is a recent graduate of the Institute of Medical Science of the University of Toronto and a consultant to the Centre for Complex Interventions (CCI) at CAMH.

Darby J.E. Lowe, MSc

Special Report Chairperson: Tony P. George, MD, FRCPC

 has become a pervasive topic in discussions around mental health and addictions because of its complexities and high impact. When diagnosed with a mental illness or 

 (SUD), individuals experience barriers directly related to their disorder that can affect their personal and professional life (eg, depression and anxiety) and overall health and well-being. Stigma further perpetuates these consequences through internalized, public, and institutionalized discrimination based on being labeled as having a mental illness or SUD. It is important to understand the additive effects of stigma when one experiences a comorbid SUD in order to more effectively address the consequences that ensue. This article highlights the literature around stigma in those with both a mental illness and SUD, specifically addressing the characteristics and consequences of stigma that result within dual diagnosis.

"Jim" is a 29-year-old man with major depression who has been treated for 2 years by his family doctor. He is a successful junior advertising executive and has been encouraged to apply for the job of regional manager, which would be a huge promotion. He joins several colleagues at a restaurant bar for an after-work function. He realizes he forgot to take the new medication prescribed by the addiction specialist his family doctor asked him to see for his drinking, which has been ongoing since college. He takes the bottle from his briefcase and drops it on the floor. His colleague picks it up and asks, “Naltrexone? Isn’t that the drug for alcoholics?” Jim takes the bottle back and changes the subject. At the interview later that week, Jim’s boss and a few senior executives tell him he is a great candidate for the regional manager job, but new information has come to their attention. “Have you been straight with us Jim? Depression is bad enough, but this other thing? Well, that is a deal breaker.” Jim attempts to apply for alternate jobs but is rejected several times and eventually gives up after deciding “there is no point.”

Stigma has been defined as involving components of knowledge (ie, ignorance), attitudes (ie, prejudice), and behavior (ie, discrimination)

, all of which can be observed at the individual level through internalized or self-stigma, between individuals through interpersonal stigma, and at the institutional level through structural stigma. In addition, there is experienced and anticipated stigma in those who are stigmatized, as well as intersectional influences, such as gender, race, and socioeconomic class, that further contribute to the complexities of stigma.

Stigma is consistently observed in the space of mental health and addiction and is associated with a multitude of negative consequences, such as treatment avoidance, lower employment rates, and social discrimination.

 For example, each form of stigma can be observed throughout the case vignette, as Jim experiences stigma at the interpersonal level (when his colleagues stigmatize him by calling him an “alcoholic” at the bar), at the institutional level (when he is discounted as an attractive job applicant because of his SUD), and at the individual level (when he internalizes the stigma of his diagnoses and anticipates the forthcoming barriers, losing the will to seek employment).

 There is sufficient evidence that describes stigma when addressing various presentations of both mental illness and SUD.

 However, there is less prominent information around the specific differences in stigma when assessing mental illness or SUD alone in comparison to dual diagnosis (ie, comorbid MI and SUD), despite the high prevalence of this comorbidity.

To generalize those with comorbid mental illness and SUD as having 1 shared experience is flawed, as different mental illness type, as well as intersectionality of external factors (eg, homelessness), can facilitate completely different characteristics of, and outcomes from, stigma.

 However, for the purposes of this paper, we will focus on the concurrent diagnosis of both a mental illness and SUD to provide an understanding of the current literature around stigma in dual diagnosis to make future research suggestions and understand how this may translate to actionable change.

Stigma is perpetuated toward those experiencing mental illness and SUD at the individual, interpersonal, and institutional levels, all of which are associated with negative consequences toward one’s mental health and well-being (eg, societal and structural discrimination, worsened treatment outcomes, and lowered self-esteem).

 Research has further indicated differences in stigma when addressing individuals with a mental illness diagnosis in comparison to a SUD diagnosis. Evidence describes more negative attitudes surrounding those with SUDs in comparison to those with a mental illness.

 Some of these attitudes include the perception of those with SUDs as being more dangerous and less competent in navigating treatment, as well as the association of SUDs with personal or moral “shortcomings” rather than the underpinnings of a medical illness.

Considering the prominence of, as well as differences between, stigma in those with mental illness and those with SUDs, it is important to address the characteristics of stigma among those with a diagnosis of both disorders. This population experiences distinct barriers to treatment and worsened outcomes, with only 72% of this population receiving treatment.

 In addition to the inaccessibility of treatment, there is low recognition of and support toward dual diagnosis by health care professionals.

 However, despite the high prevalence and vulnerable nature of dual diagnosis, there has been incongruous research addressing stigma within this population.

Of the research that has been conducted, stigma remains pervasive and has been associated with worsened symptomatology and heightened substance misuse.

