Dual Diagnosis

When a mental health problem goes untreated, the substance abuse problem usually gets worse. And when alcohol or drug abuse increases, mental health problems usually increase too. Therefore, which issue do you treat first? One runs parallel with the other and has to be treated together to gain any success and allow an individual to move forward to a happier life.

• It is thought that roughly 50% of individuals with severe mental disorders are affected by substance abuse. Often caused my self-medication to mask mental health symptoms. It is suggested that approximately 37% of alcohol abusers and 53% of drug abusers also have at least one serious mental illness, usually exacerbated by substance abuse. Of all people diagnosed as mentally ill, it is considered that more than 30% abuse alcohol or drugs. All these figures are approximate. COVID and lockdown will undoubtedly have caused an increase in these figures. 

Substance abuse problems and mental health issues will not improve when they are ignored. Without professional intervention, they are likely to get much worse. Professional support can make a huge difference, slow measured support with the right help will help repair relationships and start acknowledgement that will help and start the road to recovery. There is a life after addiction and a person’s mental health can improve with counselling, patience and a lot of help. With the right support, self-help, and treatment, you can overcome a co-occurring disorder, reclaim your self-esteem, and get your life back on track. That help is paramount.

Mental health issues or substance misuse, what comes first?

Substance abuse and mental health disorders such as depression and anxiety are closely linked, although one doesn’t necessarily directly cause the other. Abusing substances such as marijuana or methamphetamine can cause prolonged psychotic reactions while abusing alcohol can make depression and anxiety symptoms worse.

Alcohol and drugs are often used to self-medicate the symptoms of mental health problems. 

People often abuse alcohol or drugs to ease the symptoms of an undiagnosed mental disorder. This may be to cope with difficult emotions or to temporarily change their mood. Unfortunately, self-medicating with drugs causes side effects, in the long run undoubtedly this will make the symptoms worse and exacerbate the symptoms that an individual is trying to mask.

Alcohol and drug abuse can increase the underlying risk for mental disorders. 

Mental health problems are caused by a complex interplay of genetics, the environment, and other influencing factors, it is very difficult to say if abusing substances is the direct cause of mental health problems. Anyone prone to mental health issues, will increase symptoms by using drugs. For example, there is some evidence that people who abuse drugs such as opioids are at greater risk for depression and heavy cannabis use has been linked to an increased risk for schizophrenia and paranoia.

Alcohol and drug abuse can make symptoms of a mental health problem worse. Substance abuse can increase the terrible issues of mental health problems. Using certain drugs mixed with alcohol can cause depression for example.  Alcohol is among the most used and abused drugs. Alcohol generally has central nervous system depressant actions; however, at very small doses, individuals who consume it may experience mild stimulant-like effects. Combining benzodiazepines, or benzos, with alcohol can be dangerous. Not only do you run a higher risk of side effects from using the substances together, but you also have a higher chance of overdose and death.

It can be difficult to identify a dual diagnosis. It takes time to establish what might be a mental health disorder and what might be a drug or alcohol problem. 

The signs and symptoms also vary depending upon both the mental health problem and the type of substance being abused, whether it’s alcohol, recreational drugs, or prescription medications. For example, the signs of depression and marijuana abuse can manifest into very symptoms and signs from that of schizophrenia with alcohol abuse. This is why it is important to get professional help and advice.

Some signs can be apparent in individuals:

• Is alcohol or drugs used to cope with unpleasant memories or feelings, difficulty to control pain or the intensity of moods, to face situations that frighten, or to stay focused on tasks?
• Is there a relationship between substance use and your mental health? For example, depression or very low mood when drinking? Or drink when you’re feeling anxious or emotionally distressed by unhappy memories.
• Family history can be a factor with either a mental disorder or alcohol or drug abuse?
• Has the individual had previously been treated for either addiction or mental health problems? Did the substance abuse treatment fail because of complications from a mental health issue or vice versa?
• Does the individual feel depressed, anxious, or otherwise out of balance, especially when not under the influence of alcohol or drugs?

