Since the early 1980s, there has been increasing academic interest in the comorbidity of substance abuse and mental illness. "Dual diagnosis," as it is most commonly known, is a term that describes a heterogeneous population of people who suffer from a variety of substance abuse and psychiatric disorders. These Psychiatrically Impaired Substance Abusers (PISA), or Mentally Impaired Substance/Chemical Abusers (MISA/MICA), are perhaps better understood as being highly heterogeneous in symptomology and clinical presentation. Just as there is no typical medical patient with dual cardiac and pulmonary diagnoses, there is no "typical" dual diagnosis patient (Weiss et al. 1992). Rather, what is typical about dual diagnosis individuals is the complexity of their illnesses and the difficulties they encounter in treatment and non-treatment settings.

Definition and etiology. In its strictest sense, "dual diagnosis" refers to people with independent primary substance and non-substance psychiatric disorders, reflecting the exclusionary nature of diagnostic approach in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV); however, common usage does not require independent primary diagnoses. Although it is possible that the etiologies of substance disorders and other mental disorders are independent, many would argue that there exists some overlap in causal factors (Mueser et al. 1998). Among more interactive etiologic hypotheses are that (1) substance abuse causes mental illness, (2) mental illness causes substance abuse, and (3) both are caused by a common etiologic factor(s). Clinical and empirical evidence support all of these, but definitive causation remains unclear. The person with antisocial personality disorder who becomes a cocaine addict may likely have causal factors different from an alcoholic who develops chronic major depression.

Prevalence and costs. Comorbidity of substance disorders and other mental disorders is often the rule, rather than the exception, in treatment settings. Studies have suggested that between 30 and 50% of patients in substance abuse treatment have comorbid psychiatric disorders, and 50 to 75% of patients in general psychiatric treatment have comorbid substance disorders (quoted in NIDA 1992).

In the general population, prevalences are lower, but still dramatic. The landmark Epidemiology Catchment Area (ECA) Study (Regier et al. 1990) and the National Comorbidity Survey (Kessler et al. 1994) revealed lifetime prevalences and comorbidity prevalences of substance and mental disorders. In people with a mental disorder in their lifetime, the lifetime prevalence of a substance disorder was slightly above 50% for both studies. In people with a substance disorder in their lifetime, the lifetime prevalence of a mental disorder was 50.4% for the NCS study and 39% for the ECA study. These high rates can be compared with the ECA general population prevalences of 22.5% lifetime mental disorder, 13.5% alcohol disorder, and 6.1% other drug disorder. The ECA study showed that comorbidity rates were especially high for severe mental illnesses (bipolar disorder, schizophrenia, antisocial personality disorder).

The economic impact to society of the treatment of dual diagnosis patients is substantial. The NIDA estimated that treatment of substance-induced psychiatric disorders was $3 billion in 1992 (NIDA 1992). In one study of 16,395 Medicaid patients with a psychiatric disorder, treatment costs of mentally ill patients with substance disorders was 60% higher than for mentally ill patients without a substance disorder (Dickey and Azeni 1996). In a study of 58,001 VA patients, dually diagnosed outpatients incurred significantly higher inpatient psychiatric and substance abuse treatment costs (Hoff and Rosenheck 1998).

Obstacles to care. Ironically, one of the greatest obstacles to effective treatment for people with dual diagnoses is the health care establishment. Both mental health and substance abuse treatment programs are relatively recent developments, with substance abuse programs sprouting in the 1970s. Unfortunately, programs and services are so separated that care is infrequently integrated, and sometimes conflictual. Managed care, federal, and state services are all guilty of this segregation. Caregivers in the substance abuse treatment sector sometimes downplay or miss patients' psychiatric disorders, and psychiatric caregivers sometimes do the same with patients' substance disorders. There remain misconceptions that substance disorders will resolve when psychiatric disorders are treated successfully, or vice versa. More troubling is the fact that when a dual diagnosis is appropriately made, treatment programs such as psychiatric or substance abuse residential treatment centers will often reject patients with the other diagnosis because of the difficulties in treating dually diagnosed patients, such as noncompliance, extensive psychosocial needs, and cognitive impairment. This barrier to residential care is exacerbated by the deinstitutionalization in recent decades of the mentally ill, leaving many dually diagnosed people homeless and with poor access to care (Drake et al. 1991).

Treatment. Studies in the 1990s have shown that the foundation of effective care of dually diagnosed people is an integrative, mutually respectful multi-disciplinary approach based upon rigorous assessment, empathy for the complex psychosocial problems experienced by dually diagnosed patients, and active long-term continuity of care (Drake et al. 1998).

