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Real-World Challenges Real-worldReal-world challengeschallenges Real-world challenges inin managingmanaging ‘dual‘dual diagnosis’diagnosis’ patientspatients Diligent assessment and judicious prescribing can help optimize outcomes Joseph M. Pierre, MD Health Sciences Clinical Professor he term “dual diagnosis” describes the clinically challeng- Department of Psychiatry and ing comorbidity of a substance use disorder (SUD) along Biobehavioral Sciences with another major mental illness. Based on data from the David Geffen School of Medicine at University of T California, Los Angeles Epidemiologic Catchment Area study, the lifetime prevalence of SUDs Los Angeles, California among patients with mental illness is approximately 30%, and is higher Disclosure among patients with certain mental disorders, such as schizophrenia The author reports no financial relationships with any (47%), bipolar disorder (61%), and antisocial personality disorder (84%).1 company whose products are mentioned in this article, or with manufacturers of competing products. These statistics highlight that addiction is often the rule rather than the exception among those with severe mental illness.1 Not surprisingly, the combined effects of having an SUD along with another mental illness are uniformly negative (Table 1,2-4 page 26). Based on outcomes research, the core tenets of evidence-based dual- diagnosis treatment include the importance of integrated (rather than parallel) and simultaneous (rather than sequential) care, which means an ideal treatment program includes a unified, multidisciplinary team whose coordinated efforts focus on treating both disorders concur- rently.2 Evidence-based psychotherapies for addiction, including moti- vational interviewing, cognitive-behavioral therapy, relapse prevention, contingency management, skills training, and/or case management, are a necessity,3,5 and must be balanced with rational and appropriate pharmacotherapy targeting both the SUD as well as the other disorder (Table 2,2,3,5-9 page 27). 3 ‘Real-world’ clinical challenges Ideal vs real-world treatment Treating patients with co-occurring disorders (CODs) within integrated dual-disorder treatment (IDDT) programs sounds straightforward. However, implementing evidence-based “best practice” treatment is a significant challenge in the real world for several reasons. First, indi- viduals with CODs often struggle with poor insight, low motivation to change, and lack of access to health care. According to the Substance Current Psychiatry BRIAN STAUFFER Vol. 17, No. 9 25 Table 1 become dual diagnosis–capable is pos- Combined effects of comorbid sible, but it is a time-consuming and costly substance use disorders with endeavor that, once achieved, requires con- tinuous staff training and programmatic another mental illness adaptations to interruptions in funding.13-16 Greater symptomatic morbidity With myriad barriers to the establishment Decreased motivation to change and maintenance of IDDTs, many patients Dual diagnosis Decreased completion of treatment with dual disorders are left without access to the most effective and comprehensive patients Increased relapse and rehospitalization care; as few as 4% of individuals with CODs Increased violence and suicide are treated within integrated programs.17 Greater rates of incarceration Increased homelessness Diagnostic dilemmas Increased unemployment Establishing whether or not a patient with Greater risk of human immunodeficiency virus an active SUD has another serious mental infection illness (SMI) is a crucial first step for opti- Clinical Point More family problems mizing treatment, but diagnostic reliability can prove challenging and requires careful Both SUDs and other Increased cost of health care clinical assessment (Table 3, page 28). As Source: References 2-4 disorders can result always in psychiatry, accurate diagnosis in insomnia, anxiety, is limited to careful clinical assessment18 depression, mania, and, in the case of possible dual disor- and psychosis Abuse and Mental Health Services ders, is complicated by the fact that both Administration (SAMHSA), 52% of indi- SUDs as well as non-SUDs can result in the viduals with CODs in the U.S. received no same psychiatric symptoms (eg, insomnia, treatment at all in 2016.10 For patients with anxiety, depression, manic behaviors, and dual disorders who do seek care, most are psychosis). Clinicians must therefore distin- not given access to specialty SUD treat- guish between: ment10 and may instead find themselves • Symptoms of substance intoxication treated by psychiatrists with limited SUD or withdrawal vs independent symptoms training who fail to provide evidence- of an underlying psychiatric disorder (that based psychotherapies and underutilize persist