The National Council on Alcoholism and Drug Dependence fights the stigma and the disease of alcoholism and other drug addictions.

Interviews with the Experts

Daniel Hall-Flavin, MD on Dual Diagnosis

Daniel K. Hall-Flavin, of Rochester, MN, is the Assistant Professor of Psychiatry at the Mayo Medical School. He also has served as NCADD's medical/scientific director.

Q	What is the nature of dual diagnosis? Can you describe it?
A	Dual diagnosis typically refers to the coexistence in a person of an addiction disorder and some other type of psychiatric problem. This interaction might take the shape of one of the following three scenarios: 1) the coexistence of an addiction and a person's particular mood, for example; the coexistence of an addiction and some type of anxiety disorder; or the coexistence of an addiction and psychotic problems that leave a person out of touch with reality. Some research indicates that personality disorders should perhaps be included more frequently here, but it is important to remember that those kinds of diagnoses require a lot of time to establish. Also, dual diagnosis sometimes describes what might be called dual addictions where there is an addiction to two or more types of drug(s) occurring at the same time.
Q	Are there tell-tale symptoms of this condition, or is it best to let a psychiatrist or psychologist discern what is going on?
A	It is best to get help because the situation requires a difficult and important distinction to be made. The psychiatrist, the addiction psychiatrist, and/or other caregivers have to ask the question: is what is happening with the person primary or secondary? In other words, does the person actually have a depression, psychotic disorder, or anxiety disorder in addition to their addiction, or is their situation simply the result of the drug they are using? That is the distinction that must be made.
Q	How do you go about making the distinction?
A	There are several things that we look for. First, it is important to know what the person was like before they began drinking or using whatever substance they are using. Understanding their background helps us begin to piece the puzzle together. Second, I would ask whether there have been any significant periods of sobriety in their drinking or using careers, periods in which they have been alcohol- or drug-free. If so, we can ask if they remember having similar symptoms during those times. For many, depressive symptoms that persist for several weeks or more indicate the existence of a primary depression that will require treatment in and of itself. Family history is also very important. If there is a family history of depression, for example, it is likely that first-degree relatives are going to have depressive symptoms. Similarly, there is some difference in gender. Research suggests that for some problems like depression the coexistence of alcoholism is more evident for women than for men. These kinds of indicators are not always foolproof, but they provide a number of clues we can look for.
Q	Are there other specific patient groups who face a high risk for dual diagnosis?
A	One large epidemiologic study stated that of the individuals with a history of alcohol disorder, 20 percent will have a co-existing drug abuse/dependence problem at some point in their life. Another similar study put the figure at 40 percent. Moreover, if an individual starts out with a drug disorder (be it drug abuse or drug dependence), there is a 50 percent chance he/she will have either alcoholism or alcohol dependence at some point in their life. That is the dual addiction issue. Here are some other numbers to consider: Individuals with other psychiatric disorders are two times more likely to develop an alcohol disorder and four times more likely to have a drug disorder in their lifetime. Of individuals with an alcohol disorder, one-third will have at least one other psychiatric disorder in their lifetime. For those with a drug-abuse disorder, 53 percent will have at least one other psychiatric disorder in their lifetime.
Q	So, a substance abuse counselor really needs to understand dual diagnosis in order to send their patient or family to someone with a psychiatric background?
A	Yes, absolutely. Counselors who are working with chemically-dependent individuals need to be aware of the dual-diagnosis potential. There are considerable risk factors that need attention. Specifically, it is good to become familiar with the resources that are out there. Screening instruments, for example, can help determine if there is a clinically significant depression/anxiety problem going on. Following what is called an `index of suspicion' will help counselors keep their diagnostic antennae up so they can proceed and refer individuals for treatment. Here we also see the crucial value of teamwork. Psychiatric consultation is not always a must, but it is really best to work in a team where a psychiatrist is at least routinely available. Ideally the team would also work with a hospital physician who is an addiction specialist, or is at least educated about the issue. A physician who, for example, has a certification from the American Society of Addiction Medicine (ASAM), or has some degree of expertise in this area would be best. To my knowledge, ASAM is the only group that certifies non-psychiatrists; psychiatrists can either go through ASAM or their own specialty board.
Q	How do you treat dual diagnosis?
A	The first question is do we treat a person's dual disorders in parallel or sequentially? I think it is best to treat in parallel in the same program. If there is a more severe psychiatric illness, a sequential model is sometimes required whereby the doctor starts by treating one disorder then moves on to the other one. The problem is there are still some people out there who believe that if the underlying depression is treated, for example, the alcoholism will go away. But, alcoholism is not a symptom, it is a disease. That said, there are three different kinds of therapeutic interventions we do. Medication treatment requires a very individualized assessment that considers the patient's own experience, family history, and underlying medically-related problems. Psychotherapy treatment can be helpful if it is patient, supportive, and focused on sobriety. Unfortunately, a lot of people delve right in trying to do a lot of quick problem solving. There are several cognitive behavioral techniques. I am an abstinence-oriented therapist but I acknowledge it is difficult to make predictions about how patients will respond to this treatment. When we encounter patients who are not quite willing to give up their addiction because of denial or a psychiatric difficulty I prefer to meet them halfway and keep them involved in treatment as long as we are not actively enabling or supporting destructive behavior. Rather than endorsing drinking, this follows in line with Marty Mann's old rule: if you choose to drink, let's see if you can stay to two.
Q	Does pharmacological treatment for a psychiatric condition ever conflict with the abstinence-based philosophy of 12-step programs? Some recovering individuals have remarked that Prozac does for them exactly what drinking did.
A	For some people, refusing medication may very well be helpful to maintaining their abstinence, but I am finding that less and less these days. What matters first is that the emphasis be on quality assessment and responsible prescribing. Careful assessment should be made of the patient's underlying medical and psychiatric status; then, if the assessment indicates that medication may be helpful, it is responsible to prescribe an anti-depressant. There needs to be a healthy respect for medications but not a fear of using them when the assessment calls for it.
Q	What is the percentage of success in treating dual disorders?
A	It is very hard to judge. The coexistence of anxiety disorders and alcoholism, for example, has not been studied longitudinally through life; there are surveys that look at cross sections but it is hard to pinpoint a true incidence. So it is difficult. That said, we do work to make success as likely as possible by doing very careful assessments. Once we know that a patient has two primary disorders, we move ahead with treatment. It is an unscientific guess, but at this point the individual has about a 40 percent chance of being sober by the end of the year.
Q	When you have an individual with dual diagnosis, is the actual recovery harder for the patient's family?
A	Yes. Not only is the family dealing with all the addiction-related problems, but they are also facing the difficulties posed by the psychiatric problem. This two-fold challenge is most dramatic in cases where patients have problems such as obsessive compulsive disorder or severe psychotic symptoms. Some families also have to learn to see the addiction as an illness requiring extensive treatment, not just an extension of the psychiatric problem. To put it another way, dual diagnosis is challenging for the families because they have things compounded geometrically, depending on the severity. Families are the first to experience the disease, and the last to recover.

National Council on Alcoholism and Drug Dependence, Inc.

244 East 58th Street, 4th Floor, New York, NY 10022 phone: 212/269-7797   fax: 212/269-7510 email: national@ncadd.org   http://www.ncadd.org HOPE LINE: 800/NCA-CALL (24-hour Affiliate referral)