Mood

Alcohol and Substance Use

Unfortunately, far too many of us have to contend with this.

"By the time I was 17," writes Brenda on the website Bipolar World, "I was a full-blown alcoholic and that's when the drugs came in. I still to this very day do not know how I made it though high school and then some college. The alcohol did not work to keep me in check, and someone introduced me to crack. Well, my god, I thought I found my answer, but that was short-lived. There was a time in 1991 that I was in such a manic state that I actually set my own apartment on fire. I do not remember much of it because I was way out of it."

Two suicide attempts followed the birth of her first child, and after three hospitalizations she learned she had bipolar disorder. Medications soon stabilized her, and in 1992, following the birth of her second child, she went into detox and has been clean ever since.

Nevertheless, she feels she is living with a sword of Damocles hanging over her head:

"I am now 35 years old, I have been sober and stable for nearly nine years now, and sometimes I feel like I’m going to lose it all. Everything I’ve worked for feels like it’s just slipping away and I know I can’t let this happen. My life depends on it. I do not have another recovery in me. For now all I can do is stay with my therapy, stay on my meds, and pray to God I make it through just one more day. For me one day at a time is all I can do, some days I have to take it minute by minute."

Dual Diagnosis

Welcome to the real world, where mental illness rarely is so considerate as to neatly dole out one disorder per person for easy diagnosis and treatment. In Brenda’s case, Mother Nature has dealt her both barrels, a powerful double whammy - a mood disorder coupled with a substance use problem, commonly referred to as dual diagnosis - where one illness tends to feed off the other, creating a cruel reverse synergy that drastically worsens the outcome of both.

According to an article in April 2001 Psychiatric Times by Mark Albanese MD of Harvard, bipolar patients with a substance use problem experience more mixed episodes and rapid-cycling, longer recovery times, and greater resistance to lithium. They also must deal with earlier onset of bipolar disorder, earlier and more hospitalizations, and greater likelihood of yet another psychiatric or personality disorder. Meanwhile, major depression is a surefire indicator of a likely relapse into alcoholism, and the combination of major depression and substance use accounts for the largest group of those who attempt suicide.

According to the Department of Health and Human Services, in any given year seven to 10 million individuals in the US have at least one mental disorder as well as an alcohol or drug use disorder. The Surgeon General in his 1999 Report on Mental Health estimated 51 percent of those with lifetime mental illness also have a lifetime history of at least one substance use disorder. For people with bipolar disorder, the Epidemiologic Catchment Survey reports 61 percent with a lifetime substance use disorder, more than five times the rate of the general population.

Unfortunately, “individuals experiencing these disorders simultaneously ... have particular difficulty seeking and receiving diagnostic and treatment services, even though, separately, these disorders often are as treatable as other chronic illnesses.”

Dual Diagnosis and SAMHSA

The above is from a timely and comprehensive 2002 Report to Congress on the Treatment and Prevention of Co-Occurring Substance Abuse and Mental Disorders by the Substance Abuse and and Mental Health Services Administration (SAMHSA), part of the US Department of Health and Human Services. Sadly, SAMHSA notes, one type of disorder or the other tends to go untreated, resulting in worsened outcomes for both, with tragically predicable results - of the mentally ill in prison, for example, 72 percent of them also have a substance use disorder, and of the mentally ill who are homeless, 50 percent have a substance use disorder.

To summarize SAMHSA’s Report:

“Dual diagnosis” is an “unfortunate misnomer,” as rarely do people experience ONLY two disorders. SAMHSA favors the term, “co-occurring disorders.” One type of disorder may trigger the other, but 90 percent of the time, according to National Comorbidity Survey (NCS) data, mental illness precedes substance use. On average, mental illness occurs at around age 11 followed by substance use five to 10 years later. On the other side of the coin, drug use can produce psychotic symptoms, result in a relapse of a psychotic illness, or create a need for meds adjustments.

Dual Diagnosis Treatment

Regardless of which disorder an individual experiences first, SAMHSA emphasizes that “both disorders must be considered as primary and treated as such.” Unfortunately, according to NCS findings, of those with co-occurring disorders, only 49 percent are treated for serious mental illness, 29 percent for substance use, and a mere 19 percent for both. Putting it another way, citing other studies, of an estimated prevalence rate of 4.8 percent for co-occurring disorders, only 0.2 to 0.9 percent are getting the full range of treatment.

