Substance Use & Misuse, 40:1765–1776

Copyright © 2005 Taylor & Francis Inc.

ISSN: 1082-6084 (print); 1532-2491 (online)
DOI: 10.1080/10826080500260800

Dual Diagnosis and Quality of Life in Patients

in Treatment for Opioid Dependence

JACOPO BIZZARRI,1 PAOLA RUCCI,2,3

ALESSIA VALLOTTA,1 MASSIMO GIRELLI,1
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ANNA SCANDOLARI,1 ELISABETTA ZERBETTO,1

ALFREDO SBRANA,3 CLAUDIA IAGHER,3
AND ELIO DELLANTONIO1
1
Servizio per le Dipendenze, Azienda Sanitaria di Bolzano, Bolzano, Italy
2
Western Psychiatric Institute and Clinic, University of Pittsburgh, Pittsburgh,
Pennsylvania, USA
3
Dipartimento di Psichiatria, Neurobiologia, Farmacologia e Biotecnologie,
Universita’ di Pisa, Pisa, Italy
For personal use only.

This study examined the relationship between quality of life (QOL) and dual diagno-
sis among patients in treatment for opioid dependence. The study sample includes 57
patients with opioid dependence alone (OD) and 41 with opioid dependence and a psy-
chiatric axis-I disorder (DD), recruited in 2001 and 2004 at the Drug Addiction Services
(SerT) of Bolzano and Pontedera (Italy). Participants were 73.5% males, with a mean
age of 35.1 years (SD = 8.0). A comparison group of 45 healthy controls was also in-
cluded. Assessments included a structured psychiatric interview (SCID) and a self-report
quality of life assessment (WHOQOL-BREF). Patients with DD reported significantly
(p < 0.05) poorer QOL in the physical and psychological domains as compared with
patients with OD. Both groups of patients with and without DD showed significantly
(p < 0.001) poorer QOL in the physical, psychological, and social domains with respect
to healthy participants. The scores on the “relationship with environment” domain did
not differ among OD, DD, and controls. The present study provides preliminary evi-
dence that dual diagnosis is associated with poorer QOL and emphasizes the need to
target treatment for the mental disorder concomitantly with the dependence problem in
patients in treatment for opioid dependence.

Keywords dual diagnosis; quality of life; opioid dependence

Introduction
In the last two decades, the focus on co-occurrence of psychiatric disorders in patients with
substance dependence (dual diagnosis) has significantly increased. As Drake et al. (2000)
emphasized, “even though the term dual diagnosis is misleading because the individuals in
this group are heterogeneous and tend to have multiple impairments rather than just two
illnesses, this term appears consistently in the literature and has acquired some coherences
as a referent to particular clients, treatments, programs, and service systems issues.” The

Address correspondence to Jacopo Bizzarri, M.D., Ser.D. Servizio per le Dipendenze, Via del
Ronco 3, 39100 Bolzano, Italy. E-mail: sert-dfa@asbz.it
1765
 1766 Bizzarri et al.

estimated prevalence of dual diagnosis is 3% in the U.S. general population (Regier et al.,
1990; Watkins et al., 2001; Kessler et al., 1996). Clinical studies conducted among patients in
treatment for opioid addiction (OD) indicate that prevalence of comorbid mental disorders
in Europe and in the U.S. ranges between 24% and 77% (Brooner et al., 1997; Mason
et al., 1998; Milby et al., 1996). The most frequent comorbid diagnoses in OD are major
depression (15.8%–56%) and anxiety disorders (8.2%–55%) (Brooner et al., 1997; Mason
et al., 1998; Milby et al., 1996; Franken and Hendriks, 2001; Clerici et al., 1989; Tempesta
and Pozzi, 1994; Pozzi et al., 1997), while in the general population the prevalence of
mood and anxiety disorders ranges respectively between 0.8% and 9.6% and 2.4% and
18.2% worldwide (Clerici et al., 1989). Converging evidence indicates that individuals with
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opiate dependence have lower physical and psychological QOL than the general population
(Ryan and White, 1996; Millson et al., 2004), and comparable QOL with respect to other
psychiatric disorders (Millson et al., 2004) at entry into a methadone program. However,
studies focusing on the evaluation of effectiveness of methadone maintenance program
provided encouraging evidence that participants experienced a substantial improvement in
health-related QOL (Torrens et al., 1997; Reno and Aiken, 1993) starting from the second
month of therapy.
Empirical research comparing quality of life in OD with and without a dual diagno-
sis is scanty. Using the BASIS-32, a recent study identified four predictors of psychiatric
comorbidity among drug users in treatment, i.e., unemployment without looking for work,
difficulties related to self and others, not having received prior outpatient treatment, and
poorer physical health (Johnson et al., 2002). Indeed, the therapeutic challenge of this
For personal use only.

