Jefferson Journal of Psychiatry Jefferson Journal of Psychiatry

Volume 8 Issue 1 Article 5

January 1990

Treating Dual Diagnosis Patients: Challenges and Opportunities Treating Dual Diagnosis Patients: Challenges and Opportunities

Robert H. Howland, M.D. Western Psychiatric Institute, University of Pittsburgh

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Recommended Citation Recommended Citation Howland, M.D., Robert H. (1990) "Treating Dual Diagnosis Patients: Challenges and Opportunities," Jefferson Journal of Psychiatry: Vol. 8 : Iss. 1 , Article 5. DOI: https://doi.org/10.29046/JJP.008.1.002 Available at: https://jdc.jefferson.edu/jeffjpsychiatry/vol8/iss1/5

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Treating Dual Diagnosis Patients:Challenges and Opportunities

Robert H. Howland, M.D.

T Ra DUCTI ON

T he use and abuse of drugs and alc ohol ha ve recently gained grea terattention both from the public and the medical profession . Desp ite increasingcognizance of its un fo r tunate consequences, substance use has become a morepervasive element of conte mporary society. As substance abuse ha s come toaffect more segments of the population, it is not surprising that this problem a lsohas affected the mentally ill. Awareness of the mentally ill subs ta nce ab user ha sgrown , a lthough this population has not been well studied or well served by th emental health system . These dually diagnosed patients often a re depict ed as thesquare pegs of psychiatry, not quite fitting into the round hol e of menta l healthtreatment. The reason for this is clear. Because of the curren t structure of th emental health service delivery syste m , psychiatric and subs tance abuse servicesare provided almost exclusivel y by independent syste ms (1 ,2). As a result , thosepatients who are perhaps most in need of treatment are most likel y to fallthrough the cracks of the system. Providing services for this group of patientsrepresents a clinical and administrative challenge, wh ich has no t bee n ade­quately addressed by the psychiatric profession . In this paper, I suggest thatpsychiatrists can accept greater responsibility for working with th e d ually di ag­nosed , and that this responsibility could begin with th e psych iatrist-i n-tra in ing.Although the prob lem may be difficult to overcome, psychiatry is in a uniqueposition to accept this responsibility, effect changes in th e syste m , and have apositive impact on the lives of patients with dual diagnoses.

CLINICAL PRO BLEM

Although clinical experience may give a rough idea of th e number and typesof patients with dual di agnoses, there are a small number of sur veys th at definethe extent of this problem more co mpletely. Many of the stud ies examinespecific patient popu lations, such as psychiatric inpatients (3) or persons whopresent for substance abuse treatment (4), so that the results are no t easilygeneralized . However, most studies do support the clinical impression thatindividuals wit h a psychiatric disorder are at higher ri sk of also having ordeveloping a su bstance abuse disorder and vice versa . Comorbidity rat es varyconsiderably between studies depending on the population sample, but have

12

TREATING DUAL DIAGNOSIS PATIENTS 13

been reported to range from six percent to as high as 80 perce nt (3-10). Thus,by considering the dually diagnosed as a single di agnostic category, th ese resultssuggest that clinicians are much more likely to encounter a patient with th isproblem than one with just schizophrenia or bipolar di sorde r alone, for exa m­ple.

The variability reported in the rates o f comor bid ity is in part due to thekinds of patients studied, suggesting that the duall y d iagn osed are a veryheterogeneous group. Hi storicall y, clinicians have fel t that the dua lly diagnosedrepresent patients who are primarily personality-di sordered, especially soc io­pathic personalities (11), or who are severely and chron icall y mentally ill (12).However, more comprehensive stud ies show that this is not entirely true andthat all types of psychiatric di sorders are sign ifica n tly represented among pa­tients with dual diagnoses (4-6 ,13).

The dually diagnosed also are distinguished in many respects by th eirclinical characteristics. These patients may be more difficult to work with (5,14) ,are more noncompliant with , a nd less responsive to treatm ent (14-1 8), morefr equently use eme rge ncy services (13,19), a nd are a t increased risk for suicideand vio lence (14, 20- 22). The clinical picture that emerges is not very appealingto clinicians, especially psychiatrist s-in-training, although it is important torealize that this picture is a composite drawn from many different experienceswith psychiatric patients who are substance abusers. Substance abuse may not berecognized in many patients who are other wise e ngaged in treatment (2 ,5,6,9,13),a lthough it may greatly contribute to their morbidity. Many of these patientsalso may be relatively better functioning individuals who are troubled byinterpersonal or family difficulties and are not significantly or chronically dis­abled. They may be treated with individual psychothe rapy or fami ly therapy,perhaps using adjunctive medications, but do not do we ll because of theirunrecognized substance abuse. As a result , they may become d issatisfied withand drop out of treatment, go on to develop a chronic co urse , or be ter minatedas a treatment failure .

