Chapter 3

The Problem of Dual Diagnosis

 Dual Diagnosis and Comorbidity
• Comorbidity
– Combinations of any types of psychiatric disorders
that co-occur in the same individual
• Dual diagnosis
– Describes individuals who meet diagnostic criteria for
a mental disorder(s) along with one or more
substance use disorders
• More than half of patients in psychiatric
treatment meet criteria for more than one
diagnosis
 Methodological Issues in the
Assessment of Dual Diagnosis
• Sample selection influences findings

• Clinical sample vs. general population

• Berkson’s fallacy
 Dual Diagnosis: Methodological Issues

• Factors that affect rates of dual diagnosis:

– Demographics (e.g., age and sex)
• Males and those of younger age are more likely to
abuse substances
– Inpatient or outpatient status and chronicity of illness
• More severely impaired inpatients (e.g., schizophrenics)
are less likely to abuse substances than are patients
who are less ill
– Setting
• Hospital emergency rooms reflect higher estimates
than other settings
Dual Diagnosis: Methodological Issues

• Definitions of what constitutes dual diagnosis

are far from uniform
– Studies often use differing definitions and
measures of substance use disorders, making
prevalence rates diverse and difficult to compare
Dual Diagnosis: Methodological Issues

• Methods used to determine psychiatric and

substance use diagnoses can influence findings
– Research with clinical samples will often employ
less-standardized assessments
– Assessments measure different substances in their
assessments of dual diagnosis
• Split between the mental health and substance
abuse treatment systems impacts dual-
diagnosis research
 High Rates of Dual Diagnosis
• Exist in community samples
– Overall, studies find that a psychiatric diagnosis
yields at least double the risk of a lifetime alcohol
or drug use disorder
• Rates of dual diagnosis persist over time
• Changes in definitions (DSM-5) will impact
prevalence rates of dual diagnosis in future
research
 General Psychiatric Patients
• Highest rates are among patients with severe mental
illnesses
– Bipolar disorder
• 45% have an alcohol use disorder and 39% have a drug use disorder
– Schizophrenia or paranoid disorders
• 42% have an alcohol use disorder and 38% have another substance
use disorder
• Other patient groups
– Major depression
• 33% have an alcohol use disorder and 18% have a drug use disorder
– Anxiety disorders
• 19% have an alcohol use disorder and 11% have another substance
use disorder
 Dual Diagnosis: Patients With Primary Substance Use Disorders

• High rates of dual disorders across diverse

samples of patients seeking substance abuse
treatment
• Treatment-seeking substance abusers show high
rates of both major depression and bipolar
disorder
• Comorbid patients showed greater problems at
baseline (more disabled, drank more heavily)
than did substance-abuse-only patients
– Difference persisted at 3-month follow-up
 Dual Diagnosis: Impact on
Patient Functioning

• Impacts the severity and course of many

disorders, especially among patients with serious
mental illnesses
– Schizophrenia, bipolar disorder, and recurrent major
depression
• More frequent hospitalizations and more relapses
for comorbid substance abusers
• Poorer overall life functioning
– Social stability
– Health quality
– Life satisfaction
 Dual Diagnosis: Impact on
Patient Functioning

• Cognitive functioning
– Chronic or sustained substance use can contribute to
cognitive impairment and resulting brain dysfunction
– Overall, no difference on composite scores of
cognitive functioning exist between individuals with
schizophrenia with or without an SUD
– Significantly more work is needed to understand the
specifics of cognitive functioning in dual disorders
both with regard to preexisting impairment as well
as a sequelae of chronic substance use
 Dual Diagnosis: Impact on
Patient Functioning

• Treatment noncompliance
– Substance use often interferes with compliance with both
behavioral and pharmacological treatments
– Linked to poorer outcomes
• Violence
– Substance use and its associated noncompliance with
treatment is also linked to greater risk for violence
– Risk for violent crime among individuals with bipolar
disorder is almost entirely due to substance abuse
comorbidity
• Those with bipolar-only diagnoses show extremely low risk for
violent crime
 Dual Diagnosis: Impact on
Patient Functioning

