Homelessness & Dual Diagnosis

A person who has both an alcohol or drug problem and an emotional/psychiatric problem is said to have a dual diagnosis. To recover fully, the person needs treatment for both problems.

The following questions and answers, and chart are reprinted, courtesy of the National Mental Health Association of Georgia

What is Dual Diagnosis?
A person who has both an alcohol or drug problem and an emotional/psychiatric problem is said to have a dual diagnosis. To recover fully, the person needs treatment for both problems.

What Kind of Mental or Emotional Problems are Seen in People with Dual Diagnosis?
The following psychiatric problems are common to occur in dual diagnosis - i.e., in tandem with alcohol or drug dependency.

Depressive disorders, such as depression and bipolar disorder. Anxiety disorders, including generalized anxiety disorder, panic disorder, obsessive-compulsive disorder, and phobias. Other psychiatric disorders, such as schizophrenia and personality disorders.

The following table based on a National Institute of Mental Health study, lists seven major psychiatric disorders and shows how much each one increases an individual’s risk for substance abuse.

Psychiatric Disorder		Increased Risk For Substance Abuse
Antisocial personality disorder		15.5%
Manic episode		14.5%
Schizophrenia		10.1%
Panic disorder		4.3%
Major depressive episode		4.1%
Obsessive-compulsive disorder		3.4%
Phobias		2.4%

Thus, someone suffering from schizophrenia is at a 10.1 percent higher-than-average risk of being an alcoholic or drug abuser. Someone who is having an episode of major depression is at a 4.1 percent higher-than-average risk of being an alcohol or drug abuser…and so on.

Which Develops First - Substance Abuse or the Emotional Problem?
It depends. Often the psychiatric problem develops first. In an attempt to feel calmer, more peppy, or more cheerful, a person with emotional symptoms may drink or use drugs; doctors call this “self-medication.” Frequent self-medication may eventually lead to physical or psychological dependency on alcohol or drugs. If it does, the person then suffers from not just one problem, but two. In adolescents, however, drug or alcohol abuse may merge and continue into adulthood, which may contribute to the development of emotional difficulties or psychiatric disorders.In other cases, alcohol or drug dependency is the primary condition. A person whose substance abuse problem has become severe may develop symptoms of a psychiatric disorder: perhaps episodes of depression, fits of rage, hallucinations, or suicide attempts.

How Can a Physician Tell Whether the Person’s Primary Problem is Substance Abuse or an Emotional Disorder?
At the initial examination, it may be difficult to tell. Since many symptoms of severe substance abuse mimic other psychiatric conditions, the person must go through a withdrawal from alcohol and/or drugs before the physician can accurately assess whether there’s an underlying psychiatric problem also.

If a Person Does Have Both an Alcohol/Drug Problem and an Emotional Problem, Which Should Be Treated First?
Ideally, both problems should be treated simultaneously. For any substance abuser, however, the first step in treatment must be detoxification - a period of time during which the body is allowed to cleanse itself of alcohol or drugs. Ideally, detoxification should take place under medical supervision. It can take a few days to a week or more, depending on what substances the person abused and for how long. Until recently, alcoholics and drug addicts dreaded detoxification because it meant a painful and sometimes life-threatening “cold turkey” withdrawal. Now, doctors are able to give hospitalized substance abusers carefully chosen medications which can substantially ease withdrawal symptoms. Thus, when detoxification is done under medical supervision, it’s safer and less traumatic.

What Is Next After Detoxification?
Once detoxification is completed, it’s time for dual treatment; rehabilitation for the alcohol or drug problem and treatment for the psychiatric problem. Rehabilitation for a substance abuse problem usually involves individual and group psychotherapy, education about alcohol and drugs, exercise, proper nutrition, and participation in a 12-step recovery program such as Alcoholics Anonymous. The idea is not just to stay off booze and drugs, but to learn to enjoy life without these “crutches .”Treatment for a psychiatric problem depends upon the diagnosis. For most disorders, individual and group therapy as well as medications are recommended. Expressive therapies and education about the particular psychiatric condition are often useful adjuncts. A support group of other people who are recovering from the same condition may also prove highly beneficial. Adjunct treatment, such as occupational or expressive therapy, can help individuals better understand and communicate their feelings or develop better problem-solving or decision-making skills.

Must a Dual Diagnosis Patient Be Treated in a Hospital?
Not necessarily. The nature and severity of the illness, the associated risks or complications, and the person’s treatment history are some of the facts considered in determining the appropriate level of care. There are several different levels or intensities of care including full hospitalization or inpatient treatment, partial hospitalization, and outpatient treatment.

What is the Role of the Patient’s Family in Treatment?
With both rehabilitation for substance abuse and treatment for a psychiatric problem, education, counseling sessions, and support groups for the patient’s family are important aspects of overall care. The greater the family’s understanding of the problems, the higher the chances the patient will have a lasting recovery.