condition, frequently associated with social problems and poor daily functioning, requires
biopsychosocial interventions aimed to improve not only the specific symptoms of psychi-
atric disorders and substance use disorder (SUD); the evaluation of QOL in patients with
dual diagnosis could represent a useful outcome measure of these integrated treatments
(Judd et al., 2003; Schaar and Öjehagen, 2003). While the recent need to document the
levels of activity and the effectiveness of the health care services in Italy has led to an
increased use of evaluation instruments, there is a lack of published data on quality of life
in patients being treated for substance dependence and psychiatric disorders.
To fill this gap, we compared the quality of life of opioid addicts with that of healthy
controls and investigated the relationship of QOL with dual diagnosis.

Method
This cross-sectional study was conducted at the Drug Addiction Services of Bolzano
(Italy) between January 1, 2001 and December 31, 2001 and of Pontedera (Italy) between
January 31, 2004 and July 15, 2004. Participants were consecutive opiate-dependent patients
aged between 18 and 55 years who were part of a multifaceted medical and psychosocial
outpatient program. Of those initially approached, 15 patients refused to participate, 21 who
had consented to participate missed the assessment visit and could not be interviewed, and
16 failed to complete the assessment. Ninety-eight participated in the study and were ad-
ministered a diagnostic interview and a self-report QOL assessment. The comparison group
consisted of healthy controls recruited for the validation study of the WHOQOL-BREF (De
Girolamo et al., 2001) among adult individuals attending the ambulatories of the primary
care physicians of three Italian towns for administrative procedures or for accompanying
relatives. Inclusion criteria for this group were: no physical or psychological problems in the
month preceding the index assessment, no regular assumption of drugs in the last 15 days.
 Quality of Life of Opioid Dependents 1767

For the purpose of the present study, we selected healthy controls in the same age range as
those with opioid addiction.
The diagnostic assessment, conducted using the Structured Clinical Interview for DSM-
IV axis-I disorders (SCID-I/P; First et al., 1995), includes a substance abuse and dependence
section and allows determining whether psychiatric symptoms are related to a psychiatric
disorder or to the use of substances (intoxication or abstinence). The interview was con-
ducted by three psychiatrists, one clinical psychologist, and four residents in psychiatry, who
had been trained and certified at the University of Pisa. Certification was obtained when the
inter-rater reliability with the trainer was >0.90. The World Health Organization Quality of
Life Assessment (WHOQOL-BREF; De Girolamo et al., 2001) is a self-report instrument
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consisting of 26 items organized into four domains: the physical domain, the psychological
domain, the social relationships domain, and the environment domain. Quality of life is de-
fined by the World Health Organization Quality of Life Group as “individuals’ perception
of their position in life in the context of the culture and value systems in which they live
and in relation to their goals, expectations standards and concerns” (The WHOQOL Group,
1998).
The Ethics Committee of the Azienda Ospedaliera Pisana approved all recruitment and
assessment procedures and eligible patients provided written informed consent. In order to
maintain participants’ confidentiality, assessment data were labeled only with an assigned
ID number. SPSS, version 11.5, was used to carry out statistical analyses.
For personal use only.

