Is “Dual Diagnosis” Even Necessary Anymore?

Last updated on November 4th, 2019

When I first went through my education and training, I didn’t understand why the term Dual Diagnosis even existed.

Drug abuse and dependence are mental disorders, same as depression, anxiety, borderline personality disorder etc. Whether you subscribe to the medical model of addiction or not, substance use disorders have been in the DSM since its inception.

When the DSM-III was published in 1974, substance dependence was given a separate classification from substance abuse, obviously reflecting an increase in understanding of the unique complexities of this disorder.-Keith McAdamIn the first edition of the DSM, alcohol and drug abuse were classified as sociopathic personality disturbances. When the DSM-III was published in 1974, substance dependence was given a separate classification from substance abuse, obviously reflecting an increase in understanding of the unique complexities of this disorder. Prior to the DSM-V, Dual Diagnosis also applied to diagnoses across axes, but I must say I had never heard it used in that context.

We know that “addiction” (a term never actually used in the DSM) presents a unique set of circumstances that require a specific knowledge base and clinical skills: the impact of social factors, specific neurochemical processes, multiple substances with varying effects and routes of transmission, legal consequences, the spectrum of the disorder from use to abuse to dependence. On that level, the term Dual Diagnosis seems appropriate, as a clinician should have the appropriate training to treat a specialized condition.

So why all the fuss?

There is a debate over the strength of the correlation between substance use and (other) mental health diagnoses, and the whole ‘chicken and egg’ thing. According to SAMHSA’s 2013 National Survey on Drug Use and Health (NSDUH) 3.2 percent of adults had co-occurring mental health and substance use disorders.

The SAMHSA survey questions were the standard diagnostic – “in the last year” type inquires. But how valid is that really? If you’ve used drugs enough in the last year to have a substance use disorder, your mental state has been altered.

The effects of drugs can mimic psychiatric symptoms – anxiety, paranoia, mania are symptoms of cocaine and meth use; marijuana can produce paranoia and anxiety, alcohol can cause depression, hallucinogens can produce psychosis. For each of these disorders, the DSM specifically states:

“The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.”

So how can an accurate mental health diagnosis be given? Other studies have estimated up to 50% to 66% of people in substance abuse treatment had a pre-existing mental health disorder. But, if respondents received a mental health diagnosis previously, how accurate was it? How long ago was the diagnosis given and by whom? Was it a mental health professional or, as is seen too often, a primary care provider possibly making an inappropriate diagnosis to justify a quick-fix antidepressant or benzo to an insurance carrier? If study participants had not received a diagnosis, was it because a condition didn’t exist or that it had simply never been diagnosed? Another study I heard about claimed a 50% rate of substance use disorders in patients on a psychiatric lock-down ward.

“Addiction” is a mental health disorder. Whether it’s genetic, driven by social factors, trauma, diagnosed or undiagnosed mental illness – it effects our brains, our emotions, our coping skills, our psyche.-Keith McAdam

So how much can we really take from such data? And really, in the grand scheme of things, how much do the numbers matter? “Addiction” is a mental health disorder. Whether it’s genetic, driven by social factors, trauma, diagnosed or undiagnosed mental illness – it effects our brains, our emotions, our coping skills, our psyche. There are really only two options: mental health issues played a part in the development of substance use or arose as a product of use. So why bother with another term to simply distinguish between two co-occurring mental health disorders?

It only makes sense to treat everything at once, and there are data showing it is most effective to do, so why separate them out? To what end do we perpetuate the idea that addiction can be effectively treated without a mental health component? I already ranted once on here about the financial disparity in treatment, and here we are again. Providing comprehensive mental health treatment costs more and so agencies can charge more. Let’s face it, Golden Pillars of the Malibu Beaches provides more psych care than State Detox and 14-day 12-Step.

Of the estimated 22.7 million individuals aged 12 or older in 2013 who needed treatment for an illicit drug or alcohol use problem, 2.5 million received treatment at a specialty facility.

There are other issues too. Many of the programs that don’t provide “dual diagnosis” treatment are abstinence-based to the extent that they don’t allow any medication that can be abused, even if prescribed and taken appropriately. It’s that same old, “talk only about your addiction or you’re in denial” nonsense.

I’ve also had patients denied for being too “psychiatrically complicated” because they’ve had crisis admissions and a suicide attempt. Now, we all know that poverty and untreated mental illness are highly correlated, so, yeah… (It’s like when I was told a patient was being denied for having one “violent criminal charge” – assault on a police officer. Does that truly belie a criminally violent personality?)

I’m all for not working outside your scope of practice, but a cop-out is a cop-out. Mental illness – (others, besides substance use disorders) – should not be a vehicle by which addicts are further defined.-Keith McAdamDual Diagnosis “status” further widens the financial treatment gap while facilitating further entrenchment in one-size-fits-all ego-crushing pull yourself up by your bootstraps philosophy that we know doesn’t work for most addicts. We should know better. While the world rallies around “evidence based” this and “best practice” that, why does the addiction field, again, remain mired in the past.

So what about singling out “Dual Diagnosis?”

At this point, I guess I don’t care what you call it; let’s just do what research tells us works best. And do it for everyone. If you weren’t emotionally damaged before your addiction, you’re in treatment because of it, and likely suffering with some emotional difficulties as a result. I mean, what’s the harm in someone whose only diagnosis is a substance abuse disorder getting some “mental health” care?
Image Courtesy of Unsplash/Andrew Phillips

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