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The epidemiology of dual diagnosis

Kessler, Ronald C.·2004·Biological Psychiatry

DOI 10.1016/j.biopsych.2004.06.034

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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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Background
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Background
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Background
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BackgroundResult
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Kappa opioid receptor in nucleus accumbens regulates depressive-like behaviors following prolonged morphine withdrawal in mice
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“Studies on opioid addiction find that most heroin abuse patients developed depressive symptoms after withdrawal.(4,5) Importantly, depressive symptoms could be an important factor in relapse of opioid addiction.”
Background
Predictors of mental distress among substance abusers receiving inpatient treatment
Hoxmark, E. M., Nivison, M. E., & Wynn, R. (2010) · Substance Abuse Treatment Prevention and Policy · doi:10.1186/1747-597x-5-15 · Cited by 19
Recidivism and the “Worst of Both Worlds” Hypothesis
Walters, G. D. (2014) · Criminal Justice and Behavior · doi:10.1177/0093854814551018 · Cited by 19
“Given the comorbidity known to exist between mental health problems and substance misuse (Grant et al., 2004; Kessler, 2004), a second set of Poisson Class regression analyses were conducted on inmates from the current study who did not suffer from serious mental health problems, as indicated by the PSR (n = 1,203).”
Background
LOS DESÓRDENES EMOCIONALES EN ATENCIÓN PRIMARIA
Vindel, A. C. (2011) · Ansiedad y Estrés · Cited by 18
The Penrose Effect and its acceleration by the war on drugs: a crisis of untranslated neuroscience and untreated addiction and mental illness
Grecco, G. G., & Chambers, R. A. (2019) · Translational Psychiatry · doi:10.1038/s41398-019-0661-9 · Cited by 18
The Effects of Education, Social Class and Income on Non-alcohol- and Alcohol-Associated Suicide Mortality: A Register-based Study of Finnish Men Aged 25–64
Mäki, N., & Martikainen, P. (2008) · European Journal of Population / Revue européenne de Démographie · doi:10.1007/s10680-007-9147-1 · Cited by 18
Adverse Consequences of Co-Occurring Opioid Use Disorder and Cannabis Use Disorder Compared to Opioid Use Disorder Only
Aquino, J. P. D., Sofuoglu, M., Stefanovics, E. A., & Rosenheck, R. A. (2019) · The American Journal of Drug and Alcohol Abuse · doi:10.1080/00952990.2019.1607363 · Cited by 20
“Conforming with these data, several cross-sectional and prospective epidemiological studies (40,41) have found”
Result
How integrated are homelessness, mental health and drug and alcohol services in Australia?
Flatau, P., Conroy, E., Thielking, M., Clear, A., Hall, S., Bauskis, A., & Farrugia, M. (2013) · AHURI Final Report · doi:10.18408/ahuri-8201301 · Cited by 18
“The significant co-occurrence of substance use disorders and (other) mental health disorders (co-morbidity) has been the subject of an extensive international research literature and of major Australian health initiatives (e.g., see Teesson & Proudfoot 2003; Kessler 2004; Compton et al. 2005; Conway et al. 2006).”
Background
Self-wise, Other-wise, Streetwise (SOS) training: a novel intervention to reduce victimization in dual diagnosis psychiatric patients with substance use disorders: protocol for a randomized controlled trial
de Waal, M. M., Kikkert, M., Blankers, M., Dekker, J., & Goudriaan, A. E. (2015) · BMC Psychiatry · doi:10.1186/s12888-015-0652-1 · Cited by 18
“Dual diagnosis patients with comorbid psychiatric and substance use disorders are especially prone to victimization [2, 5, 6].”
Background
Gender differences among Veterans with alcohol use disorder nationally in the Veterans Health Administration
Kalpakci, A. H., Sofuoglu, M., Petrakis, I. L., & Rosenheck, R. A. (2018) · Journal of Addictive Diseases · doi:10.1080/10550887.2019.1653739 · Cited by 17
Attachment and Therapeutic Alliance in Substance Use Disorders: Initial Findings for Treatment in the Therapeutic Community
Rübig, L. L., Fuchshuber, J., Köldorfer, P., Rinner, A., Fink, A., & Unterrainer, . (2021) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2021.730876 · Cited by 19
“It is also important to state that individuals suffering from SUD form a quite heterogenous group often presenting a variety of comorbid psychiatric disorders (50).”