Sample
Based on the results of the diagnostic assessment, participants were divided into those with
(N = 41, DD) and without (N = 57, OD) a dual diagnosis. In the first group, psychiatric
diagnoses were major depression (N = 4), bipolar disorder (N = 8), dysthymia (N =
2), psychotic depression (N = 1), panic disorder (N = 15), generalized anxiety (N = 3),
obsessive-compulsive disorder (N = 4), social phobia (N = 4), anorexia nervosa (N = 1),
somatoform disorder (N = 1), schizophreniform disorder (N = 1), and schizophrenia (N =
1). Participants with DD were significantly younger and unemployed (49% vs. 26%) than
those with OD (Table 1). As expected, the educational level of healthy controls was higher
than the other two groups because opioid dependence frequently leads to early termination of
studies. However, all patients were therapeutically engaged and benefited from the constant
support of the community social services for their financial and housing needs. At the
time of the assessment, of the 57 participants with OD, 42 were in agonist treatment with
methadone (mean dosage 49.88, range 10–140 mg) and 10 with buprenorphine (mean
dosage 8.3, range 2 –24 mg), and five had no agonist treatment. Of the 41 participants with
DD, 26 were in agonist treatment with methadone (mean dosage 44.6, range 8–90 mg), 13
with buprenorphine (mean dosage 10.1, range 2–24 mg), and two patients had no agonist
treatment. The large majority of participants were HCV- or HBV-positive but asymptomatic
at index visit. Toxicological characteristics of the study samples are shown in Table 2.

Results
Mean scores on the four domains of the WHOQOL-BREF are provided in Fig. 1. Compar-
isons of scores across OD, DD, and healthy controls were conducted by using analysis of
covariance, to control for gender imbalance and for the possible confounding effect of age.
Differences across OD, DD, and controls were significant at p < 0.001 for the physical,
 1768 Bizzarri et al.

Table 1
Demographic characteristics of the study samples

Opioid
Dual diagnosis dependence only Healthy controls
(N = 41) (N = 57) (N = 45)
Age Mean ± SD Mean ± SD Mean ± SD
32.7 ± 8.3 36.7 ± 7.4 34.0 ± 9.2
N % N % N %
Gender
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Male 26 63.4 46 80.7 23 51.1

Female 15 36.6 11 19.3 22 48.9
Martial status
Never married 32 78.0 34 59.6 27 60.0
Separated or divorced 3 7.3 8 14.0 1 2.2
Widowed 2 4.9 1 1.8 0 0
Married or living with partner 4 9.8 14 24.6 17 37.8
Educational level
Primary school 3 7.3 9 15.8 1 2.2
Secondary school 25 61.0 36 63.1 7 15.6
High school 12 29.3 11 19.3 19 42.2
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University degree 1 2.4 1 1.8 18 40.0

Occupational status
Currently not employed 24 58.6 18 31.6 13 28.9
Full or part-time work 14 34.1 37 64.9 32 71.1
Disability pension 3 7.3 2 3.5 0 0

Table 2
Toxicological characteristics of the study samples

Opioid
Dual diagnosis dependence only
(N = 41) (N = 57)
Years of heroin use (median, range) 13 (0–31) 15 (1–29)
Route of heroin use (%)
Inject 92.3 93.0
Snort 5.1 7.0
Smoke 2.6
Sedatives abuse/dep. (%) 29.3 28.1
Alcohol abuse/dep.(%) 61.0 50.9
Cannabis abuse/dep. (%) 80.5 68.4
Cocaine abuse/dep. (%) 43.4 56.1
Stimulants abuse/dep. (%) 32.1 31.6
Years since first ever treatment 9 (0–27) 12 (0–26)
at the Drug Addiction Service
(median, range)
 Quality of Life of Opioid Dependents 1769
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For personal use only.

Figure 1. WHOQOL-BREF scores in the three study samples.

psychological, and social relationship domain scores and at p < 0.05 for the environment
domain. Post-hoc comparisons indicated that participants with DD had significantly poorer
levels of QOL on each of the domains than controls except environment (see Fig. 1), with
differences ranging between 10 and 18 percentage points. The OD participants also reported
lower levels of QOL than controls in the physical, psychological, and social relationship
domains. The pairwise comparisons between OD and DD revealed that the latter had signif-
icantly poorer physical and psychological health. To determine whether these differences
were at least partly affected by current substance use, a multivariate analysis of covariance
model was fitted on the 98 participants with OD or DD. In this model, the four areas were
used as dependent variables and the presence/absence of DD, gender, age, and current sub-
stance use as independent variables. The multivariate tests indicated an overall significant
effect of DD (p = 0.015) on the QOL domains. Inspection of the parameters for each of the
four QOL domains indicated that among those with DD, there was a significant decrease in
the physical and psychological domain scores (Table 3). While current substance use was
not associated with any of the four QOL domains, increasing age was associated with poorer
QOL in the physical, social, and environment domains, and female gender with poorer QOL
in the physical, psychological, and environment domains.
 1770 Bizzarri et al.

