Dual diagnosis
Dual diagnosis (also called co-occurring disorders (COD) or dual pathology)
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.[5]
Differentiating pre-existing and substance induced
The identification of substance-induced versus independent psychiatric symptoms or disorders has important treatment implications and often constitutes a challenge in daily clinical practice. Similar patterns of comorbidity and risk factors in individuals with substance induced disorder and those with independent non-substance induced psychiatric symptoms suggest that the two conditions may share underlying etiologic factors.[6]
Substance use disorders, including those of alcohol and prescription medications, can induce a set of symptoms 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 people who use alcohol or illicit substances disappear with prolonged abstinence. Substance induced psychiatric symptoms can occur both in the intoxicated state and also during the
Prospective epidemiological studies do not support the hypotheses that comorbidity of substance use disorders with other psychiatric illnesses is primarily a consequence of substance use or dependence or that increasing comorbidity is largely attributable to increasing use of substances.
Research instruments are also often insufficiently sensitive to discriminate between independent, true dual pathology, and substance-induced symptoms. Structured instruments, as Global Appraisal of Individual Needs - Short Screener-GAIN-SS and Psychiatric Research Interview for Substance and Mental Disorders for DSM-IV-PRISM,[9] have been developed to increase the diagnostic validity. While structured instruments can help organize diagnostic information, clinicians must still make judgments on the origin of symptoms.
Prevalence
Comorbidity of addictive disorders and other psychiatric disorders, i.e., dual disorders, is very common[10] and a large body of literature has accumulated demonstrating that mental disorders are strongly associated with substance use disorders. 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;[11] this works out to 7.98 million people.[12] 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.[13]
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 with a psychotic illness than in those without a psychotic illness.[14][15]
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
Further UK studies have shown slightly more moderate rates of substance misuse among mentally ill individuals. One study found that individuals with 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.[17]
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.[clarification needed] A lifetime history of any illicit drug use was observed in 35% of the sample.[18]
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
Treatment
Only a small proportion of those with co-occurring disorders actually receive treatment for both disorders. Therefore, it was argued that a new approach is needed to enable clinicians, researchers and managers to offer adequate assessment and evidence-based treatments to patients with dual pathology, who cannot be adequately and efficiently managed by cross-referral between psychiatric and addiction services as currently configured and resourced.[19] In 2011, it was estimated that only 12.4% of American adults with co-occurring disorders were receiving both mental health and addictions treatment.[12] Clients with co-occurring disorders face challenges accessing treatment, as they may be excluded from mental health services if they admit to a substance use problem and vice versa.[5]
There are multiple approaches to treat 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.[5]
Integrated treatment involves a seamless blending of interventions into a single coherent treatment package developed with a consistent philosophy and approach among care providers.[20][21] With this approach, both disorders are considered primary.[22] Integrated treatment can improve accessibility, service individualization, engagement in treatment, treatment compliance, mental health symptoms, and overall outcomes.[23][24] 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.[22] Green suggested that treatment should be integrated, and a collaborative process between the treatment team and the patient.[25] Furthermore, recovery should to be viewed as a marathon rather than a sprint, and methods and outcome goals should be explicit.
A 2019 Cochrane meta-analysis that included 41 randomized controlled trials found no high-quality evidence in support of any one psycho-social intervention over standard care for outcomes such as remaining in treatment, reduction in substance use and/or improvement in global functioning and mental status.[26]
Theories of dual diagnosis
There are a number of theories that explain the relationship between mental illness and substance use.[27]
Causality
The causality theory suggests that certain types of substance use may causally lead to mental illness.
There is strong evidence that using cannabis can produce psychotic and affective experiences.[28] When it comes to persisting effects, there is a clear increase in the 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.[28] However, this connection between cannabis and psychosis does not prove that cannabis causes psychotic disorders.[28] 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.[29][30][31]
Attention-deficit hyperactivity disorder
One in four people who have a substance use disorder also have
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 use. This is because introversion, inhibition and lack of sensation seeking personality traits, which are typical of autism spectrum disorder, protect against substance use and thus substance use levels are low in individuals who are on the autism spectrum.
