Mental Health, Dual Diagnosis & Addiction Treatment

The relationship between addiction and other mental health disorders is a complex one, with substance abuse potentially either driving, or being driven by (or even, in particular complicated cases, both) other disorders: the emergence of disorders such as depression, psychosis and many others can lead to an individual’s feeling isolated and profoundly unhappy, and to their seeking escape in drugs, while substance abuse itself and, in particular, the damage addiction can do to an individual’s life prospects, can contribute to the emergence of an array of troubling and potentially extremely destructive mental health conditions.

Although medical professionals are now typically extremely capable of identifying – and treating – cases of dual diagnosis, it remains a huge problem:

• approximately 50% of individuals with serious mental disorders also suffer from substance abuse disorders;
• approximately one third of alcoholics, and over half of drug users, also suffer from at least one identifiable mental illness.

The treatment of one element of a dual diagnosis to the exclusion of another typically results in the failure of that treatment, and potentially to the worsening of either or both conditions as the patient falls further into despair and addiction. Only treating both elements simultaneously as part of a holistic and bespoke treatment plan provides the greatest likelihood of optimal long-term recovery.

Alcoholism is the most prevalent form of substance abuse worldwide, and the one which contributes to the most destruction in the form of death and illness on the part of the sufferer, and accidents and acts of violence affecting others. The social cost of alcoholism is extraordinary and the treatment of those suffering from it – especially in cases which have not yet led to potentially terminal conditions – is moving higher up the political agenda in many countries.

Alcoholism is also – perhaps predictably – the form of substance abuse which is most frequently identified in cases of dual diagnosis. Some studies have found that up to 37% of all those identified as being addicted to alcohol have at least one serious mental disorder – which could have preexisted the addiction, or resulted from it – and some of the most problematic individuals dealt with by mental health authorities on a regular basis are affected by dual diagnosis within which alcoholism is a component (while alcoholism and co-occurring mental health disorders are also a major driver of the ongoing homelessness epidemic in the UK).

Addressing alcohol-related dual diagnosis is an especially complex issue since prolonged alcohol abuse ravages the body and mind and makes exposure to certain medication significantly more dangerous. It is vital to identify each component of such dual diagnosis, and to take steps to treat the alcohol addiction in particular, as early as possible, as the longer an individual suffers from the conditions in question, the worse the prognosis in terms of the chances of long-term recovery.

Millions of people each year require treatment for either addiction, other mental health disorders, or both. Approximately one third of all individuals seeking medical help for their addictions also have co-occurring mental health issues, and getting the correct diagnosis is absolutely vital if treatment for either aspect of a dual diagnosis is to have any long-term benefit.

Tackling an addiction without addressing any underlying mental health issues which may have contributed to its development is effectively merely window-dressing, since a patient may be trying to enter recovery without having dealt with the primary causes of their addiction.

On the other hand, attempting to address a mental health disorder without treating the addiction which may have caused it (for example, depression resulting from the awareness of a deterioration in life circumstances caused by a heroin addiction) is typically similarly futile: the patient may leave treatment with their health disorder temporarily eased, but immediately return to their life of substance abuse and undo any good work achieved by the treatment.

Furthermore, treating one condition without an awareness of the other can be extremely dangerous if pharmaceutical measures are applied, since some medicine can interact very badly with certain substances of abuse or can further damage parts of the body and brain which may have been adversely affected by prolonged substance abuse. Only as complete an awareness as possible of the patient’s true condition can allow for a treatment plan which safely tackles both or all elements of dual diagnosis, and maximises the likelihood of as full a recovery as possible.

Both addiction and co-occurring mental disorders need to be treated simultaneously in cases of dual diagnosis for such treatment to be as effective as possible. Residential treatment allows for the on-site provision of all necessary treatment, according to an optimal schedule drawn up by the assessing medical staff, rather than – as is often the case in instances of outpatient care – according to the availability of appointment times and/or the professional, academic or other schedules of the patient in question. Furthermore, any medical or psychiatric emergencies which may result from any aspects of the treatment may be dealt with on site immediately, making treatment infinitely safer (especially in cases where the client is suffering from disorders which could lead them to harm themselves or others).

Moreover, residential care typically takes place in secure, attractive and confidential environments perfectly suited to an individual’s recovery, where they will not have access to substances of abuse and will be kept away from many triggering elements which could previously disrupt or derail treatment altogether. While this is not to say that outpatient treatment is invariably unsuccessful, it is accepted that residential treatment combining various pharmaceutical and psychotherapeutic approaches is the preferred option for treating cases of dual diagnosis.