Table 3
Association between dual diagnosis and QOL domains in the study sample (N = 93a )

Domain

Physical Psychological Social relationships Environment

F p F p F p F p
Dual diagnosis 6.22 0.014 6.04 0.016 1.55 0.217 0.076 0.784
(DD)
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Gender 4.84 0.030 8.47 0.005 0.057 0.811 3.04 0.085

Age 5.53 0.021 3.16 0.079 9.11 0.003 7.71 0.007
Current 0.08 0.779 0.040 0.842 2.11 0.150 0.091 0.763
dependence
∗
For five out of the 98 participants not all the domain scores were available because of missing
data.

Discussion
To our knowledge, this is the first study that explores the association between severity of
dependence, dual diagnosis, and QOL, in a sample of opioid addicts with an established
relationship with a Drug Addiction Treatment Service. We included relatively “stabilized”
For personal use only.

patients in order to obtain a more reliable psychiatric diagnosis. Indeed, among opioid
addicts, it is difficult to differentiate symptoms of intoxication or abstinence from psychiatric
symptoms. In particular, the diagnostic assessment of new patients seeking treatment at a
drug addiction treatment service is especially difficult, because virtually all of them report
symptoms of anxiety, irritability, or depression. Forty-one percent of our sample met criteria
for a current DSM-IV Axis-I psychiatric diagnosis, in line with other studies, conducted in
the U.S. and Europe. Our results indicate that participants with opioid dependence (with
and without DD) have on average significantly decreased QOL levels compared to healthy
controls in the physical, psychological, and social relationships domains. These results are
consistent with other studies (Millson et al., 2004; Torrens et al., 1997) that used the SF-36
and the Nottingham Health Profile (NHP).
In our sample, participants with DD had poorer physical and psychological QOL than
those with OD. In other words, syndromal-level psychiatric symptoms are associated with
decreased levels of QOL even among participants in whom the prolonged use of substances
has to a certain extent already compromised the physical health and the interpersonal rela-
tionships. This finding provides further evidence, in a new setting, of the well-established
relationship of QOL with mood and anxiety disorders (Wells et al., 1989; Mendlowicz and
Stein, 2000). Our results confirm the high prevalence of DD in women (Brooner et al.,
1997; Chatham et al., 1999) and are at variance with other authors (Puigdollers et al.,
2004), who did not find gender differences in the total NHP score. Our study has several
limitations: first, the overall sample size is small, which makes our results preliminary and
needing further confirmation in larger samples. Second, the sample includes patients al-
ready in treatment and cannot be generalized to all patients with opioid addiction. Third,
the psychiatric diagnoses are heterogeneous, making it difficult to attribute the decrease
in QOL to a specific pattern of psychiatric symptoms. However, most of the psychiatric
disorders included common disorders such as depression or anxiety because patients with
severe mental disorders in Italy are usually referred to community mental health services.
 Quality of Life of Opioid Dependents 1771

In summary, our data show that among patients in treatment for opioid addiction, those
with psychiatric disorders have poorer QOL. These results underscore the importance of
performing a psychiatric assessment of patients presenting for treatment at Drug Addiction
Services in order to start, when needed, an integrated mental health and substance use treat-
ment for patients with dual disorders, addressing the complexity of their illness. A review of
36 studies on the effectiveness of integrated treatment for patients with schizophrenia and
co-occurring substance use disorders provides encouraging evidence that comprehensive,
integrated outpatient treatment programs are useful in helping patients reduce substance use
and attain remission, although not all strategies prove successful (Drake et al., 1998). We
argue that multidisciplinary case management with a special focus on psychosocial needs
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has the potential to enhance patients’ motivation, help them to develop new relationships,
work activities, coping strategies, and eventually improve their quality of life. Evidence
from future longitudinal studies using QOL as one of the outcome measures will help clar-
ify to what extent patients with mood and anxiety and co-occurring substance use disorders
benefit from integrated treatment strategies involving community mental-health services
and drug addiction services.