Gambling
The inclusion of behavioral addictions like pathological gambling must change our way of understanding and dealing with addictions. Pathological (disordered) gambling has commonalities in clinical expression, etiology, comorbidity, physiology and treatment with substance use disorders (DSM-5). A challenge is to understand the development of compulsivity at a neurochemical level not only for drugs.[37]
Past exposure to psychiatric medications theory
The past exposure theory suggests that
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.[43]
Khantizan proposes that substances are not randomly chosen, but are specifically selected for their effects. For example, using stimulants such as
that such medications sometimes evoke.Some studies show that nicotine administration can be effective for reducing motor side-effects of antipsychotics, with both
(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 alcohol use disorder and other drug misuse.[46]
Multiple risk factor theory
Another theory is that there may be shared risk factors that can lead to both substance use 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.[47][48]
Other evidence suggests that traumatic life events, such as sexual abuse, are associated with the development of psychiatric problems and substance use.[49]
The supersensitivity theory
The supersensitivity theory
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.[50]
Avoiding categorical diagnosis
Current nosological approach does not provide a framework for internal (sub-threshold symptoms) or external (comorbidity) heterogeneity of the different
History
The traditional method for treating patients with dual diagnosis was a parallel treatment program.[53] In this format, patients received mental health services from one clinician while addressing their substance use with a separate clinician.[53] However, researchers found that parallel treatments were ineffective, suggesting a need to integrate the services addressing mental health with those addressing substance use.[54]
During the mid-1980s, a number of initiatives began to combine mental health and substance use disorder services in an attempt to meet this need.[55][56][57] These programs worked to shift the method of treatment for substance use from a confrontational approach to a supportive one.[58] They also introduced new methods to motivate clients and worked with them to develop long-term goals for their care.[56] 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.[56][59]
References
- SAMHSA. November 2001. Archived from the originalon 1 May 2012. Retrieved 1 May 2012.
- ^ Casas M. Trastornos duales. Vallejo Ruiloba J, Gastó Ferrer C (eds). Trastornos afectivos: ansiedad y depresión (2ª ed). Barcelona, Masson; 2000:890-899.
- OCLC 899586899.
- ^ Austin, Infinite Recovery; USA –206-9063, Austin Drug Rehab. "Sober Living Austin". Infinite Recovery. Retrieved 19 February 2019.
{{cite web}}
: CS1 maint: numeric names: authors list (link) - ^ a b c 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 2 February 2019.
- ^ Blanco 2012 p. 865-873.
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- ^ Frisher 2005 p. 847-850.
- ^ Hasin 2006 p. 689-696
- ^ Adamson 2006 p. 164-170; Hasin et al, 2011
- ^ "What Are Co-Occurring Disorders?". Oxford Treatment Center. Retrieved 18 January 2021.
- ^ a b Substance Abuse and Mental Health Services Administration (2012). "Results from the 2011 National Survey on Drug Use and Health: Mental Health Findings". Archived from the original on 17 April 2013. Retrieved 5 April 2013.
- ^ Health Canada (2012). "Best Practices: Concurrent Mental Health and Substance Use Disorders" (PDF). Government of Canada. Retrieved 5 April 2013.
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- ^ Sciacca, Kathleen_2009. "Best Practices for Dual Diagnosis Treatment and Program Development: Co-occurring Mental Illness and Substance Disorders in Various Combinations". In Angela Brown-Miller (ed.). The Praeger International Collection on Addictions. Vol. 3. Praeger. pp. 161–188.
