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The epidemiology of dual diagnosis
Abstract
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.
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“For example, there are high rates of comorbidity between substance abuse and other Axis I conditions [747-749], schizophrenia and bipolar disorder [750], and ASD and mood and anxiety disorders [751].”
From Reward circuitry dysfunction in psychiatric and neurodevelopmental disorders and genetic syndromes: animal models and clinical findings (2012) · cites this paper as [747]
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Rodríguez-Cintas, L., Daigre, C., Braquehais, M. D., Palma-Álvarez, R. F., Grau‐López, L., Ros‐Cucurull, E., Rodríguez-Martos, L., Abad, A. C., & Roncero, C. (2017) · Psychiatry Research · doi:10.1016/j.psychres.2017.09.021 · Cited by 533
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“Kessler, Chiu, Demler, Merikangas, and Walters (2005) report that 27% of people have at least one psychiatric disorder, and 45% of people with psychiatric conditions actually have two or”
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Neuroscience of Addiction: Relevance to Prevention and Treatment
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“For example, there are high rates of comorbidity between substance abuse and other Axis I conditions [747-749], schizophrenia and bipolar disorder [750], and ASD and mood and anxiety disorders [751].”
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“For instance, the finding of this review that depressed men report higher alcohol or other drug misuse is consistent with data showing that substance misuse and comorbidity of depression with substance use disorders are more prevalent in men.(74,75) It remains unclear from the current study, however, whether the incre…”
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“In addition, other behavioral health factors at baseline were controlled for, including delinquency, suicidality and depressive symptoms, due to the high rates of comorbidity of mental health diagnoses among persons with substance abuse [24].”
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“The few reviews available in the current literature have focused on epidemiology (Kessler, 2004; Jane-Llopis and Matytsina, 2006) and substance relapse predictors (Bradizza et al., 2006).”
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“Among representative community samples, 12-month estimates from both the Epidemiologic Catchment Area Survey (Regier et al. 1990) and the U.S. National Comorbidity Study (Kessler 2004, Kessler et al. 1996) show that about 22%– 23% of the adult population has a diagnosable psychiatric disorder.”
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“However, it is consistent with clinical thinking on the etiology of dual diagnosis and the reciprocal associations between mental and substance use disorders (Kessler, 2004; Mueser, Drake, & Wallach, 1998).”
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On the development of nicotine dependence in adolescence
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“This association among adolescents replicates findings among adults (Breslau et al., 1991,1993b,1994,2004;John et al., 2004;Kendler et al., 1993;Kessler, 2004).”
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“As suggested by Kessler (27) and Faraone et al. (28), several possibilities may explain some observed patterns of comorbidity between somatoform disorders and anxiety and depressive disorders: 1) The association is spurious, resulting from methodological problems; e.g., reporting or recall bias may explain the observe…”
MethodInfluentialGenetics of substance use disorders: a review
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“Genetic studies have begun to elucidate the molecular mechanisms underlying SUDs and related traits, including other psychiatric conditions with which SUDs frequently co-occur (Grant et al., 2016; Kessler, 2004).”
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“These studies fit into a more broad well-documented area f research indicating that psychiatric disorders occur more freuently in drug using and dependent individuals than among on-drug using individuals (Kessler et al., 2003; Kessler, 2004; andel et al., 1997; Regier et al., 1990; Rounsaville et al., 1991; rant and H…”
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“Mental health difficulties and substance use increase rapidly during adolescence and young adulthood (Kessler et al. 2001; Kessler 2004 ), and depression and anxiety are among the most common mental health difficulties faced by youth (Birmaher et al. 1996; Pine et al. 1999).”
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“…consistent with the results from other clinical and epidemiological studies that have investigated the comorbidity of anxiety disorders and substance use disorders with MDD (Fava et al., 2000; Grant, 1995; Grant and Harford, 1995; Kessler, 2004; Swendsen et al., 1998; Weaver et al., 2003).”
Global research challenges and opportunities for mental health and substance-use disorders
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“The clinical utility of psychiatric epidemiologic research lies in its potential to identify and evaluate causal factors that can be modified to facilitate primary and secondary preventive efforts (Kessler 2004).”
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“These patterns of genetic correlation are consistent with and may reflect high rates of co-occurrence of OUD with SUDs and psychiatric disorders in epidemiologic studies [25, 36].”
