Introduction

Alcohol and other drug abuse and addiction constitute major health and safety concerns in the United States, with costs running into the billions of dollars annually for health care, related injuries and loss of life, property destruction, loss of productivity and more. Treatment is proven to be effective, but very few who need it have access to and receive care. Private and public funding for treatment remains meager. Families are devastated and children are at increased risk for their own addiction and mental health problems.

For people struggling with co-occurring mental health and substance abuse disorders, physical safety and overall health risks are greater; the impairment of life skills is greater; and the chances for successful treatment are much less - all of which contribute to stigma.

This area of the NMHA website is designed to assist mental health advocates in increasing their understanding of key issues in the area of substance abuse and co-occurring disorders. We are committed to providing accurate and timely materials and information about alcohol and other drug abuse and addiction to the advocates, consumer supporters and consumers in the mental health field.

If you have comments or questions about NMHA's work in the area of substance abuse/addiction, please contact:

Mental Health Information Center
800/969-NMHA
TTY Line 800/433-5959
infoctr@nmha.org

• Introduction
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Substance Abuse - Dual Diagnosis

What is Dual Diagnosis?
A person who has both an alcohol or drug problem and an emotional/psychiatric problem is said to have a dual diagnosis. To recover fully, the person needs treatment for both problems.

How Common Is Dual Diagnosis?
Dual diagnosis is more common than you might imagine. According to a report published by the Journal of the American Medical Association:

• Thirty-seven percent of alcohol abusers and fifty-three percent of drug abusers also have at least one serious mental illness.
  
  
• Of all people diagnosed as mentally ill, 29 percent abuse either alcohol or drugs.

What Kind of Mental or Emotional Problems are Seen in People with Dual Diagnosis?
The following psychiatric problems are common to occur in dual diagnosis - i.e., in tandem with alcohol or drug dependency.

• Depressive disorders, such as depression and bipolar disorder.
  
  
• Anxiety disorders, including generalized anxiety disorder, panic disorder, obsessive-compulsive disorder, and phobias.
  
  
• Other psychiatric disorders, such as schizophrenia and personality disorders.

The following table based on a National Institute of Mental Health study, lists seven major psychiatric disorders and shows how much each one increases an individual's risk for substance abuse.

Thus, someone suffering from schizophrenia is at a 10.1 percent higher-than-average risk of being an alcoholic or drug abuser. Someone who is having an episode of major depression is at a 4.1 percent higher-than-average risk of being an alcohol or drug abuser...and so on.

Which Develops First - Substance Abuse or the Emotional Problem?
It depends. Often the psychiatric problem develops first. In an attempt to feel calmer, more peppy, or more cheerful, a person with emotional symptoms may drink or use drugs; doctors call this "self-medication." Frequent self-medication may eventually lead to physical or psychological dependency on alcohol or drugs. If it does, the person then suffers from not just one problem, but two. In adolescents, however, drug or alcohol abuse may merge and continue into adulthood, which may contribute to the development of emotional difficulties or psychiatric disorders.

In other cases, alcohol or drug dependency is the primary condition. A person whose substance abuse problem has become severe may develop symptoms of a psychiatric disorder: perhaps episodes of depression, fits of rage, hallucinations, or suicide attempts.

How Can a Physician Tell Whether the Person's Primary Problem is Substance Abuse or an Emotional Disorder?
At the initial examination, it may be difficult to tell. Since many symptoms of severe substance abuse mimic other psychiatric conditions, the person must go through a withdrawal from alcohol and/or drugs before the physician can accurately assess whether there's an underlying psychiatric problem also.

If a Person Does Have Both an Alcohol/Drug Problem and an Emotional Problem, Which Should Be Treated First?
Ideally, both problems should be treated simultaneously. For any substance abuser, however, the first step in treatment must be detoxification - a period of time during which the body is allowed to cleanse itself of alcohol or drugs. Ideally, detoxification should take place under medical supervision. It can take a few days to a week or more, depending on what substances the person abused and for how long.

Until recently, alcoholics and drug addicts dreaded detoxification because it meant a painful and sometimes life-threatening "cold turkey" withdrawal. Now, doctors are able to give hospitalized substance abusers carefully chosen medications which can substantially ease withdrawal symptoms. Thus, when detoxification is done under medical supervision, it's safer and less traumatic.

What Is Next After Detoxification?
Once detoxification is completed, it's time for dual treatment; rehabilitation for the alcohol or drug problem and treatment for the psychiatric problem.

Rehabilitation for a substance abuse problem usually involves individual and group psychotherapy, education about alcohol and drugs, exercise, proper nutrition, and participation in a 12-step recovery program such as Alcoholics Anonymous. The idea is not just to stay off booze and drugs, but to learn to enjoy life without these "crutches."

