Dual Diagnosis: Chronic Mental Illness And Addiction

Recently, there was a suicide by a patient who was treated for mental illness, as reported in the Washington Post.  He had abused drugs and one of the psychiatrists reporting about the incident stated that this was the choice of the patient. Other psychiatrists and mental health experts reacted harshly, reminding all of us that those individuals affected by psychotic illnesses do not make rational choices, especially when abusing drugs.

The story reminded me of my past experiences working with the severely mentally ill.

During the 1990's I worked at a psychiatric Day Hospital. The patients were people who were recovering from a psychiatric hospitalization for acute psychotic episodes. most were diagnosed with things such as Paranoid Schizophrenia, Bipolar Disorder with Psychotic Symptoms, Schizoaffective disorder and other types of psychoses that severely interfered with their lives.

Patients lived either at home with their families or at specific psychiatric residences staffed by mental health experts who closely monitored their lives. The patients could live at the residences on the condition that their time was spent either at the day hospital or a continuing day treatment facility. Day hospital patients took the subway system and public transport to attend day hospital.

The Day Hospital ran like a school with patients being given their medications, attending a variety of groups ranging from psychotherapy to medication management, socialization and vocational counseling. They were also provided with psychoe-ducation about their specific illnesses, how to manage their symptoms and how to reduce stress in their lives in order to prevent relapse. Each patient also had a psychotherapist with whom they met on a weekly basis or as emergency and crisis situations emerged.

The program was successful for many patients. However, the most successful of these people were the ones who were compliant with program recommendations and did not use alcohol or other drugs.

One of the most serious of problems affecting our patients and that staff would discuss at many of our meetings was the phenomenon of Dual Diagnosis. Some of the older staff would talk about the fact that the days of treating people who suffered purely from schizophrenia were over because of insidious impact of drug abuse. In fact,patients were referred to as CAMI, or the Chemically Abusive Mentally Ill.

Then as now, there are a large number of the chronically mentally ill whose symptoms are aggravated by drugs such as marijuana, crack cocaine, alcohol and many other substances. While these patients naturally want to be normal and make the same choices as other people who do not suffer from these mental illnesses, the facts are that these substances not only undermine their medications but aggravate and elevate such things as auditory and visual hallucinations, delusional thinking and impulsive and dangerous behaviors.

Sadly, we constantly witnessed patients who, after their inpatient hospitalization, emerged into the day hospital community and started on a course of recovery. Of course, there is no cure for schizophrenia. However, symptoms would abate enough so that they could be prepared to either work on a part time basis or return to college classes.

Then, the day would come when many of them would enter the day hospital, sometimes after a weekend, looking regressed and symptomatic. All too often, they had spent the weekend having abused substances.

People who do not suffer from a severe mental illness can become dangerously impulsive under the influence of certain drugs and alcohol. For those suffering from one of the psychotic illnesses that impulsiveness can quickly turn to suicide during an episode of intoxication.

We knew back during the 1990's about the high correlation between mental illness and drug abuse. It is about time that the world awoke to the fact that those suffering from these illnesses must be treated for their addiction as well as for their mental illness.

Your comments and questions are welcome

Allan N. Schwartz, PhD

  • JustTrying

    I agree completely about substance abuse being very dangerous for the mentally ill. I can speak from personal experience. I have poor impulse control when I am not under the influence and almost none when I am. Most of my suicidal attempts ( not the idealization) have been while under the influence. Thank God that I was not too up on which pill to take or the best way to find a vein, or I may not be here.

    As you know Allen, I have been struggling with dual diagnosis for some time. The best decision I ever made was to seek out the right therapist that deals with addictions. By receiving therapy for the underlying cause of my addiction, i.e. Bipolar , and by taking my medication and not drinking, I am feeling much better.

