Dublin: BREAKING THE SILENCE: 5: Co-morbidity/Dual Diagnosis – Combined Mental Health & Drug Addiction Problems

8 Feb

Lost Children in the Wilderness ©

By J. P. Anderson (International registered copyright of the author 2006)

Is defined by the World Health Organization (WHO) as the ‘co-occurrence in the same individual of a psychoactive substance use disorder and another psychiatric disorder’ (WHO1995). According to the United Nations Office on Drugs and Crime (UNODC). A person with dual diagnosis is a ‘person diagnosed as having an alcohol or drug abuse problem in addition to some other diagnosis, usually psychiatric, (e, g; mood-disorder, schizophrenia’ (UNODCCP, 2000). In other words, co-morbidity in this context refers to the temporal (*worldly) coexistence of two or more psychiatric or personality disorders, (* Authors note; character disorders or disposition) one of which is problematic substance use:


Existing research about the casual relationship between psychiatric and substance disorder is inconclusive. The symptoms of mental disorder and addiction problems interact and mutually influence each other.

Research evidence indicates that psychiatric and personality disorders usually occur before substance use disorders, (I, e; ‘they increase the individual’s susceptibility to such problems). However, psychiatric disorders may also be aggravated by drug use (e, g; for depression; or occur in parallel).

The co-occurrence of psychiatric illness and substance disorders, commonly termed co-morbidity is not a new phenomenon, but in recent years has gained momentum, as it has become apparent that a large and probably growing number of people are affected. Care and treatment services are usually inadequately equipped to deal with the diagnostic and treatment needs of this client group, disregarding and/or being incapable of cooping with the totality of the clients problems. The result is frequently a ‘revolving door’ situation, with individuals in great need of treatment being referred from one service to another, while all the time their situation deteriorates.

Drug use can also be perceived as a component or symptom of psychiatric or personality disorder and as an attempt to self-medicate. The fact that substance use alleviates distressing symptoms encourages the development of addiction. Once the drug use is discontinued, (e, g; through withdrawl or substitution treatment, (methadone for example) the symptoms may reappear.

Acute drug-induced *psychoses (*mental disorder) occur particularly in users of cocaine, *amphetamines (*speed) and hallucinogens and usually subside relatively quickly. It may however, be very difficult to differentiate between symptoms due to substance intoxication and unrelated psychotic (disturbed) episodes.

In 2002, Irish studies concluded that there is a strong association between problem drug uses, in particular the use of opiates and benzodiazepines, and high rates of depression. Similar studies by German researchers drew similar conclusions. While in Norway a survey found that a high proportion of drug users have experienced severe family problems during childhood and youth. Some 70% had experienced learning and behaviour problems in school, 38% had been the victims of ‘bullying’ and 21% had received psychiatric treatment during childhood and adolescence. Female drug users with psychiatric co-morbidity have often been the victims of traumatic sexual abuse. Except in some particularly aware and/or specialised services, mental symptoms and disorders are rarely explored in drug treatment services. Co-morbidity is notoriously difficult to diagnose. Drug addiction and the disruptive behaviour it causes often dominate the clinical picture and disguises psychiatric symptoms.

In addition, substance abuse can cause psychiatric symptoms that are barley distinguishable from those of psychiatric disorders, while substance withdrawl or acute intoxication can also mimic almost any such disorder. Furthermore, depression and anxiety can be viewed as inherent symptoms of the intoxication-withdrawl cycle; symptoms that used to be alleviated by drugs become *manifest (*not concealed) in the course of abstinence or substitution treatment.

A wide range of standardised and validated instruments are now available to measure psychiatric symptoms and personality disorder, as are various instruments that assess the level of drug use-patterns and addiction, such as the ‘Addiction Severity Index’ (ASI) which has the advantage of being multi-dimensional, measuring past and current problems in seven areas: Health status, employment and self-support, alcohol use, drug use, legal status, family and social relationships and psychiatric symptoms. It is standardised and has been translated from English into most other European languages.

