A Call for Standardized Definition of Dual Diagnosis

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.


1. Buckley P. Prevalence and consequences of the dual diagnosis of substance abuse and severe mental illness. J Clin Psychiatry 2006;67:5–10.
2. Drake R, Mercer-McFadden C, Mueser K, et al. Review of integrated mental health and substance abuse treatment for patients with dual diagnosis. Integrated Mental Health and Substance Abuse 1998;24(4):589–605.
3. Center for Substance Abuse Treatment. Definitions and Terms Relating to Co-Occurring Disorders. COCE Overview Paper 1. DHHS Publication No. (SMA) 06-4163 Rockville, MD: Substance Abuse and Mental Health Services Administration, and Center for Mental Health Services, 2006.
4. NSDUH. Co-occurring major depressive episode (MDE) and alcohol use disorder among adults. The NSDUH Report. Office of Applied Studies, Substance Abuse and Mental Health Services Administration. February 16, 2007.
5. Substance Abuse and Mental Health Services Administration. Results from the 2005 National Survey on Drug Use and Health: National Findings (Office of Applied Studies, NSDUH Series H-30, DHHS Publication No. SMA 06-4194). Rockville, MD, 2006.
6. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Press, Inc, 2002.
7. Tiet Q, Mausbach B. Treatments for patients with dual diagnosis: A review. Alcohol Clin Exp Res 2007;31(4):513–36.
8. Linszen D, Dingemans P, Lenior M. Cannibas abuse and the course of recent-onset schizophrenia. Arch Gen Psychiatry 1994;51:273–9.
9. Haywood T, Kravitz H, Grossman L, et al. Predicting the “revolving door” phenomenon among patients with schizophrenic, schizoaffective, and affective disorders. Am J Psychiatry 1995;152:856–61.
10. Soyka M. Substance misuse, psychiatric disorder, and violent disturbed behaviour. Br J Psychiatry 2000;176:345–50.
11. Cuffel B, Shumway M, Chouljian T, MacDonald T. A longitudinal study of substance use and community violence in schizophrenia. J Nerv Ment Dis 1994;182:704–8.
12. Wu L, Ringwalt C, Williams C. Use of substance abuse treatment services by persons with mental health and substance use problems. Psychiatr Serv 2003;54(3):363–9.
13. Todd J, Green G, Harrison M, et al. Defining dual diagnosis of mental illness and substance misuse: some methodological issues. J Psychiatr Mental Health Nurs 2004;11;48–54.
14. Ridgely M, Goldman H, Talbott J. Chronic Mentally Ill Young Adults with Substance Abuse Problems: A Review of Literature and Creation of a Research Agenda. Baltimore, MD: Mental Health Policy Studies Center, University of Maryland, 1986.
15. Ridgely M, Osher F, Goldman H, Talbott J. Executive Summary: Chronic Mentally Ill Young Adults with Substance Abuse Problems: A Review of Research, Treatment, and Training Issues. Baltimore, MD: Mental Health Services Research Center, University of Maryland School of Medicine, 1987.
16. Ridgely M, Goldman H, Willenbring M. Barriers to the care of persons with dual diagnosis. Schizophr Bull 1990;16(1):123–32.
17. Seal K, Bertenthal D, Miner C, et al. Mental health disorders among 103,788 US veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs Facilities. Arch Intern Med 2007;167(5):476–82.

With regards,
Kathyrn Hryb, MSW
Rob Kirkhart, PhD, PA-C
Rebecca Talbert, PharmD
From the Department of Veteran Affairs Medical Center, Chillicothe, Ohio

Dear Editor:
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) revision process is just now getting underway with anticipated publication in 2012. The various workgroups are now being formed and should start their initial deliberations in the Fall. Given that the DSM-V revision process is only in its early stages, the diagnostic issues raised in the Hyrb, et al.’s letter have not yet been formally considered. There was, however, a DSM-V research planning conference on substance use disorders that took place in February, 2005, at the NIAAA in Rockville, Maryland, which reviewed the available research and made recommendations for future research. A summary of this conference has been posted on the DSM-V website
(http://dsm5.org/conference4.cfm) and papers based on the presentations were presented in a supplement to the September, 2006, issue of the journal Addiction.