The first step involves obtaining a thorough chronological psychiatric and drug history from all patients who present with psychiatric or substance-related complaints. A combination of structured and semi-structured interview techniques is useful, with instruments such as the NIMH Diagnostic Interview Schedule (DIS), the Composite International Diagnostic Interview (CIDI), the Addiction Severity Index (ASI), and the Beck Depression Inventory. The physical exam should focus on the mental status and neurological exams, with recognition of the signs of intoxication, withdrawal, and neurological sequelae of substance abuse. Good assessment can be difficult, and diagnostic measures may be discordant, making accurate or definitive diagnosis problematic. Nevertheless, every effort should be made to avoid missing diagnoses or making misdiagnoses (i.e. paranoia of cocaine abuse) and to repeatedly reassess patients when they are less acutely influenced by alcohol or drugs (Brem and Johnson 1997; Carey and Correia 1998).

Ambiguity of diagnosis should not preclude acute treatment of urgent psychiatric or substance-related problems (i.e. intoxication, withdrawal, psychosis). However, early accurate assessment and knowledge of substance abuse and psychiatric interactions is crucial in the acute setting, as well as later on. Early prescription of pscychoactive drugs requires an understanding of the dangers of certain drugs with specific substance abuse disorders (Zweben and Smith 1989). For example, benzodiazepines, MAO inhibitors, and SSRI's can be particularly harmful in alcohol abusers. In the less acute setting, physicians should also take into account the patient's concerns about prescribed drugs, such as control and fear of addiction issues.

After a patient is stabilized, the real work of treatment begins. It is not uncommon for dually diagnosed patients to be released from the hospital without good long-term follow-up preparations. Follow-up must be made with either inpatient or outpatient substance abuse treatment, including a 12-step program, group and individual therapy, and programs to help dually diagnosed patients deal with issues of homelessness, lack of social support, unemployment and vocational disability, and legal problems (Sloan and Rowe 1995). Prolonged inpatient stays can be complemented with inpatient substance abuse group therapy such as the multiple sessions program proposed by Braddiza and Stasiewicz (1997).

One of the distinctive characteristics of an integrative approach to treating dually diagnosed people is the recognition of the heterogeneity of patients and the need for individualized treatment tailored to the patient. Such an approach accounts for the different stages of recovery and the benefits of non-confrontational, yet assertive outreach efforts by caregivers (Drake 1998).

Prevention. Although the etiology of comorbid substance abuse and mental disorders is unknown, efforts can be made to prevent morbidity from these illnesses by continuing to treat dually diagnosed patients effectively. This involves integrated multi-disciplinary care, ongoing research in etiology and treatment, and training of physicians, medical students, and other caregivers in dual diagnosis issues. Currently, residents and medical students could benefit from much more training in dual diagnosis and substance abuse issues (Chappel 1993).

Children and adolescents should be assessed early on for comorbid substance abuse and mental illness, as early substance use is highly correlated with substance and mental disorders, particularly disruptive disorders (Kandel et al. 1997).

Supportive social care can have a dramatic impact, such as housing for the homeless. Chappel found that simply arranging a ride for patients to the first AA meeting led to 100% attendance, in contrast to the poor attendance by patients who were given only instructions.

Informative web sites

National Institute on Alcohol Abuse and Addictions: www.niaaa.nih.gov
National Institute on Drug Abuse: www.nida.nih.gov
National Institute on Mental Health: www.nimh.nih.gov