    However, it took me over a year to find the right kind of treatment. People tend to just want to ignore you if you are addicted to something. Some professionals included. Some tend to think ... well , just quit drinking and all your problems will go away. I expect that from lay persons, but is the mental health system still so far behind? If you can find the right kind of treatment, miracles can happen. You still have to take your meds and do the work but it can happen.


  • Claire

    Indeed, it is crucial with dually diagnosed people that both the addictive behaviors and the mental illness be addressed. Therefore, it is critical that mental health treatment providers do not send mentally ill patients into an environment that is not supportive of mental illness treatment. Unfortunately, AA and other 12 step programs can be exactly such a non-supportive environment.

    It is not unusual for mentally ill AA members to be told by their sponsors or other highly regarded AA members to avoid getting professional mental health care, or even to stop taking their medications. I am not saying this practice is universal or that everyone who is so advised actually takes the advice to heart. But I have seen it happen with terrible results. Here are a couple of examples:

    1. I sponsored a woman who was, even to a layperson such as myself, obviously mentally ill in addition to being a raging alcoholic (my guess: BPD). She was beginning to behave in ways that were dangerous to herself and others, to talk of suicide, etc. so I (and a few others who were truly concerned) took her to a mental hospital for an evaluation. At the hospital they refused to treat her, because she was drinking. They referred her to alcohol rehab. From rehab, it was back to AA meetings. There, people were actually angry at me for taking her to the psych hospital. "She needs meetings, not doctors," I was told. "She's mentally ill and needs more help than we can give her," I replied, but the other voices were stronger.

    She killed herself by turning on her car in the garage. Her bloated body was on display in the funeral home and her death was declared by the AA members present to be yet another example of the "cunning, baffling and powerful disease of alcoholism."

    I say it was an example of the failure of our mental health system.

    2. A friend of mine from my AA days has bipolar disorder. She had been sober 7 years when she relapsed. She was in rough shape (puking, shaking, etc.) so a group of us took her to the hospital. While there, she told us that she had stopped taking her mood stabilizers because her sponsor and husband (also in the program) had told her that she did not actually have bipolar disorder and needed to stop taking her meds and go to more meetings. Without the meds, her moods began to cycle again and she relapsed during a manic phase.

    So while dual diagnosis treatment absolutely needs to take into account the mental illness and the addictive behavior, the use of AA/12 step should be minimized or at least carefully monitored. Lives are at stake.

  • Jim

    I have a 33 year old son that has mental problems and abuses drugs daily. He has been in and out of hospitals and rehabs since her was 18. He currently lives in Oklahoma with his Mother and sisters. He is on the brink of suicide but he can't stop himself. We don't know where to turn for help. He has checked into emergenecy rooms with suicidal thoughts. He says he wants to quit drugs so bad because he is a burden on us and society but he can't stop. He needs desperate long term help.

    His drug of coice is cough syrup. It's easy to steal from stores and he drinks 2 or 3 bottles and gets very high. His Mother even went around town with his picture and showed it to store managers and warned them about him possibly stealing cough syrup but no one has caught him yet. Believe me, we don't to see him get arrested but it's better then him being found dead.

    We are not wealthy people and cant afford expensive treatment facilities. Does anyone have any suggestions as to what I can do next?

    I trully believe that he will not last out the year if we don't get him some help.

  • Joanne W

    Two years ago, my son had a psychosis breakdown, he has dual diagnosis but he also has an emotional disorder. He is living at home with me and I am at my wits end. He has mood swings.

    I do not what support group to go to. He has many problems along with dual diagnosis. I am at a loss. A friend who is a psych nurse thinks he would benefit in a group's home but he has anxiety disorder and won't leave me ( I had kidney cancer) and it did not help his situation.

    Is there a site where people who are going through this can talk to one another, it would help me vent my feelings even though I can't get him motivated.


  • Allan N. Schwartz, PhD


    I will post your question and comment under the section of our site called: Reader Questions. In addition, I strongly urge you to sign into our Online Support Community. The link is in green just above this box. There is no cost, you can remain anonymous and get lots of support from other people.

