Millions of adults and teens who suffer from addiction also live with undiagnosed or untreated psychiatric disorders. Statistics from the Substance Abuse and Mental Health Services Administration indicate that nearly 9 million Americans with psychiatric illness also have a substance use disorder. Even more disturbingly, less than 8 percent of these individuals are treated for both conditions, and nearly 56 percent are not treated at all. The co-occurrence of a psychiatric disorder with a substance use disorder is known as a dual diagnosis. Dually diagnosed individuals face a lot of challenges when they take the first steps toward recovery. The mentally ill are less likely to seek out treatment for addiction, and more likely to be noncompliant with therapies or medications.
What Is Dual Diagnosis Treatment?
In the past, psychiatry and addiction treatment were considered to be separate realms of care. People with co-occurring disorders were treated at conventional rehab facilities where mental illness — if it was diagnosed at all — was considered a secondary problem. Addiction treatment specialists believed that if an individual with an alcohol or drug problem were treated for substance abuse, the symptoms of mental illness would simply disappear. More recently, the addiction treatment community has become more aware of the need for specialized dual diagnosis recovery services. These services target the needs of the dually diagnosed by:
- Offering treatment for mental illness and substance abuse at the same time, at the same location
- Providing cross-trained therapists who specialize in both addiction therapy and psychiatric treatment
- Creating a supportive environment that motivates and empowers the dually diagnosed client
- Offering intensive counseling and education for family members
When mental illness and substance abuse are treated at the same time, the chances of successful recovery are greatly increased. A study published in the Journal of Studies on Alcohol showed that dual diagnosis patients who participated in a specialized treatment program for both mental illness and substance abuse were 39 percent more likely to stay sober after treatment and up to 68 percent more likely to be free from psychiatric symptoms
According to the National Alliance on Mental Illness, clinical research consistently shows that mental illness increases the risk of developing a substance abuse problem — and vice versa. The two conditions can be intertwined in a number of ways:
- Alcohol or drugs can be used as a maladaptive coping mechanism for mental illness (self-medication).
- Substance abuse can mask the symptoms of psychiatric illness.
- Chemical imbalances in the brain may predispose some individuals to mental illness and addiction.
- Heavy substance abuse can cause neurological changes that increase the risk of developing mental illness.
Although substance abuse can occur along with any form of mental illness, the American Society of Addiction Medicine notes that there are several psychiatric conditions that are commonly diagnosed in people seeking addiction treatment:
- Bipolar disorder
- Obsessive-compulsive disorder (OCD)
- Generalized anxiety disorder
- Post-traumatic stress disorder (PTSD)
- Borderline personality disorder
- Attention deficit disorder
Co-occurring conditions are not limited to a single psychiatric disorder. In fact, many dually diagnosed patients have the symptoms of more than one form of mental illness, such as depression and PTSD, or social phobia and OCD. Common substances of abuse in the mentally ill include nicotine, alcohol, marijuana, opiates (heroin, morphine, oxycodone, hydrocodone, and other drugs derived from opium), stimulants (cocaine, meth, amphetamines), and hallucinogens (Ecstasy, LSD, mushrooms). Many dual diagnosis
Diagnosing mental illness in a patient with an addictive disorder is a complicated process, especially when the patient is still actively using drugs or alcohol.
Acute intoxication can resemble many of the symptoms of mental illness, such as:
- Mood swings
- Poor impulse control
- Flat emotional affect
A patient with a co-occurring disorder doesn’t have to be in full recovery before psychiatric treatment begins. However, making an initial diagnosis is easier when the patient has been through a period of detox to clear the drugs from his or her system.
During the diagnostic process, the therapist gathers information from several important sources: personal interviews, interviews with family members, medical history, psychiatric history, and standardized tests or rating scales.
Through face-to-face interviews, the therapist gathers information about the patient’s background, current mental status, substance abuse history, relationships with others, and level of motivation to recover.
Diagnostic testing can reveal data that point to specific mental health issues, such as:
- Poor focus or concentration
- Level of anxiety
- Ability to remember information
- Cognitive processing speed
- Perceptions of the external world
- Perceptions of self
- Relationships to others
- Personality traits
- Self-destructive thoughts
- Suicidal ideation
Alcohol Use Disorders Identification Test (AUDIT)
A 10-question test developed by the World Health Organization as a simple way to identify harmful alcohol use. The Drug Use Disorders Identification Test (DUDIT) is a similar tool that tests for the harmful drug use.