With regards,
Michael B. First, MD
Professor of Clinical Psychiatry, Columbia University, Research Psychiatrist, New York State Psychiatric Institute, New York, New York

Regarding pulmonary embolism during an episode of catatonic depression

The report[1] of pulmonary embolism during an episode of catatonic depression [Psychiatry 2007;4(6):51–56] unjustifiably stated that lorazepam is effective therapy for catatonia. However, this has never been established by long-term study. Studies have reported observations for only a few days. This is analogous to the Tensilon® (edrophonium) test for myasthenia gravis, in which illness signs and symptoms are temporarily reversed but the medication is useless for maintenance. There has been no systematic long-term followup group study of benzodiazepine efficacy in catatonia. I observe that if a patient with acute catatonia shows complete remission with 1mg/day or less of lorazepam, a stable remission is reasonably likely. With higher doses patients relapse into melancholia, psychosis, or catatonia within a few days to a month. The only long-term followup treatment study of catatonic depression with statistical results used electroconvulsive therapy (ECT).[2]

Ignatowski, et al.,[1] observed that ECT is not available in many state facilities. Administrative refusal to provide ECT when needed does not make benzodiazepines suitable for the task. The authors state there is stigma surrounding the ECT procedure. However, there is surely more stigma surrounding a patient remaining catatonic because of undertreatment and from being learning-impaired and oversimplistic from high-dose tranquilizers than from achieving remission with ECT. The authors state they have difficulty obtaining informed consent; informed consent is surely easier to obtain in psychiatric facilities that regularly provide ECT. Still, the authors’ report is highly constructive because it clearly and irrefutably conveys that in treating catatonia ECT is necessary and irreplaceable, and state psychiatric hospitals that do not facilitate ECT for these patients are harming them. Why can these state hospital administrators forget the basic medical ethic of “Above all do no harm?”

1. Ignatowski M, Sidhu S, Rueve M. Pulmonary embolism as a complication of major depressive disorder with catatonic features: A case report. Psychiatry 2007;4(6):51–6.
2. Swartz CM, Morrow V, Surles L, James JF. Long-term outcome after ECT for catatonic depression. J ECT 2001;17(3):180–3.

With regards,
Conrad M. Swartz, PhD MD
Professor of Psychiatry (Emeritus)
Southern Illinois University School of Medicine

The evidence-based data backing efficacy of benzodiazapines in acute catatonia is vast.[1] Although there is controversy whether this treats the underlying mechanism, the mood, or psychotic disorder, we do not imply that this is the case.[2] Surely the antidepressant will be the effective long-term agent once the catatonia is resolved acutely and the antidepressant is given optimal time for efficacy, at which time the patient would no longer need to be on benzodiapines. We agree with Dr. Swartz that ECT makes sense as the single best modality for long-term care of MDD with catatonic features as his article indicates, because ECT shows evidence-based indications for both depression and catatonia.[3] To state that there is no justification for the use of a proven modality, such as benzodiazapines, for acute catatonia if ECT is not available is to miss the significance of this case study. Breaking the catatonia even if the depression is not treated initially is crucial in preventing the devastating consequences such as pulmonary embolism in the acute setting seen on an inpatient ward. The Tensilon test for myasthenia gravis is purely diagnostic and does not save lives, whereas benzodiazapines for catatonia is a treatment that may.

1. Lee JW, Schwartz DL, Hallmeyer J. Catatonia in a psychiatric intensive care facility: Incidence and response to benzodiazepines. Ann Clin Psychiatry. 2000;12(2):89–96.
2. Ignatowski M, Sidhu S, Rueve M. Pulmonary embolism as a complication of major depressive disorder with catatonic features: A case report. Psychiatry 2007;4(6):51–6.
3. Swartz CM, Morrow V, Surles L, James JF. Long-term outcome after ECT for catatonic depression. J ECT 2001;17(3):180–3.

With regards,
Michael Ignatowski, DO
Santokh Sidhu, BA
Marie Rueve, MD
From the Department of Psychiatry, Wright State University Boonshoft School of Medicine, Dayton, Ohio