by Amy Novicoff-Fackrell
After approximately 20 years of development and research, dual diagnosis services for clients with severe mental illness are emerging as an evidence-based practice. Effective dual diagnosis programs combine mental health and substance abuse interventions that are tailored for the complex needs of clients with co-morbid disorders. This article seeks to describe the critical components of effective programs, which include a comprehensive, long-term, staged approach to recovery, assertive outreach, motivational interventions, provision of help to clients in acquiring skills and supports to manage both illnesses and to pursue functional goals, and cultural sensitivity and competence. While there have been some state implementation dual diagnosis services within the mental health system, funding has been markedly decreased and high-quality services are rare. This article also seeks to provide a current, comprehensive approach to implementing a dual diagnosis program that incorporates clarity of program mission with structural approaches designed to support dual diagnosis services, training and supervision of clients, and to disseminate accurate information to consumers and families to support understanding.
Although treatment centers and programs traditionally have focused on drug addiction within the framework of 12-Step philosophies and treated the associated conditions that perpetuate addiction as secondary, it is more effective to address chemical dependency, substance use, and the “associated conditions” equally and simultaneously. The goal of dual diagnosis interventions is recovery from two or more serious illnesses. “Recovery” means that the individual with a dual diagnosis learns to manage both illnesses so that he or she can pursue meaningful life goals.
A client-centered approach to working with people “where they are” rather than “where they should be,” as dictated by many treatment providers and therapists who specialize in dual disorders is more effective. Clients should be encouraged to set their own goals while staff continues to provide support and assistance as these goals change over time.
What is Dual Diagnosis?
“Dual diagnosis” is defined as having a severe mental illness associated with dependence on alcohol, or other substances. Epidemiologic studies have shown that between 25% and 50% of people with one mental disorder have at least one co-occurring mental disorder. There are two subgroups of patients: major substance abuse disorder coupled with another major psychiatric disorder; and abuse of alcohol and/or other drugs in ways that affect the course of treatment of the mental disorder.
Surveys have shown that one third of dual diagnosis psychiatric patients will abuse or depend on alcohol and that one third of individuals suffering from alcohol abuse will be additionally diagnosed with a psychiatric disorder. Sixty percent of individuals who abuse drugs other than alcohol will be dually diagnosed
For individuals who experience mania, the lifetime risk for developing alcoholism is six times greater than compared to the general population while major depression carries a risk of twice the average. Individuals who are dually diagnosed may have slower rate of recovery than individuals without major substance abuse. Currently, there are few comprehensive, integrated, recovery programs for these individuals, although research is continuing. A moderate lifestyle will help control the illness.
The term mood describes a pervasive and sustained emotional state that may affect all aspects of an individual’s life and perceptions. Mood disorders are pathologically elevated or depressed disturbances of mood, and include full or partial episodes of depression or anxiety. A mood episode (for example, major depression) is a cluster of symptoms that occur together for a discrete period of time. People are more likely to seek help when moderately depressed versus when they are experiencing an episode of mania.
Everyone has feelings of sadness and disappointment. Depression’s main symptom is that of intense, pervasive, persistent feelings of sadness, hopelessness, and frustration that cause considerable impairment in social and occupational functioning. Untreated, moderate to the more severe depression can lead to suicide attempts or psychotic thinking and behavior.
Some typical symptoms of depression are: poor appetite and weight loss or marked increase in appetite and associated weight gain; sleep disturbance; loss of energy, excessive fatigue or tiredness; slow speech and movements; change in activity level; loss of interest or pleasure in usual activities; decreased sex drive; diminished ability to think or concentrate; indecisiveness; withdrawal and isolation from family; decreased memory function and lack of concentration; disorganization; highly critical of self; low self-esteem feelings of worthlessness or excessive guilt which may reach delusional proportions; recurrent thoughts of death or self harm contemplating or attempting suicide; heightened or changed perceptions
Mood Disorders Due to a Medical Condition
Mood disorder due to a general medical condition can be described as having (1) manic features, (2) depressive features, or (3) mixed features in which symptoms of both mania and depression are present and neither predominates (DSM-IV-TR, 2000).
Medical conditions that can either precipitate or mimic mood disorders include the following:
- Hyper- and hypothyroidism
- Brain disease
- Post-cardiac condition
- Stroke, especially among elderly people.
Medications, including medications that treat hypertension and hypotension, can cause conditions that may be confused with psychiatric or alcohol or drug (“AOD”) disorders. Both prescribed and over-the-counter (OTC) medications can precipitate depression.
Diet pills and other OTC medications can lead to mania. Patients treated with neuroleptic (antipsychotic) drugs may have a marked constriction of affect that can be misinterpreted as a symptom of depression.
The anxiety disorders are the most common group of psychiatric disorders (DSM-IV-TR, 2000). The term anxiety refers to the sensations of nervousness, tension, apprehension, and fear that emanate from the anticipation of danger, which may be internal or external. Anxiety disorders describe different clusters of signs and symptoms of anxiety, panic, and phobias.
Post-traumatic stress disorder (PTSD) begins with an individual experiencing a psychologically traumatic stressor such as witnessing death, being threatened with death or injury, or being sexually abused. At the time of the stressor event, the individual experiences intense fear, helplessness, or horror (Retrieved 3/12/2010 from http://www.obad.ca). PTSD entails a persistent re-experiencing of the trauma in the form of recurrent and intrusive images and thoughts, or recurrent dreams, or experiencing episodes during which the trauma is relived (perhaps with hallucinations) (Retrieved 3/12/2010 from http://www.obad.ca). People with PTSD experience persistent symptoms of increased arousal such as insomnia, irritability, hypervigilance, and exaggerated startle response. They persistently avoid stimuli related to the trauma such as activities, feelings, and thoughts associated with the traumatic event (Retrieved 3/12/2010 from http://www.obad.ca).
