How to Treat Coexistent Mental Illness and Substance Abuse

Written by Joel Velasco, MD, Arthur Meyer, MD, and Steven Lippman, MD

ABSTRACT: Integration of mental illness and substance abuse treatments is important for patients with dual diagnosis, the coexistence of an emotional ailment and a chemical dependency. Such comorbidity is usually associated with a poor prognosis. Both disorders require appropriate therapy so that remission of psychiatric symptoms and maintenance of sobriety become reachable goals for these individuals. A joint therapeutic approach improves outcome, functional expectation, and community adjustment.

COEXISTENCE of mental illness and a substance abuse disorder known as dual diagnosis vastly compromises management of both conditions. The lifetime prevalence rate for psychiatric conditions is 22.5% in the general population, and 19.6% of people have a chemical dependence; having both at the same time occurs in approximately one third of people with either of these conditions. Comorbidity results in an outcome much worse than when only one of these conditions is present.

Managing both aspects of the dual diagnosis conjointly can be advantageous. The core treatment provides an opportunity to approach both illnesses at the same time. Staff members are trained to assess and treat these problems in a unified way. The therapeutic team can integrate within the program the knowledge and skill needed to treat both disorders and lessen the patient's denial of either entity.

In addition, prognosis for improvement in each of these disorders is enhanced by treatment of the other condition. Physicians, other clinicians, and health care planners document benefit from an integrated, therapeutic method versus an isolated approach to each ailment separately. For example, a patient with severe mental illness and alcoholism could derive significant improvement in psychologic symptoms by avoiding intoxication; in the same manner, control over a component of psychiatric illness would help an emotionally compromised drug addict attain sobriety. Compliance with prescribed treatment and adherence to follow-up is greatly improved when both aspects of the problem are attended. One study assessing the 4-year outcome of patients with mental illness treated in a dual diagnosis program showed a 61% remission from alcohol abuse.

Dichotomous, suboptimal care is sometimes the result of poor coordination of therapeutic services by mental health agencies and substance abuse centers. Some individuals with either one of these ailments are barred from treatment facilities that focus on the other condition, leaving them in a gap between these two disciplines.2,4 Because they are difficult to treat, people with chemical addictions and mental illnesses are excluded from care by some clinicians. Differences in treatment philosophy or mistrust between professionals can lead to barriers between the psychiatric, general medical, and addiction treatment teams, exaggerating the already negative effects on recovery rates.3 On the other hand, a comprehensive, dual diagnosis approach to both types of illness from the beginning potentially improves the prognosis.

Careful diagnostic evaluation in dual diagnosis cases offers important prognostic and treatment implications. More severe psychiatric disorders indicate worse outcomes.5 The prognosis for patients with psychiatric disorders is typically poorer with accompanying substance abuse than without such problems. For individuals with chemical dependence, the best predictor of improvement is a lessening in severity of concomitant psychiatric symptoms.5 Improved mental status has a positive impact on the addiction remission potential.

TREATMENT METHODS

Central State Hospital in Louisville, Ky, has a dual diagnosis treatment unit. Admission criteria for this section of the hospital include patient motivation with a comorbid, major psychiatric disorder and substance abuse. Exclusions include persons who are medically unstable or require one to one personal psychiatric supervision, those who are unable to comprehend educational material or participate in group and milieu offerings, and those whose behavior is uncontrolled to the point of exhibiting a high violence potential. The dual diagnosis staff screens applicants for admission on an elective basis, with primary focus on acceptance of chemically dependent individuals with motivation, who have the desire for sobriety and need for psychiatric treatment. Admission is denied to those not highly committed to the process of recovery.

A comprehensive history and physical examination are done on the day of admission.6 Appropriate laboratory studies are done. Feedback about the patient from family, a previous physician, or through other means greatly improves the evaluation. Assessment and observation of symptoms that could arise from either or both conditions help identify problems and direct therapy in the proper direction.1,4

Dual diagnosis treatment begins with the detoxification procedure, lasting a week or more, depending on the type and quantity of substances used. The detoxification period is also an opportune time to develop doctor-patient rapport and carefully assess the source of psychiatric manifestations, determining whether they are primary or induced by drug abuses.1 In this population, establishing a productive therapeutic alliance is critical to gaining trust and keeps the patient in the program. Psychiatric management follows a thorough evaluation of all signs, symptoms, and history. Routine psychiatric pharmacotherapies and/or electroconvulsive therapy are used as warranted by clinical indications. Psychotherapy, individual counseling, and group therapy are provided, as are educational and recreational activities.

Attendance at Alcoholics Anonymous (AA) meetings is expected. With its strong peer group involvement, AA is a potent factor in confronting denial. Patients are given the opportunity to initiate support from the community by choosing AA sponsors from people in recovery from chemical dependencies.7 Such contacts should be maintained through discharge from the inpatient program. These sponsors are an essential part of recovery, facilitating the individual's growth in the process of long-term rehabilitation by their counsel and regular interpersonal contact. Each individual receives support in this manner. They are instructed to choose as sponsors recovering individuals who have maintained steady recovery for at least 1 year. Finding enough local sponsors has never been a problem; many such people are willing to assist patients with dual diagnosis in their integration to the AA community.

Double Trouble is a new type of 12-step program8 for persons with both a psychiatric disorder and an addiction. Smaller than the traditional group, it provides stronger support and openness to its members. Double Trouble groups are available to our discharged patients.

Educational programs, film and discussion groups about drug abuse, family conferences, and sessions with chemical dependence counselors are other treatment modalities for people with these difficulties.1 Such activities are effective in rallying members of the immediate family to give full support not only to the program, but most of all to the patient, who at one time was alienated and lost credibility with family and friends.