We’ve seen them shuffling along the streets in cities and towns throughout the country, dirty, dressed shabbily, muttering to themselves or responding to voices that may be only they can hear, quite often nipping from an alcoholic beverage in a brown paper bag. That many are homeless only adds to the tragedy. Clearly, they are the inhabitants of a nether world that consists of substance abuse and often some form of psychiatric disorder. But if we think that this represents the total population of individuals suffering from substance abuse and mental illness, we would be sadly mistaken. The truth is that there are millions of individuals in America with either substance abuse problems, or mental health disorders, or a combination of both. And they are just as likely to live in the suburbs or in high-rise apartments or work in a rural area or be your next-door neighbor. In the last 50 years, we’ve come a long way in this country in terms of how we deal with those less fortunate than ourselves, specifically in how we treat people with mental illness. That there are still tragic incidents where police act with callous disregard or outright brutality to an obviously mentally ill person when called to the scene of a suspected crime only points up the reality that we still have a lot more work to do in educating law enforcement and others about the mentally ill individual and how to effectively and humanely deal with them. But what about the people who have, or are suspected to have, a drug or alcohol problem and an underlying psychiatric disorder? Assuming they can be entered into treatment, what should be treated first? Is there, in fact, any point to rehab if the psychiatric disorders are not also treated? Let’s look at this situation a little more closely. Substance Abuse and Psychiatric Disorders: Dual Diagnosis When a person has a mental illness and also suffers from substance abuse, the term that is used to refer to the coexistence of both is called “dual diagnosis.” The problem is that this occurs more often than we may readily admit or even comprehend. Researchers and treatment providers say that more than 50 percent of those with mental illness also have a co-occurring substance abuse problem. That means that they are abusing substances at the same time as they are suffering from a mental health disorders. And the situation gets even worse among those who are severely mentally ill, with estimates as high as 85 percent having both conditions simultaneously. The fact that one condition goes untreated is often due to the fact that use of alcohol or drugs by mentally ill persons goes undetected or is misdiagnosed by treatment professionals. In some cases, this is partly due to symptom similarities between mental illness and substance abuse. It could also be that the individual is adept at denying the existence of either, and has the ability to mask or cloak one or both. What happens with individuals with dual diagnosis? They may have started off with an underlying psychiatric disorder and began to use drugs or alcohol as a means of self-medicating medical symptoms or coping with intense emotional or psychological pain, to quiet the voices, to calm the hallucinations, and get some peace. Over a period of time, they can become addicted to those self-medicating and coping drugs and alcohol. Others have been abusing drugs or alcohol for some time and have become addicted to them. They may develop agitation and aggression and other psychiatric symptoms as their addiction progresses. There is a school of thought among many researchers that substance abuse and addiction itself may trigger an underlying psychiatric disorder that may have gone undiagnosed for years. Whether the psychiatric illness precedes or follows substance abuse, or vice versa, individuals suffering with both are often in great distress and seriously disabled. Their judgment may be seriously impaired, making them at greater risk for suicide. As such, dual diagnosis patients pose unique and special treatment challenges. They often deny the existence of both conditions. They come into treatment resistant, still at high risk of suicide, with a higher risk of relapse, and with a history of great difficulty in functioning and maintaining relationships at home and at work. Psychiatric Illnesses Most Often Found in Dual Diagnosis While every patient is different, research has found that there are some commonly found psychiatric illnesses in dual diagnosis patients. These include:

• Anxiety
• Adjustment disorders
• Bipolar disorder
• Conduct disorder
• Depression
• Eating disorders
• Learning disabilities
• Mania
• Obsessive-compulsive disorder (OCD)
• Panic disorder
• Phobias
• Post-traumatic stress disorder (PTSD)
• Schizophrenia