Denial is common in both substance abuse and mental health issues. For many, it is extremely difficult to admit how dependent someone is on drugs or alcohol and how much it affects lives. Similarly, the symptoms of conditions such as depression, anxiety, bipolar disorder, or PTSD can be frightening. They may be ignored in the hope that the symptoms and feelings may go away on their own. People can be ashamed or afraid of being viewed as weak if they admit they have a problem.

It is very important to know that:  Admitting you have a problem and seeking help is the first step on the road to recovery. Engagement with services and groups is a sure way of starting the road to sobriety.

Signs and symptoms of substance abuse

Abused substances include prescription medications (such as opioid painkillers, ADHD medications, and sedatives), recreational or street drugs (such as marijuana, methamphetamines, and cocaine), and alcohol (beer, wine, and spirits).

Substance abuse is not defined by what drug is taken or what type of alcohol is consumed, Drug or alcohol use affects people’s lives and relationships. If drinking or drug use is causing problems in someone’s life, this can be classified as a substance abuse problem.

To spot signs of addiction and substance abuse problems these are good indicators to look for.

• Have you ever felt you should cut down on your drinking or drug use?
• Do you need to use more and more drugs or alcohol to attain the same effects on your mood or outlook?
• Have you tried to cut back, but couldn’t?
• Do you lie about how much or how often you drink or use drugs?
• Are you going through the prescription medication at a faster-than-expected rate?
• Have your friends or family members expressed concern about your alcohol or drug use?
• Do you ever feel bad, guilty, or ashamed about your drinking or drug use?
• Have you done or said things while drunk or high that you regret and have caused family upset or difficulties?
• Has your alcohol or drug use caused problems at work, school, or in your relationships?
• Has your alcohol or drug use caused interactions with police or the judicial system.

Mental Health problems from substance misuse usually manifest themselves into Depression, Bipolar and Anxiety disorders.

Common signs and symptoms of depression

• Feelings of helplessness and hopelessness
• Appetite or severe weight changes
• Concentration problems
• Anger, physical pain, and reckless behaviour (especially in men)
• Sleep changes
• Loss of energy and enthusiasm for life. 
• Strong feelings of worthlessness or guilt
• Loss of interest in daily activities for instance staying in bed or washing
• Inability to experience pleasure

Common signs and symptoms of anxiety

• Racing heart or shortness of breath
• Nausea, trembling or dizziness
• Excessive tension and continuous worry
• Irritability or feeling “on edge” all the time. 
• Trouble concentrating
• Insomnia (trouble sleeping) 
• Muscle tension, headaches
• Feeling restless or jumpy

Common signs and symptoms of mania with bipolar disorder

• Feelings of euphoria or extreme irritability
• Unrealistic, grandiose beliefs
• Rapid speech and racing thoughts
• Impaired judgment and impulsivity
• Decreased need for sleep
• Increased energy, manic behaviour
• Anger or outbursts of rage, unpredictable behaviour 
• Hyperactivity

Other mental health problems that commonly co-occur with substance abuse or addiction include PTSD, Schizophrenia and Borderline Personality Disorder

Treatment for a dual diagnosis

The best treatment for co-occurring disorders is an integrated approach, where both the substance abuse problem and the mental disorder are treated simultaneously. Whether your mental health or substance abuse problem came first, long-term recovery depends on getting treatment for BOTH disorders by the same treatment provider or team. Depending on your specific issues:

Treatment for your mental health problem includes medication, individual or group counselling, self-help measures, lifestyle changes, and peer support.

Treatment for your substance abuse includes detoxification, managing withdrawal symptoms, behavioural therapy, and support groups to help maintain your sobriety.

Authors: Lawrence Robinson, Melinda Smith, M.A., and Jeanne Segal, Ph.D