References

• Bradizza, CM, and Stasiewicz, PR (1997). Integrating substance abuse treatment for the seriously mentally ill into inpatient psychiatric treatment. Journal of Substance Abuse Treatment, 14(2): 103-111.
• Brems, C, and Johnson, ME (1997). Clinical implications of the co-occurrence of substance use and other psychiatric disorders. Professional Psychology: Research and Practice, 28(5): 437-447.
• Carey, KB, and Correia, CJ (1998). Severe mental illness and addictions: Assessment considerations. Addictive Behaviors, 23(6): 735-748.
• Chappel, JN (1993). Training of residents and medical students in the diagnosis and treatment of dual diagnosis patients. Journal of Psychoactive Drugs, 25(4): 293-299.
• Dickey, B, and Azeni, H (1996). Persons with dual diagnosis of substance abuse and major mental illness: Their excess costs of psychiatric care. American Journal of Public Health, 86(7): 973-977.
• Drake, RE, Mercer-McFadden, C, Mueser, KT, McHugo, GJ, and Bond, GR (1998). Review of integrated mental health and substance abuse treatment for patients with dual disorders. Schizophrenia Bulletin, 24(4): 589-608.
• Drake, RE, Osher, FC, and Wallach, MA (1991). Homelessness and dual diagnosis. American Psychologist, 46(11): 1149-1158.
• Hoff, RA, and Rosenheck, RA. Long-term patterns of service use and cost among patients with both psychiatric and substance abuse disorders (1998). Medical Care, 36(6): 835-843.
• Kandel, DB, Johnson, JG, Bird, HR, Canino, G, Goodman, SH, Lahey, BB, Regier, DA, and Schwab-Stone, M (1997). Psychiatric disorders associated with substance use among children and adolescents: Findings from the methods for the epidemiology of child and adolescent mental disorders (MECA) study. Journal of Abnormal Child Psychology, 25(2): 121-132.
• Kessler, RC, McGonagle, KA, Zhao, S, Nelson, CB, Hughes, M, Eshleman, S., Wittchen, HU, and Kendler, KS (1994). Lifetime and 12 month prevalence of DSM-III-R psychiatric disorders in the United States: Results from the National Comorbidity Survey. Archives of General Psychiatry, 51: 8-9
• Mueser, KT, Drake, RE, and Wallach, MA (1998). Dual diagnosis: A review of etiologic theories. Addictive Behaviors, 23(6): 717-734.
• The National Institute on Drug Abuse and the National Institute on Alcohol Abuse and Addictions (1992). The Economic Costs of Alcohol and Drug Abuse in the U.S.
• Regier, DA, Farmer, ME, Rae, DS, Locke, BZ, Keith, SJ, Judd, LL, and Goodwin, FK (1990). Comorbidity of mental disorders with alcohol and other drug abuse. JAMA, 264(19): 2511-2518.
• Sloan, KL, and Rowe, G (1995). Substance abuse and psychiatric illness: Psychosocial correlates. American Journal on Addictions, 4(1): 60-69.
• Weiss, RD, Mirin, SM, and Frances, RJ (1992). The myth of the typical dual diagnosis patient. Hospital and Community Psychiatry, 43(2): 107-108.
• Zweben, JE, and Smith, DE (1989). Considerations in using psychotropic medication with dual diagnosis patients in recovery. Journal of Psychoactive Drugs, 21(2): 221-228.

Summary: The goal of this paper is to 1) educate medical students on the dangers of alcohol misuse and 2) examine alcohol use by medical students.

I. Medical School and Drinking

At many universities and medical schools, social life centers on alcohol. Class functions are held at bars and nightclubs, often on "special" evenings when alcohol is discounted and plentiful. Alcohol is often used to motivate and reward the stressed-out medical student. Students distribute flyers promising a post-Gross Anatomy exam party with "four kegs, frozen margaritas, and room to crash." The Second Year Class President announces that the winner of the interclass blood drive will win a keg for the next class party….

Do most medical students drink? In a 1991 survey of senior medical students at 23 schools, 87.5% of the students responded that they consumed alcohol during the thirty days preceding the survey1. Of the 1,980 students in this survey who responded that they consume alcoholic beverages, 18.1% began drinking in grade school or before, 64.5% began drinking during high school, 16.3% begin in college and 1.1% began in medical school. The top three reasons cited by students for alcohol use were "to have a good time", "to relax" and "to feel good."1 Although medical students as a group have a slightly higher percentage of use of alcohol, the pattern and prevalence of alcohol dependence is very consistent with their age mates in the general population2.

Several studies have documented the common use of alcohol among medical students and the significant fraction of students (7% to 17%) that show a pattern of alcohol abuse3. In a 1986 study of 116 freshman medical students (96% of one class), the heavier drinking students were more likely to be: male and single; aggressive; heavy drinkers prior to medical school; from larger social networks which include fewer relatives; less concerned with evaluation by others3. In this study mood, academic performance, and parental alcohol abuse were not associated with drinking level3.

A longitudinal four-year study of one medical school class showed: male students drank consistently more than their female counterparts during the preclinical years; men reduced their alcohol consumption during the clinical years to a level consistent with their female classmates; over the four years of medical school 11% of students met criteria for excessive drinking for at least one six month period; and alcohol abusers had better first-year grades and better USMLE scores, part I, than their classmates4.

II. Alcohol-Related Disorders: The "Unadvertised" Effects of Alcohol

Think about the last commercial you watched for an alcoholic beverage. It seems that by purchasing "Alcoholic Beverage X" you instantly become the life of the party. With one sip, well-endowed, bikini-clad models will appear from nowhere and find even the most awkward male irresistible. A female seen drinking the right brand of beverage will instantly become a stud magnet, attracting only the best looking men to her side. By drinking alcohol, the advertisers promise you that you will feel more relaxed, attractive youthful and confident.