TRAINING ISSUES

For the psychiatrist-in-training, dual diagnosis patients pose severa l appar­ent problems related to training. However, lack of exposure to these patients isnot one. As noted above, many psychiatric patients who are subs ta nce ab userspresent to emergency rooms in crisis and at odd hours, and often are admitted toacute psychiatric inpatient units. They may be seen in th e ge neral psychiatr icclinic because they are not appropriate for specialty services or are unwanted byprivate practitioners. In each of these situations, the primary responsib ility forcare often falls on the psychiatric resident.

One issue that is important to the psychiatrist-in-trainin g in working withthe dually diagnosed is the lack of fo r mal train ing ex per iences in substanceabuse evaluation and treatment. Most medical sch ools a nd resid ency p rograms

14 JEFFERSO N JOUR NAL OF PSYCHIATRY

have minimal educational opportunities in this area. They usuall y tak e the formof electives for those who are interested and motivated and generally involvepatients with " p ure" substance abuse disorders rather th an dua l diagnoses.Without adequate training, treating the substance abuser can be as difficult astreating any other psychiatric illness. This is especially true wit h a patient whohas both conditio ns.

Another issue that is equally important is whether th e d uall y diagnosed areappropriate training " cases" . Because of their substance abuse, th ey may not bethought of as good candidates for psychotherapy or even pharmacothe rap y. Ifthey are difficult patients to work with , then th ey ma y be term inat ed from orallowed to drop out of treatment, using the substance abuse as a rationale andperhaps suggesting that substance abuse treatment would be more helpful orappropriate for the patient. O f course, it is likely that a substance abuse clinicianmay find the presence of a psych iatric di sorder to be an equally co mplicatingfactor in treatment.

The importance of these issues should not be minimized. Howeve r , theyalso should not deter psychiatrists from making a commitment to providingtreatment for the dually d iagnosed , especially when they have few alternativesava ilable to them. Rathe r than refusing to accept them for treatment, or lettingthem drop out of treatment with little effort to engage th em becau se ofinexperience and lack of training, psyc hiatric training should encom pass theevaluation an d treat ment of substance abuse. O ngoing supervision an d inst ruc­tion typica lly is provided th roughout the period of training in psychi at ry andcou ld easily include substance abuse disorders, rather than limiting th is trainingto a single rotation or elective. In addition, it also is important to see k consulta­tion from those professionals who can provide assistance in working with thesepa tients , in much the same way that other consultants are used for d ifficultcl inica l situa tio ns. For example , this might involve active co llaboration wit h asubstance abuse counselor or treatment faci lity.

Finally, the training value of the dual d iagnosis patient cannot be overempha­sized. Because of their sheer numbers alone, it is inconceivable th at any psych ia­trist will be able to avoid them in their clinical practice. Moreover , howpsyc hiatrists practice after training depends to a large extent on th eir experi­ences du ring train ing. Therefore, avoid ing these patients and ne glecting tolearn about substance abuse disorders makes it unlikely that they will ever feelcomfortable with or capab le of treating them. In th e approach to trea tm ent ,there is much that can be learned from patients with dual d iagnoses. Forexample, a broad array of biological and psychosocial approach es to treatingpatients with schizophrenia, social phobia, or borderline personal ity are nowavai lable to psychiat r ic residents . Simi larly, those strategies that ma y be usefu l intreating the dually diagn osed also are important and can become a part of th etraining curricu lum.

