In this format, patients received mental health services from one clinician while addressing their substance abuse with a separate clinician.[40] However, researchers found that parallel treatments were ineffective, suggesting a need to integrate the services addressing mental health with those addressing substance abuse.[41]

During the mid-1980s, a number of initiatives began to combine mental health and substance abuse services in an attempt to meet this need.[42][43][44] These programs worked to shift the method of treatment for substance abuse from a confrontational approach to a supportive one.[45] They also introduced new methods to motivate clients and worked with them to develop long-term goals for their care.[43] Although the studies conducted by these initiatives did not have control groups, their results were promising and became the basis for more rigorous efforts to study and develop models of integrated treatment.[43][46]

References

  1. ↑ "Report to Congress on the prevention and treatment of co-occurring substance abuse disorders and mental disorders". SAMHSA. November 2001. Retrieved 1 May 2012.
  2. 1 2 3 Standing Senate Committee on Social Affairs, Science, and Technology (2006). "Out of the Shadows at Last: Transforming Mental Health, Mental Illness and Addictions Services in Canada" (PDF). Government of Canada. Retrieved 5 April 2013.
  3. ↑ Evans, Katie; Sullivan, Michael J. (1 March 2001). Dual Diagnosis: Counseling the Mentally Ill Substance Abuser (2nd ed.). Guilford Press. pp. 75–76. ISBN 978-1-57230-446-8.
  4. 1 2 Substance Abuse and Mental Health Services Administration (2012). "Results from the 2011 National Survey on Drug Use and Health: Mental Health Findings". Retrieved 5 April 2013.
  5. ↑ Health Canada (2012). "Best Practices: Concurrent Mental Health and Substance Use Disorders" (PDF). Government of Canada. Retrieved 5 April 2013.
  6. ↑ Kessler RC; McGonagle KA; Zhao S; Nelson CB; Hughes M; Eshleman S; Wittchen HU; Kendler KS (1994). "Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Results from the National Comorbidity Survey". Archives of General Psychiatry 51 (1): 8–19. doi:10.1001/archpsyc.51.1.8. PMID 8279933.
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  8. ↑ Drake RE; Wallach MA (1993). "Moderate drinking among people with severe mental illness". Hospital & Community Psychiatry 44 (8): 780–2. PMID 8375841.
  9. ↑ Cantwell, R; Scottish Comorbidity Study Group (2003). "Substance use and schizophrenia: effects on symptoms, social functioning and service use". British Journal of Psychiatry 182 (4): 324–9. doi:10.1192/bjp.182.4.324. PMID 12668408. Retrieved 26 February 2008.
  10. ↑ Wright S; Gournay K; Glorney E; Thornicroft G (2000). "Dual diagnosis in the suburbs: prevalence, need, and in-patient service use". Social Psychiatry & Psychiatric Epidemiology 35 (7): 297–304. doi:10.1007/s001270050242. PMID 11016524.
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  13. 1 2 Center for Co-Occurring Disorders (2006). "Overarching Principles to Address the Needs of Persons with Co-Occcurring Disorders" (PDF). Substance and Mental Health Services Administration. Retrieved 5 April 2013.
  14. ↑ American Psychiatric Association (2006). "Practice Guidelines for the Treatment of Patients with Substance Use Disorders, 2nd ed". Retrieved 5 April 2013.
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  16. ↑ Green MD (19 March 2009). "Development of a Dual Disorders Program Methodology for Better Outcomes". Psychiatric Times.
  17. ↑ Mueser KT; Essock SM; Drake RE; Wolfe RS; Frisman L (2001). "Rural and urban differences in patients with a dual diagnosis". Schizophrenia Research 48 (1): 93–107. doi:10.1016/S0920-9964(00)00065-7. PMID 11278157.
  18. 1 2 3 Moore TH; Zammit S; Lingford-Hughes A; Barnes TR; Jones PB; Burke M; Lewis G (2007). "Cannabis use and risk of psychotic or affective mental health outcomes: a systematic review" (PDF). The Lancet 370 (9584): 319–28. doi:10.1016/S0140-6736(07)61162-3. PMID 17662880.
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  20. ↑ Martin Frisher, Ilana Crome, Orsolina Martino, and Peter Croft. (2009). "Assessing the impact of cannabis use on trends in diagnosed schizophrenia in the United Kingdom from 1996 to 2005" (PDF). Schizophrenia Research 113 (2–3): 123–128. doi:10.1016/j.schres.2009.05.031. PMID 19560900.
  21. ↑ http://www.nhsconfed.org/Publications/Documents/MHN_factsheet_August_2009_FINAL_2.pdf Key facts and trends in mental health, National Health Service, 2009
  22. ↑ van Emmerik-van Oortmerssen, K.; van de Glind, G.; van den Brink, W.; Smit, F.; Crunelle, CL.; Swets, M.; Schoevers, RA. (Apr 2012). "Prevalence of attention-deficit hyperactivity disorder in substance use disorder patients: a meta-analysis and meta-regression analysis.". Drug Alcohol Depend 122 (1-2): 11–9. doi:10.1016/j.drugalcdep.2011.12.007. PMID 22209385.