Affecting Factors to Treatment Again, each individual entering treatment for dual diagnosis has a unique and distinct profile. Yet there are some factors that affect dual diagnosis treatment that treating professionals need to pay careful attention to. These include the type and severity of the individual’s psychiatric illness; the duration of illness (whether it is ongoing, occasional, or a reaction to a specific event); any drug or combination of drugs used; how severe the addiction is; how motivated the person is for recovery, and family history of mental illness or substance abuse. Treatment Evidence-based treatment that has been shown to be effective seeks to treat both conditions simultaneously. That is, the drug and alcohol addiction or substance use disorder is treated at the same time as the patient receives treatment for psychiatric disorder. This can be complicated, however, as the symptoms for both are similar and may be misinterpreted. How? Let’s take the example of an alcoholic. He or she may develop symptoms that are commonly associated with a person with a psychiatric disorder, such as anxiety, depression, erratic behavior, mood swings, aggression, and suicidal thoughts and so on. By the same token, treatment of a psychiatric disorder is more difficult when the person also has a substance abuse problem. Should the treatment professional fail to recognize the substance abuse problem (either because the person has not used recently and is not exhibiting overt signs of the problem, or because he or she is adept at hiding it), treatment can be adversely affected. And undiagnosed psychiatric disorders complicate treatment for substance abuse. If both conditions are to be treated simultaneously, how does this happen? The only way to proceed with any chance of success is to undertake a comprehensive biopsychosocial assessment (physical, psychological, and social) of the individual entering treatment. It helps, of course, if the person being admitted volunteers the information, but it also helps if family offers this information as well during the assessment process. The assessment is generally performed by a multi-disciplinary team consisting of a psychiatrist, medical physician, clinical social worker, nursing staff, and dual diagnosis counselor. If necessary and appropriate, other personnel may be consulted, including a psychologist to do intelligence or personality testing, a dietician to evaluate the patient’s nutritional needs, and a neuropsychologist to assess the individual’s cognitive functioning. Experts believe that the more comprehensive the assessment is at intake, the better the treatment plan that can be tailored to treat both substance abuse and underlying psychiatric disorder simultaneously. Treatment will consist of an individually tailored treatment plan that includes one-on-one counseling, group therapy, different treatment modalities appropriate to the type of addiction and the kind of psychiatric disorder present, introduction to and participation in 12-step groups such as Alcoholics Anonymous and Narcotics Anonymous, and non-addictive medications that may be prescribed to treat the psychiatric disorder. Some treatment modalities that may be used include, but are not limited to:

• Relapse prevention – to help identify triggers to using and learn techniques to prevent substance abuse relapse.
• Cognitive Behavioral Therapy (CBT) – to help alter and change negative beliefs and thoughts regarding mental health issues as well as addiction.
• Trauma, grief and loss group – to help the patient manage symptoms of abuse, grief, or PTSD and to prevent alcohol or drug relapse.
• Eye Movement Desensitization and Reprocessing (EMDR) and Somatic Experiencing (SE) therapies – to help patients work through past traumatic events and strengthen their sense of self.
• Eating disorder group – to help the affected patient learn how to gain control over self-destructive eating disorders and replace them with healthier behaviors.
• Dialectical Behavior Therapy (DBT) – to help the patient regain emotional stability and learn to improve impulse control.

Dangers to Not Treating Underlying Psychiatric Disorders Suppose an individual enters treatment to “dry out,” to get their act together and overcome addiction to alcohol or drugs, but does not seek or admit to any underlying psychiatric disorder. Maybe the individual feels that getting sober is more important than the anxiety, depression, panic attack, PTSD, suicidal thoughts or other psychiatric symptoms he or she has been experiencing. After completing drug rehab, the individual may return to their normal life and think that everything is completely under control. He or she may begin to attend 12-step meetings as recommended, yet may very shortly begin experiencing difficulties in life. Without having undergone any treatment to deal with the underlying psychiatric issues, those issues are still there, ready to lay claim to the individual’s psychological well-being. He or she may begin to think that the only way out of the psychological pain and emotional distress is to again return to using alcohol or drugs as a means of coping and dealing with what is otherwise intolerable. As a result, relapse is a very real risk. In fact, it is more likely to occur than not. But relapse itself is not a sign of failure. Many addicts in recovery relapse, go back in to treatment, redouble their attendance at 12-step group meetings, and regain their momentum in recovery. But relapse without getting help to treat underlying psychiatric disorders will just perpetuate the problem. Getting back to the original question: Is there any point to drug rehab if underlying psychiatric disorders remain untreated? The answer is a resounding “No.” How Long Does it Take to Get Better? As with any consideration of treatment, whether for substance abuse or psychiatric disorders or both occurring simultaneously, the obvious question that will ultimately be asked is how long before the patient will get better? The short answer is that it will take time. The longer answer is that the person who is addicted will always be an addict and will need to be working an active program of recovery for the rest of their life. The individual with a psychiatric disorder will also begin to show improvement over time and with continued counseling, taking the appropriate medication as prescribed, and learning how to cope with and deal with their mental illness in a productive and healing manner. Some individuals will show dramatic improvement in psychiatric symptoms earlier than others, but most all will improve somewhat over time. The true test of how well a person in recovery is doing is how strong their support network is. There can be no underestimating the power and strength of adequate support systems in place, both at home with family and loved ones, and in the rooms of the 12-step groups such as Alcoholics Anonymous and Narcotics Anonymous. There are also groups that meet both online and in-person to help fellow members deal with dual diagnosis and mental health issues. The bottom line in all this is that just because you, or a loved one or family member, a close friend, or a co-worker, have dual diagnosis, does not mean that you are any less of a person than anyone else. It does mean that there are some things that have to be paid attention to, certain things that need to be done differently, and learning how to live life according to a different set of behaviors is an adjustment that must be made. Life is, after all, what we make of it. In recovery, everyone deserves a chance at happiness. Yes, it is a lot of work, doing the work of recovery, but it is more than worth it.