The epidemiology of dual diagnosis

doi:10.1016/j.biopsych.2004.06.034

Biological Psychiatry

Volume 56, Issue 10, 15 November 2004, Pages 730-737

https://doi.org/10.1016/j.biopsych.2004.06.034 Get rights and content

The English language literature on the epidemiology of dual diagnosis is reviewed. The literature shows mental disorders to be significantly related to alcohol and drug use disorders. The strongest associations involve externalizing mental disorders and alcohol-drug dependence. Mental disorders are associated with alcohol-drug use, problems among users, dependence among problem users, and persistence among people with lifetime dependence. These dual diagnoses are associated with severity and persistence of both mental and alcohol-drug disorders. A wider range of mental disorders is associated with nicotine dependence. Most people with dual diagnosis report their first mental disorder occurred at an earlier age than their first substance disorder. Prospective studies confirm this temporal order, although significant predictive associations are reciprocal. Analyses comparing active and remitted mental disorders suggest that some primary mental disorders are markers and others are causal risk factors for secondary substance disorders. The article closes with a discussion of ways epidemiologic research can be used to help target and evaluate interventions aimed at preventing secondary substance use disorders by treating early-onset primary mental disorders.

Section snippets

Cross-sectional disorder specific associations

Analysis of cross-sectional associations among disorders in community surveys typically shows much stronger ORs within than between two broad classes of mental disorders (Kessler 1995; Merikangas and Stevens 1998), usually referred to as internalizing disorders (anxiety and mood disorders) and externalizing disorders (oppositional-defiant disorder, conduct disorder, attention-deficit/hyperactivity disorder). Factor analysis finds two major factors that correspond to these two classes (Krueger

Temporal priority and age of onset

A number of community epidemiologic surveys have collected retrospective information about age of onset (AOO) of mental and substance disorders, which consistently suggest that mental disorders typically start at an earlier age than substance use disorders (Kessler et al 2003; Merikangas and Stevens 1998; Sareen et al 2001; Swendsen et al 1998; Wittchen et al 1996). Consistent with parallel research in clinical samples (Hahesy et al 2002), this pattern is somewhat stronger among women than men,

Predictive associations based on retrospective reports in cross-sectional surveys

Simple comparisons of temporal priorities are inadequate to document predictive associations (Kessler and Price 1993). This documentation requires analysis of reciprocal series of survival analyses in which each of the two sets of disorders is treated as a series of time-varying covariates that predict first onset of the disorders in the other set. The most comprehensive analyses of this sort were carried out in the ICPE surveys (Kessler et al 2001, 2003). These analyses used a discrete-time

Predictive associations based on prospective data

As recall bias could be involved in retrospective AOO reports, it is important to turn to longitudinal studies for confirmation. The evidence is most clear and consistent for conduct disorder. McCord and McCord (1960), for example, found in a long-term prospective study that childhood aggressiveness preceded alcohol use and predicted later development of alcoholism. Jones (1975) found much the same results in a long-term follow-up of respondents from the Oakland Growth Study. Similar

Comorbidity and course of illness

Long-term prospective epidemiologic surveys have also been used to study associations of comorbidity with course of illness (Hagnell and Grasbeck 1990; Murphy 1990). These studies show consistently that comorbid disorders are more chronic than pure disorders. Indirect evidence based on cross-sectional epidemiologic surveys is also consistent with these prospective findings in showing that respondents with a retrospectively reported lifetime history of mental or substance use disorder report a

Making sense of the associations

Based on the results reviewed above, at least some evidence exists for each of four broad possibilities to explain observed patterns of mental-substance comorbidity. The first is that mental disorders lead to the onset and/or persistence of substance use disorders, most plausibly through processes that involve increased exposure to drug use (associated largely with conduct disorder), disinhibition to experiment with drugs (associated with impulse-control disorders), and self-medication of