Interest in the role of sexual abuse and incest in PTSD and other psychiatric and AOD disorders has increased. Clinicians note that long-term responses to childhood and adult sexual abuse often include symptoms associated with PTSD and other psychiatric problems, including an increased risk for AOD disorders (Retrieved 3/12/2010 from http://www.obad.ca). Many such problems are addressed in treatment efforts popular in adult children of alcoholic (ACOA) programs, some of which are controversial and unsubstantiated by research or long-term observation (Retrieved 3/12/2010 from http://www.obad.ca). Such treatment approaches may exacerbate AOD use and psychiatric disorders and should be cautiously undertaken. Amnesic periods have to be carefully evaluated both as blackout phenomena and as possible dissociated states (Retrieved 3/12/2010 from http://www.obad.ca). Such differentiation can be extremely complicated. While a clinician’s immediate response may be to identify these patients as being intoxicated, they may be experiencing independent psychiatric phenomena (Retrieved 3/12/2010 from http://www.obad.ca).
Prevalence rates for anxiety disorders in the general population can be estimated from the Epidemiological Catchment Area (“ECA”) studies. According to the ECA studies, anxiety disorders affect more than 7 percent of adults in the general population, the lifetime prevalence rate of anxiety disorders is 14.6 percent. Women, individuals under age 45, those who are separated or divorced, and those in low socioeconomic groups all have a higher rate of anxiety disorders than individuals in other groups.
These same ECA studies indicate that in the general population:
- The 1-month prevalence rate for any anxiety disorder is 7.3 percent (4.7 percent for males and 9.7 percent for females), and the 6-month rate is 8.9 percent.
- The 1-month prevalence rate for phobia is about 6.2 percent (3.8 percent for males and 8.4 percent for females).
- The 1-month prevalence rate for panic disorder is about 0.5 percent (0.3 percent for males and 0.7 percent for females).
- The 1-month prevalence rate for obsessive-compulsive disorder is 1.3 percent (1.1 percent for males and 1.5 percent for females).
- Lifetime prevalence of post-traumatic stress syndrome in the general population is estimated to be less than 1 percent. The prevalence among individuals who have experienced a psychologically traumatic stressor and then developed psychiatric symptoms is poorly understood.
Among patients with AOD problems, there is a significant likelihood of a coexisting anxiety disorder. One study noted that more than 60 percent of patients being treated for AOD disorders had a lifetime diagnosis of an anxiety disorder, and about 45 percent experienced an anxiety disorder within the past month (Grant, et al., 2004). Other studies have demonstrated that most anxiety disorders among patients in addiction treatment are AOD induced (Grant, et al., 2004).
Treating Dual Diagnosis
Those who have both a mental illness and an addiction to drugs or alcohol present a challenge for medical professionals. Treating these individuals is complicated by the overlapping symptoms of the addiction and the mental illness. Complete treatment takes time and great care due to the delicate nature of the individual and due to the fact that symptoms of one condition complicate or impede the symptoms and treatment of the other.
Because these individuals have a mental illness, getting them to comply with the rules and regulations of a typical drug rehab program can be difficult. It is difficult to get them to take their meds, attend counseling or other basic necessities associated with success in a rehab program.
The most successful approaches for dual diagnosis patients are the integrated programs that treat all aspects of the illnesses in a single location. Mental health professionals and addiction rehab counselors work together in these programs to provide well-rounded care that encompasses everything involved in the diagnosis.
The dual diagnosis treatment process may include:
Intake interviews from mental health professionals to assess the psychiatric issues the patient is experiencing. This stage will help identify which mental illness the individual is experiencing.
Psychiatric/clinical diagnosis and assessment of the mental illness. Medication may be prescribed at this point, as well as general psychiatric counseling to address the illness.
Integration of addiction rehab. Using the knowledge gained from the psychological evaluation, counselors will begin working with individuals to address their drug or alcohol addiction. This process may be move at a more deliberate pace than “stand alone” rehab because of the complications caused by the mental illness.
- Treat for the mind, body and spirit. Programs that employ holistic treatments such as massage therapy, yoga, nutritional counseling and meditation help the individual find balance in their lives (often for the first time). Not all dual diagnosis rehab programs offer holistic care, but those that do enjoy high rates of success, and low relapse rates.
- Coping skills. Individuals are taught new methods for coping with their mental illness and shown how to avoid the triggers that can cause relapse. In this final phase of the dual diagnosis rehab, the individual learns to master the tools needed to succeed in the outside world.
- Relapse prevention. Aftercare programs provide a support structure and accountability for the individual. The period after leaving rehab can be difficult, and indeed, scary for the recovering addict with a mental illness.
- There is much to do (take meds regularly, avoid triggers of addiction) and even more to rebuild (personal relationship, careers, etc.) but the aftercare program lets the individual know that they are not alone during this part of their journey and provides much needed structure.
Professional and Vocational Planning
Although some patients with dual disorders have severe and poorly remitting mood and AOD disorders, most patients improve, especially with careful psychiatric treatment. Since these disorders are generally well controlled, patients can experience very high levels of vocational, social, and creative functioning. As a result, vocational planning should be long term and accentuate patient strengths.