Glossary
Dual diagnosis: Co-occurrence of substance use disorder and axis-I psychiatric disorders
as defined by the DSM-IV.
Quality of life: Individuals’ perception of their position in life in the context of the culture
For personal use only.

and value systems in which they live and in relation to their goals, expectations, standards,
and concerns.

Acknowledgments
The paper has been funded by the Italian Fondo Nazionale Lotta alla Droga. The authors
appreciate the comments of Angelo Fioritti, M.D. and Gian Paolo Guelfi, M.D. on an earlier
draft of this article.

RÉSUMÉ

Cette étude a examiné la relation entre la qualité de vie (QOL) e le double diagnostic parmi
les patients en traitement pour dépendance d’opiacées. L’échantillonnage de l’étude com-
prend 57 patients atteints de dépendance seule (OD) et 41 avec une dépendance d’opiacées
et un désordre psychiatrique axis-I (DD) recrutés en 2001 et 2004 auprès du Centre de la
Dépendance des Drogues (SerT) de Bolzano et Pontedera (Italie). Les participants étaient
73.5% mâles, avec un âge moyen de 35.1 ans (DS = 8.0) Un groupe de comparaison de
45 contrôles sains a été aussi inclus. L’évaluation a compris une interview psychiatrique
structurée (SCID) et un auto rapport de l’évaluation de la qualité de vie (WHOQOL-BREF).
Les patients atteints de DD ont révélé un QL sensiblement plus pauvre (p 0.05) dans
les domaines physiques et psychologiques comparés aux patients atteints de OD. Les deux
groupes de patients avec et sans DD ont révélé un QOL sensiblement plus pauvre dans les
domaines social, physique et psychologique par rapport aux participants sains. Les scores
dans le domaine du “rapport avec l’environnement” n’ont donné lieu à aucune différence
entre les OD, DD et les groupes de contrôle. La présente étude livre l’évidence préliminaire
que le diagnostic double est associé à un QOL inférieur et met en relief le besoin de cibler
le traitement pour le désordre mental au même temps que le problème de dépendance chez
les patients soignés pour dépendance d’opiacées.
 1772 Bizzarri et al.

RESUMEN
El estudio examina la relación entre calidad de vida (CV) y diagnóstico dual en pacientes
bajo tratamiento para dependencia de opioides. La muestra incluye 57 pacientes con de-
pendencia de opioides (DO) y 41 con dependencia de opioides y un trastorno psiquiátrico
perteneciente al Eje I (DD), atendidos en los Servicios para las Toxicodependencias (SerT)
de Bolzano y Pontedera (Italia) en 2001 y 2004. La media de edad de los participantes fue
de 35.1 años, el 73.5% eran hombres. Se incluye además un grupo de contraste formado por
45 controles sanos. La evaluación incluye una entrevista psiquiátrica estructurada (SCID) y
auto-informe de la calidad de vida (WHOQOL-BREF). Los pacientes con DD informaron
de una CV significativamente más pobre (p < 0.05), en los dominios fı́sico y psicológico,
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que los pacientes con DO. Ambos grupos de pacientes, con y sin DD, mostraron una CV
significativamente más pobre (p < 0.001) que los participantes sanos en los dominios fı́sico,
psicológico y social. Las puntuaciones en el dominio “relaciones con el ambiente” no di-
fieren significativamente entre los tres grupos. El presente estudio proporciona evidencia
preliminar acerca de que el diagnóstico dual se asocia con una peor calidad de vida, y
enfatiza la necesidad de dirigir la intervención terapéutica hacia el trastorno mental, junto
al problema de dependencia, en pacientes bajo tratamiento para adicción a opioides.

