Double Trouble

The Challenges of Co-occurring Disorders
By David Oshman , BA (Hons), Dip HE, RN

“Had I not been blessed with wise and loving advisers, I might have cracked up long ago. A doctor once saved me from death by alcoholism because he obliged me to face up to the deadliness of that malady. Another doctor, a psychiatrist, later on helped me save my sanity because he led me to ferret out some of my deep-lying defects. From a clergyman I acquired the truthful principles by which we Alcoholics Anonymous now try to live. “As Bill Sees It’ By Bill Wilson (Page 303)”

Chemical dependency treatment has certainly come a long way in the past 50 years. It is easy, but disturbing, to recall that even 30 years ago, the main treatment protocol came from the ‘Minnesota Model’, a treatment expansion from the wisdom and experience of Alcoholics Anonymous. While this treatment protocol is effective for many patients, it was sadly ineffective for a large segment of others. So what exactly was the deficiency? The founders of Alcoholics Anonymous actually realized the dilemma, and it was succinctly stated in the ‘How It Works’ section of the Big Book (page 23): _”There are those, too, who suffer from grave emotional and mental disorders, but many of them do recover if they have the capacity to be honest.”

When we talk about these “grave emotional and mental disorders”, we are really talking about what is commonly known as co-occurring disorders or dual diagnosis. These are mental and emotional conditions that co-exist with the alcohol or drug abuse. Statistically, substance abuse and mental health conditions are intrinsically linked. Substance abuse often arises as a symptom of underlying psychiatric diagnoses and most individuals seeking assistance are in fact, dual diagnosis patients. Compelling peer reviewed research, recently published in the Journal of Psychiatric Services, states that the overwhelming majority of rehabilitation patients are in fact experiencing co-occurring disorders. This population is also growing at an alarming rate, and they are often miss-categorized due to an ongoing lack of proper diagnostic techniques.

Epidemiological data suggests a co-occurring disorder rate of 79 percent in patients initially presented for substance abuse treatment. Unfortunately, only 8 percent of these individuals receive the necessary simultaneous treatment for both their addiction and co-morbid psychiatric conditions (Source: Kessler et al., 1996). This demonstrates a shocking gap in health care delivery systems for dual diagnosis patients suffering from co-occurring disorders. To further support this alarming situation, the Journal of the American Medical Association (JAMA) estimates that 37 percent of alcohol abusers and 53 percent of drug abusers also have at least one serious mental illness. Conversely, of all those diagnosed with a mental illness, 29 percent abuse either alcohol or drugs.

Patients who present with a need for treatment can suffer from a wide variety of mental health issues. However, there are a few emotional/psychiatric problems that are more likely to be related with drug or alcohol abuse, either as a pre-existing condition, or a condition that was created, or at least exacerbated, by substance abuse. Most modern clinicians have already realized that depression and bipolar disorders are commonly linked with substance abuse. Not only do these adversely affect their patients’ lives, but they also make treatment more complex and critical. Anxiety disorders such as panic disorders and obsessive-compulsive disorders are also frequently seen in dual diagnosis cases. Not surprisingly, drug and alcohol abusers also often have schizophrenia and/or personality disorders to contend with.

It is interesting to note that certain unaddressed emotional and psychiatric problems create a higher likelihood for substance abuse. For example, antisocial personality disorder has a 15.5 percent increased risk for substance abuse, schizophrenia has a 10 percent increased risk and someone who has an obsessive-compulsive disorder has a 3.4 percent higher than average risk of abusing alcohol or drugs (Source: National Institute of Mental Health).

One of the challenges of accurate diagnosis is that substance abuse problems, especially severe ones, can mimic emotional and psychiatric problems. So it is quite natural that during the intake process and the early phases of treatment, symptoms that would indicate the presence of other psychiatric problems are often overlooked or even summarily dismissed. Often the clinicians blame even observable abnormalities as a function of acute withdrawal and simply wait for the symptoms to disappear. This of course is dangerous as this might result in a negative outcome to the treatment experience (i.e. when the facility program fails the patient often fails in the recovery process). Accurate evaluations and assessments are all too often not utilized, and the patient becomes categorized as either suffering primarily from a mental health condition or an addiction. If the conditions are not properly recognized as being dual diagnosis or co-occurring disorders this dramatically impacts the patient’s subsequent quality of care and of course treatment.

The vital elements of treating patients with both an addiction and a mental health condition, such as mood or anxiety disorders, are to acknowledge the strong likelihood that this condition exists and then to have therapists that are educated and trained to make an accurate assessment. Minimally, it is imperative that the psychosocial history is thorough, and the interviewers have the knowledge, training and resources available to obtain a further psychiatric assessment. Often the untrained diagnostician has a copy of a DSM-IV manual and endeavors to make assessments without proper credentials or clinical expertise. This is dangerous.

Again, the initial assessments conducted by the clinical team need to take into account the possibility, and even probability, of dual diagnosis or underlying psychiatric conditions. This is vital for the formulation of a comprehensive and appropriate treatment plan to simultaneously treat these conditions with maximum clinical value. It should also be mentioned that there is an obligation, a duty of care, for a treatment facility to have the skills and resources available to make an accurate diagnosis. If such skills are unavailable, outsourcing for assessment is the next best strategy. All too often, a patient has only one opportunity to get the help and treatment they need to get better. Understandably, this opportunity should not be missed.

Primary treatment for co-occurring disorders is not just an option or adjunct to the recovery process, it is vital. Getting concurrent help for both substance abuse and emotional problems from a qualified multi-disciplinary treatment team can be the only way for some patients to stay sober and get a new lease on life. This of course includes a determination as to whether medication might be necessary in order to improve their symptoms and help normalize their emotional and psychological states. Once an accurate and thorough dual diagnosis assessment has been made, it is critical to develop a thorough and effective treatment plan that will respond to the patient’s needs, and present a long-term strategy to adequately address and resolve these issues. This need is the driving force behind breakthroughs in the field of treatment for dual diagnosis patients. The medical community must close the gap for individuals with dual diagnosis, and recognize that co-occurring disorders must be treated simultaneously. Combining evidence based practice with innovative and experimental methodology is vital for the development of effective interventions that foster both sobriety and psychiatric stability.

Strategies to aggressively treat individuals who are deemed as having dual diagnosis or co-occurring disorders should be implemented in treatment if possible – these issues should not be left for aftercare. Traditional clinical interventions such as individual and group psychotherapy, medication management, symptom management, coping skills training, and family therapy, in conjunction with alternative medicine and complimentary therapies are the methodologies of choice for people with co-occurring disorders.

At DARA we actively redress this gap for clients with co-occurring disorders by utilizing a comprehensive evaluation processes, including extensive psychiatric and psychosocial assessments, which accurately diagnose patients who have co-occurring disorders. Acknowledging that the treatment process needs to be individualized, DARA then uses this information to create and implement an appropriate treatment program to meet these patients’ unique needs and to truly prepare them for a life of recovery. At the end of the day, fostering the belief that each client is a unique individual will help them find balance, sobriety and a heightened quality of life.

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