The Importance of Dual Diagnosis Inpatient Treatment for Co-Occurring Disorders
About half of people who suffer from mental health issues at some point in their life also abuse substances.1 This tendency also works in the opposite direction: people with substance use disorders (SUD) are also prone to developing mental health conditions.1
Although the term co-occurring disorders is now probably the most widely used one to refer to interwoven SUDs and mental disorders, they may also be referenced as dual diagnosis, dual disorders, and comorbid disorders.2,3
According to the results of the National Survey on Drug Use and Health from 2019, as many as 9.5 million people in the U.S. suffer from co-occurring disorders.4 Since the incidence of co-occurring disorders is so high among treatment seekers at mental and substance abuse treatment facilities, this creates a strong need for effective and accessible treatment that can help patients suffering from multiple conditions.2 This includes dual diagnosis inpatient treatment options which may be a necessary part of 24-hour treatment and care for patients suffering from severe mental disorders and substance abuse.
What Is the Correlation Between Substance Abuse and Mental Health?
It is more likely that a person with any kind of mental disorder may also suffer from substance abuse compared to healthy individuals.1 The mental disorders that co-occur with SUD include:1
- Anxiety disorders: generalized anxiety, panic disorder, post-traumatic stress disorder (PTSD).
- Mood disorders: depression and bipolar disorder.
- Personality disorders: borderline, antisocial, avoidant, paranoid.
- Attention-deficit hyperactivity disorder (ADHD).
- Psychotic disorders, including schizophrenia.
Moreover, patients with the most severe forms of psychiatric disorders tend to have the highest rate of co-occurring SUDs.2
It can be said that a person suffers from a serious or severe mental illness when:2
- There is a diagnosis of a major mental disorder.
- The person is unable to function, meaning take care of themselves, maintain relationships, be able to study or work.
- This condition lasts for at least two years.
How Can the Relationship Between SUDs and Mental Disorders Be Explained?
When a person suffers from a mental disorder, there is a likelihood that they will use alcohol or drugs to self medicate, hoping to make their condition more bearable and improve their mood. However, although substances may provide a momentary relief, after this effect passes, the negative effects of substance use such as withdrawal symptoms make the original mental health condition even worse. In addition, alcohol and drugs can trigger a somewhat latent condition and make the symptoms of a mental disorder even stronger.2
Another theory that aims to explain this relationship and draw relevant conclusions for treatment practice states that there is a significant overlap between the neurobiological pathways to SUDs and mental disorders.2 Some individuals are more prone to their neurons being “kindled” i.e. sensitized or disrupted. It is hypothesized that this disruption of nervous cells happens both owing to a mental disorder or substance abuse, which can explain why the same person is susceptible to both conditions.2
Not less importantly, demography and family history also play an important role in vulnerability to both mental health issues and SUDs, which also partly explains the relatively high rate of their comorbidity.2
What Are the Dual Diagnosis Implications for Treatment?
The first challenge in treating co-occurring disorders is establishing an accurate diagnosis. This is in no way a simple task because symptoms often overlap and it may be hard to disentangle them.5
For example, a patient may be exhibiting some symptoms typical for a mood disorder when intoxicated or going through withdrawal. These symptoms may be induced by the substance or reaction to the absence of substance, but it may also be the case that the person has a preexisting mental health issue.6
In order to tackle this uncertainty, the general recommendation is to first ensure that a person has had a long enough period of abstinence so that the symptoms of intoxication and withdrawal would disappear. The length of this period will depend on the type of substance and is generally longer for long-acting drugs (e.g. methadone) than for short-acting ones (e.g. cocaine or alcohol). If symptoms of a mental disorder persist after one month of abstinence, then it can be established that a person has a co-occurring mental health issue and qualifies for dual diagnosis treatment.6
Compared to people suffering from only one kind of disorder, people with co-occurring disorders are at a high risk of many additional issues, including:7
- Serious medical illnesses.
- Financial problems.
- Family problems.
- Social isolation.
- Being a victim of a sexual or physical crime.
As a result of these multiple factors, patients with dual diagnosis are less likely to complete substance abuse treatment programs than the patients who do not suffer from a co-occurring mental condition.3 Since staying in treatment long enough is essential for successful outcomes, co-occurring disorder treatments, including long-term residential treatment for co-occurring conditions, aim to improve treatment retention.8
What Is Dual Diagnosis Inpatient Treatment?
Dual diagnosis inpatient or residential treatment requires patients to stay in a treatment facility 24/7. This is the recommended treatment option when:
- The patient has not responded well to outpatient interventions for any reason (e.g. they do not have a supportive family or they are homeless).2
- The patient’s condition is so severe that they need constant medical supervision provided by dual diagnosis inpatient treatment professionals both in the area of substance abuse and mental health.9
Who Benefits From Dual Diagnosis Inpatient Treatment
The initial stage of any substance abuse treatment is detoxification, i.e. eliminating the harmful intoxicating substances from the body. While in some cases detoxification can be done in outpatient settings, there are cases when this may be too risky, so it is only safe to do it at a residential treatment facility. This is strongly advised in the following circumstances:9
- The patient has a history of delirium tremens and withdrawal seizures.