The complexities of dual diagnosis mean that each case needs to be approached on an individual basis; this requires a bespoke treatment plan provided by medical professionals experienced in dealing with both substance abuse, the co-occurring disorder/s in question, and their concurrent presence in dual diagnosis.

Some facilities which usually provide care to either addicts or those struggling with other specific disorders are not set up, or willing, to tackle cases of dual diagnosis. However, certain other facilities do have such expertise and are able to treat dual diagnosis patients, either solely or alongside clients suffering from only one such disorder.

At a treatment centre – whether dual diagnosis-specific or otherwise – the client will receive a full assessment of their condition and be provided with a treatment plan which is likely to include at least partial detoxification (to tackle the substance abuse disorder) followed by a combination of psychotherapy, other therapies, dietary and fitness management and other elements, with monitoring by medical staff. Such treatment is typically provided on a residential basis (partly to allow such monitoring to be as constant and informative as possible, and to ensure that the patient does not have access to any substances of abuse during treatment) though outpatient options may be available.

The treatment of dual diagnosis is typically more complex than that provided to someone with only one disorder, since both (or in the case of more than two co-occurring disorders, all) disorders need to be treated successfully and simultaneously in order for the treatment to be effective. If someone is suffering from major depressive disorder, for example, which has contributed to the development of an addiction, treating the addiction alone will not address the underlying depression, and the patient is thus more likely to relapse once treatment has ended.

The treatment of co-occurring disorders is typically psychotherapy-based (as is treating addiction alone), aimed at developing the person’s awareness of negative behaviours and thought processes, and creating mechanisms by which such negativity can be avoided – but may also include a pharmaceutical element (which may not be present in treatment for addiction only) targeting specific aspects of a given disorder (for example, antipsychotic medication for conditions in which psychosis is symptomatic).

Because of the presence of the substance abuse disorder, and the impact of drugs upon the individual in question, such pharmaceutical treatment needs to be extremely carefully administered and some medication may simply be inappropriate (for instance, prescribing benzodiazepines to someone struggling with an addiction to them poses obvious dangers). As a result, each treatment plan needs to be highly tailored to the individual’s specific situation, and monitoring needs to be even more careful.

Dual diagnosis occurs when a person has a mood disorder or mental illness, as well as a substance abuse problem. Although the reasons for the condition can vary greatly from one individual to another, there are a number of common factors that together can contribute to the development of dual diagnosis, including:

• Genetics: an individual’s genetic make-up can make them more likely than others to be susceptible to the development of imbalances in the brain’s reward system which play a fundamental part in addiction. Moreover, many other disorders of the brain, including some of those which most commonly occur part of dual diagnosis, can also have genetic origins.
• Environment: a person’s upbringing – and indeed their adult life – can expose them to events and experiences which can contribute to the development of, or even trigger, brain disorders including addiction. For example, a child brought up in a household featuring chronic substance abuse is several times more likely to become an addict in later life. Similarly, some traumatic events can be drivers of both addiction and other disorders such as depression.
• Illness: some diseases can be debilitating or unpleasant enough to trigger disorders such as depression which may coexist with – or themselves trigger – substance abuse disorders.

Dual diagnosis treatment combines the most effective aspects of substance abuse treatment and mental health care. This treatment integrates both disorders in the recovery process, rather than focus on each disorder separately, and rehab facilities now offer recovery services tailored to clients suffering with dual diagnosis.However, finding the right rehabilitation program can still be challenging, especially if you are struggling with depression or anxiety along with substance abuse.

Addressing both disorders together recognizes that both have a powerful impact on the person’s life, and may even have positive synergistic effects when it comes to treating them. Treatment will often target common symptoms of the disorders, such as negative mood or impulse control problems. This will include CBT, DBT and one-to-one counselling as well as a range of other holistic approaches.

Treatment should also encourageincentives for change in order to keep dual diagnosis patients engaged. Because drugs provide instantaneous positive effects, it is important that treatment help the patient find their own alternative incentives and rewards for recovery.

It is generally advised that treatment for dual diagnosis is undertaken at a residential rehab facility where fully trained and dedicated members of staff can offer around-the-clock care.

Dual diagnosis (also referred to as co-occurring disorders) is the condition of suffering from a mental illness and a substance abuse problem. This term 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 generalised 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, hospitalisation, homelessness, and HIV and hepatitis C infection compared to those with either mental or substance use disorders alone.