Background
Drug Use and Mental Health: Comorbidity between Substance Use and Psychiatric Disorders
Sullivan, M. A. (2022) · Springer eBooks · doi:10.1007/978-3-030-84834-7_1 · Cited by 20
Integrated Mental Health/Substance Abuse Responses to Justice Involved Persons with Co-Occurring Disorders
Osher, F. C. (2008) · Journal of Dual Diagnosis · doi:10.1300/j374v04n01_02 · Cited by 17
“The prevalence of high rates of co-occurring mental and substance related disorders within the general population has been well documented (Kessler, 2004, SAMHSA, 2004).”
Background
Prescription Drug Monitoring Program Inquiry in Psychiatric Assessment
Hackman, D. T., Greene, M., Fernandes, T. J., Brown, A. M., Wright, E. R., & Chambers, R. A. (2014) · The Journal of Clinical Psychiatry · doi:10.4088/jcp.14m09020 · Cited by 17
General and Specific Predictors of Comorbid Substance Use and Internalizing Problems from Adolescence to Age 33
Jones, T. M., Epstein, M., Hemphill, S. A., Bailey, J. A., & Hawkins, J. D. (2018) · Prevention Science · doi:10.1007/s11121-018-0959-5 · Cited by 19
“Additionally, there is a lack of adequate integrated treatments specific to dually diagnosed patients, and pharmacological treatments for these patients pose additional risk (Kessler 2004).”
BackgroundInfluential
Patología dual y rasgos de personalidad: situación actual y líneas futuras de trabajo
Marquez-Arrico, J. E., & Adán, A. (2013) · Adicciones · doi:10.20882/adicciones.46 · Cited by 16
Trends of Cocaine Use and Manifestations in Hospitalized Patients: A Cross-Sectional Study
Gangu, K., Bobba, A., Basida, S. D., Avula, S. R., Chela, H. K., & Singh, S. (2022) · Cureus · doi:10.7759/cureus.22090 · Cited by 16
“It is also known to have negative effects on work productivity and social engagement [29, 30].”
Background
Mechanism of psychological distress-driven smoking addiction behavior
Hwang, J., & Yun, Z.-S. (2015) · Journal of Business Research · doi:10.1016/j.jbusres.2015.03.019 · Cited by 17
Temperament and character dimensions in male patients with substance use disorders: Differences relating to psychiatric comorbidity
Marquez-Arrico, J. E., López-Vera, S., Prat, G., & Adán, A. (2016) · Psychiatry Research · doi:10.1016/j.psychres.2016.01.061 · Cited by 16
“…unemployed (Farris et al., 2003; Astals et al., 2008; Torrens et al., 2011; Fenton et al., 2012) or having a disability pension (Benaiges et al., 2012, 2013), and by high rates of poly drug use and medical disease comorbidity (Drake, 2004; Kessler, 2004; Arias et al., 2012; Evren et al., 2012).”
BackgroundInfluential
A Comparison of Treatment Outcomes for Individuals with Substance Use Disorder Alone and Individuals with Probable Dual Diagnosis
Cridland, E. K., Deane, F. P., Hsu, C.-I., & Kelly, P. J. (2011) · International Journal of Mental Health and Addiction · doi:10.1007/s11469-011-9364-z · Cited by 16
“Individuals with DD typically indicate more negative treatment outcomes compared to individuals with SUD (Kessler, 2004).”
Background
The influence of the comorbidity between depression and alcohol use disorder on suicidal behaviors in the São Paulo Epidemiologic Catchment Area Study, Brazil
Coêlho, B. M., Andrade, L. H., Guarniero, F. B., & Wang, Y. (2010) · Brazilian Journal of Psychiatry · doi:10.1590/s1516-44462010005000027 · Cited by 15
“, depressive disorders, AUD, and SUD seem to be independently associated with increased risk of suicide.(4,21) The crude odds resulting from the bivariate approach could give only a limited view of the effect of psychiatric comorbidity on SCB, as most relationships between covariates and suicidality cannot be directly…”
Background
The Drinking Motives Questionnaire among Swedish psychiatric patients: An exploration of the four‐factor structure
Öster, C., Arinell, H., & Nehlin, C. (2016) · Drug and Alcohol Review · doi:10.1111/dar.12421 · Cited by 16
Prevalence of Alcohol Use Disorders and Their Association with Sociodemographic Determinants and Depression/Anxiety Disorders in a Representative Sample of the Greek General Population
Bellos, S., Petrikis, P., Malliori, M., Mavreas, V. G., & Skapinakis, P. (2020) · Psychiatry Journal · doi:10.1155/2020/4841050 · Cited by 16
Emotional Regulation in Substance-Related and Addictive Disorders Treatment: A Systematic Review
Chrétien, S., Giroux, I., Smith, I., Jacques, C., Ferland, F., Sévigny, S., & Bouchard, S. (2025) · Journal of Gambling Studies · doi:10.1007/s10899-024-10366-8 · Cited by 18
Age of onset of substance use in patients with dual diagnosis and its association with clinical characteristics, risk behaviors, course, and outcome: A retrospective study
Nanjayya, S. B., Sahoo, S., Basu, D., & Mattoo, S. K. (2019) · Indian Journal of Psychiatry · doi:10.4103/psychiatry.indianjpsychiatry_454_18 · Cited by 15
“[18-21] Epidemiological-based and clinical-based studies had revealed that dual diagnosis (DD) or co-occurring disorders exist in about one-third of patients with SUDs.”
