Patti's World

Dual Diagnosis Essay – We Need to Know More

According to Samuel T. Gladding (2004), a diagnosis is important for three reasons. First, a diagnosis will be necessary for reimbursement by insurance companies. Second, a diagnosis is vital if a proper treatment plan is going to be developed. Lastly, a common language is important to establish when more then one doctor or therapist is involved in the treatment of a client. In some cases, a dual diagnosis will be made, which describes a condition where both a substance abuse and a mental health diagnosis are made. Mental health diagnosis can include depressive disorders, such as depression and bipolar disorder, anxiety disorders, including generalized anxiety disorder, panic disorder, obsessive-compulsive disorder, and phobias as well as other psychiatric disorders, such as schizophrenia and personality disorders. This paper will focus on dual diagnosis, the treatment plans available, and the obstacles that need to be addressed to ensure better health for the patients.
Which came first, the chicken or the egg? A similar question can be asked of dual diagnosis: Which comes first – substance abuse or the emotional dis-ease? At times psychiatric problems seem to develop first. “In an attempt to feel calmer, more peppy, or more cheerful, a person with emotional symptoms may drink or use drugs; doctors call this ‘self-medication.’ Frequent self-medication may eventually lead to physical or psychological dependency on alcohol or drugs. If it does, the person then suffers from not just one problem, but two. In adolescents, however, drug or alcohol abuse may merge and continue into adulthood, which may contribute to the development of emotional difficulties or psychiatric disorders(citation needed).” Other times it seems that alcohol or drug addition is the primary condition, “developing symptoms of a psychiatric disorder, perhaps episodes of depression, fits of rage, hallucinations, or suicide attempts” (NMHA).
Ever more frequently, “dual diagnosis” is a common diagnosis. The National Mental Health Association says that according to a report published by the Journal of the American Medical Association: “Thirty-seven percent of alcohol abusers and fifty-three percent of drug abusers also have at least one serious mental illness. Of all people diagnosed as mentally ill, 29 percent abuse either alcohol or drugs.” According to Walsh and Franklin, “people seeking treatment who are diagnosed with a drugs misuse disorder and a concurrent psychiatric disorder rose by over 40% between 1993 and 1998 and continue to rise (Frischer et al cited in Drugscope, 2002). Frischer et al also state that over 50% of clients presenting to primary care in England and Wales with addiction problems have a dual diagnosis.” A dual diagnosis can be described in four categories:
A primary diagnosis of a major mental illness with a subsequent (secondary diagnosis) of substance misuse, which adversely affects mental health
A primary diagnosis of drug dependence with psychiatric complications leading to mental illness
A concurrent diagnosis of substance misuse and a psychiatric disorder
An underlying traumatic experience resulting in both substance misuse and mood disorders eg post-traumatic stress disorder.
Walsh and Franklin go on to cite the Weaver etal, 2003 report that states: “The recent multi-centre collaborative study of comorbidity (three or more diagnosis’) of substance misuse and mental illness (COSMIC) found that:
75% of users of drugs services and 85% of users of alcohol services experienced mental health problems
approximately 30% of the drug treatment population and over 50% of those in treatment for alcohol problems experienced the cooccurrence of a number of psychiatric disorders in addition to substance misuse
44% of CMHT patients reported drug use and/or harmful alcohol use in the preceding 12 months
in London over half the CMHT patients reported substance misuse problems in the previous year (Weaver etal, 2003).”
Clearly the rate of dual diagnosis cases is on the rise. According to Libby & Riggs, “The high prevalence of the dual diagnosis of mental and substance use disorders (SUD) has been increasingly documented for both adolescents and adults.” It is clear there is an ever increasing need for quality programs that address both SUD’s and mental health diagnosis in adults as well as in adolescents. What would a treatment program look like?
Typically, SUD treatment begins with a detoxification program and a period of sobriety is required before any psychiatric pharmacology treatment will be allowed to begin. However, new studies show this may not be the best way to proceed. “Emerging research indicates that integrated treatment of mental health and SUD may produce better outcomes than those reported in previous research that targeted mental health or SUD alone” (Libby & Rogers). Although both problems should be treated simultaneously, for any substance abuser the initial focus is on detoxification, preferably under medical supervision so make it safer and less traumatic.
Once detoxification is completed, dual treatment can begin. Dual treatment includes rehabilitation for the alcohol or drug problem and treatment for the psychiatric problem. According Flynn’s review of Rosenthal & McCance-Katz’s book, Dual Diagnosis, some of the successful treatments for patients with a dual diagnosis include psychosocial interventions such as psychotherapy and Alcoholics Anonymous (AA), including relapse prevention therapy, pharmacological treatment, and network therapy, or cognitive behavior therapy with peers and relatives concomitantly with the identified patient. It has been proven that “family education, counseling sessions, and support groups are important aspects of overall care. The greater the family’s understanding of the problems, the higher the chances the patient will have a lasting recovery (NMHA).
Although there are many promising new treatments emerging for dual diagnosis patients, there are many roadblocks to overcome. Libby & Rogers explain that “Three barriers to (adolescent) treatment systems recurrently emerge: 1) Supply of providers familiar with integrated treatment; 2) Recognitions by primary care gatekeepers of integrated car; and 3) Economic support for integrated care by those managing health care resources and monies.” My own experience concurs with this, and in addition the stigma attached to such programs can make a family hesitant to explore such options. To combat the obstacles, some managed care organizations have offered incentives to companies who will attempt to treat mental health, substance abuse and medical problems holistically. This is a promising development for the future of dual diagnosis treatment. Treatments can take place in outpatient settings as well as inpatient facilities. Care must be taken to ensure that the different health practitioners stay connected and informed.
Caroline Hawkings has developed a “Practical Toolkit” to bridge the gap between the different branches of health practitioners, offering core principles and guidelines to ensure effective treatment and support. This first important area covered is assessment. Client’s needs must always be emphasized when determining the course of treatment. The client’s current lifestyle, domestic arrangements and life history should be taken into account to establish the chronology of presenting problems and their relationships, and treatments required. It has been found that a “key worker” is invaluable to a well connected team of health care professionals. This person will co-ordinate the care of the patient, ensuring that roles, responsibilities and boundaries are clear by “sharing information, organizing services, advocacy, advising, supporting, handling conflict, writing reports and monitoring resources”(Hawkings).
According to Hawkings, the key worker should:
Help to set realistic and achievable goals
Help to make best use of available assistance
Develop an integrated package of care and support
Promote the client’s independence and empowerment.
A care plan should take into account any risk assessments and should specify:
The treatment goals and milestones to be achieved
Treatment interventions, stating which agency and professional is responsible
How information will be shared, which information will be given to which agencies and under what circumstances
An engagement plan – this is particularly for people who have found it difficult to engage with services
Consideration of any relevant issues relating to the client’s culture and ethnicity
A review date (National Treatment Agency, 2004).”
As you can see the key worker is in the unique position to keep the treatment co-coordinated and effective. This “toolkit” highlights problem areas and gives a practical guide to ensuring that the treatment progresses without vital information falling between the cracks. This could prove to be the link that makes the difficult treatment of dual diagnosis more effective.
Dual diagnosis is certainly on the rise, as is the need for coordinated, quality treatment programs. Knowledge is power, and as this condition becomes more well known awareness will increase, not only to the diagnosis, but to the treatments available. The future will certainly bring better and more successful treatment programs, bringing relief and the possibility for a healthier, more fulfilling life to many sufferers.