AC-Co-Occurring Disorder Screen (AC-COD)
A 17-question screening tool that can be used at the intake stage to quickly identify individuals who need further assessment for mental illness. The AC-COD was designed in 2007 for use at substance abuse treatment facilities, mental health centers, correctional facilities, primary care clinics, and other locations where people with co-occurring disorders might seek help.
Comprehensive Addictions and Psychological Evaluation (CAAPE)
A structured interview that identifies psychiatric disorders that may affect the outcomes of substance abuse treatment, such as depression, bipolar disorder, panic disorder, PTSD or OCD. Developed in 2000, the CAAPE can be used to identify patients who need motivational enhancement or additional support services to increase their chances of recovery.
PRISM-IV (Psychiatric Research Interview for Substance and Mental Disorders)
A semi-structured series of interview questions that helps the practitioner identify signs of mental illness in individuals who abuse drugs or alcohol. The PRISM-IV was developed in 1990 by psychiatric professionals at Columbia University and the New York State Psychiatric Institute.
Substance Use Event Survey for Severe Mental Illness (SUESS)
An interview tool that assesses the individual’s substance abuse patterns, history of addiction treatment, emotional issues, medication history, personal support system, and other concerns that are relevant to dual diagnosis rehab.
In addition to these tests, the therapist may use more specific screening tools that target the symptoms of mental illness, such as the Beck Depression Inventory, the Beck Anxiety Inventory, the Young Mania Rating Scale, the ADHD Rating Scale, or the Young-Brown Obsessive Compulsive Scale. To make an accurate diagnosis, a number of tests and tools must be used in the evaluation process.
Dual Diagnosis Therapies
Conventional approaches to addiction treatment are often ineffective for patients who are struggling with an underlying mental health disorder. In order to be successful, a dual diagnosis treatment program must be tailored to the needs of the individual client. Dually diagnosed patients often struggle with low motivation, a short attention span, and social anxieties that interfere with treatment. They may need to spend more time in rehab to fully experience the effects of dual diagnosis therapy. Helping the dually diagnosed individual recover from mental illness and substance abuse requires a multidimensional approach to treatment. Here are a few of the most popular therapies used to treat co-occurring disorders:
Cognitive behavioral therapy teaches effective coping skills for dealing with the symptoms of mental illness and substance abuse. Patients learn how to identify the destructive thought patterns and behaviors that lead to a cycle of substance abuse. They then learn how to replace these patterns with more positive, self-affirming ones. In a study of substance abusers with post-traumatic stress disorder published in Addictive Behaviors, cognitive behavioral therapy proved to be highly effective at minimizing the symptoms of PTSD. Three months after participating in CBT, only 20 percent of the members of a PTSD recovery group continued to have symptoms of this debilitating disorder.
Dialectical behavior therapy was developed as a modification of cognitive behavioral therapy by psychologist Marsha Linehan. DBT was originally created to help chronically self-destructive patients lead mindful, meaningful lives. This therapy has since been applied successfully to the treatment of individuals with substance abuse disorders and co-occurring disorders. DBT teaches the patient effective methods for coping with the uncomfortable thoughts that lead to destructive behavior. Once the patient has learned how to tolerate painful thoughts or emotional states, he or she gradually learns how to make the changes that are necessary for recovery.
Motivational enhancement therapy, which brings the therapist and patient together into a collaborative effort to heal, is a valuable tool in dual diagnosis treatment. A literature review published in Alcohol and Alcoholism revealed that MET is an effective way to help heavy drinkers recover from alcoholism. Individuals with co-occurring disorders tend to have higher relapse rates and are more likely to drop out of substance abuse treatment before completing a program. MET is a supportive, client-centered treatment philosophy that focuses on helping the dually diagnosed patient find the internal motivation to change. Also known as motivational interviewing, or MI, this therapy was developed as an alternative to the more traditional, confrontational approach to addiction treatment, which placed the therapist and client in an adversarial relationship. In MET, the therapist helps the client overcome ambivalence to change, so that he or she can successfully complete the stages of rehab.
Relapse prevention therapy helps the recovering addict learn the necessary coping skills to maintain sobriety after rehab. For dually diagnosed patients, RPT is especially important in identifying the mental states and emotional triggers that lead to substance abuse. RPT helps patients with co-occurring disorders build social support systems, strengthen their emotional resilience, and learn healthy ways to reduce stress.
