Dual diagnosis is a term that has been increasingly prevalent during the past several years in both the psychiatric and addictionology fields. This article will present a definition of the term, research data, evaluation issues, categorization, and treatment strategies and issues. Dual diagnosis refers to the coexistence of a substance use disorder and a separate psychiatric disorder. Dual diagnosis patients are heterogeneous as to their psychiatric diagnoses, as well as the various substances they abuse. The psychiatric disorder (s) may range from a mild form of depression to a severe and chronic psychosis. The substance use disorder may range from episodic alcohol abuse to severe daily intravenous opiate dependence. Because of the heterogeneity of dual diagnosis patients, it must be recognized that diagnostic, prognostic, and treatment issues will vary significantly among individual patients. It has been suggested that the symptom severity as well as the type of psychiatric diagnosis may have predictive value in the treatment response of patients with substance use disorders.1-4
There has been growing body of research data that supports the coexistence of substance use disorders and psychiatric disorders.5"9 Recent data from the National Institute of Mental Health Epidemiologie Catchment Area Program have shown that several psychiatric disorders commonly begin in late adolescence or young adult life.10 In this study the onset of symptoms of anxiety disorders was at a median age of 15. This study also demonstrated a doubling of the risk for subsequent drug use disorders for patients who have had an early depressive or anxiety disorder. This finding had previously been reported by Newcombe et al,11 who found that elevated scores on certain depressive symptom scales was one of the feetors predicting later drug use in the adolescent population that was studied.
Self-assessment from a number of adolescent chemical dependence residential centers12 revealed that approximately 40% of 1824 substance-abusing adolescents had suicidal thoughts. Symptoms of depression and sadness were found in 74% of the substance-abusing adolescents. Associated symptoms of lack of energy, sleep problems, irritability, and anxiety were found in 55% of this population. In a more recent analysis of adolescent aggregate inpatient data from the centers, Huffman reported (personal communication, April 1989) that out of 29 U patients, 18% reported a suicide attempt and 38% reported frequent suicidal thoughts. Lifetime anxiety/panic attacks were reported by 43% of the patients. Associated data from this study showed that 37% of this substance-abusing population experienced physical abuse; 22% of these patients reported sexual abuse. Onset of chemical use in this population showed drinking of alcohol by age 12, smoking of marijuana by age 13, and use of other chemicals by age 14 (median ages).
Analysis of lifetime prevalence of mental illnesses and alcohol and other drug abuse disorders, as shown in the National Institute of Mental Health Epidemiologie Catchment Area Study,13 revealed comorbidity rates of 28% substance abuse disorders among patients with a primary mental disorder diagnosis. Among those with an alcohol abuse diagnosis, there was a 45% comorbidity of mental disorders, and among those with a primary drug abuse diagnosis, 71 % showed a mental disorder. In another study14 involving adult patients seeking assistance at different levels of care at an addiction research treatment facility, the authors reported that 78% of the sample had a Diagnostic Interview Schedule (DIS) lifetime psychiatric disorder in addition to a substance abuse disorder.
At the present time, there are limited reported data on dually diagnosed adolescent inpatients, From the standpoint of the clinical approach to substance abuse in adolescents entering inpatient treatment, it is important to know the incidence as well as types of comorbid psychiatric disorders. It is important to understand the possible relationships between substance abuse disorders and the psychiatric disorders. Meyer15 has outlined possible relationships between addictive disorders and coexisting psychopathology. Psychopathology may serve as a risk factor for addictive disorders and also may modify the course of the addictive disorder in terms of its repetition, symptom picture, and response to treatment. On the other hand, psychiatric symptoms can develop during the course of an addictive disorder, and psychiatric symptoms can emerge as a consequence of sustained substance abuse. In other cases, the mental disorder and substance abuse disorder may not be related to each other in a significant way.
There has been a need to establish the specific psychiatric disorder profile in adolescents with substance abuse disorders. Toward this end, the author conducted a pilot study of 226 adolescents entering inpatient treatment because of a primary substance abuse disorder (unpublished data, 1990). In this study, 82% met DSM-UI-R criteria for an Axis I psychiatric disorder, and 74% of this population had two or more psychiatric disorders.
Mood disorders were found in 61%, conduct disorders in 54%, and anxiety disorders in 43%. Substanceinduced organic mental disorders were found in 16% of the population.
The data in this pilot study argue strongly for the simultaneous evaluation of both the substance use and psychiatric disorders in this type of adolescent population. As to specific dual diagnosis subgroups, the study revealed a high frequency of conduct/ opposi tional, depressive, and anxiety disorders associated with alcohol and marijuana with a range of 26% to 48% of the entire sample having these particular dual diagnostic relationships.
Further results from this study show that of 201 adolescents with conduct/oppositional disorders, abuse of marijuana occurred in 60% and abuse of alcohol in 48%. Of the 18 adolescents with depressive disorders, abuse of alcohol was found in 72% and abuse of marijuana in 64%. Of the 97 adolescents with anxiety disorders, 70% abused alcohol and 60% abused marijuana. In the 36 adolescents diagnosed as having an organic mental disorder, 53% abused marijuana, 28% abused hallucinogens, 25% abused alcohol and 22% abused inhalants.