RIASSUNTO
Questo studio esamina la relazione tra qualitá della vita (QOL) e doppia diagnosi in
pazienti in trattamento per dipendenza da oppiacei. Il campione dello studio comprende
For personal use only.

57 pazienti con sola dipendenza da oppiacei (DO) e 41 con dipendenza da oppiacei e una
diagnosi psichiatrica in asse I (DD), reclutati nel 2001 e nel 2004 presso i Servizi per le
Dipendenze (SerT) di Bolzano e Pontedera (Italia). I partecipanti sono per il 75% maschi
e hanno un’eta’ media di 35.1 anni (DS = 8.0). E’ stato inserito un gruppo di confronto di
45 soggetti sani. La valutazione comprende un’intervista psichiatrica strutturata (SCID) e
un questionario auto-valutativo della qualita’ della vita. I pazienti con DD hanno riportato
una QOL significativamente (p < 0.05) piu’ compromessa nelle aree fisica e psicologica
rispetto ai pazienti con DO. Entrambi i gruppi di pazienti con e senza DD presentavano
una QOL significativamente (p < 0.001) piú compromessa nelle aree fisica, psicologica e
sociale rispetto ai partecipanti sani. I punteggi relativi all’area “relazione con l’ambiente”
non differivano tra pazienti con DO, DD e controlli. Il presente studio fornisce una evidenza
preliminare che la doppia diagnosi é associata con una maggiore compromissione della QOL
e enfatizza la necessita’ di un trattamento che affronti in concomitanza il disturbo mentale
e il problema della dipendenza nei pazienti in trattamento per dipendenza da oppiacei.

THE AUTHORS
Jacopo Bizzarri, M.D., psychiatrist. He has been working
since 2000 at the Drug Addiction Service of Bolzano. His
main research interests are in psychiatric comorbidity in
drug users.
 Quality of Life of Opioid Dependents 1773

Paola Rucci, statistician and research assistant professor

of psychiatry at the University of Pittsburgh. She is cur-
rently working at Department of Psychiatry, University of
Pisa as coordinator of a NIMH study on phenotypes of
depression. Her main research interests are related to in-
strument development, validation and testing in clinical
practice.
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Alessia Vallotta, psychologist. She has worked from 1997

to 1999 in a therapeutic community for patients with psy-
chiatric disorders. She has been working at the Drug Ad-
diction Service of Bolzano since 2000. Her main research
interests are related to dual diagnosis, eating disorders and
bioenergetic analysis.
For personal use only.

Massimo Girelli, psychologist, PhD. in Experimental Psy-

chology. He has been working at the Drug Addiction Ser-
vice of Bolzano since 1998 as researcher on epidemiology
of substance use (funded by the Italian ‘Fondo Nazionale
Lotta alla Droga’), and as clinical psychologist from 2002.
His interests in this research field include neuropsychology
of addiction and related mental diseases.

Anna Scandolari, MD. She has been working since 1990

at the Drug Addiction Services of Bolzano and currently
is Assistant Chief and Medical Coordinator. She is in-
terested in the field of research on designer drugs and
group-analytical therapy and collaborates with a Health
and Social Network for treatment of parents with opioid
dependence and their children.
 1774 Bizzarri et al.

Elisabetta Zerbetto, M.D., toxicologist. She has been

working at the Drug Addiction Service of Bolzano since
1998.
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Alfredo Sbrana, M.D., psychiatrist. He has been working

since 1987 in the field of drug use and has been the Head
of the Drug Addiction Service of Pisa for five years. He
is currently working at the male inpatient unit of the De-
partment of Psychiatry of the University of Pisa. His main
research interests are the spectrum of substance use and its
relationship with mental disorders.
For personal use only.

Claudia Iagher, specialist in rehabilitation in psychiatry

at the Department of Psychiatry, University of Pisa. Her
main research interests are in quality of life of drug users.

Elio Dellantonio, M.D., psychiatrist. He has worked at the

psychiatric Hospital and at the psychiatric outpatients and
rehabilitation services in Bolzano from 1979 to 1989. Since
1989 is Head of the Drug Addiction Service of Bolzano.
 Quality of Life of Opioid Dependents 1775

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