Those who do get treatment generally wind up in the hospital. In 1996 there were 87 hospital stays per 1,000 for individuals with mental illness only and 23 hospital stays for those with substance use only. Having both disorders, however, resulted in a rate of 457 (no typo) hospitalizations per 1,000. Meanwhile, those with co-occurring disorders comprise 10 percent of the homeless population but use nearly half of all homeless emergency assistance resources.

Lack of integrated treatment is the rule. Instead, patients tend to be treated sequentially (first one provider, then another) or in parallel (two separate providers concurrently) with few attempts to integrate services and with cross-trained clinicians in short supply. Conflicting treatment philosophies, separate sources of funding, different eligibility requirements, local zoning, and lack of wraparound services (such as providing transportation to a facility on the other side of town) frustrates even the best-intentioned.

SAMHSA favors an integrated approach, ranging from consultations between separate providers to a single treatment setting, depending on the severity of one or both disorders. A series of 1998 studies comparing integrated treatment with non-integrated treatment found better progress toward substance use and alcohol use recovery in the integrated treatment group, including less hospitalizations. Other studies have found integrated treatment to be cost effective.

Dual Diagnosis Risk and Protective Factors

A common set of childhood risk factors such as poverty, family discord, and pre and postnatal complications appear to be implicated in both mental illness and substance use. Stress and trauma loom large. For example between 51 and 97 percent of women with serious mental illness have been physically or sexually abused and 41 to 71 percent of women treated for alcohol or drug use report being sexually abused. Children with two or more family risk factors for mental illness are four to 10 times more likely to develop a psychiatric disorder than children with no risk or just one risk factor, and similar outcomes govern substance use.

Forty-three percent of youth who use mental health services in the US have been diagnosed with a co-occurring disorder. Adolescents with depression are four times more likely to develop substance use disorders. Two-thirds of the one million youth who have contact with the justice system have one or more substance use and mental disorders. Kids using marijuana are four times more likely to report symptoms related to conduct or attention deficit disorders or to have dropped out of school, been in a fight, or been engaged in an illegal activity.

Troubled youth in transition to adulthood represent a special risk, many who leave child services with few skills and little support. For adults, risks include breakup of intimate relations, death of a family member or friend, economic hardship, racism, and trauma, while in seniors bereavement, chronic illness, physical disability, and social isolation are things to watch out for.

By contrast, protective factors include the ability to cope, and family, peer, and institutional support.

The time lag between childhood onset of a mental disorder and later substance use presents what SAMHSA calls a “window of opportunity” for prevention, where early diagnosis and treatment of the mental disorder may nip potential substance use in the bud. Accordingly, SAMHSA strongly advocates K-12 prevention in the schools, as well as early intervention programs involving the family. For adults and seniors, SAMHSA emphasizes the need for primary care practitioners to be more alert, with the need for routine screening.

SAMHSA notes that individuals with mental illness are more likely to be using drugs or alcohol when they commit a crime, and that some jurisdictions find it easier to incarcerate rather than treat. Some communities, however, are finding ways to divert offenders into integrated services.

Families

The innocent bystanders to dual diagnosis tend to be family. The National Alliance for the Mentally Ill advises its members (largely family of those who are mentally ill) to avoid making threats about calling the police or hospitalization unless you mean to do it, to try to find a family consensus on the problem and how to solve it, and to give the matter time.

According to NAMI:

"It will be easier if the family can close ranks, avoid blaming each other, agree on a plan of action, and provide support to each other. It is also important to seek support from other families who are dealing with dually diagnosed relatives."

NAMI also advises not to regard this as a family disgrace, not to preach, not to get jealous of the method of recovery the individual chooses (such as turning to other people for support), don't expect an immediate recovery, try to protect the individual from using or drinking situations, don't do for the individual what he can do himself, and do offer love, support, and understanding.

An Encouraging Word

With dual diagnosis, it may seem that you are pushing two rocks uphill. Lest you allow yourself to become overwhelmed at the thought, permit me state that I am familiar with people in my support group who successfully manage both their mood disorder and their substance or alcohol use problem. They would be the very last to tell you it's a rose garden, but they would also be the first to let you know it's not a reason to abandon hope, either. You have your work more than cut out for you, but keep in mind four simple words: You are worth it.

Published 2002, reviewed Feb 10, 2008

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