Works Cited

Flynn, William R., Dual Diagnosis/Psychosocial Treatments, The American Journal of Psychiatry, Book Review-Comparative. Washington: May 2005.Vol.162, Iss. 5;  pg. 1040, 1 pgs, http://proquest.umi.com/pqdweb?index=12&did=842750961&SrchMode=1&sid= 1&Fmt=3&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=11414 48865&clientId=46656#fulltext

Gladding, Samuel T., Counseling a Comprehensive Profession, 5th edition, 2004, Merrill Prentice Hall.
Hawkings, Caroline, Dual Diagnosis: Developing a Practical Toolkit, . Brighton: Jun 2005.Vol.10, Iss. 2;  pg. 15, 4 pgs, http://proquest.umi.com/pqdweb?index=11&did=872193231&SrchMode=1&sid= 1&Fmt=3&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=11414 48865&clientId=46656

Libby, Anne M.& Riggs. Paula D., Integrated Substance Use and Mental Health Treatment for Adolescents: Aligning Organizational and Financial Incentives, Journal of Child and Adolescent Psychopharmacology. New York: Nov 2005. Vol. 15, Iss. 5; p. 826, http://proquest.umi.com/pqdweb?index=2&did=988641381&SrchMode=1&sid=1 &Fmt=6&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=114144 8713&clientId=46656

(NMHA) National Mental Health Association, Mental Health Resource Center , Substance Abuse – Dual Diagnosis, Fact sheet index, http://www.nmha.org/infoctr/factsheets/03.cfm
Walsh, Yvonne & Frankland, Alan, June 2005. The Mental Health Review. Brighton: Jun 2005.Vol.10, Iss. 2;  pg. 7, 8 pgs, http://proquest.umi.com/pqdweb?index=10&did=872193261&SrchMode=1&sid= 1&Fmt=3&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=11414 48865&clientId=46656#fulltext