 However, the uniqueness of this stigma is yet to be fully understood.

There has been some research to suggest that those with dual diagnosis experience more stigma and, therefore, more treatment barriers in comparison to those with a single diagnosis of either mental illness or SUD.

 Some research has suggested that this stronger stigma is due to the presence of a SUD, which has been proposed to be more heavily stigmatized in comparison to mental illness.

With this conceptualization, there is literature to support how stigma can possibly act as a mediating factor toward dual diagnosis, perpetuating substance use in those experiencing stigma toward their mental illness.

 For example, 1 theory proposes that a lack of self-esteem, identity, and social engagement due to the stigmatization of one’s mental illness may trigger substance use, which leads to meaning and identity within a community of substance users.

 This association falls in line with data around higher posttreatment stigma correlating to higher substance use.

Clearly, there is a need for further research on stigma in individuals with dual diagnoses in comparison to either mental illness or SUDs alone. Which mental illness diagnoses and SUDs are associated with the most stigma, and which combinations are the most impacted by stigma? How can we best address the dual stigma faced by these individuals? We hope this brief article provokes further interest and action toward understanding and managing stigma in the lives of individuals with dual diagnoses.

is a research consultant at the Centre for Complex Interventions, Centre for Addiction and Mental Health (CAMH) in Toronto, Ontario, Canada. 

 is a research nurse in the Addictions Division at CAMH. 

 is a professor of psychiatry in the Temerty Faculty of Medicine, University of Toronto, and physician-scientist at CAMH. He is currently deputy editor and incoming co-principal editor of 

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Articles

Understanding the additive effects of stigma surrounding dual diagnosis with both substance use disorder and a mental illness.

Dual Diagnosis: Double the Stigma, Double the Trouble

Substance misuse has become increasingly common in the 21st century, especially among students enrolled in colleges and universities. It has social, economic, psychological, and physiological consequences among adolescents, especially with the emergence of the COVID-19 pandemic and its societal complications. The most used substances on college campuses include alcohol, 

, cocaine, prescription opioids, recreational drugs (eg, MDMA), and nicotine, and, more recently, 

 (vaping). Behavioral addictions (eg, internet gambling) are also very common.

Not only have substance use trends increased in the past 2 decades among university students, but negative perceptions and societal attitudes toward the use of illicit substances have also lessened. The adolescent brain is in a unique period of development at this age, leaving students at a heightened susceptibility to abnormalities on measures of brain functioning, including neurocognition

 which are risk factors for the initiation and maintenance of 

Substance misuse is a strong predictor of student well-being, as it is associated with worsened mental health outcomes, poorer grades, and chronic health problems. According to the National Survey on Drug Use and Health (NSDUH), of the students aged 18 to 22 years, 5.9 million young adults smoked cigarettes in the past month (26.7%), 12.0 million drank alcohol (54.8%), almost 7.8 million engaged in 

 more than 4.5 million young adults used cannabis (20.7%) and 299,000 used cocaine (1.4%).

Recovery-Based Approaches and Forward-Thinking Policy: Implications for Addiction Care

Nonabstinent Recovery From Alcohol Use Disorder

Cassandra L. Boness, PhD; Alena Kuhlemeier, PhD; Katie Witkiewitz, PhD

Cannabis Legalization: What Psychiatrists Need to Know

Samantha Johnstone, BA; Kevin P. Hill, MD, MHS; and Tony P. George, MD, FRCPC

Darby J.E. Lowe, MSc; Emily Simpkin, RN; Tony P. George, MD, FRCPC

Substance use trends for alcohol use, binge drinking, and cocaine use in the past month were higher in full-time college students aged 18 to 22 years compared with their counterparts who were not enrolled in college.

 Between 2007 and 2014, the percentage of students who used 

 Recent results from the NSDUH published in 2020 have reported that cannabis use has continuously increased over the past 5 years in college students, reaching the highest level in more than 3 and a half decades in 2020 at 44%.

Trends in lifetime vaping rose from 26% of college students to 36% between 2015 and 2017. In 2020, the increase in vaping had leveled off, with only a 1% increase in lifetime users from 2019.

 E-cigarettes have become increasingly popular among university students for multiple reasons, including accessibility, a perception of low risk, and the appeal of e-cigarette flavoring in comparison to other smoking methods.

 As with the consumption of tobacco products, there are negative health effects associated with e-cigarettes. The use of 

 during development increases the risk of long-term addiction and long-lasting consequences toward cognitive development.

In another cluster sample by Primack et al, 114,245 individuals from 158 institutions were sampled from the 2008 to 2009 National College Health Assessment conducted by the American College Health Association to evaluate smoking behaviors.