    Look for my response under Reader Questions.

    Dr. Schwartz

  • Anonymous-1

    We have a 18 year old son with schioaffective bipolar/dual diagnosis with marijuana being his drug. We also are at wits end. We attend NAMI support groups, but I am "mom". I am so scared of his behaviors. I wish he did not have the dual diagnosis. Several web sites state that people with mental disability with dual diagnosis are prone to violence against themselves or a family member. He does become "scary" at times. I do fear this will happen. Statistics say the violence is mostly directed at the one they are closest to and care about most...me. He gets severe anxiety until he gets his "fix". This happens daily. He as I stated is 18..yes I can kick him out, but that will most likely bring on a violent act. So what do I do? He has pawned almost all his belongings...starting to sell his clothes to get his marijuana. Next he will most likely steal from me. I hate what this illness has caused. I have no life, no hope, no future.

  • Allan N. Schwartz, PhD

    It is true that the combinatiion of schizophrenia or schizoaffective disorder and drug abuse can increase the chances of a violent act. Even if that increase of the likelihood of violence is only slight, no one wants to be the target.

    As a parent, you will have to make some hard choices with regard to your son's problems. Hard choices mean that, in the event that he becomes threatening, you must immediately call 911, report being under a threat from your son, and they will come.

    Your son's best chances are if they hospitalize him due to the threat and, when he is stabilized, move him to a halfway house for the mentally ill. He is 18 years old and should not be living at home. Also, there is no need for him to be homeless. At a halfway house or at a group home, he will receive medication, therapy and vocational rehab as well as drug counselling.

    His living at home makes it too easy for him to get himslef into trouble.

    You should check this website: http://schizophrenia.com

    Good Luck,

    Dr. Schwartz

  • Anonymous-2

    my ex has been going to aa for years now. he believes that all 'bad' behaviors are the result of character deffects that can be overcome through God's help and by working the program. He insists that his problems will be solved be turning his attention to the needs of others. PROBLEM: my ex was diagnoised earlier in his life with schziodaffective disorder. In the 9 month relationship we had I witnessed him experiencing horrible delusions- those that were of morbid jealousy. He too went off his meds shortly after we met. He was insulted by an aa members criticism of medications then responded by quitting his. His pride was too damaged I guess. He considers himself a great teacher and highly spiritual. He considers himself so even though he abused me pscychologically and physically for 9 months. I am talking about real abuse that steemed from hatred and anger that consumes him when he is delusional. He excuses the cause and calls this 'stress or conflict' in a relationship. He has 2 restraining orders served by 2 other women and spent a night in jail when I had to be rescued out of the home we shared. It seems to me that he uses aa as a tool of distraction- and that members may be unknowingly enabling him to continue to be sick. I believe that his continued faith in aa as THE SOLUTION will hold what needs to be addressed in abeyance and he may never get the real help he needs. I can't help the woman who comes behind me, but, it's so sad to know that others will meet him, be deceived and likely suffer greatly due to his denial.

  • cathy

    I have been in and out of aa for 25 years, I was diagnosed as bipolar years ago. After a brief period of treatment I was off all meds because I was told I only needed AA. I am at my wits end. My family is also very tired. I see noway out. My relapses are brief. I feel so negative about myself and undeserving of anything good. When ly life seems to be getting back on track I relapse. I feel responsible for families happiness and so out of control. I feel they would be better off without me. I don't have the money needed for treatment and have no idea where to turn. Everything costs so much and my family is tapped out with treatment costs. Cathy