How Can Family and Friends Help with Recovery from the Substance Abuse?
They need to learn to stop enabling. Enabling is acting in ways that essentially help or encourage the person to maintain their habit of drinking or getting high. For instance, a woman whose husband routinely drinks too much, might call in sick for him when he is too drunk to go to work. That’s enabling. Likewise, family members or friends might give an addict money which is used to buy drugs, because they’re either sorry for him or afraid of him. That’s enabling also. When family and friends participate in the recovery program, they learn how to stop enabling. If they act on what they’ve learned, the recovering substance abuser is much less likely to relapse into drinking or taking drugs.

How Can Family and Friends Help with Recovery from a Psychiatric Condition?
They should be calm and understanding, rather than frightened or critical. They should be warm and open, rather than cool or cautious. Although it is fine to ask the person matter-of-factly about the psychiatric treatment, that shouldn’t be the only focus of conversation.

If Someone I Know Appears To Have A Substance Abuse Problem And The Symptoms Of A Psychiatric Disorder, How Can I Help?
Encourage the person to acknowledge the problems and seek help for themselves. Suggest a professional evaluation with a licensed physician, preferably at a medical center that’s equipped to treat addiction problems and psychiatric conditions. If the person is reluctant, do the legwork yourself - find the facility, make the appointment, offer to go with the person. A little encouragement may be all it takes. If you talk to the physician first, be honest and candid about the troubling behavior. Your input may give the doctor valuable diagnostic clues.

There Is Hope
As a relative or friend, you can play an important role in encouraging a person to seek professional diagnosis and treatment. By learning about dual diagnosis, you can help this person find and stick with an effective recovery program.
The more you know about dual diagnosis, the more you will see how substance abuse can go hand-in-hand with another psychiatric condition. As with any illness, a person with dual diagnosis can improve once proper care is given. By seeking out information, you can learn to recognize the signs and symptoms of dual diagnosis - and help someone live a healthier or more fulfilling life.
End of National Mental Health Association article

How Common is Dual Diagnosis?

The Numbers...

Among Homeless People 33% (approx.) have a severe and disabling mental illness ( Morrissey & Dennis, 1986 ; Morrissey & Levine, 1987 ; Tessler & Dennis, 1989 ), 30% to 40% have problems with alcohol ( Fischer & Breakey, 1987 ; Koegel & Burnam, 1987 ; Wright, Knight, Weber-Burdin, & Lam, 1987) 10% to 20% have problems with other drugs ( Milburn, 1989 ) 10% to 20% of homeless persons are dually diagnosed with severe mental illness and alcohol or other drug problems ( Tessler & Dennis, 1989 ).

Among All People in U.S. 37%of alcohol abusers and 53% of drug abusers also have at least one serious mental illness. 29% of all people diagnosed as mentally ill abuse either alcohol or  drugs. According to a report published by the Journal of the American Medical Association

More Numbers
The best data available on the prevalence of co-occurring disorders are derived from two major surveys: the Epidemiologic Catchment Area (ECA) Survey (administered 1980-1984), and the National Comorbidity Survey (NCS), administered between 1990 and 1992.

Results of the NCS and the ECA Survey indicate high prevalence rates for co-occurring substance abuse disorders and mental disorders, as well as the increased risk for people with either a substance abuse disorder or mental disorder for developing a co-occurring disorder. For example, the NCS found that:

42.7 percent of individuals with a 12-month addictive disorder had at least one 12-month mental disorder. 14.7 percent of individuals with a 12-month mental disorder had at least one 12-month addictive disorder.

The ECA Survey found that individuals with severe mental disorders were at significant risk for developing a substance use disorder during their lifetime. Specifically:

7 percent of individuals with schizophrenia also had a substance abuse disorder (more than four times as likely as the general population). 61 percent of individuals with bi-polar disorder also had a substance abuse disorder (more than five times as likely as the general population).

Continuing studies support these findings, that these disorders do appear to occur much more frequently the previously realized, and that appropriate integrated treatments must be developed.

3 Excellent Links
Homelessness and Dual Diagnosis
Go to www.psychosocial.com/addicts.html and scroll down to “Dual Diagnosis Articles” then scroll further to “Homelessness and Dual Diagnosis”. This very comprehensive article, though dated (1991), continues, it appears, to be the most authoritative on the subject of homelessness and dual diagnosis, It was published by the International Journal of Psychological Rehabilitation and is authored by Robert E. Drake, New Hampshire-Dartmouth Psychiatric Research Center, Fred C. Osher, National Institute of Mental Health, Michael A. Wallach, Duke University
National Alliance for the Mentally Ill (NAMI)

Go to www.nami.org and under “find”, enter “dual diagnosis”

Need More Information?
Go to www.google.com and search for “homelessness and dual diagnosis”