- The patient has no capacity for informed consent.
- The patient is potentially dangerous for others and himself/herself.
The last point has is extremely important when deciding whether a patient needs dual diagnosis residential treatment because suicide is frequent among people with co-occurring disorders. One study even showed that as many as two-thirds of suicides were committed by people with an SUD.6 Another study found that suidice risk was highest among people suffering from a major depressive disorder who were dependent on drugs or alcohol.6 Dual diagnosis inpatient treatment helps reduce this risk by supervising the patient 24/7.
How Are Dual Diagnosis Patients Treated In a Residential Facility?
Dual diagnosis residential treatment involves a joint treatment of mental health issues and substance abuse. This is achieved through pharmacotherapy and behavioral therapy.2
Some medications may help with treating both disorders. In inpatient treatment, treatment drugs need to be managed carefully in order to avoid potentially dangerous interactions and potentially addictive medications.2
In addition to medication used to stabilize the patient physically, behavioral therapy is also used in dual diagnosis inpatient treatment as it is proven to help both with SUDs and mental disorders.2 According to the National Institute on Drug Abuse, the methods that show most promise include:3
- Cognitive-behavioral therapy.
- Dialectical behavioral therapy.
- Assertive community treatment.
- Therapeutic communities.
- Contingency management.
- Exposure therapy.
- Integrated group therapy.
- Seeking safety therapy.
Peer groups can be very effective in helping people recover from co-occurring disorders. These groups can be very different (for example, some of them focus on spirituality while others are secular), but in any case, the patient needs to attend them regularly for at least several months.2
Frequently Asked Questions
Residential facilities provide a safe environment when the person may be at a serious risk owing to a co-occurring disorder. However, one of the key advantages of dual diagnosis inpatient treatment programs over separate treatment options for substance abuse and mental health disorders is that they have the necessary resources for assessing and treating both disorders. This is not always the case with specialty addiction or mental health treatment because they may not have sufficient expertise to meet the complex treatment needs of dual diagnosis patients.10
Although there is an evident need for dual diagnosis treatment options, treatment facilities in the U.S. have traditionally addressed mental disorders and SUDs separately.10 The number of treatment facilities capable of offering adequate services to dual diagnosis patients is still not sufficient — a survey from 2014 found that it was 1 or 2 out of 10 treatment facilities at that point.11
Another challenge recognized by the National Institute on Drug Abuse is that many substance abuse treatment centers insist on not using medications. While in some cases this is possible, in many cases, including dual diagnosis patients with severe conditions, this is hardly helpful.10
It is possible to search treatment programs in the Behavioral Health Treatment Services Locator of the Substance Abuse and Mental Health Service Administration, and see which residential treatment facilities are equipped for offering dual diagnosis inpatient treatment.12 It is important that they have clinicians from both the field of addiction treatment and mental disorders, and that these clinicians are able to prescribe medications and monitor their use.
In addition to responding well to pharmacotherapy, it is important that the patient responds well to behavioral therapy. When making a treatment plan that involves group therapy sessions, special consideration should be given to the fact that a patient may feel a lot more comfortable in one setting than another one.
Therefore, some centers may provide a gender-sensitive environment or offer programs especially designed for a particular group, such as war veterans struggling with PTSD and addiction, and their unique needs. Another example are the programs that put emphasis on spirituality, such as 12-step programs, that are suitable for patients who are religious.
1. National Institute on Drug Abuse. (2020). The Connection Between Substance Use Disorders and Mental Illness.
2. Drake, R. E., Mueser, K. T., & Brunette, M. F. (2007). Management of persons with co-occurring severe mental illness and substance use disorder: program implications. World psychiatry : official journal of the World Psychiatric Association (WPA), 6(3), 131–136.
3. National Institute on Drug Abuse. (2020). What are the treatments for comorbid substance use disorder and mental health conditions?
4. Substance Abuse and Mental Health Service Administration. (2020). National Survey on Drug Use and Health.
5. National Institute on Drug Abuse. (2020). What are some approaches to diagnosis?
6. Quello, S. B., Brady, K. T., & Sonne, S. C. (2005). Mood disorders and substance use disorder: a complex comorbidity. Science & practice perspectives, 3(1), 13–21.
7. Psychology Today. (2019). Co-Occurring Disorders.
8. National Institute on Drug Abuse. (2018). Principles of Effective Treatment.
9. Substance Abuse and Mental Health Service Administration. (2020). Detoxification and Substance Abuse Treatment. Treatment Improvement Protocol (TIP) Series, No. 45.
10. National Institute on Drug Abuse. (2020). Part 4: Barriers to Comprehensive Treatment for Individuals with Co-Occurring Disorders.
11. McGovern, M. P., Lambert-Harris, C., Gotham, H. J., Claus, R. E., & Xie, H. (2014). Dual diagnosis capability in mental health and addiction treatment services: an assessment of programs across multiple state systems. Administration and policy in mental health, 41(2), 205–214.
12. Substance Abuse and Mental Health Service Administration. Behavioral Health Treatment Services Locator.