Comorbidity between mental disorders and nicotine dependence

Although the review has thus far focused on comorbidities of mental disorders with alcohol and drug use disorders, there is a separate, but related, epidemiologic literature on comorbidities between mental disorders and nicotine dependence. Significant positive associations of smoking with both mental disorders and alcohol-drug use disorders have been documented in a number of epidemiologic studies (Breslau et al 2001; Covey et al 1994; Glassman et al 1990; Lasser et al 2000). The literature on

Primary prevention of secondary substance disorders

The most obvious area where the epidemiologic evidence has potential clinical relevance is in regard to the finding that primary mental disorders strongly predict later substance use disorders. This raises the question of whether early successful treatment of primary mental disorders would be effective in reducing subsequent substance disorders. The effect sizes in epidemiologic surveys are such that the question is of more than passing interest. Simulations in the ICPE surveys, for example,

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Impact of substance abuse on the diagnosis, course, and treatment of mood disordersThe epidemiology of dual diagnosis

Section snippets

Cross-sectional disorder specific associations

Temporal priority and age of onset

Predictive associations based on retrospective reports in cross-sectional surveys

Predictive associations based on prospective data

Comorbidity and course of illness

Making sense of the associations

Comorbidity between mental disorders and nicotine dependence

Primary prevention of secondary substance disorders

Behav Res Ther

Biol Psychiatry

J Am Acad Child Adolesc Psychiatry

Addict Behav

Drug Alcohol Depend

Psychiatry Res

Compr Psychiatry

Schizophr Res

J Affect Disord

Addict Behav

Addict Behav

Compr Psychiatry

Psychiatry Res

Addict Behav

Anger and depressive states among treatment-seeking drug abusersTesting the psychopharmacological specificity hypothesis

Am J Addict

Comorbidity of anxiety and depression in the Zurich cohort study of young adults

Psychiatric comorbidity and not completing jail-based substance abuse treatment

Am J Addict

Daily smoking and the subsequent onset of psychiatric disorders

Psychol Med

Nicotine dependence in the United StatesPrevalence, trends, and smoking persistence

Arch Gen Psychiatry

Smoking and panic attacksAn epidemiologic investigation

Arch Gen Psychiatry

Major depression and stages of smoking

Arch Gen Psychiatry

Behavioral observations at age 3 years predict adult psychiatric disorders. Longitudinal evidence from a birth cohort

Arch Gen Psychiatry

Anxiety disorders and alcoholismA study with inpatient alcoholics

J Anxiety Disord

Epidemiologic evidence for early onset of mental disorders and higher risk of drug-abuse in young-adults

Am J Psychiatry

Prevalence and development of psychiatric disorders in childhood and adolescence

Arch Gen Psychiatry

Ever-smoking, quitting, and psychiatric disordersEvidence from the Durham, North Carolina, Epidemiologic Catchment Area

Tob Control

Risk of heavy drinking and alcohol use disorders in social phobiaA prospective analysis

Am J Psychiatry

Exploring the association between cannabis use and depression

Addiction

A comparison of schizophrenic patients with or without coexisting substance use disorder

Psychiatr Q

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Med Care

A comparison of the patterns of drug use among patients with and without severe mental illness

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Smoking, smoking cessation, and major depression

JAMA

Variation in youthful risks of progression from alcohol and tobacco to marijuana and to hard drugs across generations

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Comorbid major depressive disorder as a prognostic factor in cocaine-abusing buprenorphine-maintained patients treated with desipramine and contingency management

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Depressive symptoms and cigarette smoking among teens

Pediatrics

Treatment of panic attack and risk of major depressive disorder in the community

Am J Psychiatry

Comorbidity of anxiety and depression in the Lundby 25-year prospective studyThe pattern of subsequent episodes

Predictors of alcoholism in the Lundby Study. II. Personality traits as risk factors for alcoholism

Eur Arch Psychiatry Neurol Sci

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The co-occurrence of alcoholism with other psychiatric disorders in the general population and its impact on treatment

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Drinking to cope, emotional distress and alcohol use and abuseA ten-year model

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Impact of substance abuse on the diagnosis, course, and treatment of mood disorders
The epidemiology of dual diagnosis