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“Substance misuse, besides representing an independent risk factor for developing a psychiatric disorder (Barkus & Murray, 2010), also alters the course of psychiatric illness, as well as a decrease in psychological status may induce relapse or increase in substance misuse (Hill, 1965; Kessler, 2004).”
BackgroundGlantz, M. D., Anthony, J. C., Berglund, P. A., Degenhardt, L. J., Dierker, L., Kalaydjian, A., Merikangas, K. R., Ruscio, A. M., Swendsen, J. D., & Kessler, R. C. (2008) · Psychological Medicine · doi:10.1017/s0033291708004510 · Cited by 121
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“On the other side, addictive behavior, such as online gaming [14], could be a way of coping with pre-existing emotional difficulties, such as depression [6].”
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“Individuals with mental health disorders have an increased likelihood of substance use disorders [16, 23, 27] and in those cases where mental health disorders are comorbid with substance use disorders, the mental health disorder typically precedes the substance use disorder [28], or is often independent of the substan…”
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Co-morbid anxiety disorders predict early relapse after inpatient alcohol treatment
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“Prior research has consistently shown a strong association between alcohol dependence and anxiety disorders [1–6].”
MethodQuality of life improved following in-patient substance use disorder treatment
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Adult hippocampal neurogenesis in the pathogenesis of addiction and dual diagnosis disorders
Chambers, R. A. (2012) · Drug and Alcohol Dependence · doi:10.1016/j.drugalcdep.2012.12.005 · Cited by 110
“These disorders, including schizophrenia, post-traumatic stress disorder (PTSD), major depression and cluster B personality syndromes are highly comorbid with substance use disorders (Kessler, 2004).”
BackgroundButler, T. R., Karkhanis, A. N., Jones, S. R., & Weiner, J. L. (2016) · Alcoholism Clinical and Experimental Research · doi:10.1111/acer.13075 · Cited by 114
“These findings are consistent with a large body of literature suggesting a high degree of comorbidity between AUD and a wide range of affective disorders (Brenhouse and Andersen, 2011; Brodie et al., 1999; Buckley, 2006; Buckley and Brown, 2006; Kessler, 2004; Kushner, 2014).”
ResultSarvet, A. L., Wall, M. M., Keyes, K. M., Olfson, M., Cerdá, M., & Hasin, D. S. (2018) · Drug and Alcohol Dependence · doi:10.1016/j.drugalcdep.2018.01.009 · Cited by 122
Landheim, A. S., Bakken, K., & Vaglum, P. (2006) · BMC Psychiatry · doi:10.1186/1471-244x-6-44 · Cited by 105
“Background Most help-seeking substance abusers have comorbid symptom disorders and/or personality disorders [1-3].”
Backgroundvan Duijvenbode, N., VanDerNagel, J., Didden, R., Engels, R. C. M. E., Buitelaar, J. K., Kiewik, M., & de Jong, C. A. J. (2015) · Research in Developmental Disabilities · doi:10.1016/j.ridd.2014.12.029 · Cited by 109
Goldner, E. M., Lusted, A., Roerecke, M., Rehm, J., & Fischer, B. (2014) · Addictive Behaviors · doi:10.1016/j.addbeh.2013.11.022 · Cited by 102
Sterling, S., Chi, F., & Hinman, A. (2011) · Europe PMC (PubMed Central) · Cited by 101
Concurrent Disorder Management Guidelines. Systematic Review
Hakobyan, S., Vazirian, S., Lee-Cheong, S., Krausz, M., Honer, W. G., & Schutz, C. G. (2020) · Journal of Clinical Medicine · doi:10.3390/jcm9082406 · Cited by 99
“In mental health, the focus of research and guidelines has been on individual disorders, despite concurrent disorders being common and seemingly increasing [5].”
BackgroundThe role of substance use in child welfare caseloads
Ghertner, R., Waters, A., Radel, L. F., & Crouse, G. (2018) · Children and Youth Services Review · doi:10.1016/j.childyouth.2018.05.015 · Cited by 99
Zlotnick, C., Clarke, J. G., Friedmann, P. D., Roberts, M. B., Sacks, S., & Melnick, G. (2008) · Behavioral Sciences & the Law · doi:10.1002/bsl.831 · Cited by 99
“Research in the general community suggests that individuals with comorbid disorders tend to report that their first mental disorder occurred at an earlier age than their first substance disorder (Kessler, 2004).”
