People with mental illness are vulnerable to developing addiction problems. Research shows 30% of people with a mental illness will have a substance abuse problem in their lifetime and 37% of people who abuse alcohol (53% who abuse drugs) will have a mental illness.[1] This group is described by researchers as “people who are experiencing a combination of mental/emotional/psychiatric problems with the abuse of alcohol and/or other psychoactive drugs.”[2]

Confusion On The Formal Name Of This Diagnosis

While people who are struggling with mental illness and addiction don’t really care what health professionals call these problems when they occur together, it is useful to take a moment and talk briefly about the confusion that exists regarding the formal name for this diagnosis. In some parts of Canada, it is called concurrent disorders. In others – as well as in international circles – it is called dual diagnosis. So as not to add to the confusion, this brief paper will stick to the term dual diagnosis.

The Differences Between Substance Use And Addiction

Substance use: Refers to the use of psychotropic (mood altering) substances) such as medications and alcohol. Many Canadians use these substances and products with no ill effect.

Substance abuse: Involves heavy use of these substances which interfere with family, social and work life.

Dependence: Involves loss of control and continued use despite severe negative consequences (drunk driving charges, loss of work and relationships, injury, deteriorating health or invovlement with the law). Dependence involves physiological dependence (bodily cravings with withdrawal symptoms if they are not satisfied) or psychological dependence (use is required to manage moods or is thought to be necessary to function day-to-day).[3]

Addiction: Is defined in the same terms as dependence.[4]

Addiction To Legal Substances

Alcohol

While the press if preoccupied with the prevalence of illegal drugs, it is legally available substances, particularly alcohol, that has the greatest impact on Canadians’ lives and health, principally because of its wide availability and common usage.

• 13.6% of Canadians are high-risk drinkers. [5]
• 8% of all hospitalizations and 10% of the total number of days spent in hospital annually are a result of substance abuse. [6]
• In Canada, substance abuse accounts for $11.8 billion losses in productivity or 1.7% of the gross national product (GNP).[7]
• The leading cause of preventable birth defects in North America is drinking alcohol during pregnancy. There are 365 babies – one per day – born in Canada annually with Fetal Alcohol Spectrum Disorders.[8]

A common health consequence of heavy drinking is depression.[9]

Prescription Medication

In addition to alcohol, prescription medicines are also sources of legal substances that can carry with them a risk of addiction. Canadians are among the highest per capita users of psychotropic medications in the world. They are the second highest users of sedatives and hypnotics and the fourth highest for prescription narcotics. [10]

Tobacco

People with mental illness have an extraordinarily high rate of tobacco use. It is estimated that 80% of people with schizophrenia smoke.[11] In the United States, researchers estimated that 44.3% of all cigarettes produced are consumed by people with mental illness. [12]

It is not uncommon for people with mental illness to be “cross-addicted.” They use alcohol, tobacco and prescription medications – all interacting with one another.

Other Addictions

Problem gambling: The prevalence of problem gambling in Canada has risen significantly over the past 25 years. It is estimated that 5% of gambling Canadians become problem gamblers. All levels of governments in Canada earn significant revenue from gambling and gaming. In 2004, earnings for governments were $6.2 billion – more than the net profit to government of tobacco and alcohol combined ($5.9 billion).[13]

Internet addiction: The now common availability of the internet has given rise to excessive use which, in extreme instances, is classified as addiction. Researchers estimated that 86% of those addicted to the Internet also have some form of mental illness.[14]

Women

Women’s experiences of mental illness and addiction are different from men’s. A main reason is that women have certain vulnerabilities that make them more susceptible to experiencing a mental illness in their lifetime – and, because addiction often accompanies a mental illness, substance abuse as well. The reasons for women’s vulnerability are:

• Less financial security
• More experiences of interpersonal violence
• Greater incidence levels of childhood sexual abuse
• Reproductive vulnerabilities related to childbirth and menopause
• Relatively speaking, women are high users of medication, particularly psychotropic medications, some of which can be addictive, and
• Women’s’ bodies are more susceptible to the harmful effects of addiction. [15]

Aboriginal Peoples

Aboriginal people attribute their mental health and addiction problems to the result of colonization which assaulted their culture and created a pervasive atmosphere of despair.[16]

Serial relocations of whole communities and removal of Aboriginal children to residential schools has disrupted families and communities resulting in a whole generation of traumatized peoples, along with the perpetuation of mental health and substance use problems through intergenerational effects. [17] The results have been:

• multi-generational losses
• a profound sense of grief
• a weaken cultural identity
• reduced ability among people to learn and to teach
• Westernized helping strategies that focus on individuals and problems rather than communities and strengths
• poverty and dependence on social welfare.

Mental health problems such as suicide, depression, domestic violence, substance abuse, elder abuse, childhood sexual and physical abuse, and child neglect are significantly higher in Aboriginal communities. For example, the suicide rate is three to four times higher than the Canadian average.[18]

Aboriginal leaders call for the application of a model of “cultural safety” to already-established best practices in mental health and addiction care. Cultural safety counters tendencies in health care that create cultural risk (or “unsafety”) – situations that arise when people from one ethnocultural group believe they are “demeaned, diminished or disempowered by the actions and the delivery systems of people from another culture.” [19] Cultural safety reminds us that it is important for all health care providers to reflect upon the ways in which policies, research, and practices may unintentionally exclude or devalue particular peoples. It also involves the recognition of the social, economic, and political position of Aboriginal peoples in Canada, and the impact on their health.