When was the last time that you saw a commercial for alcohol that boasted "alcohol can cause cancer, liver, neurological, cardiovascular, psychiatric and other physical disorders"? Have you ever seen an ad with computer-generated frogs croaking "cirr…hos…is….cirr…hos…is"? Youth, beauty, good times - not liver cancer, drunk driving, pancreatitis - that's what the advertisers want you to think about when it comes to alcohol. After heart disease and cancer, alcohol-related disorders constitute the third largest health problem in the United States5. Disorders caused by high alcohol consumption include:

1. Cancer - Cancer of the mouth, tongue, pharynx, larynx, esophagus, liver
2. Liver Damage - Fatty Liver, Alcoholic Hepatitis, Cirrhosis, Liver Cancer
3. Nervous System Disorders - Thiamine (Vitamin B1) deficiency (Beri Beri), Wernicke's Encephalopathy, Korsakoff's Psychosis
4. Cardiovascular Disorders - Heart failure, Edema, Hypertension, Stroke, Cardiomyopathy
5. Other Disorders - Gastritis, Pancreatitis, Peptic Ulcer, Renal Failure, Fetal Alcohol Syndrome, Weight Gain, Impotence
6. Psychiatric Disorders - Anxiety, Depression, Dementia, Suicide

III. The Effects of Alcohol

Which contains more alcohol? A) Eight ounces of beer, B) 4 ounces of wine, C) 2 ounces of Sherry, D) 1 ounce of Whiskey, or E) They all contain the same amount of alcohol. The correct answer is E. A person who consumes 8 ounces of wine has ingested twice as much alcohol as someone who has had one eight-ounce serving of beer.

Alcohol is a depressant. At a blood alcohol level (BAL) of 0.05, the drinker becomes talkative and feels more socially at ease. As the blood alcohol level increase, the drinker becomes clumsy, perhaps irritable, and may act impulsively and irrationally (at about .1 percent BAL). At 0.2 percent BAL the function of the entire motor area of the brain becomes depressed. At 0.3 percent BAL the drinker becomes extremely confused, drowsy, and has a difficult time staying upright. If the drinker's BAL reaches 0.4 to 0.5 percent, the drinker will become comatose. At higher blood alcohol levels, death occurs, usually from arrested breathing or aspiration of vomitus. People with long-term histories of alcohol abuse can tolerate much higher concentrations of alcohol than alcohol-naïve people; their alcohol tolerance may cause them to falsely appear less intoxicated than they really are5.

One of the extreme dangers of drinking is the loss of judgement as a drinker continues to consume alcoholic beverages. An inebriated person may not be able to remember how many drinks he has consumed and continue to drink to dangerous blood alcohol levels. Also, drinking removes inhibitions and clouds judgement, leading to impulsive (and often regretful) behavior.

The following characteristics strongly suggest alcoholism: need for daily or episodic use of alcohol for adequate function; inability to discontinue or reduce alcohol intake; episodes of anesthesia or amnesia during intoxication; episodes of violence during intoxication; and interference with social and familial relationships and occupational responsibilities6. The CAGE questionnaire is an effective clinical tool used to identify alcohol abuse. The CAGE questions are: 1) Have you ever tried to Cut down on your drinking?; 2) Have you ever been Annoyed at other people's concern with your drinking?; 3) Have you ever felt Guilty about your drinking?; and 4) Have you ever had an Eye-opener to ease shakes or a hangover? The more questions a student answers "yes", the greater the likelihood that a drinking problem exists.

Total abstinence is the only effective treatment. Supportive programs that offer detoxification, rehabilitation, and aftercare (including continued involvement in Alcoholics Anonymous) produce the best long term results6. If you would like more information about Alcoholics Anonymous, please visit their website at http://www.alcoholics-anonymous.org or call them at (212) 870-3400.

References

1. Baldwin, DeWitt C., et al. "Substance Abuse among Senior Medical Students: A Survey of 23 Medical Schools." JAMA 265 (1991): 2074-2078.
2. Flaherty, Joseph A. and Judith A. Richman. "Substance Abuse and Addiction among Medical Students, Residents and Physicians." Psychiatric Clinics of North America 16 (1993): 189-196.
3. Kuzel, Anton J., et al. "A Survey of Drinking Patterns during Medical School." Southern Medical Journal. (need full citation).
4. Clark, David C. et al. "Alcohol Use Patterns of First-Year Medical Students: II. Psychosocial Characteristics Associated with Drinking Level." Alcoholism: Clinical and Experimental Research 10 (1986): 65-69.
5. Kaplan, Harold J. and Benjamin J. Saddock. Synopsis of Psychiatry. 8th Ed. Baltimore: Williams and Wilkins, 1998.
6. Springhouse Corporation. Professional Guide to Diseases. Third Ed. Pennsylvania: Springhouse Corporation.