The Dangerous Duality of “Dual Diagnosis”

When psychiatric illness coexists with a substance use disorder, we refer to this as a “dual diagnosis.” This term makes clear that we’re talking about two conditions in the same person, which could exist independently of each other (hence they’re also sometimes called “co-occurring disorders”), rather than one disorder causing the other—as seen, for example, in cases of a methamphetamine-induced psychotic reaction or an alcohol-induced depression.

Of course, no two conditions in medicine ever exist truly independently of each other, particularly in psychiatry, and the high prevalence of “dual diagnosis” patients (more than a third of alcoholics, for example, have a co-occurring mental illness, and at least 20% of persons with a mood disorder have a drug use problem) suggests that there’s something about mental illness that makes people more susceptible to addictive disorders, and vice versa.

A “dual diagnosis” label should, theoretically, draw attention to the special concerns these patients face, and to the need for specialized and integrated treatment.  Unfortunately, in practice, this rarely occurs.  Instead, this knowledge often results in compartmentalized care, which may have unfortunate consequences for the dually diagnosed.

How so?  Consider an inpatient psychiatric ward.  Patients are admitted to these units for brief “acute stabilization,” when they are actively symptomatic, often with psychosis, thoughts of suicide, or other poorly controlled symptoms.  Because these hospitalizations are very short, there’s little or no opportunity to engage in meaningful addiction treatment.  Even when the immediate precipitant of the patient’s acute episode is identified as the abuse of a drug or alcohol, we often discharge patients with little more than a written instruction to “go to AA” or “consider rehab” (or my personal favorite, shown above [click for larger version], which would be funny if it weren’t real).  Similarly, in the psychiatrist’s office—particularly when the visits are only 10 or 15 minutes long—there’s usually no time to discuss the addiction; at best, the patient might get something along the lines of, “oh, and be sure to try to cut down on your drinking, too.”

Even though this is commonplace, it sends a powerful yet dangerous message to the addict:  it says that his addiction is less important than the mental disorder, less worthy of treatment, or, perhaps, impossible to treat.  It might signal to the addict that his psychiatrist is unwilling or unable to talk about the addiction, which may be (subconsciously) interpreted as a tacit approval of the addictive behavior.  (If you think I’m exaggerating, then you’ve probably never experienced the overwhelming power of addictive thinking, and its unique ability to twist people’s judgment and common sense in extreme ways.)

It’s also just bad medicine.  As any ER psychiatrist can attest, substance-induced exacerbations of mental illness are rampant and a major cause of hospital admissions (not to mention medication noncompliance, aggression, criminal activity, and other unwanted outcomes).  Ignoring this fact and simply stabilizing the patient with the admonition to “consider” substance use treatment is unlikely to improve the long-term outcome.

In the drug or alcohol treatment setting, the situation is often quite similar.  Sometimes a therapist may not be aware of a patient’s mental health history or active symptoms, in which case he or she might have unrealistically high expectations about the patient’s progress. On the other hand, if the patient is known to carry a psychiatric diagnosis, a therapist might incorrectly attribute even the slightest resistance—and addicts show a lot of it—to that mental illness (even when the symptoms are well-controlled) and miss the opportunity to make substantial inroads in treatment.  Neither alternative “meets the addict where he is,” challenging him with demands that are appropriate for his capabilities and his level of understanding.

True “dual diagnosis” treatment, where it exists, involves close interaction among addiction therapists, rehab counselors, psychiatrists, and others involved in the mental, physical, social, and spiritual well-being of each patient.  Some psychiatrists are well-versed in the nature of addiction (those who have first-hand experience of addiction and recovery are often well positioned to understand the demands on the recovering addict), and, similarly, some addiction experts are adept at identifying and managing symptoms of mental illness.  With this combination, patients can benefit from individualized treatment and are given fewer opportunities to fly beneath the proverbial radar.

However, for most patients this is the exception rather than the rule.  “Addition psychiatrists” are sometimes little more than prescribers of a replacement therapy like Suboxone or naltrexone, and rehab programs often include mental health treatment “at a distance”—i.e., sending clients to a 15-minute visit with a psychiatrist who’s not involved in the day-to-day challenges of the recovering individual.  Addicts need more than this, and I’ll return to this topic in later posts.