Dual Diagnosis Treatment

People with both mental illness and addiction problems complain that they are often bounced from mental health to addiction services – and back again – with neither prepared to address both problems at once. Present best practice literature recommends that mental health and addiction programs screen clients for the presence of both mental illness and addiction and, when they are discovered; fully assess people to ensure proper diagnosis and treatment. It also calls for integrated treatment meaning that both problems are treated at the same time,[20] by the same team, using compatible techniques and philosophies.[21]

The other dual diagnosis

As a special note, the term dual diagnosis is also applied to people with developmental disabilities and/or intellectual disabilities – and mental health needs.

It is estimated that 2 – 3 % of Canadians have a developmental disability. This translates to approximately 1 million people. A conservative estimate of the percentage of people with a developmental disability who also have a mental health problem is 38%. [22]

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[1] Skinner, W. O’Grady, C. Bartha, C. & Parker, C. (2004). Concurrent substance use and mental health disorders: An information guide. Toronto ON: The Centre for Addiction and Mental Health.

[2] Rush, B. Team Lead (2002). Best practices: concurrent mental health and substance abuse disorders. Prepared by the Centre for Addiction and Mental health for Canada’s Drug Strategy, pg. v. Available at: http://www.cds-sca.com/.

[3] Mental health, mental illness and addiction (Report # 1) (2004). Interim report of the Standing Committee on Social Affairs, Science and Technology. Available at: http://www.parl.gc.ca/38/1/parlbus/commbus/senate/com-e/soci-e/rep-e/repintnov04-e.htm

[4] American Psychiatric Association, (2004). Practice guidelines for the treatment of patients with substance abuse disorders: Alcohol, cocaine, opioids. http://www.psych.org/.

[5] National survey of Canadians’ use of alcohol and other drugs: Prevalence of use and related harms (June, 2005). Available at: http://www.ccsa.ca/.

[6] Single, E. Robson, L. Xiaodi, X. & Rehm, J. (1996). The costs of substance abuse in Canada. Available at: http://www.ccsa.ca/.

[7] Canadian Profile 1999. Canadian Centre on Substance Abuse. Available at: http://www.ccsa.ca/

[8] Source: CCSA Literature Review: Evaluation strategies in Aboriginal Substance Abuse Programs: A discussion. (2004) Available at: http://www.ccsa.ca/.

[9] National survey of Canadians’ use of alcohol and other drugs: Prevalence of use and related harms (June, 2005). Available at: http://www.ccsa.ca/

[10] Rehm, J. & Weeks, J. (2005). Abuse of controlled prescription drugs. In Substance abuse in Canada: Current challenges and choices. Ottawa, ON: Canadian Centre on Substance Abuse. Available at: http://www.ccsa.ca/.

[11] Rethink – a website for people with mental illness and their families. Available at: http://www.rethink.org/living_with_mental_illness/everyday_living/physical_health_and_wellbeing/staying_healthy/smoking.html

[12] Lasser, K. Wesley Boyd, J. Woodhandler, D. Himmelstein, D. McCormick, D. & Bor, D. (2000). Smoking and mental illness. Journal of the American Medical Association. Vol 284, p. 2606 – 2610. Available at: http://jama.ama-assn.org/cgi/content/full/284/20/2606

[13] Skinner, W. (September 2005) Submission to the Standing Senate Committee on Social Affairs, Science and Technology.

[14] Block, J. (March, 2008). Editorial. Issues for the DSM-V: Internet addiction. American Journal of Psychiatry. Vol 165, p. 306 – 307.

[15] Women, mental health and mental illness and addiction in Canada: An overview (2006). Available here. 

[16] Brant, C. 1993. Suicide in Canadian Aboriginal peoples: causes and prevention. In the Royal Commission on Aboriginal peoples: The path to healing: Report on the national round table on Aboriginal health and social issues. Ottawa, ON: Ministry of Supply and Services.

[17] Mussell, B. Cardiff, K. White, J. (2004). The mental health and well being of Aboriginal children and youth: Guidance for new approaches and services. http://www.mheccu.ubc.ca/

[18] Brant, C. (1993). Suicide in Canadian Aboriginal peoples: causes and prevention. In the Royal Commission on Aboriginal peoples: The path to healing: Report on the national round table on Aboriginal health and social issues. Ottawa, ON: Ministry of Supply and Services.

[19] Wood, P. & Schwass, M. (1993). Cultural safety: A framework for changing attitudes. Nursing Praxis in New Zealand, 8(1), p. 4 – 15 (p. 2).

[20] The one exception is that best practice guidelines (Rush, 2002) call for substance abuse to be treated first among people with mood and anxiety disorders – although integrated treatment is recommended for Post-traumatic Stress Disorder.

[21] Rush, B. Team Lead (2002). Best practices: concurrent mental health and substance abuse disorders. Prepared by the Centre for Addiction and Mental health for Canada’s Drug Strategy. Available at: http://www.cds-sca.com/.

[22] Griffiths, D. Taillon-Wasmund, P. & Smith, D. (2002). Offenders who have a developmental disability. In Dual diagnosis: An introduction to the mental health needs of persons with developmental disabilities. Editors: D. Griffiths, C. Stavrakaki, and J. Summers. Sudbury, ON: Habilitative Mental Health Resource Network. Available online at: http://www.naddontario.org/pdf/EnglishPublication/Chapter12.pdf