Synapse - reconnecting lives

Some people may find themselves coping not only with the effects of a brain injury, but also a mental illness.

A mental illness can cause additional stress for the person and their family after a brain injury. Common forms of mental illness include depression, anxiety, and obsessive or compulsive behaviour. A brain injury can be caused by a brain tumour, Alzheimer's disease, traumatic brain injury, meningitis, encephalitis or epilepsy. 

It can be very difficult obtaining support as services are normally provided specifically for brain injury, or mental illness - not both. 

Living with a brain injury and a mental illness lead to a very poor quality of life, particularly as there is often also a dependence on alcohol or other drugs and contact with the criminal justice system. Life is often a matter of simply surviving each day with minimal to no support. 

What does dual diagnosis mean?

'Dual diagnosis' is used when someone is affected by two different conditions at one time. It can also be called co-morbidity, co-existing disorders or dual-disability. The terms used may depend on the country and professional background of a person, For example, a psychiatrist or health professional may commonly use the terms co-morbidity or dual-diagnosis, whereas someone from disability organization may use the term 'dual disability.'

To be diagnosed as a disorder, the condition needs to be of such severity that it interferes with a person's cognitive, emotional or social abilities.  Some of the most common mental health disorders are:

• clinical depression
• schizophrenia
• bipolar disorder
• anxiety disorder
• Personality disorder
• social anxiety disorder
• substance abuse disorder

The link between mental illness & brain injury 

A mental illness may have been present prior to brain injury. A brain injury is also known risk factor for developing a mental illness.¹ One report indicates 42% of people as having a dual diagnosis.²  Issues following a brain injury that may lead to a mental illness include grief and loss, adjustment to disability, pre-injury personality traits and strengths, coping skills and level of social support.³

It can also occur in the other direction. People with a mental health disorder are at an increased risk of brain injury when changes in cognitive abilities include reaction time, alertness and increased risk of self-harm.

Dual diagnosis issues

The effects of brain injury and mental illness can look very similar, so misdiagnosis is possible if there are no clear medical records.⁴

Problems associated with a person's ABI can be heightened by the presence of a mental illness. A mental illness in itself can affect skills in memory, attention and planning.

The brain injury itself can cause symptoms similar to syndromes such as psychosis and dementia, which can increase chance of mis-diagnosis.

A mental illness can affect the rehabilitation process due to low motivation and creating unhelpful coping mechanisms and a negative mind set.

A mental health disorder can increase risks associated with a brain injury, including social isolation, family breakdown, unemployment, aggression and risk of exploitation.⁴

Treatment & support

Dual-diagnosis situations require additional support and a holistic approach, which may include medication, psychological therapy, and programs focusing on social skills/living skills re-training.

The first step is to get an appropriate assessment by a qualified specialist, such as a neuropsychologist or psychiatrist. There should be a care plan upon discharge outlining supports and services in the community to prevent relapse. Case management should be provided to co-ordinate any mental health and brain injury services. 

 It is not uncommon for people with a dual diagnosis to access support - mental health services will say they need a brain injury service, but the brain injury services say they should go to a mental health service.  You may like to seek the support of an advocate to resolve this lack of support for dual diagnosis situations. 

How can family help?

Signs that a mental illness may be developing following brain injury, include;

• A gradual decline in ability to perform everyday tasks
• Decline in ability to cope with every day stressors
• Increased behavioural issues e.g. anger, frustration, agitation
• Exaggeration of the effects of the acquired brain injury.

Seek advice from an appropriate professional or service for a suspected mental illness. Read about mental illness and brain disorders such as traumatic brain injury. Contact your local Brain Injury Association for more information and local supports.

Steps needed to plug gaps in service provision

At the policy level, no government agency takes responsibility for this group of people. This plays out at the service level where people with a dual diagnosis are bounced back and forth between the disability, health and homelessness sectors. The following recommendation would go a long way to plugging the gaps in service provision: 

• Dual diagnosis  recognized by governments at the policy level
• Psychiatric and disability groups in partnership with a focus on the client
• Training on dual diagnosis is required within mental health services.
• Neuropsychiatric services within mental health services
• Crisis teams experienced in dual diagnosis
• Screening for brain injury within the criminal justice system
• A 24 hour dual diagnosis crisis team is needed.