Any discussion about improving real-world psychiatric treatment must address the dual-diagnosis issue.  We desperately need more psychiatrists who are knowledgeable about substance abuse disorders and the interplay between addictions and mental illness, and not just the latest “anticraving” drugs or substitution therapies.  We also need to educate other addiction treatment providers about the manifestations of mental illness and the medications and other therapies available.  Providing compartmentalized or lopsided care—even when well-intentioned—does no service to a struggling patient, and may in the long run do more harm than good.

5 Responses to The Dangerous Duality of “Dual Diagnosis”

  1. moviedoc says:

    Every psychiatrist will treat or has treated addicted or recovering patients and should attend at least one AA or other 12 step meeting to understand how it works. (I also recommend watching the film You Kill Me.) It is unfortunate that physicians who do not understand addiction, particularly those who subscribe to the myth of “self medication,” attempt to treat addiction with buprenorphine. The key here is not for psychiatrists to attempt to replace addiction counselors or AA sponsors but rather to monitor the patient’s recovery and coordinate treatment with the rest of the team. Psychiatrists treating dual disorder patients must also become expert at treating psychiatric disorders without using benzodiazepines and other drugs that can wreck recovery.

  2. stevebMD says:

    moviedoc, I agree with everything you wrote…. except for your movie pick. Personally, I found “You Kill Me”‘s portrayal of AA to be cartoonish, simplistic, and somewhat pejorative. (And don’t even get me started on the “wisdom” of sending Ben Kingsley’s character to San Francisco — alone — to “dry out” simply by attending AA meetings.)

    For my money, the classic remains “My Name Is Bill W” with James Garner, which illustrates AA’s roots and early years– and the real disease of alcoholism.

  3. moviedoc says:

    Bill W is a classic, the only film that illustrates the founding of AA. You Kill Me ( may not be perfect, but it illustrates how meetings, sponsors and the steps work in entertaining fashion, which Bill W does not. Geographical cures often fail, but the mob’s “intervention” gets an alcoholic into recovery, wise or not, and the film may help others put their need to make amends in perspective. We should point out, too, that neither story involves dual disorders, and that for addiction alone psychiatry may do more harm than good.

  4. Jake says:

    Psychiatry has no business in the treatment of alcoholism. It hangs labels on people they do not deserve.To assume that all alcoholics are mentally ill,you must also assume that all mentally ill people are alcoholic,and this is simply untrue.A dual diagnosis is dangerous,because most therapists,treat the perceived mental problem and forget about the addiction.Mental illness in alcoholics is a symptom not a cause.Psychiatrists get into the field because it is an easy and lucrative way to justify all those little ltters behind their names,without much effort. Mental problem or no,You can’t treat it o\if the person is not sober.Sobriety is an attitude,and despite what places like Passages Malibu,or some other for profit country club rehab says,you CANNOT cure it,and you CANNOT treat someone who does not want help. It is not about will power. If that was all there was to it,nobody would ever become addicted to anything. It IS about WILLINGNESS. Psychiatrists,get a real job and leave the treatment of alcoholism to people who have been there. AA will work for anyone IF THEY WANT IT TO.

  5. I have read your article carefully. However i have noticed in getting to know quite a few addicts that they use drugs and or alcohol as a way to “dull” their senses. Avoid feeling their pain. What i think should be part of drug treatment is psychotherapy that deals with that pain. Most often (from those i have talked to) they had a very traumatic childhood. The addicts i have known have gone to rehab however theses rehabs deal only with the addiction and better coping skills to avoid relapses. However would it not be more lasting if the addict after rehab could enter an outpatient dual diagnosis where the therapist does not just focus on the addiction but helps the addict deal with or cope better with their mental pain? Perhaps help them to deal with those childhood traumas.

    The thing i don’t like about the AA meetings is the idea that some one is powerless and that they some how have an incurable problem. AA might be good for a while but it seems not be a more permanent solution.

    When you refer to a mental illness it seems like the addiction is a symptom of a problem rather than the actual problem.

    I think it is rare that a well adjusted person decides one day i am going to be an addict. All of the addicts i have known come from broken families or from abusive parents. And while not all who have broken homes and abusive families abuse drugs and or alcohol. Many who experience abuse do.
    Also the stigma attached to mental illness coupled with the mass media treating drug addiction with more respect than actually getting the psychiatric help does not help matters.

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