BackgroundPsychiatric disease and drug abuse
Santucci, K. (2012) · Current Opinion in Pediatrics · doi:10.1097/mop.0b013e3283504fbf · Cited by 97
“Most individuals with both disorders report SUD preceding their mental disorder [15].”
BackgroundSloboda, Z., Glantz, M. D., & Tarter, R. E. (2012) · Substance Use & Misuse · doi:10.3109/10826084.2012.663280 · Cited by 94
“…age of onset of these conditions in community samples typically find that mental disorders begin at earlier ages than substance use disorders (Kessler, 2004; Merikangas et al.,1998) and that prior occurring mental disorders predict subsequent substance use disorders (Armstrong&Costello,…”
BackgroundSuicide and deliberate self-harm in personality disorders
Krysinska, K. E., Heller, T., & Leo, D. D. (2005) · Current Opinion in Psychiatry · doi:10.1097/01.yco.0000191498.69281.5e · Cited by 94
Martins, S. S., & Gorelick, D. A. (2011) · Drug and Alcohol Dependence · doi:10.1016/j.drugalcdep.2011.05.010 · Cited by 93
“Substance use disorders and other psychiatric disorders are ighly co-morbid in the general population, as well as among atients in treatment (Buckley and Brown, 2006; Compton et al., 007; Conway et al., 2007; de Leon and Diaz, 2005; Grant, 1995; regg et al., 2007; Jane-Llópis and Matytsina, 2006; Lammertink t al., 200…”
BackgroundKelley, M. L., Lawrence, H. R., Milletich, R. J., Hollis, B. F., & Henson, J. M. (2015) · Child Abuse & Neglect · doi:10.1016/j.chiabu.2015.01.017 · Cited by 94
“…and drug use is likely bidirectional, drug or alcohol use can produce mood swings, irritability, or mood disorders especially when consumed in high doses (e.g., Kessler, 2004; see O’Brien et al., 2004 for a review; Schuckit et al., 2007), suggesting that SUD may provide one pathway to depression.”
BackgroundBizzarri, J. V., Sbrana, A., Rucci, P., Ravani, L., Massei, G. J., Gonnelli, C., Spagnolli, S., Doria, M. R., Raimondi, F., Endicott, J., et al. (2007) · Bipolar Disorders · doi:10.1111/j.1399-5618.2007.00383.x · Cited by 92
Nonmedical Prescription Opioid Use and Mental Health and Pain Comorbidities: A Narrative Review
Amari, E., Rehm, J. T., Goldner, E. M., & Fischer, B. (2011) · The Canadian Journal of Psychiatry · doi:10.1177/070674371105600808 · Cited by 82
Degenhardt, L. J., Saha, S., Lim, C. C. W., Aguilar‐Gaxiola, S., Al‐Hamzawi, A., Alonso, J., Andrade, L. H., Bromet, E. J., Bruffaerts, R., Caldas‐de‐Almeida, J. M., et al. (2017) · Addiction · doi:10.1111/add.14145 · Cited by 82
Self-citationMental Health Among Reserve Component Military Service Members and Veterans
Cohen, G. H., Fink, D. S., Sampson, L., & Galea, S. (2015) · Epidemiologic Reviews · doi:10.1093/epirev/mxu007 · Cited by 81
Fischer, B., Lusted, A., Roerecke, M., Taylor, B., & Rehm, J. T. (2012) · Journal of Pain · doi:10.1016/j.jpain.2012.07.013 · Cited by 77
Young, J. T., Heffernan, E., Borschmann, R., Ogloff, J. R. P., Spittal, M. J., Kouyoumdjian, F. G., Preen, D. B., Butler, A., Brophy, L. M., Crilly, J. L., et al. (2018) · The Lancet Public Health · doi:10.1016/s2468-2667(18)30052-5 · Cited by 80
Cares, A., Pace, E. M., Denious, J. E., & Crane, L. A. (2014) · Substance Abuse · doi:10.1080/08897077.2014.933725 · Cited by 77
“The National Comorbidity Survey found that 51% of those surveyed with a lifetime alcohol or other drug disorder also indicated that they had a lifetime mental health disorder.(28) Although some studies have examined the prevalence of substance use problems among nurses, few have assessed substance use in the workplace…”
BackgroundRape, sex partnership, and substance use consequences in women veterans
Booth, B. M., Mengeling, M., Torner, J., & Sadler, A. G. (2011) · Journal of Traumatic Stress · doi:10.1002/jts.20643 · Cited by 75
Patterns of major depression and nonmedical use of prescription opioids in the United States
Fink, D. S., Hu, R., Cerdá, M., Keyes, K. M., Marshall, B. D. L., Galea, S., & Martins, S. S. (2015) · Drug and Alcohol Dependence · doi:10.1016/j.drugalcdep.2015.05.010 · Cited by 75
“…depression pose a greater disease burden than either condition alone, as such cases are more likely to experience more severe psychiatric symptoms (Kessler, 2004), rehospitalization (Appleby et al., 2001), incarceration (Hawthorne et al., 2012), and suicidal behaviors (Effinger and Stewart, 2012).”