A review of different studies covering the area of psychiatric and personality disorders, as well as drug-use patterns in the general population, as well as among psychiatric patients and drug users in and outside of treatment services, concluded that the most common psychiatric diagnosis among drug users is personality disorder, (affecting 50 – 90%) followed by (affective disorder 20 – 60%) and (psychotic disorders 20%).

Between 10 and 50% of patients exhibit more than one psychiatric or personality

Co-morbidity disorder.

In a review of different international studies on psychopathology in drug dependant subjects, which outlined a clinical picture of co-morbidity in drug addiction that has been confirmed by his own studies in Lund, Sweden (Fridell 1991, 1996) in which three main groups of disorders could be identified: (Personality disorder 65 – 85%), (depression and anxiety states 30 – 50%) and (psychoses 15%). In another overview of six studies of treated addicts, (Verheul 2001), found that (Antisocial 23%), (borderline 18%) and (paranoid 10%), personality disorders were particularly prevalent.

Treatment periods for opiate use combined with psychiatric disorders have tripled since 1996. This is consistent with the increase in drug use. In Ireland, the rate of first admission of drug users to in-patient psychiatric services increased almost four-fold between 1990 and 2001. Data on psychiatric disorders in drug treatment settings are not readily available, (as such), and under-diagnosis is likely in many cases.

The more limited the extent of socially unacceptable behaviour the more it is, that socially deviant individuals are involved in it. A Norwegian study examined gender differences between poly-substance abusers, (of whom 85% were heroin users) and pure alcoholics. The sample included a very high proportion of subjects with psychiatric and personality disorders (93%). Overall, women had significantly higher levels of major depression, simple phobia and borderline personality disorder than men. The co-occurrence of an Antisocial Personality Disorder was highest in male poly-substance abusers.

The prison population deserves particular attention. The prevalence of psychiatric disturbances, like the prevalence of drug use, is much higher in the prison population than among the population overall. Irish data suggest that 48% of male and 75% of female prisoners are mentally disturbed, while 72% of men and 83% of women in prison report lifetime experience of drug use.

In 1999, (23% of problem drug users held at the Vienna Police Detention Centre had psychiatric problems). The relapse rate among drug users who have served prison sentences is high, and there is increasing recognition that ’incarceration’ (imprisonment) can contribute to a worsening of mental health problems. The situation is even more dramatic in long-term and high-security prisons.

In Sweden, between 72% and 84% of adults in compulsory drug treatment was found to suffer from psychiatric problems in addition to being substance abusers. Of 46 substance-dependant girls in compulsory care for children and young people, two-thirds had psychiatric diagnoses or personality disorders.

(*Authors note: Source, EMCDDA Annual Report 2004).

As in so many drug-related areas, documentation, evaluation and research in the area of co-morbidity treatment is deplorable. Both psychiatric teams and substance abuse services, regularly fail to identify significant numbers of patients with co-morbidity.When patients with dual-diagnoses seek treatment, their acute psychiatric syndromes are often mistaken for substance-induced symptoms or, conversely, withdrawl or intoxication phenomena misinterpreted as psychiatric illness.

One of the main obstacles to the diagnosis and treatment of co-morbidity is the fact that psychiatric staff generally has little knowledge of drug treatment and drug treatment staff generally know little about psychiatry. Too often, mental health workers are inclined to send people with co-morbidity to addiction care, and workers in addiction care, promptly send them back-or vice-versa. Continuity of care is impossible under such circumstances. Even when co-morbidity is diagnosed, it is often considered no further in the subsequent interventions. The same is true of patients diagnosed with substance use problems in psychiatric care, who normally do not receive any substance-related interventions. (Not to exclude the fact that some psychiatric and drug services achieve very good results with patients with co-morbidity).