A systematic review of substance use screening in outpatient behavioral health settings
Woodward, D. W., Wilens, T. E., Glantz, M. D., Rao, V., Burke, C. W., & Yule, A. M. (2023) · Addiction Science & Clinical Practice · doi:10.1186/s13722-023-00376-z · Cited by 15
Heterogeneity of Mental Health Service Utilization and High Mental Health Service Use Among Women Eight Years After Initiating Substance Use Disorder Treatment
Evans, E., Padwa, H., Li, L., Lin, V., & Hser, Y. (2015) · Journal of Substance Abuse Treatment · doi:10.1016/j.jsat.2015.06.021 · Cited by 18
“(Kessler, 2004; McGovern, Matzkin, & Giard 2007, Drake, O’Neal, & Wallach, 2008).”
Relationships Among Depression, PTSD, Methamphetamine Abuse, and Psychosis
Lecomte, T., Paquin, K., Mueser, K. T., MacEwan, G. W., Goldner, E. M., Thornton, A. E., Brink, J., Lang, D. J., Kang, S., Barr, A. M., et al. (2013) · Journal of Dual Diagnosis · doi:10.1080/15504263.2013.778930 · Cited by 15
“Furthermore, methamphetamine abuse has been associated with psychiatric disorders such as depression and psychosis (Kessler, 2004).”
Background
Relations between mental health team characteristics and work role performance
Fleury, M., Grenier, G., Bamvita, J., & Farand, L. (2017) · PLoS ONE · doi:10.1371/journal.pone.0185451 · Cited by 15
“Considering the increasing frequency of complex mental health disorders and co-occurring mental disorders and substance use disorders [46], systematic use of these procedures and evaluation tools is essential in order to maintain proficiency among professionals [22].”
Background
Screening for Mental Health Problems among Patients with Substance Use Disorders: Preliminary Findings on the Validation of a Self-Assessment Instrument
Castel, S., Rush, B. R., Kennedy, S. H., Fulton, K. A., & Toneatto, T. (2007) · The Canadian Journal of Psychiatry · doi:10.1177/070674370705200105 · Cited by 15
“S tudies with either general population or clinical samples show conclusively that individuals with SUDs have a significantly higher prevalence of comorbid mental disorders than those with no SUDs.1 Nevertheless, the detection of comorbidities declines markedly in natural practice, and they are often not integrated in…”
BackgroundInfluential
Older adults who use or have used marijuana: Help-seeking for marijuana and other substance use problems
Choi, N. G., DiNitto, D. M., & Marti, C. N. (2017) · Journal of Substance Abuse Treatment · doi:10.1016/j.jsat.2017.02.005 · Cited by 16
“…that marijuana use disordermay co-occurwith other substance use disorders andmental disorders, including major depression, dysthymia, mania, hypomania, anxiety disorders, and schizophrenia (Conway et al., 2006; Glantz et al., 2008; Kessler, 2004; Martins & Gorelick, 2011; Swendsen et al., 2010).”
Background
Even More Complex…. When Mental Disorder Meets Addiction in Youth: Dual Pathology
Torales, J. C., Castaldelli-Maia, J. M., da Silva, A. G., Campos, M. W., González, I., & Barrios, I. (2018) · Current Drug Research Reviews · doi:10.2174/2589977511666181128165358 · Cited by 14
Depression and Substance Use: A Temporal-Ordered Model
Lo, C. C., Cheng, T. C., & de la Rosa, I. A. (2015) · Substance Use & Misuse · doi:10.3109/10826084.2014.998236 · Cited by 14
“Our understanding of comorbidity’s dynamics could benefit from research using prospective designs and proper controls on potentially confounding factors (Kessler, 2004).”
