Dual Diagnosis

Dual Diagnosis (Mental Illness + Substance Abuse)

Introduction

Dual Diagnosis: substance abuse/dependance (SA) comorbid with serious mental illness (SMI) Þ SAMI

the big question is: which came first - the abuse or the mental illness

SMI: schizophrenia; schizoaffective disorder; bipolar disorder; recurrent major depression; personality disorders

Prevalence

substance abuse much more common in the mental health populations than in the general public

substance abuse in the general population is 17%; estimates in the mental health population are 25 - 75%

EtOH abuse in the general population is 13%; 33% among schizophrenics; 44% among bipolar; 16% with depression

other drug abuse is 6.7% in general; 38% among schizophrenics; 51% with bipolar

conversely, 90% of patients with opioid dependence qualify for psychiatric diagnosis; 40% of alcoholics have major depression

Adverse Outcomes of dual diagnosis patients:

decline in psychosocial function:

can’t keep a job

homelessness (many subsidized homes for mentally ill require sobriety)

estrangement and isolation (crime, irritability, etc Þ loss of support from family and friends)

exacerbation of psychiatric symptoms

direct effect (cocaine Þ psychosis; EtOH Þ depression)

medication non-compliance

cumulative effect of stressors (pts are stressed to begin with, substance abuse adds to that)

rehospitalization rates are 2-3x that of non-abusing patients; cost of care is 2x that of single diagnosis

failure to progress in treatment: only 1 oz. of EtOH per day is enough to cause major depression to fail to remit

suicide: substance abusers 20x more risk of suicide than the general population; add to already increased risk with SMI

criminalization: 10x more risk in SAMI than general population; 90% of SMI in prison have a dual diagnosis

also at greater risk for victimization (i.e. strawberries - women who prostitute for drugs)

medical comorbidity: cigarette smoking, Hep C, and HIV are very prevalent in the SAMI population

Prognositic Factors

Positive

lack of physiological dependance: i.e. no withdrawal symptoms
participation in an ongoing comprehensive treatment program
previous sobriety: 1 yr is the usual definition of extended sobriety, but even a month leads to a better prognosis
lower risk patterns of substance use

Negative

continued use despite negative consequences
physiologic dependence
medication non-compliance
deterioration in nutritional status

Treatment

Goals:

(1) reduce risk of harm from SA
(2) promote behavior to facilitate self-sufficiency

engagement: develop relationship, provide housing, etc Þ convince them to get treatment

continuity: treatment is long-term, and continuity is key

comprehensiveness: all services must be at the same place to ensure that nothing slips through the cracks

accurate assessment is also key: which came first - SA or MI

stages of motivation to change: pre-contemplative, contemplative, preparation, action, maintenance

traditionally, treatments for SA and MI are opposed, but treatment of dual disorders attempts to bridge the gap

	Mental Health System	Dual Disorders Approach	Addiction System
Medications	central to management, both short and long term	central, but used with caution; addicting meds are avoided	used ONLY for acute detox; the standard view is that all drugs are BAD; some long-term use is becoming accepted
Confrontations	minimal use	used on individualized basis	extensive use Þ otherwise is considered enabling
Group Therapy	central to treatment	central to treatment	central to treatment
12-Step Programs	use is growing; disclosure aspect is not used	becoming more numerous	central to many treatments; disclosure is a big aspect AA, NA, CA
Other Self Help Groups	many national groups; local groups growing in #	increasing use	many groups are available
Relapse	results in more treatment	depends on the individual	results in termination of treatment

SAMI - Substance Abuse and Mental Illness Program (one example of a treatment program)

referrals: 25% voluntary; 75% forensic (even though court-ordered, can still do well in program)

structure: partial hospitalization, intensive outpatient, aftercare

key elements

multidisciplinary team: psychiatrist, case manager, counselors, therapists, peer counseling, etc

psychiatric treatment: engagement, accurate diagnosis (may only be possible after sober), aggressive treatment

group therapy: education, support, self-discovery (whatever the hell that means)

case management: food; entitlements (social security, Medicaid), housing, socialization, advocacy

primary medical care: SA and MI often have many unattended medical problems

individual psychotherapy: issues of loss and abuse are common

12-step program

monitoring for relapse: used therapeutically rather than punitively (but also used in probation issues)