Addiction and mental illness don’t develop in a vacuum. Family dynamics play a critical role in both substance abuse and psychiatric disorders. The chances of maintaining long-term recovery are much greater if spouses, parents, and partners receive education and counseling as part of the treatment process. Family therapy focuses on improving communication skills, identifying destructive coping mechanisms, setting healthy boundaries, and building stronger emotional bonds. Through comprehensive support, the family becomes an active partner in recovery.
Medications for Co-Occurring Disorders
Medication alone is not an adequate treatment for psychiatric illness, nor is it a miracle cure for substance abuse. But anti-addiction medications and psychiatric drugs can be important tools in a comprehensive rehab program. When taken appropriately under a doctor’s supervision, medication can help the recovering patient in several ways:
- By reducing the craving for drugs
- By curbing the pleasurable effects of alcohol or narcotics
- By minimizing the effects of anxiety or depression
- By improving impulse control
- By strengthening focus and concentration
The medications most often prescribed in dual diagnosis treatment programs fall into the following categories:
This category includes selective serotonin reuptake inhibitors (SSRIs) like Prozac (fluoxetine), Lexapro (escitalopram) and Paxil (paroxetine), as well as older antidepressants in the tricyclic (TCA) and monoamine oxidase inhibitor (MAOI) families. Antidepressants can elevate mood and energy levels.
Anti-anxiety agents include tranquilizers in the benzodiazepine family, such as Xanax (alprazolam) and Valium (diazepam). This category also includes drugs with a lower potential for dependency, such as buspirone and certain antidepressants. SSRIs are often prescribed to treat anxiety in individuals with a history of drug or alcohol addiction, because the potential for abuse and addiction is much lower.
Mood stabilizers are often prescribed to even out emotional states in people with bipolar disorder. Many of these drugs are also used to treat seizures, such as Depakote (divalproex sodium), Tegretol (carbamazepine) and Lamictal (lamotrigine). The most widely used mood-stabilizing drug is lithium, a drug used since the 1970s to treat bipolar disorder.
Antipsychotic drugs are used to treat severe mood disorders as well as psychiatric conditions that cause delusions or hallucinations. Examples include Zyprexa (olanzapine), Risperdal (risperidone), Geodon (ziprasidone) and Clozaril (clozapine).
Traditionally, there has been a stigma attached to the use of psychotropic medications in addiction treatment. Some addiction treatment specialists believe that the use of antidepressants, sedatives or opiate replacement drugs is a threat to sobriety. Dual diagnosis treatment programs support the use of psychoactive medications and anti-addiction drugs in the treatment of co-occurring disorders. However, therapists must take the patient’s history of substance abuse into consideration when prescribing drugs with a high abuse potential.
Aftercare and Long-Term Recovery
Dual diagnosis recovery doesn’t end after detox and rehab. Recovering from mental illness and addiction is a lifelong process of healing and growth. A comprehensive dual diagnosis treatment program includes a full range of recovery services, such as:
- Ongoing psychotherapy
- Medication management
- Self-help support groups
- Life skills classes
- Relapse preventing training
Many people who suffer from co-occurring disorders must completely rebuild their lives after treatment.
Aftercare programs can help by providing referrals to therapists, vocational counseling programs, and community-based support groups. Life skills classes help people with psychiatric disorders acquire the practical skills they need to develop a sense of competence and self-determination, such as budgeting, job hunting and relationship building. Relapse prevention training and self-help groups can provide valuable support in the months and years after rehab. Self-help groups founded on the 12-step philosophy include Narcotics Anonymous (NA), Alcoholics Anonymous (AA), Cocaine Anonymous (CA), and Dual Recovery Anonymous (DRA). Twelve-step meetings are available throughout the country in most communities, as well as through online forums and chat groups. At Futures of Palm Beach, we provide a complete range of integrated dual diagnosis treatment services. From detox to rehab and aftercare, we offer comprehensive support throughout the recovery process. Located in a spa-like setting in Palm Beach County, Florida, we offer a serene, supportive retreat from the stresses of everyday life. Call our admissions counselors today to find out whether our research-based treatment programs could help you or a loved one recover from mental illness and addiction.
Some services listed may not be included in our core program. An admissions counselor will be able to provide you a complete list of core services. Information provided for educational purposes. Premium services or programs may be arranged through your therapist or case manager.