Substance Abuse and Mental Health Issues; Dealing with Dual Diagnosis

Dual diagnosis affects many addicts. Poor mental health and substance abuse are common co-occurring disorders. The two go hand in hand, mental disorders can drive someone to use to cope with symptoms, or a mental disorder can pop up or be exacerbated because of substance abuse. When an addict deals with this it is identified as a dual-diagnosis. There is considerable debate surrounding the appropriateness using a single category for a group of individuals with complex needs and a varied range of problems.

The concept of dual diagnosis can be used broadly, for example depression and alcoholism. It can also be restricted to specify severe mental illness, like psychosis, schizophrenia and substance misuse disorder. Or like me, a person who has a mild mental illness and a drug dependency, such as panic disorder or generalized 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. This presents a clinician with unique challenges when treating a patient. Only in recent years has treatment begun to accurately identify and treat these conditions. After a slow start in understanding, progress is quickly being made.

I am a dual diagnosis patient. I have generalized anxiety disorder, depression, social anxiety, while also having an opioid dependency. I have dealt with these problems for a long time before ever being diagnosed. I began to use opiates to dull and numb the symptoms that were so hard to deal with for so long. The two started to become intertwined as the opiate use began to really worsen my depression as I felt bad about myself using it because I felt I needed it. I thought it gave me happiness when really it was internally doing the opposite. My social anxiety also worsened as I had to hide my use from friends who disapproved and it made me feel even more different and ashamed.

When I decided to go to an inpatient treatment facility my therapist at the time recommended me to look for ones that specialized in dual diagnosis. I decided that this was the right course of action because I knew I needed help with my mental issues and inpatient intensive therapy would help. Being sober was a foreign concept to me at the time, it just was not on my radar so I was less concerned with getting off drugs and alcohol but knew I needed some sort of help. I also thought a dual diagnosis facility would not be 12 step focused, without knowing anything about it I knew I didn’t want it based on some sort of stigma I had for alcoholics and addicts. Of course I didn’t think I was an alcoholic or an addict, I was just using it like a medicine to cope with mental illness. I thought that once I got help with my underlying issues I could use like a normal person again. I found the facility that fit my needs and once I got there I was shocked at what the program was really about, but something did click with me as it set in. I was tired of what I was doing to myself, I realized that opiates were exacerbating my issues and just the symptom of the larger problem.

My treatment support system was really understanding of prior trauma and depression and worked with me. Especially when those character defects showed themselves much more fiercely when I no longer had drugs to cope. Without the support of dual diagnosis treatment, I don’t think I would still be sober today.

That said lets look at the history of dual diagnosis and how treatment for it came to fruition. In the mid-1980s mental health agencies and addiction specialists recognized that patients presenting with co-occurring disorders required help beyond their existing capabilities. Mental health services were challenged by patients whose primary disorders were schizophrenia, bipolar disorder, and major depressive disorders that required a high amount of care, and adjustment disorders that required only small but specialized attention. The clinical needs of many patients suffering from these problems were compounded by secondary substance use disorders that mental health facilities were not equipped to treat. On the other hand, facilities for alcoholism and addiction treatment found that entry-level patients met their criteria for admission, but mental health issues were interfering with assessment and therapy.

The research and literature on these co-occurring disorders were in their beginning stages and hard to even find. A treatment overhaul was in order and cooperation between both treatment providers was imperative to start treating patients with these needs. Over the next decade both types of treatment providers slowly began to change in order to meet the needs of patients with co-occurring disorders. Now there is widespread recognition that this challenging population requires its own tailored treatment. Yet some still resist these changes, holding onto old practices or not fully implementing new treatment programs. They fail to accept the evidence of many epidemiological studies that mental health disorders and substance use disorders are not separate issues but coexist in a large segment of the population that are treated.

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; this works out to 7.98 million people. Only a small proportion of those with co-occurring disorders actually receive treatment for both disorders. In 2011, it was estimated that only 12.4% of American adults with co-occurring disorders were receiving both mental health and addictions treatment. Clients with co-occurring disorders face challenges accessing treatment, as they may be excluded from mental health services if they admit to a substance abuse problem, and vice versa.

The reason these figures are so low is because of the problems that come with actually diagnosing and treating patients. Drug abuse, including alcohol and prescription drugs, can induce symptomatology 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 drug or alcohol abusers disappear with prolonged abstinence. Substance induced psychiatric symptoms can occur both in the intoxicated state and also during the withdrawal state. In some cases these substance induced psychiatric disorders can persist long after detoxification, such as prolonged psychosis or depression after amphetamine or cocaine abuse. Abuse of hallucinogens can trigger delusional and other psychotic phenomena long after cessation of use and cannabis may trigger panic attacks during intoxication and with use it may cause a state similar to dysthymia. Severe anxiety and depression are commonly induced by sustained alcohol abuse which in most cases abates with prolonged abstinence. Even moderate sustained use of alcohol may increase anxiety and depression levels in some individuals. In most cases these drug induced psychiatric disorders fade away with prolonged abstinence. A protracted withdrawal syndrome can also occur with psychiatric and other symptoms persisting for months after cessation of use. Benzodiazepines are the most notable drug for inducing prolonged withdrawal effects with symptoms sometimes persisting for years after cessation of use.

Those with co-occurring disorders face a higher rate of relapse, hospitalization, and homelessness than those with just mental or substance abuse alone. They are at higher risk because the treatment while much better today is not widely accepted and adopted. Many are just treated for 1 disorder or both but not in a way that recognizes that one feeds off of the other. The cause is not yet known but there are many theories that are a bit out of the scope of this article. While treatment for dual diagnosis has come a long way it is still lacking and not widely accepted or available yet. It is important for awareness for dual diagnosis to be raised so treatment option standards can be raised so more people can be helped to recover from addiction and regain mental health.

C.S. Bridger is an LA based writer and photographer trying to make sense of recovery

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