{{cite book}}
: CS1 maint: numeric names: authors list (link) - ^ a b Center for Co-Occurring Disorders (2006). "Overarching Principles to Address the Needs of Persons with Co-Occurring Disorders" (PDF). Substance and Mental Health Services Administration. Archived from the original (PDF) on 6 October 2014. Retrieved 5 April 2013.
- ^ American Psychiatric Association (2006). "Practice Guidelines for the Treatment of Patients with Substance Use Disorders, 2nd ed". Archived from the original on 14 February 2013. Retrieved 5 April 2013.
- ^ Rush B Fobb B Nadeau L Furlong A (2008). "On the Intregation of Mental Health and Substance Use Services and Systems: Main Report" (PDF). Canadian Executive Council on Addictions. Archived from the original (PDF) on 3 December 2011. Retrieved 5 April 2013.
- ^ Green MD (19 March 2009). "Development of a Dual Disorders Program Methodology for Better Outcomes". Psychiatric Times.
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- ^ Degenhardt L, Hall W, Lynskey M (2001). Comorbidity between cannabis use and psychosis: Modelling some possible relationships (PDF) (Report). Technical Report No. 121. Sydney: National Drug and Alcohol Research Centre. Archived from the original (PDF) on 19 August 2006. Retrieved 19 August 2006.
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{{cite journal}}
: CS1 maint: numeric names: authors list (link - ^ 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).
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Further reading
- Blanco, Carlos; Alegría, Analucía A.; Liu, Shang-Min; Secades-Villa, Roberto; Sugaya, Luisa; Davies, Carrie; Nunes, Edward V. (2012). "Differences Among Major Depressive Disorder with and Without Co-occurring Substance Use Disorders and Substance-Induced Depressive Disorder". The Journal of Clinical Psychiatry. 73 (6): 865–873. PMID 22480900.
- Sciacca, Kathleen_2009. "Best Practices for Dual Diagnosis Treatment and Program Development: Co-occurring Mental Illness and Substance Disorders in Various Combinations". In Angela Brown-Miller (ed.). The Praeger International Collection on Addictions. Vol. 3. Praeger. pp. 161–188.
{{cite book}}
: CS1 maint: numeric names: authors list (link) - Sciacca, K. (2011). "Integrated Group Treatment for People Experiencing Mental Health - Substance Use Problems". In David B. Cooper (ed.). Intervention in Mental Health - Substance Use. Radcliffe Pub. pp. 114–127.
- Sciacca, K.; Hatfield, A. B. (1995). "The Family and the Dually Diagnosed Patient". In Lehman, A. F.; Dixon, L. B. (eds.). Double Jeopardy. Harwood Academic Publishers. pp. 193–209.
- Giglioti, M. A. (October 1986). "Program Initiatives for Dually-Diagnosed at Harlem Valley Psychiatric Center. Dual Diagnosis -Co-occurring Disorders". New York State Commission on Quality of Care Publication (28).
- Samet S, Nunes E, Hassin D, et al. (2006). "Diagnosis of comorbid psychiatric disorders in substance users assesses with the Psychiatric Research Interview for Substance and Mental Disorders for DSM-IV". American Journal of Psychiatry. 163 (4): 689–696. PMID 16585445.
- Sciacca, K. (1997). "Peer Support for People Challenged by Dual Diagnosis: 'Helpful People in Touch' (Consumer Led Self-Help)" (PDF). In Mowbray, C.T.; Moxley, D.P.; Jasper, C.A.; Howell, L.L. (eds.). Consumers as Providers in Psychosocial Rehabilitation. IAPSRS Publisher. p. 82. Archived from the original (PDF) on 1 February 2012. Retrieved 2 September 2011.
- Adamson, Simon J.; Todd, Fraser C.; Douglas Sellman, J.; Huriwai, Terry; Porter, Joel (2006). "Coexisting Psychiatric Disorders in a New Zealand Outpatient Alcohol and other Drug Clinical Population". Australian & New Zealand Journal of Psychiatry. 40 (2): 164–170. S2CID 208628311.