• Suicide
– Lifetime rates of suicide attempts were higher for those with dual
bipolar disorder and alcohol use disorders (25.29%) than for
respondents with bipolar disorder alone (14.78%)
– Psychiatric inpatients with major depressive disorder and a
substance use disorder had higher levels of suicidal ideation
• Service utilization and health care cost
– Increased rate of treatment seeking
– Patients with dual diagnoses had psychiatric treatment costs that
were approximately 60% higher than the costs of psychiatrically
impaired individuals without substance abuse
– Yet poorer outcomes often associated with short-term treatment,
noncompliance, and lack of integrated care
 Dual Diagnosis: Impact on
Patient Functioning
• Physical illness
– Individuals with dual diagnosis show increased risk
for HIV and AIDS
• People with schizophrenia and other severe mental
illness are now one of the highest-risk groups
– Substance use substantially increases the
likelihood of unsafe sex practices and other high-
risk behaviors (injection drug use) in those with
mental illness
 Dual Diagnosis: Impact on
Patient Functioning
• Legal problems
– While rates of arrest are high, patients are four times
more likely to have encounters with the legal system that
do not result in arrest
• Continued substance abuse over a long-term follow-up
period was significantly associated with a greater likelihood
of arrest
• Homelessness
– Patients are more likely to live in an unstable housing
situation or to be homeless
– Those with mental illness and substance abuse are more
than 4 times as likely to be homeless than are patients
who did not abuse substances
 Dual Diagnosis: Impact on
Patient Functioning

• Issues for Women

– Those with comorbid severe mental illness and
substance abuse show:
• Poorer retention in treatment
• Elevated levels of anxiety, depression, and medical
illness
• More difficult to engage in treatment and are
underrepresented in treatment overall
• Higher rates of sexual and physical victimization than
the general population
Interpretation of Psychopathology and Treatment Outcome Research

• The overall result of screening out those with

substance use disorders is that there are very few
data to inform treatment
– Given the significant rates of dual disorders found in
clinical samples, such an omission is clearly
problematic
– It is unclear how well findings will generalize to the
larger population of individuals with a particular
disorder if patients with dual diagnoses are not
included
• Solutions involve statistical analyses
 Dual Disorders: Assessment
and Diagnosis

• Symptom overlap
– Symptoms of many psychiatric disorders overlap
with those of substance use disorders
• For example, DSM lists problems in social functioning as
symptoms of both schizophrenia and substance use
disorders
• Criteria counting toward multiple diagnoses can
potentially increase comorbidity rates and can make a
diagnosis of substance abuse difficult
 Dual Disorders: Assessment
and Diagnosis

• Substance-induced disorders may resemble

psychiatric disorders
– Because symptoms of substance use and
withdrawal can resemble psychiatric symptoms,
differential diagnosis may be confounded
– Incorrect treatment decisions may be made if
interventions are aimed at what appear to be
acute symptoms of psychiatric disorder but are in
fact substance-induced symptoms
 Theories of Dual Diagnosis
• Common factors models
– Some shared influence is responsible for the
development of both psychiatric and substance use
disorders (e.g., genetic)
– Twin, adoption, and family studies clearly show that
both mental illness and substance abuse run in families
– Studies of familial transmission for comorbid
psychiatric and substance use disorders find little
evidence for a common genetic factor
– Family history may inspire both dysfunctional family
interactions and inheritance of deviant personality
traits
• Borderline personality disorder and substance use disorders
 Theories of Dual Diagnosis
• Causal models: Secondary substance use disorder
model
– Self-medication model
• Patients with psychiatric disorders use substances to self-
medicate and relieve discomfort associated with the primary
psychiatric disorder
– Social facilitation model
• Patients with severe mental illness may have fewer
opportunities for social interaction, and substance abuse helps
the process of social engagement in patients who lack
appropriate social and interpersonal skills
– Neurobiological mechanisms
• Neurobiological deficits and abnormalities that provide the basis
for different forms of mental illness may also predispose for
substance abuse
 Theories of Dual Diagnosis
• Causal models: Secondary psychiatric disorder
model
• Substance abuse causes psychopathology
• Substance-induced psychiatric disorder
• Chronic alcohol use causes depression, but how?
– Considerable life stress that alcohol dependence promotes for
the drinker
– Pharmacological properties of alcohol as a depressant
substance
 Theories of Dual Diagnosis
• Bidirectional models
– Suggest that either psychiatric or substance use
disorders can increase risk and exacerbate the
impact of the other
– Alcohol and anxiety interact to produce an
exacerbation of both anxiety symptoms and drinking
– Feed-forward cycle
• Drinking is promoted by the short-term, anxiety-reducing
effects of alcohol
• At the same time, anxiety symptoms are worsened by
heavy drinking, leading to continued drinking in response
to these worsened anxiety symptoms