Diagnosis: Substance Abuse And Mental Illness
Families who have mentally ill relatives whose problems
are compounded by substance abuse face problems of enormous proportions.
Mental health services are not well prepared to deal with patients having
both afflictions. Often only one of the two problems is identified. If
both are recognized, the individual may be bounced back and forth between
services for mental illness and those for substance abuse, or they may be
refused treatment by each of them.
While the picture regarding dual diagnosis has not been very positive at
this point, there are now signs that the problem is being recognized and
there is an increasing number of programs trying to address the treatment
needs of people with both problems. Research studies are beginning to help
us understand the scope of the problem. It is now generally agreed that as
much as 50 percent of the mentally ill population also has a substance
abuse problem. The drug most commonly used is alcohol, followed by
marijuana and cocaine. Prescription drugs such as tranquilizers and
sleeping medicines may also be abused.
The incidence of abuse is greater among males and those in the age bracket
of 18 to 44. People with mental illnesses may abuse drugs covertly without
their families knowing it. It is now reported that both families of
mentally ill relatives and mental health professionals underestimate the
amount of drug dependency among people in their care. There may be several
reasons for this. It may be difficult to separate the behaviors due to
mental illness from those due to drugs. There may be a degree of denial of
the problem because we have had so little to offer people with the
combined illnesses. Care givers might prefer not to acknowledge such a
frightening problem when so little hope has been offered.
Substance abuse complicates almost every aspect of care for the person
with mental illness. First of all, of course, these individuals are very
difficult to engage in treatment. Diagnosis is difficult because it takes
time to unravel the interacting effects of substance abuse and the mental
illness. They may have difficulty being accommodated at home and may not
be tolerated in community residences of rehabilitation programs. They lose
their support systems and suffer frequent relapses and hospitalizations.
Violence is more prevalent among the dually diagnosed population. Both
domestic violence and suicide attempts are more common, and of the
mentally ill who wind up in jails and prisons, there is a high percentage
of drug abusers. Given severe consequences of drug abuse for the mentally
ill, it is reasonable to ask: "Why do they do it?" Some of them
may begin to use drugs or alcohol for recreational use, the same as many
other people do. Various factors may account for their continued use.
Probably many people continue their use as a misguided attempt to treat
symptoms of the illness or the side effects of their medications. They
find that they can reduce the level of anxiety or depression -- at least
for the short term. Some professionals speculate that there may be some
underlying vulnerability of the individual that precipitates both mental
illness and substance abuse. They believe that these individuals may be at
risk with even mild drug use.
Social factors may also play a part in continued use. People with mental
illnesses suffer from what has been called "downward drift."
This means that as a consequence of their illness they may find themselves
living in marginal neighborhoods where drug use prevails. Having great
difficulty developing social relationships, some people find themselves
more easily accepted by groups whose social activity is based on drug use.
Some may believe that an identity based on drug addiction is more
acceptable than one based on mental illness.
We realize that this overview of the problem of drugs and mental illness
is not a very positive one. However, we believe there are some encouraging
signs that better understanding of the problem and potential treatments
are on the way. Just as families have faced other very troublesome
problems in the past and developed adequate responses to them, we believe
that they can learn to deal with this one in a way that their lives become
less troubled and their relatives begin receiving better treatment.
Copyright 1993 National Alliance for the Mentally Ill
By Agnes B. Hatfield, Ph.D.
"Dual Diagnosis" refers to those who have been diagnosed
with major mental health disorders and alcohol or substance addictions at
the same time.
At least 50 percent of the 2 million Americans with
severe mental illness abuse illicit drugs or alcohol, compared to 15
percent of the general population, according to the Alcohol, Drug Abuse,
and Mental Health Administration.
The problem for professional counselors and mental
health care providers in trying to help these patients is making an
accurate diagnosis. According to Patrick Smith, M.A., of PacifiCare
Behavioral Health, "A substance abuse problem can mimic, mask, or
aggravate various mental health disorders.
Drug and alcohol problems and mental illnesses often
go hand-in-hand. Among alcoholics, nearly half have an overlapping mental
illness or other substance dependence problem. Substance dependence can
cover up a serious psychiatric illness, while depression can disguise a
The "double troubled" patient can be
extremely difficult to recognize. Often only one of the two problems is
identified. The patient diagnosed with a mental disorder may be in denial
about the drinking or substance abuse, while the obvious substance abuse
of others can disguise the mental disorder.
With teens the diagnosis can be extremely difficult.
As one counselor says, "How can (we) separate the normal mood
variations of a fifteen year old teenager from certain Bi-polar disorders?
When substance use or abuse is present, with resulting mood fluctuation,
the variables become staggering."
"It is not uncommon," according to Harold
E. Doweiko's Concepts of Chemical Dependency, "for dual diagnosed
clients to use one disorder to shield for another disorder." One
client may admit to mental health issues in order to avoid his substance
abuse and, once the psychiatric issues are resolved, drop out of
Another client may deny her disorder because "it
is less threatening to be a junkie" than to accept a diagnosis of
paranoid schizophrenia, Doweiko says. Frustration and depression may
hinder one client's ability to recognize and ask for help, while another
client may become confused by a lack of knowledge of the processes and
goals of treatment services.
Crises for Families
Families who have mentally ill relatives whose
problems are compounded by substance abuse face problems of enormous
proportions. Mental health services are not well prepared to deal with
patients having both afflictions or supporting their families.
Violence is more prevalent among the dually
diagnosed. Domestic violence and suicide attempts are more common, and of
the mentally ill who wind up in jails and prisons, there is a high
percentage of drug abusers.
It is also known that sexual abuse has been a problem
for many who are dually diagnosed. One report says that an estimated 40
percent of those attending Dual Diagnosis meetings, have had experiences
with sexual abuse also.
Copyright 1993 National Alliance for the Mentally Ill
(used with permission of NAMI 2003)