TREATING DUAL DIAGNOSIS PATIENTS

ATTITUDES AND RESPONSIBILITY

15

When confronted with the different clinical problems th at d ually diagnosedpatients pose fo r both individual clinicians and service systems, a central issue isthe question of responsibility. No matter wh ere th ese pat ie n ts initially presentfo r treatment, with few exceptions they will inv ariably be referred to the mentalhealth system. The nonpsychiatric professionals wh o have significant expertiseand success in treating substance abuse disorders a lone, also are significantlyinexperienced in working with psychiatric di sorders and may decline to workwith these patients without help or guidance . Many private practitio ners havedemonstrated an unwillingness to work with th e duall y d iagnosed . Communitymental health centers, where many of these patients are seen , are typic allyoverburdened and underfunded; because they may have minimal experiencea nd limited staff to work effectively with this type o f pat ient, responsibility fo rtreatment often is shared with or tran sferred to th e local d rug and alcoholagency and there is little incentive to coordinate these serv ices . As a result , manydual diagnosis patients are unwanted and they are all too aware of th is.

There is not much merit to a syste m wh ich ca n avoid responsibility fo rpatients sim ply because they do not have an approved or acceptable conditionfor treatment. Differentiating between psych iatric illness and su bstance abusedisorders may be useful for prescribing treatment, but is artificia l and arbitrarywhen it is used to restrict treatment. Psychiatrists have a sign ificant role to pla yin leading the efforts to change this situation and ca n accept greate r responsibil­ity for the care of these patients. Psych iatri sts-in-training have a un ique opportu­nity to stim u late and influence those effo rts, to benefit from the positive changesin the syste m, and to be a part of the proc ess of research , educa tion , and clinicalpractice that can develop to serv e dual diagnosis patients more effectively.

If psychiatry is unable to assume greater responsibil ity for the duallydiagnosed, then there is no other professional who is in a better position to do so ,ei the r. Why psychi atrists? Thei r background is sufficien tly broad that, at least intheory, they sh ould be capable of responding to the myriad problems that dualdi agnosis pati ents often present with for treatment. Psychia tr ic illness an dsubs tance abuse are merely parts of a larger spectrum of mental health prob­lems, wh ich psychi atr ists shou ld have expertise in d iag nosing and treating. Inadd ition, their exper ience in interdisciplinary se ttings is an essent ial componentto providing and integrating treatment for dual di agnosis patients .

Psychiatrists ca n become a cons ta nt and reli able element in the lives of thesepatients, whi ch may o therwise be lack in g and which may ultimately contribute to

their imp rovement. Sm aller soc ia l networ ks are associated with th e comorbid ityof substance abuse a nd psych opatho logy (23) ; if psychiatrists are unwilling orunable to wor k with th e duall y d iagnosed, then that can only contribute to theisolat ion an d poor soc ia l support man y of them experience . Furthermore ,psychiatrists-in-training are enter ing a n era in wh ich th e efforts to destigmatizepsychiatric illn ess a re beginning to show resul ts. By not accepting greater

16 JEFFERSON JOURNAL O F PSYCHIATRY

responsibility for working with the dually diagnosed , there is the risk of under­mining those efforts and furth er stigmatizing yet another group of patients.

CONCLUSIONS

Dual diagnosis patients represent a formidable challenge for psychiatr ists.The difficulty of these patients, the structure of the mental health system, thelack of experience and training, and other factors all conspire to make it morediffi cult to accept and to work with many of these patients, despite th e ir very realneeds. However, these factors do not make it impossibl e to treat the duallydiagnosed. Nor should the clinical situation be so grim as to temper e nthusiasmor limit therapeutic aggressiveness in working with them . The duall y di agn osedare a diverse group of patients who can respond to treatment (24-27), but whoalso require flexibility, collaboration, and creativity as part of th e approach totreatment.

The usual treatment paradigms that are applied to psychiat ri c illn ess orsubstance abuse disorders alone probably are not adequate for th e duallydiagnosed . Too often, noncompliance or poor treatment response are "blamed"on the patient. This neglects the very real disability that can res ult fr om th ei rcondition and assumes that a particular treatment approach is infallible. T hepsychiatrist-in-training is in a unique position not only to provid e much neededclinical services for the dually diagnosed, but also to lobby fo r changes intraining and in other administrative areas, which will have an impact on all typesof services for these patients. There is an opportunity to provide leadership andcreative energy in a problem area of psychiatry that has been poorly served.Hopefully, this opportunity can be used to begin to meet th e cha llenges ofworking with dual diagnosis patients.

REFERENCES

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2. Menicucci LD , Wermuth L, Sorensen J: Treatment providers' assessment of du al­prognosis patients: Diagnosis, treatment, referral , and fami ly involvem ent. Int JAddict 23:617-622, 1988

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TREATING DUAL DIAGNOSIS PATIENTS 17

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