 There were 6 clusters gathered, and smoking trends in the past 30 days were evaluated. These clusters included individuals who abstain from all substances (54%); individuals who use hookah but dislike cigars (5.5%); users of marijuana who will smoke cigarettes and drink (9.3%); frequent users of cigarettes with some 

 (6.9%); frequent consumers of alcohol with no smoking behaviors (17.1%); and cigar users in combination with other substances (7.3%).

 These results showcased the changes in trends over the past 10 to 15 years, with a rise in the use of tobacco and nicotine products. There is also concern from this study about combining various substances, a common practice among university students.

Alcohol is widely available through North America with the legal drinking age 21 in the United States and 19 in Canada. Not only is the perceived risk of alcohol consumption lowest in individuals aged 19 to 22 years as of 2020, but the prevalence of annual consumption is also highest in full-time college students 1 to 4 years after high school.

 High-risk populations that are more prone to alcohol consumption include fraternity and sorority members and students who used alcohol heavily in high school.

 As mentioned, alcohol is the most used substance among NSDUH survey respondents, with 54.8% of participants reporting use in the past month.

Alcohol consumption has many impacts on the body, contributing to more than 200 diseases and injury-related health conditions, both acute and chronic.

, liver cirrhosis, cancers, and physical injuries are included. Other notable effects can be observed on a student’s mental health, as alcohol misuse may be associated with an increase in depressive symptoms, attempted suicide and self-harm behaviors, and aggression.

Alcohol misuse, like any other substance misuse, is a public health concern. Because of the wide range of effects on physical, psychosocial, and mental health outcomes, monitoring alcohol use trends is essential as current use continues to increase. In 2020, both annual alcohol use (77% versus 67%) and 30-day use (56% versus 49%) were higher among college students than noncollege students.

 More alarmingly, the prevalence of binge drinking, which is defined as having 10 or more drinks in a row, was 12% for both college and noncollege respondents.

 It seems as though the drug epidemic that arose in the early 2000s paralleled a decreased perception of risk for alcohol, as well as increased consumption trends for individuals aged 18 to 22 years.

Cannabis use reached an all-time high in 2020.5 Recreational cannabis is legal in 18 states, the District of Columbia, and Guam, as well as Canada. University students are at an age when they are at a higher predisposition to behavioral effects with frequent cannabis use.

regular use of cannabis during adolescence

 places individuals at a higher risk of developing cannabis use disorder (CUD).

 Frequent use of cannabis has also been associated with compromised university performance, including lower grade point average, delayed high school completion rates, and truancy.

The perceived risk of cannabis has also significantly decreased in the last decade with all individuals between ages 18 and 30 years having the lowest recorded perception of risk for occasional marijuana use in the last 30 years.

 The annual prevalence of cannabis use is slightly higher in full-time college students compared with noncollege students in the first 4 years after high school; however, both groups report that more than 40% of individuals have used cannabis in the past year.

 On most indices of cannabis use including 30-day use and daily use, use by men was significantly higher than by women.

 CUD risk factors include living alone, recent negative life experiences, and using cannabis as a means of coping.

The use of cannabis during brain development can have profound effects on cognitive performance after just 4 weeks of regular cannabis consumption.

 The use of cannabis during adolescence has been associated with higher gray matter volumes in the brain, which was associated with poorer verbal and attentional performance.

 (eg, prescription stimulants and methamphetamine) poses great risk for university students. In 2016, it was noted that 4% of full-time college students used cocaine in the past year, 1.4% used cocaine in the past month, and 20% were exposed to opportunities for cocaine in the past year.

 In addition to cocaine, college students use other stimulants, including dextroamphetamine, a prescription stimulant for cognitive enhancement purposes.

Not only has the use of prescription stimulants increased, but so has the social acceptance around stimulants.

 The annual prevalence of mixed amphetamine salts (Adderall) compared with methylphenidate (Ritalin) for nonmedical use was much higher for Adderall, with 7.6% of individuals between 19 and 30 years old using it compared with 0.9% to 2.6% of 19- to 30-year-olds using Ritalin.

 In addition, the annual use of nonmedical amphetamines was higher among men than women (7.7% versus 5.8%), especially for Adderall (8.8% versus 6.9%).

 Comparing full-time college students to nonstudents, the percentage of cocaine use in the past month was 1.8% vs 1.1% according to the 2016 NSDUH.

 The use of stimulants becomes extremely dangerous in students when they are combined with other substances, specifically alcohol. The counteractive effects of sedative alcohol and stimulant use leads to serious effects on the central nervous system and poses an overall significant health risk.

 use also poses a potential threat to college students. Benzodiazepine use has increased over the last few decades, especially for nonmedical purposes. In 2019, the use of benzodiazepines for nonmedical purposes in college and noncollege respondents was 3% and 3.4%, respectively.