Pseudoaddiction: Fact or Fiction? An Investigation of the Medical Literature
Greene, M., & Chambers, R. A. (2015) · Current Addiction Reports · doi:10.1007/s40429-015-0074-7 · Cited by 75
Cannabis regulatory science: risk–benefit considerations for mental disorders
Borodovsky, J. T., & Budney, A. J. (2018) · International Review of Psychiatry · doi:10.1080/09540261.2018.1454406 · Cited by 75
“Historically, in the US, individuals with mental disorders have experienced stigma, marginalization (Perese, 2016), and a disproportionate amount of burden engendered by legal and illegal addictive substances (CDC, 2013; Jane-Llopis & Matytsina, 2006; Kessler, 2004).”
BackgroundFactors associated with geriatric syndromes in older homeless adults
Brown, R. T., Kiely, D. K., Bharel, M., & Mitchell, S. L. (2013) · Journal of Health Care for the Poor and Underserved · doi:10.1353/hpu.2013.0077 · Cited by 71
Canaway, R., & Merkes, M. (2010) · Australian Health Review · doi:10.1071/ah08723 · Cited by 70
Rose, R. J., Broms, U., Korhonen, T., Dick, D. M., & Kaprio, J. A. (2009) · Springer eBooks · doi:10.1007/978-0-387-76727-7_28 · Cited by 68
“But a caveat: comorbidities may be confounded by methodological factors leading to overestimation of that dual diagnosis (Kessler, 2004).”
Background
Metadata
- Authors
- Kessler, R. C.
- Affiliations
- Harvard University (US)
- Corresponding author
- Kessler, Ronald C.
- ORCID
- Kessler, Ronald C.
- Venue
- Biological Psychiatry
- Publisher
- Elsevier BV
- Published
- 2004-11
- Volume
- 56
- Issue
- 10
- Pages
- 730-737
- ISSN
- 0006-3223 (ISSN-L)
- OpenAlex
- W2028877810
- Cited by
- 588
- References
- 113
- Citations by year
- 2026: 7 · 2025: 22 · 2024: 20 · 2023: 17 · 2022: 28 · 2021: 28 · 2020: 34 · 2019: 34 · 2018: 26 · 2017: 27 · 2016: 38 · 2015: 46 · 2014: 32 · 2013: 35 · 2012: 28
- FWCI
- 2.13
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Biological Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Robert Wood Johnson Foundation (044708)
- National Institute of Mental Health (U01-MH60220)
- John W. Alden Trust
- National Institute on Drug Abuse
- Substance Abuse and Mental Health Services Administration
- Topics
- Health Sciences › Medicine › Epidemiology › Substance Abuse Treatment and Outcomes
- Health Sciences › Medicine › Psychiatry and Mental health › Mental Health Treatment and Access
- Health Sciences › Medicine › Psychiatry and Mental health › Bipolar Disorder and Treatment
- Keywords
- dual diagnosis, alcoholism, drug addiction, nicotine dependence, early-onset mental disorders
- MeSH terms
- Mental Disorders, Cross-Sectional Studies, Humans, Prospective Studies, Tobacco Use Disorder, Comorbidity, Age of Onset, Diagnosis, Dual (Psychiatry), Disease Progression, Substance-Related Disorders
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