Dual Diagnosis: How Treatment for Co-Occurring Disorders Improves Recovery OutcomesAnna Ciulla
A “dual diagnosis” or “co-occurring disorder” (COD) denotes the coexistence of another diagnosable mental condition in those with a substance use disorder (SUD). The 2014 “National Survey on Drug Use and Health (NSDUH),” an annual inquiry by the Substance Abuse and Health Services Administration (SAMHSA) regarding Americans’ behavioral health trends, found 7.9 million adults had CODs (in addition to a diagnosable substance abuse problem).
The actual number of adults living with some type of COD is probably much higher, based on several factors. One is that mental illness (including substance abuse) can often go undiagnosed and untreated for years, according to at least one report. Another is the high prevalence of mental illness within the general population. (The oft-quoted forecast is that one in five adults in the U.S. can expect to experience a mental illness in any given year.) And, if the findings of a large-scale study conducted in the 1990’s still hold true, then a majority of the nearly half of all Americans who will experience a major psychiatric illness at some point in their lifetime will also meet the diagnostic criteria for another mental condition.
This article will educate readers about types of CODs and their link to drug and alcohol addiction, with while showing how integrated treatment for co-occurring disorders and addiction can improve recovery outcomes.
Types of Co-occurring Disorders
There are many types of CODs. Like their frequent counterpart SUDs, CODs can span a wide range of mental disorders, according to the leading government agency charged with preventing and treating mental illness, the Substance Abuse and Mental Health Services Administration (SAMHSA).
In a paper titled “Definitions and Terms Relating to Co-occurring Disorders,” SAMHSA named “the major relevant disorders for COD” as the following:
- Schizophrenia and other psychotic disorders
- Mood disorders such as major depression or bipolar disorder
- Anxiety disorders such social anxiety disorder (SAD) and post-traumatic stress disorder (PTSD)
- Personality disorders, defined by the American Psychiatric Association’s Diagnostic and Statistical Manual on Mental Disorders, 4th edition (DSM-IV), as “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the culture of the individual who exhibits it”
By the same token, however, there are still other types of mental illnesses that qualify as CODs (according to the same publication by SAMHSA):
- Somatoform disorders, in which stress manifests as pain and/or other somatic symptoms
- Factitious disorders, in which a person acts as if he or she has an illness by deliberately producing, feigning, or exaggerating symptoms
- Dissociative disorders, in which thoughts, memories, actions and even one’s sense of identity can be fragmented and discontinuous
- Sexual and gender identity disorders that, as evidenced by this detailed list from the International Foundation for Gender Education, can be all over the map, symptomatically
- Eating disorders
- Sleep disorders
- Impulse-control disorders, characterized by a compulsion to do something that causes harm to oneself or others (some key examples being pathological gambling, kleptomania, pyromania)
- Adjustment disorders, characterized by emotional and physical symptoms following a difficult and stressful life event that seem disproportionate to the actual stress of the event
The Link Between Dual Diagnosis and Addiction
Just how common are dual diagnoses among Americans with SUDs? An estimate by the National Alliance on Mental Illness (NAMI) has pegged the high frequency of mental illness in people with SUDs at “about a third of all alcohol abusers” and “more than half of all drug abusers.”
This trend is mirrored by similarly high rates of SUDs in those with mental illness, according to the same report, which states that “about a third of all people experiencing mental illnesses and about half of people living with severe mental illnesses also experience substance abuse.”
As further evidence of the link between dual diagnosis and addiction, consider the following findings from the 2002 “Co-morbidity of Substance Misuse and Mental Illness Collaborative” (COSMIC) study:
- Three in four (75 percent) drug service clientele had mental health problems.
- An even higher proportion of alcohol service clientele (85 percent) had mental health
- Almost half (44 percent) of those in treatment for a mental health condition used drugs or alcohol at hazardous or harmful levels in the previous year.
Alcoholism, Depression and Anxiety Disorder
Alcoholism and depression and/or anxiety disorders are reportedly the most frequent psychiatric combination. Alcoholism’s high rate of comorbidity with depression and/or anxiety disorders (in one study, alcoholics were two to three times more likely than non-alcoholics to suffer from a co-occurring anxiety disorder) helps to illustrate how substance abuse and other mental disorders can coexist in an often complex relationship. On the one hand, for example, it would seem that alcohol abuse raises one’s risks of developing a COD: Those with a history of alcohol dependence (even former drinkers), were more than four times more likely to experience a major depressive episode than those without a history of alcohol dependence, one study found. On the other hand, it would seem that a diagnosis of depression or anxiety raises one’s susceptibility to alcohol abuse and alcoholism, and also increases and exacerbates their symptoms.
Dual Diagnosis Treatment
Not surprisingly, then, dual diagnosis generally has been associated with a lower prognosis for recovery from drugs or alcohol. The reverse is also true: An untreated SUD can worsen the prognosis for a diagnosis like depression or anxiety. That makes dual diagnosis treatment a central part of effective addiction prevention, treatment and recovery, and helps to explain the overwhelming consensus among today’s medical community: Integrated treatment is the recommended gold standard for substance abuse care.
One critical guiding ethic for addiction treatment, then, is that all clients be assessed and evaluated for co-occurring conditions upon admission to a program and/or early in the course of treatment. A detailed clinical assessment can determine whether a client may be suffering from a dual diagnosis that needs medication and/or other behavioral therapies.
And, growing research has confirmed that dual diagnosis treatment (a.k.a. integrated treatment) improves recovery outcomes for clients with a drug or alcohol problem. Ten recent studies of integrated outpatient programs evidenced higher rates of program engagement among dual diagnosed clientele, as well as higher rates of remission from substance abuse. Additionally, SAMHSA’s Integrated Treatment for Co-Occurring Disorders Evidence-Based Practices (EBP) Kit – 2010 provides detailed information on interventions that have been found to be effective for dual diagnosis clientele.