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letter
. 2007 Sep;4(9):15–16.

A Call for Standardized Definition of Dual Diagnosis

Kathyrn Hryb 1, Rob Kirkhart 1,✉, Rebecca Talbert 1
PMCID: PMC2880934  PMID: 20532112

Dear Editor:

Dual diagnosis was first identified in the 1980s among individuals with coexisting severe mental illness and substance abuse disorders.1,2 Today, the Substance Abuse and Mental Health Services Administration (SAMSHA) uses the term co-occurring disorders (COD) to refer to the aforementioned concurrent disorders. COD is defined as co-occurring substance related and mental disorders. Patients said to have co-occurring disorders have one or more substance-related disorders as well as one or more mental disorders.3 According to the National Survey on Drug Use and Health, an estimated 2.7 million adults aged 18 or older reported a co-occurring major depressive episode and alcohol use disorder during the previous year. Among these adults, 40.7 percent did not receive treatment for either disorder.4 Over 24 million Americans reported severe psychological distress and 21.3 percent of this population had active substance abuse/dependence disorders defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR).5 Currently, there are no diagnostic criteria for dual diagnosis or co-occurring disorders in the DSM-IV-TR.6 Due to the high prevalence of this disorder, standardized diagnostic criteria need to be developed and added to the DSM to assist clinicians in the proper and timely diagnosis and treatment of these patients. Critical analysis of this topic requires research to evaluate the diagnostic criteria for the dual diagnosis as well as to identify which co-occurring disorders meet criteria.

Individuals diagnosed with co-occurring disorders often need more intense treatment due to the complexity of their case emphasizing the importance for clinicians to provide effective and efficient treatment to these patients. Individuals diagnosed with co-occurring disorders face greater consequences from substance abuse compared to those patients diagnosed with only a mental illness such as schizophrenia or bipolar disorder.7 Examples of such consequences include greater exacerbation of psychiatric symptoms, medication nonadherence, an increase in aggressive and violent behaviors, poor personal hygiene, emergency room visits, and inpatient psychiatric placements.1, 8–12

In the mid-1980s, dually diagnosed patients received treatment for either the mental health or substance-related disorder.13 Due to the low success rates of this population, the National Institute of Mental Health, National Institute of Drug Abuse and National Institute on Alcohol Abuse, and Alcoholism recommended the integration of treatment for mental health and substance-related disorders for this population.2,14–16 This recommended integrated treatment approach has produced conflicting empirical evidence to substantiate the effectiveness of this type of treatment for dually diagnosed individuals.2,7 The methodological problems that arise for researchers investigating the effectiveness of integrative treatment approaches for dually diagnosed patients begin with the inconsistent diagnostic criteria that clinicians use to refer patients to appropriate treatment programs.13 This problem indicates further need for standardized diagnostic criteria for dual diagnosis in order for clinicians to identify individuals appropriate for integrated treatment and also to develop an effective modality to treat this complex population with a diverse range of mental disorders. By standardizing this definition of dual diagnosis, dually diagnosed individuals will be identified universally by clinicians rather than by individual professional opinion.

This letter's purpose is to call for research to develop standardized diagnostic criteria for individuals diagnosed with co-occurring substance-related and mental disorders. By establishing diagnostic criteria, researchers can accurately develop appropriate treatments for identified co-occurring mental and substance-related disorders. This call for research is also needed to identify effective treatment approaches for other subgroups of the dually diagnosed population such as military personnel. There is a large combat military population returning from Iraq and Afghanistan in the United States of America. Approximately 56 percent of military personnel discharged from service between September, 2001, and September, 2005, have been identified with two or more co-occurring mental disorders.17 By standardizing the diagnostic criteria of dual diagnosis, these military personnel may have the ability to be appropriately referred to integrated treatment programs as needed based upon these newly developed criteria. Soon the negative effects of the war will return home as seen among the large number of troops returning with identified co-occurring disorders. Mental health professionals need to diagnose and treat these individuals appropriately and expediently due to the potential for severe consequences associated with this disorder.

With regards,
Kathyrn Hryb, MSW
Rob Kirkhart, PhD, PA-C
Rebecca Talbert, PharmD

From the Department of Veteran Affairs Medical Center, Chillicothe, Ohio

References

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