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Dual Diagnosis

Issues with Diagnosis and Treatment


Updated July 06, 2009

by Kimberly Read

Dual diagnosis is a condition where a person with bipolar disorder also has a problem with drug and/or alcohol abuse. Members of our community are no stranger to dual diagnosis:

"I made a serious commitment to quit all drug use (street & rx) when I was pregnant (7 years ago) which actually led to my diagnosis of BP, as I could no longer hide my illness without the drug use."
~from Elizabeth

"I stopped alcohol 5 years ago and street drugs four. Of course, this is when my depression (possibly BP with no formal dx) and OCD really began to peek out from beneath the foggy cover of my substance abuse camouflage."
~from Internalburn

For those struggling with a dual diagnosis, there are most certainly many challenges to diagnosis and treatment. First and foremost, even identifying both conditions presents problems. One study found that of those with a substance problem among severely mentally ill patients seen in a university hospital emergency room, only 2 percent were detected. The state hospital did only slightly better, detecting 15 percent (Wolford, et al., 1999).

The problem of identifying dual diagnosis occurs for a number of reasons. Emergency rooms are just not often able to do structured interviews about drug and alcohol use. Patients tend to underestimate the problems caused by the drugs, and they rarely disclose that they have a problem with substance abuse (Wolford, et al., 1999).

Practitioners should also keep in mind that illicit drugs and alcohol can cause the development, the reemergence, or even worsen the severity of mental disorders. These drugs can also present symptoms that parallel those of mental disorders or even cover them up. Furthermore, Dr. Brady points out that "acute intoxications as well as withdrawal states can mimic affective illness" (1992).

In addition to these hurdles, there are many physical complications to the treatment of a person with a dual diagnosis. Douglas Polcin outlines some major challenges in his article entitled "Issues in the Treatment of Dual Diagnosis Clients Who Have Chronic Mental Illness." He cites poor treatment response, high rates of rehospitalization, aggravated psychotic thoughts, and changes in neurophysiology. He also notes that those dually diagnosed are often less responsive to medications than those who do not abuse substances, specifically stating that cocaine users have problems with lithium (Polcin, 1992).

Another issue with treatment of dual diagnosis is that "systems have not been well designed with this population in mind. Typically a community has treatment services for people with mental illness in one agency and treatment for substance abuse in another. Clients are referred back and forth between them in what some have called 'ping-pong' therapy" (NAMI).

And often the very treatment approach of one service may cause problems for the other side of the condition. For example, substance abuse workers traditionally consider the use of medications to be a crutch for those struggling with addiction. However, psychiatrists rely on prescriptions to treat the mental illness, and while psychiatrists rarely give much credence to spiritual or self-help approaches, those working with addictions place a great deal of emphasis here (Polcin, 1992).

Poor communication is yet another problem. Those struggling to reach stability with their mental illness and to achieve sobriety are, more often than not, shuffled between different practitioners. Even when these counselors and doctors work within the same facility, there is seldom good, if any, communication between offices (Zweben, 1993).

The US Department of Health and Human Services outlined some specific areas for dual diagnosis research. The first area relates to decision-making with regard to treatment plans. Second is the use of psychotropic medications. Accurate diagnostic tools is another area greatly needing research (Zweban, 1993). There is currently no good instrument for detecting or classifying substance use disorders in the mentally ill, in that those available were developed for use in the general population (Wolford, et. al., 1999).

In conclusion, a final question needs to be considered. With these facts and figures, the outlook for those with dual diagnosis seems grim. What is the long-term prognosis? Is there any hope for stability and sobriety?

The lifetime prevalence of substance use disorders is as much as seven times greater for those with bipolar disorder than those in the general population (Knowlton, 1995). However, Linda, a member of our Forum Community, shares a ray of hope in this message:

My life is quite manageable today with the proper medication, therapy, a wonderful support program and recovery program. And no booze ... not a drop. Works the best I have ever had it.

Additional Resources

(References on Page 2)

  1. About.com
  2. Health
  3. Bipolar Disorder
  4. Impact on Health
  5. Addiction
  6. Alcohol & Substance Abuse
  7. Dual Diagnosis - Issues with Dual Diagnosis and Treatment

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