Background
The Temporal Relationship between Selected Mental Disorders and Substance-Related Disorders: A Nationwide Population-Based Cohort Study
Chiu, M.-L., Cheng, C., Liang, W., Lin, P.-T., Wu, T.-N., & Chen, C. (2018) · Psychiatry Journal · doi:10.1155/2018/5697103 · Cited by 17
Psychiatric comorbidity among alcohol-dependent individuals seeking treatment at the Alcohol Rehabilitation Unit, Stikland Hospital
Gabriels, C. M., Macharia, M., & Weich, L. (2019) · South African Journal of Psychiatry · doi:10.4102/sajpsychiatry.v25i0.1218 · Cited by 14
Behavioral and neurocognitive factors distinguishing post-traumatic stress comorbidity in substance use disorders
Houghton, D. C., Spratt, H. M., Keyser‐Marcus, L., Bjork, J. M., Neigh, G. N., Cunningham, K. A., Ramey, T., & Moeller, F. G. (2023) · Translational Psychiatry · doi:10.1038/s41398-023-02591-3 · Cited by 12
“Several functional explanations for this association have been put forth [10].”
Background
Do young people with comorbid mental and alcohol disorders experience worse behavioural problems?
Salom, C., Betts, K. S., Williams, G. M., Najman, J. M., Scott, J. G., & Alati, R. (2014) · Psychiatry Research · doi:10.1016/j.psychres.2014.05.056 · Cited by 14
“Mental health and alcohol use disorders frequently co occur in clinical settings (Hirschfeld et al., 1989; Swendsen and Merikangas, 2000; Kessler, 2004; Teesson et al., 2009; Alegria et al., 2010).”
BackgroundInfluential
Improving the efficiency of drug use disorder screening in psychiatric settings: validation of a single-item screen
Hearon, B. A., Pierce, C., Björgvinsson, Þ., Fitzmaurice, G. M., Greenfield, S. F., Weiss, R. D., & Busch, A. B. (2015) · The American Journal of Drug and Alcohol Abuse · doi:10.3109/00952990.2015.1005309 · Cited by 13
“more likely than the general population to have a co-occurring substance use disorder (1,2).”
Background
Factors Associated with Unplanned Early Discharges from a Dual Diagnosis Inpatient Detoxification Unit in Israel
Sofer, M. M., Kaptsan, A., & Anson, J. (2018) · Journal of Dual Diagnosis · doi:10.1080/15504263.2018.1461965 · Cited by 12
Prevalence and Correlates of Depressive Symptomology among Young Adults Who Use Prescription Opioids Non-medically
Bouvier, B. A., Kinnard, E. N., Yedinak, J. L., Li, Y., Elston, B., Green, T. C., Hadland, S. E., & Marshall, B. D. L. (2019) · Journal of Psychoactive Drugs · doi:10.1080/02791072.2019.1654151 · Cited by 13
“Our research demonstrates possible support for the self-medication hypothesis of co-occurring NMPO use and depressive symptomology, but emphasizes the need to further investigate all potential hypotheses of the development of this cooccurrence through longitudinal design (Kessler 2004).”
Background
Chronology of illness in dual diagnosis heroin addicts: The role of mood disorders
Maremmani, A. G. I., Rovai, L., Rugani, F., Bacciardi, S., Massimetti, E., Gazzarrini, D., Dell’Osso, L., Tang, F., Akiskal, H. S., & Maremmani, I. (2015) · Journal of Affective Disorders · doi:10.1016/j.jad.2015.03.046 · Cited by 13
“Studies have suggested that anxiety disorders, passive-aggressive disorder, behavioral disorders and ADHD may generally precede substance abuse disorders, while mood disorders are generally secondary to substance abuse disorders (Kessler, 2004).”
BackgroundResultInfluential
Smoking Patterns within a Primary Care Sample of Resettled Bosnian Refugees
Weaver, T. L., Čajdrić-Vrhovac, A., & Jackson, E. R. (2007) · Journal of Immigrant and Minority Health · doi:10.1007/s10903-007-9102-6 · Cited by 13
“Arousal symptoms of PTSD overlap with other diagnostic criteria for conditions such as depression and other forms of anxiety and PTSD is frequently comorbid with these disorders [ 33 ].”
Background

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)
DOI: 10.1016/j.biopsych.2004.06.034
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
Licence: www.elsevier.com/tdm/userlicense/1.0/ (tdm)
www.elsevier.com/legal/tdmrep-license (tdm)
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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The epidemiology of dual diagnosis

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