Dual Diagnosis: Double the Stigma, Double the Trouble

SPECIAL REPORT: SUBSTANCE USE

Stigma 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 substance use disorder (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.

Case Vignette

"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.”

Defining Stigma

Stigma has been defined as involving components of knowledge (ie, ignorance), attitudes (ie, prejudice), and behavior (ie, discrimination)¹, 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.²

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.^3-5 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).^3,6 There is sufficient evidence that describes stigma when addressing various presentations of both mental illness and SUD.^7,8 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.^9,10

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.¹¹ 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 in Mental Illness and SUD

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).^3,9,12,13 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.¹⁴ 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.^9,15,16

Stigma in Dual Diagnosis

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.¹⁷ In addition to the inaccessibility of treatment, there is low recognition of and support toward dual diagnosis by health care professionals.^18-20 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.^21,22 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.²³ 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.^24-26

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.²⁷ 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.^28,29 This association falls in line with data around higher posttreatment stigma correlating to higher substance use.³⁰

Future Directions

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.

Ms Lowe is a research consultant at the Centre for Complex Interventions, Centre for Addiction and Mental Health (CAMH) in Toronto, Ontario, Canada. Ms Simpkin is a research nurse in the Addictions Division at CAMH. Dr George 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 Neuropsychopharmacology.

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