beyond a month after cessation of pharmacotherapies for SUDs.11 In the set- intoxication or withdrawal) ting of CODs, the “harm reduction model” • Subclinical symptoms vs threshold can be conflated with therapeutic nihilism, mental illness, keeping in mind that some resulting in the neglect of SUD issues, with mood and anxiety states can be normal clinicians expecting patients to seek SUD given social situations and stressors (eg, treatment on their own, through self-help turmoil in relationships, employment dif- groups such as Alcoholics Anonymous or ficulties, homelessness, etc.) in other community treatment programs • Any mental illness (AMI) vs SMI. The staffed by nonprofessionals that often are latter is defined by SAMHSA as AMI that not tailored to the unique needs of patients substantially interferes with or limits ≥1 with dual disorders. Psychiatrists working major life activities.10 with other mental health professionals who With these distinctions in mind, data provide psychotherapy for SUDs often do from the 2016 National Survey on Drug Use Discuss this article at so in parallel rather than in an evidence- and Health indicate that dual-diagnosis www.facebook.com/ based, integrated fashion. comorbidity was higher when the thres- MDedgePsychiatry IDDT programs are not widely avail- hold for mental illness was lower—among able. One study found that fewer than 20% the 19 million adults in the U.S. with SUDs, of addiction treatment programs and fewer the past-year prevalence was 43% for AMI than 10% of mental health programs in the and 14% for SMI.10 Looking at substance- U.S. met criteria for dual diagnosis–capable induced disorders vs “independent” disor- Current Psychiatry 26 September 2018 services.12 Getting treatment programs to ders, the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions Table 2 found that for individuals with SUDs, the Key components of dual- past-year prevalence of an independent diagnosis treatment programs mood or anxiety disorder was 35% and 26%, MDedge.com/psychiatry respectively.19 Taken together, these find- Simultaneous treatment of both disorders ings illustrate the substantial rate of dual- Integrated treatment of both disorders by a diagnosis comorbidity, the diagnostic het- multidisciplinary team 20 erogeneity and range of severity of CODs, Evidence-based psychosocial interventions: and the potential for both false negatives • Case management (eg, diagnosing a substance-induced syn- • Social skills training drome when in fact a patient has an underly- • Motivational interviewing ing disorder) and false positives (diagnosing • Cognitive-behavioral therapy a full-blown mental illness when symptoms • Assertive community treatment are subclinical or substance-induced) when • Contingency management performing diagnostic assessments in the • Money management/representative payees setting of known SUDs. False positives are more likely when Evidence-based pharmacotherapy Clinical Point patients seeking treatment for non-SUDs Routine/random urine toxicology screening Because receiving don’t disclose active drug use, even when Source: References 2,3,5-9 asked. Both patients and their treating cli- a dual diagnosis nicians may also be prone to underestimat- often is linked to ing the significant potential for morbidity secondary gains, associated with SUDs, such that substance- substance intoxication and withdrawal, is be savvy about the induced symptoms may be misattributed to well documented among people without high potential for a dual disorder. Diagnostic questioning and mental illness as well as those with non- thorough chart review that includes careful psychotic disorders,24 and can resolve with- malingering assessment of whether psychiatric symp- out medications or with non-antipsychotic toms preceded the onset of substance use, pharmacotherapy.25 and whether they persisted in the setting of When assessing for dual disorders, extended sobriety, is therefore paramount diagnostic false positives and false nega- for minimizing false positives when assess- tives can both contribute to inappropri- ing for dual diagnoses.18,21 Likewise, random ate treatment and unrealistic expectations urine toxicology testing can be invaluable in for recovery, and therefore underscore the verifying claims regarding sobriety. importance of careful diagnostic assess- Another factor that can complicate diag- ment. Even with diligent assessment, how- nosis is that there are often considerable ever, diagnostic clarity can prove elusive secondary gains (eg, disability income, hos- due to inadequate sobriety, inconsistent pitalization, housing, access to prescription reporting, and poor memory.26 Therefore, medications, and mitigation of the blame and for patients with known SUDs but diag- stigma
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