 With this, the overall annual prevalence of benzodiazepine nonmedical use in 2019 among respondents aged 19 to 30 years was 3.7%.

 A common benzodiazepine used among the college demographic is Xanax (“Xans”), of which misuse has risen over the past decade.

The increased media attention on this drug from celebrities may increase the temptation for high school students to try it. Many students without anxiety or depression use it for the sedation and calm that accompany a high.

Because of the addictive nature of the drug, this becomes an issue for college students who resort to benzodiazepines without a medical prescription to deal with overwhelming feelings of anxiety.

 Benzodiazepine misuse can lead to increased tolerance, which may prompt a user to take higher doses, which can then lead to habitual use, along with the risks of serious benzodiazepine withdrawal and seizures.

While the internet is a useful tool for many college students, especially with 

 and its pertinence to online classes throughout the COVID-19 pandemic, internet addiction can negatively impact the lives of college students in physical, social, and mental health aspects. While the internet facilitates research and interpersonal communication, it can also be used to indulge in pornography as well as excessive gaming or gambling and use of social media (eg, Twitter and Instagram).

Internet addiction can lead to personal, familial, financial, occupational, and academic problems, particularly in college students. Studies suggest that individuals with internet addiction have higher rates of psychiatric comorbidities, suicidal ideation, and suicide attempts compared with those without internet addiction.

 Although the internet has become an integral part of society over the last decade, excessive internet use should be monitored to prevent feelings of anxiety, depression, and social isolation.

The COVID-19 pandemic has had tremendous impacts on society, especially on 

. The disruptions in regular university life have led many students to suffer from impaired mental health and an increase in substance use.

 The COVID-19 outbreak has become temporarily associated with higher rates of anxiety, depression, stress, posttraumatic stress symptoms, and psychological distress in individuals aged 21 to 30 years.

A retrospective study of 4749 participants from 7 US universities or colleges found that university closures amid the pandemic resulted in a 13% and 24% increase of alcohol and cannabis use, respectively, after 30 days following the closure.

 Additionally, depressive symptoms and anger were modestly higher in postclosure participants compared with preclosure participants.

 Although the differences in pre- and postclosure outcomes are modest, which may show strong resilience in university students, university and college health care providers need to ensure they are providing appropriate resources to students who are experiencing significant increases in mental health symptoms and substance use.

Annual Prevalence of Use for Illicit Drugs: Full-Time College Students 1 to 4 Years Beyond High School, 2010-2020

Since the last national survey results on substance use were published in 2020, there have been few reports on substance use and mental health, which will be necessary to more comprehensively understand the impact of COVID-19 on substance use in this population. It has been observed throughout the pandemic that individuals have developed and relied on many maladaptive coping mechanisms; however, how university students have been able to cope is still to be determined.

Overall, substance misuse poses a great risk for all individuals, especially those who are still in a critical period of development such as college students. Trends in illegal and legal substance use are shown in 

, respectively. Substance use in university students can be influenced by many risk factors, such as low harm perceptions, peer influences, and coping with a difficult transition period. It is crucial for colleges and universities to assess the trends in substance use and provide resources to their students to avoid chronic substance use and related harms.

 Annual Prevalence of Use for Legal Substances: Full-Time College Students 1 to 4 Years Beyond High School, 2010-2020

With the prevalence of substance use increasing over the past 5 years among full-time college students, preventive measures must be implemented to avoid increases in substance use prevalence. High school drug awareness programs can help students who plan to enroll in college mitigate risks of substance use upon enrollment. Additionally, the inclusion of first-year drug awareness programs can help prepare newly enrolled full-time college/university students for the academic stressors they will encounter in order to develop healthy coping mechanisms.

is a senior undergraduate student at Queen’s University in Kingston, Ontario, Canada, and a research practicum student at the Centre for Addiction and Mental Health (CAMH), Toronto, Ontario.

is a recent graduate of the Institute of Medical Science of the University of Toronto and a consultant to the Centre for Complex Interventions (CCI) at CAMH. 

is professor of psychiatry in the Temerty Faculty of Medicine at the University of Toronto and clinician-scientist in the Addictions Division and the CCI at CAMH. George is on the editorial board of

and incoming coprincipal editor of Neuropsychopharmacology (NPP).

The influence of substance use on adolescent brain development.

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Substance use disorders and behavioral addictions during the COVID-19 pandemic and COVID-19-related restrictions.

The prevalence of annual alcohol consumption is highest in full-time college students 1 to 4 years after high school.

Darby J.E. Lowe, MSc

Articles

Dual Diagnosis: Double the Stigma, Double the Trouble

Substance Misuse in College Students