Drug users,

when identified, are often met with suspicion in psychiatric services, and may be refused admission, as may happen to users who are stable on ’substitution’ treatment. Similarly, clients may be excluded from drug treatment because of their mental health problems. In Greece, for example, 54% of drug-treatment programmes do not admit drug users with psychiatric disorders. In other countries, such drug treatment programmes, require patients to be drug free as a condition for admission. In the case of dual diagnosis patients, this presents a serious obstacle, as complete abstinence would require the termination of other treatments, which is not always possible.The Australian national co-morbidity project. (Commonwealth Department for Health and Ageing, 2003), has concluded from a literature review, that approaches to the management and care of co-morbidity clients, have not been studied systematically or evaluated rigorously, partly because of the difficulty of studying people with co-existing mental illness and substance abuse disorder, among other reasons, because of their irregular lifestyle.

Some experts believe that the treatment services, at least for the seriously mentally ill with substance use problems, should be based in psychiatry, possibly involving external drug therapist. … In Luxembourg and in Norway, specific measures have been initiated by psychiatric services to reach individuals in the early stages of schizophrenia, many of whom have serious substance abuse problems, as research indicates that early treatment improves the prognosis.

The Czech national report, suggests that addiction problems should usually be considered more urgent than mental health problems, as it is more difficult to treat psychiatric disorders, when addiction distorts the clinical picture….

It has long been the view of some professionals, that all pharmacotherapy should be avoided in drug addicted persons, because of the risk of combined addiction, (e, g; to heroin and benzodiazepines, but this view is beginning to be reconsidered. In some cases, there is a tendency to prescribe psychopharacological medication indiscriminately to drug users, partly because of lack of time to conduct the necessary investigations, low compliance among drug users makes pharmacological treatment of psychiatric conditions difficult and, in addiction, the combined uses of narcotic substances and medicines may, if not properly supervised, lead to interaction between illicit and prescribed medicines or to neutralisation of the prescribed medicine.

Shared responsibility for one client between a mental health and a drug service in a parallel treatment model appears to be rare in practice. In Luxembourg and Austria, drug treatment staff may follow up their clients who have been referred to psychiatric hospitals.

United Kingdom guidelines stress that professionals from both addiction and mental care services should be involved in planning the care of a dual-diagnosis client in order to prioritise care pathways. In most countries, there are only a few specialised integrated programmes or units for co-morbidity patients, and the availability is far from meeting the demand.

In Luxembourg as well as in the Netherlands, professionals have come to recognise that case management is the most effective way of dealing with dual-diagnosis patients, but it is costly and time consuming and requires specific professional skills.

The treatment of clients with co-morbidity is characterised by many problems and is extremely demanding on staff and often un-rewarding. Clients are often difficult to manage because of their disruptive and aggressive anti-social behaviour; especially those with the more ‘dramatic’ type of personality disorders, combined with their emotional instability means that, the success is generally low and drop-out rates are high.

A lack of follow-up procedures and aftercare leads to high relapse rates, and both mental and substance disorders frequently become chronic.(Staff, not surprisingly, often experience impatience, suppressed-aggression and symptoms of burn-out). Clients have often had many negative encounters with support services and may, therefore, be reluctant or unwilling to undergo treatment.

In most countries, doctors and nurses in training receive very little instruction about drug addiction and even less about the issue of co-morbidity.

In the United Kingdom, The Royal College of Psychiatry undertook a training needs analysis with a variety of professional groups, from both mental health and drug services (2001). Some 55% of the sample reported that they felt inadequately prepared to work with clients with co-morbidity and expressed a need for further training.

(*Authors note: Source, EMCDDA: Annual Report 2004).

Obstacles to treatment of co-morbidity:

In fact, often it is appropriate to speak about ‘ multi-morbidity’

as affected individuals often suffer from ‘somatic’ illness, (e, g; HIV or Hepatitis ‘C’ virus infection, as well as social disorders, such as, family problems, unemployment, imprisonment or homelessness.


Co-morbidity or dual diagnosis:


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