  23. 1 2 Frodl, T. (Sep 2010). "Comorbidity of ADHD and Substance Use Disorder (SUD): a neuroimaging perspective.". J Atten Disord 14 (2): 109–20. doi:10.1177/1087054710365054. PMID 20495160.
  24. 1 2 3 Upadhyaya, HP. (2007). "Managing attention-deficit/hyperactivity disorder in the presence of substance use disorder.". J Clin Psychiatry. 68 Suppl 11: 23–30. PMID 18307378.
  25. ↑ Ramos, M.; Boada, L.; Moreno, C.; Llorente, C.; Romo, J.; Parellada, M. (Aug 2013). "Attitude and risk of substance use in adolescents diagnosed with Asperger syndrome.". Drug Alcohol Depend 133 (2): 535–40. doi:10.1016/j.drugalcdep.2013.07.022. PMID 23962420.
  26. ↑ Uekermann J, Daum I (May 2008). "Social cognition in alcoholism: a link to prefrontal cortex dysfunction?". Addiction 103 (5): 726–35. doi:10.1111/j.1360-0443.2008.02157.x. PMID 18412750.
  27. 1 2 http://robertwhitaker.org/robertwhitaker.org/Anatomy%20of%20an%20Epidemic.html
  28. ↑ http://knowledgeisnecessity.blogspot.com/2010/11/supersensitivity-psychosis-evidence.html
  29. ↑ http://www.ahrp.org/risks/biblio0100.php
  30. ↑ http://onlinelibrary.wiley.com/doi/10.1111/j.1600-0447.1990.tb05477.x/abstract
  31. ↑ http://breggin.com/index.php?option=com_docman&task=doc_download&gid=232&Itemid=37
  32. 1 2 Khantzian EJ (1997). "The self-medication hypothesis of substance use disorders: a reconsideration and recent applications". Harv Rev Psychiatry 4 (5): 231–44. doi:10.3109/10673229709030550. PMID 9385000.
  33. ↑ Yang YK, Nelson L, Kamaraju L, Wilson W, McEvoy JP (October 2002). "Nicotine decreases bradykinesia-rigidity in haloperidol-treated patients with schizophrenia". Neuropsychopharmacology 27 (4): 684–6. doi:10.1016/S0893-133X(02)00325-1. PMID 12377405.
  34. ↑ Silvestri S, Negrete JC, Seeman MV, Shammi CM, Seeman P (April 2004). "Does nicotine affect D2 receptor upregulation? A case-control study". Acta Psychiatr Scand 109 (4): 313–7; discussion 317–8. doi:10.1111/j.1600-0447.2004.00293.x. PMID 15008806.
  35. ↑ Pristach CA; Smith CM (1996). "Self-reported effects of alcohol use on symptoms of schizophrenia". Psychiatr Serv 47 (4): 421–3. PMID 8689377.
  36. ↑ Anthony, J.C. & Helzer, J.E. 1991, "Syndromes of drug abuse and dependence", in Psychiatric Disorders in America: The Epidemiologic Catchment Area Study, L.N. Robins & D.A. Regier, eds., Free Press, New York, pp. 116–154.
  37. ↑ Berman, S; Noble, EP (1993). "Childhood antecedents of substance misuse". Current Opinion in Psychiatry 6 (3): 382–7. doi:10.1097/00001504-199306000-00012.
  38. ↑ Banerjee, S., Clancy, C., & Crome, I. 2002, "Co-existing Problems of Mental Disorder and Substance Misuse (dual diagnosis). An Information Manual. Found at http://www.rcpsych.ac.uk", Royal College of Psychiatrists' Research Unit.
  39. 1 2 Mueser KT; Drake RE; Wallach MA (1998). "Dual diagnosis: a review of etiological theories". Addictive Behaviors 23 (6): 717–34. doi:10.1016/S0306-4603(98)00073-2. PMID 9801712.
  40. 1 2 Drake, Robert E.; Mercer-McFadden, Carolyn; Mueser, Kim T.; McHugo, Gregory J.; Bond, Gary R. (1998). "Review of Integrated Mental Health and Substance Abuse Treatment for Patients With Dual Disorders". Schizophrenia Bulletin 24 (4): 589–608. doi:10.1093/oxfordjournals.schbul.a033351. Retrieved July 2013.
  41. ↑ Drake, Robert E.; Mueser, Kim T. (2000). "Psychosocial Approaches to Dual Diagnosis". Schizophrenia Bulletin 26 (1): 105–118. doi:10.1093/oxfordjournals.schbul.a033429. Retrieved July 2013.
  42. ↑ Gorman, Christine (3 August 1987). "Bad Trips for the Doubly Troubled". TIME Magazine. Retrieved July 2013.
  43. 1 2 3 Drake, Robert E.; Essock, Susan M.; Shaner, Andrew; Carey, Kate B.; Minkoff, Kenneth; Kola, Lenore; Lynde, David; Osher, Fred C.; Clark, Robin E.; Rickards, Lawrence (1 April 2001). "Implementing Dual Diagnosis Services for Clients With Severe Mental Illness". Psychiatric Services 54 (1): 469–476. doi:10.1176/appi.ps.52.4.469. Retrieved July 2013.
  44. ↑ Sciacca, K._1991. "An Integrated Treatment Approach for Severely Mentally Ill Individuals with Substance Disorders". New Directions For Mental Health Services, No. 50, Summer 1991, Chapter 6: Jossey-Bass,Publishers.
  45. ↑ Sciacca, Kathleen (July 1996). "Invited response "On Co-Occurring Addictive and Mental Disorders; A Brief History of the Origins of Dual Diagnosis Treatment and Program Development"". American Journal of Orthopsychiatry 66 (3). Retrieved July 2013.
  46. ↑ Sciacca, Kathleen; Thompson, Christina M. (Summer 1996). "Program Development and Integrated Treatment Across Systems for Dual Diagnosis: Mental Illness, Drug Addiction And Alcoholism, MIDAA". Journal of Mental Health Administration 23 (3): 288–297.

Further reading

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