An intriguing finding in this pilot study was that nicotine abuse (cigarettes) preceded both alcohol and marijuana abuse with a mean age of onset of 12.4 years, with alcohol mean age of onset being 12.5 years, and marijuana being 12.4 years. This is suggestive that nicotine as a drug may be a primary "entry" substance of abuse that sets the stage for adolescents progressing stepwise to alcohol and then to marijuana. It has been the author's clinical impression during follow-up of many of the adolescents from the pilot study, that of the adolescents who chemically relapsed, a disproportionate number first returned to their nicotine dependence.
At this time there are very limited data on the existence of substance use disorder or psychiatric disorders among family members of adolescents. The need for this is underscored in certain adult studies such as the family pedigree data outlined by Mirin and colleagues5 where it was reported that among firstdegree relatives of 160 adult substance abusers, approximately 30% met DSM-UI-R criteria for at least one Axis I psychiatric diagnosis during their lifetime. It also has been reported that regarding concurrent substance abuse among family members, there is a strong correlation between drug use by teenagers and drug use by older family members.16 Bukstein et al6 suggests family studies of substance-abusing adolescents to better understand the genetics of comorbidity and to help the relationships of substance abuse and the coexisting psychiatric disorders.
From the standpoint of evaluating an adolescent substance abuser, the first task of assessment is to look for both substance abuse and psychiatric problems. It is important to keep in mind that alcohol and drug abuse can mimic and interact with all mental illnesses. For example, prolonged alcohol abuse in adolescents may result in sufficient depressive symptoms to qualify as a depressive disorder. Similarly, a state of lysergic acid diethylamide (LSD) intoxication may mimic an acute psychosis. A frequently observed adverse psychiatric reaction to marijuana may be severe panic attacks and other forms of anxiety, severe depression, or toxic psychoses. If the psychiatric symptoms do not substantially abate after detoxification or known abstinence from alcohol and other drugs, then it is more likely that there is a dual diagnosis entity.
One of the issues raised by Lehman et al17 is the difficulty clinicians encounter in certain dual diagnosis conditions. He emphasizes that clinicians often encounter more difficulty when considering less definitive or more chronic levels of psychiatric symptoms in substance abuse. Lehman recommended that assessment of dual diagnosis patients during acute treatment and stabilization involve a thorough examination for both types of disorders; he also recommends avoiding premature decisions about which disorder might be primary.
The categorization of adolescent dually diagnosed conditions relies heavily on an accurate history regarding the development of both the psychiatric as well as the substance use disorders. In adolescents, the most frequent category involves adolescents with primary psychiatric symptoms, consisting of disturbances of conduct, depression, and jnxiety that precede the abuse of substances. The second most frequent category usually involves substance abuse preceding the development of psychiatric symptoms. The third category involves a more pure tbrm of dual diagnosis in which dual primary disorders appear to have developed independently of each other.
One of the implications in the ? ase of adolescents who start with a primary psychiatric disorder and then abuse substances is that treatment of the primary psychiatric disorder will alleviate the substance abuse difficulties. Alternatively, if an adolescent develops substance dependence first with subsequent psychiatric symptoms, treatment of the primary substance use disorder often leads to a substantial reduction in the psychiatric symptoms. Finally, if an adolescent has dual primary disorders, the focus of treatment should be on both disorders simultaneously. The categorization in these adolescents is assisted by obtaining a family history that may be positive for primary psychiatric disorders or substance use disorders. A positive family history also might lead the clinician to consider assessment of family members who could have dually diagnosed conditions.
The treatment strategies for approaching dually diagnosed adolescents reveal important differences from the treatment approach to adults. Some of the differences relate to adolescent characteristics such as:
* incomplete personality development;
* symptoms and behaviors specific to adolescents;
* types of dependence on the faniily;
* developmental tasks and issues;
* the age-specific use of defense mechanisms such as denial, rationalization, splitting and isolation, projection, sublimation, and pathological transference;
* risk factors including perceived adult alcohol and drug use, perceived peer approval of drugs, and poor academic achievement;
* rapid progression of the substance use disorder in adolescents known as "telescoping"; and
* the increased likelihood of positive treatment results with adolescent substance abusers, as underlying issues are addressed in the psychiatric, learning, and developmental areas.
These, as well as other differences between adolescents and adults, have strong implications for a separate treatment approach for adolescent substance abusers.
A critical issue in the field is that of the role of the psychiatrist in the dual diagnosis treatment approach. The author recommends that a psychiatrist knowledgeable about substance use disorders, and preferably certified by the American Society of Addiction Medicine exam, be in a central role, especially at the inpatient level of care.