  • dink

    You are right about the association of drugs or alchol and mental illness being two disorders that need two diagnoisis and two different treatments. I ' am not a trained doctor but I have seen the effects of these two disorders. Suicide is common along with incarceration for things like fighting or traffic violations, domestic battery dwi, dws, ect... These problems are esculating in small towns across America causing more and more families to doubt their worth. Prison does not always help some people need counseling and drug therapy to help attain a job. Help is needed. How many people die because of these problems? I know those that I have seen have multiple problems and no financial means to get help from anyone. I have a project that I call M.A.R.C.S. and I have a questionaire that I think should be given to those being interviewed for Addiction and Therapy. You can find it by putting M.A.R.C.S. Project by Dink in your search engine. M.urder, A.buse, R.ape, C.hronic Illness, S.uicide is the future without awareness and funding. "M.A.R.C.S. Knows no boundries M.A.R.C.S. doesn't discriminate" I will be having M.A.R.C.S. 2nd Annual Walk-A-Thon April 5th, 2010 in Marion, Indiana starting at the Sirloin Stockade come walk for awareness.

    Sincerly Dink

  • Dink

    Murder,abuse,rape, chronical illness,suicide happens to many people all around the United States and it seems to get harder and harder for the public to help with these issues. Everyone in America deals with disease of some sort others are just brought out into the public more. M.A.R.C.S. needs your support and your sponsorships to make aware to the people of her strength of hardships. Please support your fight by WALKING with me on APRIL 3rd 2010 from SIRLOIN STOCKADE in Marion, INDIANA sign up at 9:00am walk at 9:30 am to Grant Memorial Park Cemetery and back to SIRLOIN STOCKADE. Everyone is welcome to come and walk. Donations can be made out to : M.A.R.C.S. where the help can be put towards the burial funds for those less fortunate. Dink

  • Dink

    Abusing drugs and mental disorders are being missed by many agencies due to the fact there are those that cannot control their emotional traumas of life. Experiences associated with turmoil or death causes considerable emotional disabilities and then to top it off with suicide, or murder just adds to the destructive patterns associated with drugs and alcohal. Incarceration with a mental disabilitie is over looked by some so called proffessionals because of lack of caring or money. Dink

  • Anonymous-3

    Does the addicted individuals deserve a proper burial?

    Some people say no. I say we are avoiding the drug issues by giving jail time instead of counseling.

    Human beings are not perfect they should be given the help to kick their habits and become productive individuals however most are jailed and tagged as inmates. Thus causing more meyham than good. COUNSELING IS A BETTER JUDGEMENT CALL!

    Consider the obsticles if this should become you or your loved one.


  • Dink


  • kelly

    Great article, each year dual dianosis becomes more and more understood. http://www.stopoxy.com

  • Dink

    Many of the problems in todays society is being ignored to the point of death. If someone commits a crime or a repeated offense then there is probably a serious mental issue + an addication. Many people with education observes these risk factors yet they knowingly do nothing to help the person affected with these problems. Why must we loose so many people to death because no one cares to help? If these children or yound adults were their children then we would hear about them in the news media. However, if these people are not famous or rich they are thrown in jail and tagged repeated offenders by the police and lawyers. When asked if they have had medical treatment while incarcerated the answer is NO! Why?

    Because they don't have a doctor or therapist at the jail.

    Well, I guess it is to much to ask that they receive proper medical treatment while incarcerated. I believe that every human being should be treated fairly. This cannot and will not happen in the case of the indigent persons incarcerated.

    If this person has mental problems and isn't given the proper treatment while in jail then they will serve their time and be back at the jail within the year. Which costs more. jail vs: treatment? Hopefully judges will start to get more medicine involved with those in and out of jails.

    May God Bless All those that have issues that are not being diagnoised by anyone in jail.

  • Dink

    Does any one care about the issues that affect people with menta diseases and addictions in the millionaire neighbor hoods? Recently a young movie star on (GLEE) passed away from drugs + alchol Duel addictions PLEASE PEOPLE HELP OUR CHILDREN NOW. M.A.R.C.S. (murder,abuse,rape,chronical illness, suicide needs your help in helping others. M.A.R.C.S. knows no boundries M.A.R.C.S. doesn't discriminate.