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For more information National Alliance for the Mentally Ill
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By
Nancy Devine An estimated 10 million to 12 million people live with co-occurring mental and addictive disorders nationwide, which means anywhere from 50 percent to 75 percent of those with severe mental illness also have a substance-related problem. These individuals face a daunting array of mental, social and physical problems and, until recently, nonintegrated treatment that did not address their various illnesses. "We first used the term 'dual diagnosis' for the mentally ill, chemically dependent person to convey two independent, interactive illnesses," said Aline Wommack, MS, RN, deputy director of the division of substance abuse and addiction medicine at San Francisco General Hospital. "These clients typically floundered through an addiction or mental illness program, suffering frequent relapses and hospitalizations. For clients in our program, we use the term 'multidiagnosis' because of AIDS and the physical illnesses accompanying addiction. But it wasn't until the mid-'90s that we saw research documenting improved results from integrated treatment programs." The prevalence studies that revealed the estimated 10 million to 12 million dual diagnosis clients were conducted by professor Ronald Kessler, Ph.D., professor of health care policy at Harvard Medical School. His work, and that of Robert Drake, MD, Ph.D., professor of psychiatry at Dartmouth Medical Center and director of the New Hampshire-Dartmouth Psychiatric Research Center, are frequently cited by the National Alliance for the Mentally Ill (NAMI), a nonprofit grassroots, self-help, support and advocacy organization. NAMI is a strong supporter of integrated treatment programs for dual diagnosis individuals. To complicate the picture, someone with a severe mental disorder has a higher chance of developing an addictive disorder. For individuals with a diagnosis of schizophrenia, 47 percent also have a substance-related disorder, according to findings by the National Comorbidity Survey. For those diagnosed with a bipolar disorder, 60.7 percent have a substance abuse disorder. Many mentally ill people use alcohol or other substances for relief from their symptoms and become addicted. The resulting combination of disorders exacerbates symptoms and complicates diagnosis. "The impact of mental illness symptoms can prevent these clients from maintaining housing or family relationships or holding down a job, and they may have poor judgment, impairing their ability to recover toward a chemically free lifestyle," said Diane Snow, Ph.D., NP, RN, director of the psychiatric mental health nurse practitioner program at the University of Texas at Arlington School of Nursing. "Nurses must learn these are acute and chronic brain disorders, and to use an illness model rather than a moralistic one." According to Snow, dual diagnosis individuals traditionally have been and continue to be treated sequentially-one problem first, then the other-or in a parallel fashion, using two separate programs at once. As NAMI and other psychiatrists point out, however, traditional addiction programs tend to be confrontational and many individuals who suffer severe mental illness are too fragile to benefit from them. Standard addiction programs also require abstinence from all chemicals, including medications, yet someone with a severe mental illness needs medication to remain stable. The conflicting philosophies ultimately undermine recovery. Integrated treatment was developed to resolve these conflicts. "We have 10 years of evidence-based research from the National Institute on Drug Abuse demonstrating that dual disorder patients can be successfully rehabilitated from substance abuse disorders, and that integrated treatments are superior to nonintegrated treatments," said Clarke Ross, DPA, NAMI's deputy executive director for public policy. "Integrated programs are administered at a single location, ideally by staff cross-trained in both mental health and addiction treatment practices." Studies from the New Hampshire-Dartmouth Psychiatric Research Center show that patients from integrated programs had higher abstinence and employment rates and greater freedom from psychiatric disorders than nonintegrated program patients. A dual diagnosis client must be seen and re-evaluated regularly. "We must continually diagnose, knowing it takes from nine to 24 months for the brain to heal after heavy drug or alcohol use," said Max Schneider, MD, professor at the University of California, Irvine College of Medicine. "Integrated programs help the individual adapt to the absence of the chemicals, unlearn the old behavior, and learn new behavior that is positive." Treatment typically includes:
"Psychiatrists work on the team with the case manager, making sure the person is on the lowest medication for the highest functioning," said Rick Crispino, executive director of Bonita House, which has a dual diagnosis residential unit and supported independent living case management in Oakland. "Clients work on mental health and chemical dependency simultaneously, emphasizing incremental successes and individual strengths." "I have seen more successes with harm reduction and a social rehabilitation philosophy than with the old abstinence model," said James Jones, MD, psychiatrist and medical director of Baker Places Inc., a San Francisco nonprofit organization that has residential dual and multidiagnosis treatment programs. "We form a therapeutic alliance with each client to help them engage in treatment. Once they do, there's hope." |