Another important and controversial issue is the use of medication in dually diagnosed adolescent inpatients. As a general rule, psychotropic medications should be avoided where possible during the first two weeks of evaluation and treatment of the dually diagnosed adolescent. This guideline relates to the frequently observed overlap of psychiatric and substance abuse symptoms during this time. By waiting at least 2 weeks, during which there is abstinence from alcohol and/or other drugs, there is increased likelihood that a distinction can be made between psychiatric disorders and substance use disorders. If possible, it is preferable to wait for a period of at least 1 to 3 months for further observation of the response to ? on pharmacologie treatments.
A limited number of certain medical/ psychiatric conditions may indicate medication use during the beginning weeks of treatment. These are:
* detoxification /withdrawal,
* major depression (especially with endogenous symptoms and a positive family history),
* acute psychosis,
* prolonged agitation and/or combative behaviors,
* bipolar disorder, manic, or mixed types.
With the use of any psychotropic medications in the dually diagnosed adolescent, abstinence ifrom all other drugs must continue, not only at the initiation phase of pharmacologie treatment, but through the maintenance phase as well. For example, there can be an additive effect of marijuana and tricyclic antidepressants on the heart rate that could lead to a problematic tachycardia or arrhythmia. Finally, no adequately designed studies have shown the effectiveness of medications on dually diagnosed conditions in adolescents. There is a need, therefore, for further research in this area.
The role of self-help groups in the treatment of the dually diagnosed adolescent should be evaluated by the treating professional on an individualized basis. At the inpatient level of care, the author highly recommends daily participation in the 12-step recovery meetings that are composed primarily of adolescents and young adult members. In the outpatient setting, if an adolescent has an extended history of substance abuse and dependence, the same recommendation is made for regular participation in 12-step self-help groups, (ie, Alcoholics Anonymous, Narcotics Anonymous, etc).
One of the future issues in the adolescent dual diagnosis field relates to potential refinements in the classification and treatment areas. Based on current research data, it is possible that dual diagnosis symptom cluster subgroups might be identified and analyzed as to specific treatment implications. Appropriately designed research studies are needed to assist in the development of more refined treatment strategies in the dually diagnosed adolescent population.
1. McLellan, AT. Psychiatric severity as a predictor in outcome from substance abuse treatments. In: Meyer R, ed. Paychopathology and Addictive Disorders. Guilford Press; 1986: 97-139.
2. Schuckit MA. The clinical implications of primary diagnostic groups among alcoholics. Arch Gen Psychiatry, 1985; 42:1043-1049.
3. Rounsaville BJ, Dolinksi ZS, Babor TF, Zelig S, Meyer RE. Psychopathology as a predictor of treatment outcome in alcoholics. Arch Gen Psychiatry. 1987; 44:505513.
4. Kofoed L. Kania J, Walsh T, Atkinson RM. Outpatient treatment of patients with substance abuse and coexisting psychiatric disorders. Am J Psychiatry 1986; 143:867-872.
5. Mirin SM, Weiss RD, Michael J, Griffin MK. Psychopathology and substance abusers; diagnosis and treatment. Am J Drug Alcohol, Abuse. 1988; 14:139-157.
6. Bukstein OE, Brent DA, Kaminer Y. Comorbidity of substance abuse and other psychiatric disorders in adolescents. Am J Psychiatry. 1989; 146:1131-1141.
7. Demilio L. Psychiatric syndromes in adolescent substance abusers. Am J Psychiatry. 1989; 146:1212-1214.
8. Nace EP. Substance use disorders and personality disorder: comorbidity. The Psychiatric Hospital 1989; 20:65-69.
9. Estroff TW, Schwartz RH, Hoffman NG. Adolescent cocaine abuse: addictive potential, behavioral and psychiatric effects among adolescent substance abusers. Clinical Pediatrics. 1989; 28:550-555.
10. Christie KA, Burke JE, Reiger DA, Rae DS. Boyd JH, Iwcke BZ. Epidemiologic evidence for early onset of mental disorders and higher risk of drug abuse in young adults. Am J Psychiatry. 1988; 145:971-973.
11. Newcombe MD, Maddahian E, Bentler PM. Risk factors for drug use among adolescents, concurrent and longitudinal analyses. Am J Public Health. 1986; 76:525-531.
12. Hoffman NC, Harrison PA. Catar. 1987 Report Adolescent residential treatment intake and follow-up findings. 1987; St. Rau,l Minn: Cator.
13. Regier DA, Boyd JH, Burke JD. Onemonth prevalence of mental disorders in United States. Arch Gen Psychiatry. 1988; 45:977-986.
14. Ross HE, Glaser FB, Germanson T. The prevalence of psychiatric disorders in patients with alcohol and other drug problems. Arch Gen Psychiatry. 1988; 45:1023-1031.
15. Meyer R. Old wine, new bottle, the alcohol dependence syndrome. Psychiatr Clin North Am. 1986:435-453.
16. Gfeerer J. Correlation between drug use by teenagers and drug use in older family members. Am J Drug Alcohol Abuse. 1987; 13:95-108.
17. Lehman AF, Meyers CP, Gorty E. Assessment and classification of patients with psychiatric and substance abuse syndromes. Hosp Community Psychiatry. 1989; 40:1019-1024.