Treatment for a psychiatric problem depends upon the diagnosis. For most disorders, individual and group therapy as well as medications are recommended. Expressive therapies and education about the particular psychiatric condition are often useful adjuncts. A support group of other people who are recovering from the same condition may also prove highly beneficial. Adjunct treatment, such as occupational or expressive therapy, can help individuals better understand and communicate their feelings or develop better problem-solving or decision-making skills.

Must a Dual Diagnosis Patient Be Treated in a Hospital?
Not necessarily. The nature and severity of the illness, the associated risks or complications, and the person's treatment history are some of the facts considered in determining the appropriate level of care. There are several different levels or intensities of care including full hospitalization or inpatient treatment, partial hospitalization, and outpatient treatment.

What is the Role of the Patient's Family in Treatment?
With both rehabilitation for substance abuse and treatment for a psychiatric problem, education, counseling sessions, and support groups for the patient's family are important aspects of overall care. The greater the family's understanding of the problems, the higher the chances the patient will have a lasting recovery.

How Can Family and Friends Help with Recovery from the Substance Abuse?
They need to learn to stop enabling. Enabling is acting in ways that essentially help or encourage the person to maintain their habit of drinking or getting high. For instance, a woman whose husband routinely drinks too much, might call in sick for him when he is too drunk to go to work. That's enabling. Likewise, family members or friends might give an addict money which is used to buy drugs, because they're either sorry for him or afraid of him. That's enabling also.

When family and friends participate in the recovery program, they learn how to stop enabling. If they act on what they've learned, the recovering substance abuser is much less likely to relapse into drinking or taking drugs.

How Can Family and Friends Help with Recovery from a Psychiatric Condition?
They should be calm and understanding, rather than frightened or critical. They should be warm and open, rather than cool or cautious. Although it is fine to ask the person matter-of-factly about the psychiatric treatment, that shouldn't be the only focus of conversation.

If Someone I Know Appears To Have A Substance Abuse Problem And The Symptoms Of A Psychiatric Disorder, How Can I Help?
Encourage the person to acknowledge the problems and seek help for themselves. Suggest a professional evaluation with a licensed physician, preferably at a medical center that's equipped to treat addiction problems and psychiatric conditions. If the person is reluctant, do the legwork yourself - find the facility, make the appointment, offer to go with the person. A little encouragement may be all it takes. If you talk to the physician first, be honest and candid about the troubling behavior. Your input may give the doctor valuable diagnostic clues.

There Is Hope
As a relative or friend, you can play an important role in encouraging a person to seek professional diagnosis and treatment. By learning about dual diagnosis, you can help this person find and stick with an effective recovery program.

The more you know about dual diagnosis, the more you will see how substance abuse can go hand-in-hand with another psychiatric condition. As with any illness, a person with dual diagnosis can improve once proper care is given. By seeking out information, you can learn to recognize the signs and symptoms of dual diagnosis - and help someone live a healthier or more fulfilling life.

Substance Abuse/Addictive Behavior

• Addictions - Habitsmart
• Addiction Resource Guide
• Alcoholics Anonymous
• Ask Dr. Steve
• Center for Alcohol and Addiction Studies
• Center for Education and Drug Abuse Research
• Cocaine Anonymous
• College on Problems of Drug Dependence
• Do It Now Foundation
• D.R.U.G.S.
• Drug Strategies
• Hazelden
• Jews In Recovery From Alcoholism And Drug Abuse
• Mothers Against Drunk Drivers
• National Association of Alcoholism and Drug Abuse Counselors
• National Association for Children of Alcoholics
• National Inhalant Prevention Coalition
• Sex Addicts Anonymous
• Sexaholics Anonymous
• SOS: Save Our Selves
• Web of Addictions

For More Information:
Contact your local Mental Health Association, community mental health center or:

National Mental Health Association
2001 N. Beauregard Street, 12th Floor
Alexandria, VA 22311
Phone 703/684-7722
Fax 703/684-5968

Mental Health Resource Center
800/969-NMHA
TTY Line 800/433-5959

National Clearinghouse on Alcohol and Drug Information
Phone: 800-729-6686
http://findtreatment.samhsa.gov

Dual Recovery Anonymous World Services Central Office
P.O. Box 8107
Prairie Village, KS 66208
Phone: 877-883-2332
http://draonline.org

Alcoholics Anonymous
475 Riverside Drive, 11th Floor
New York, NY 10115
Phone: 212-870-3400
www.aa.org

Narcotics Anonymous World Service Office in Los Angeles
P.O. Box 9999
Van Nuys, CA 91409
Phone: 818-773-9999
www.na.org

Alanon and Alateen Family Group Headquarters Inc.
1600 Corporate Landing Parkway
Virginia Beach, VA 23454-5617
Phone: 888-425-2666
www.al-anon.alateen.org

Learn More About The National Institute of Mental Health Outreach Partnership Program Here

For more information about the National Mental Health Association or additional resources, please call 1-800-969-NMHA (6642) or visit our website resource center.

National Institute on Drug Abuse

Institutes of Health ClinicalTrials.gov

Substance Abuse and Mental Health Services Administration

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