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 and ing of a (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 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 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 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 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 , , is limited to careful clinical assessment18 depression, mania, and, in the case of possible dual disor- and 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 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- • 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- toms preceded the onset of substance use, pharmacotherapy.25 and whether they persisted in the setting of When assessing for dual disorders, extended , 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 associated with addiction) associated nostic uncertainty about a dual disorder, with having a dual disorder as opposed to the work-up should include a trial of pro- having “just” a SUD. As a result, for some spective observation, with completion of patients, obtaining a non-SUD diagnosis can appropriate detoxification, through- be highly incentivized.22,23 Clinicians must out a 1-month period of sobriety and in therefore be savvy about the high potential the absence of psychiatric medications, for malingering, embellishment, and misla- to determine if there are persistent symp- beling of symptoms when conducting diag- toms that would justify a dual diagnosis. nostic interviews. For example, in assessing In research settings, such observations for psychosis, the frequent endorsement have revealed that most of depressive of “hearing voices” in patients with SUDs symptoms among alcoholics who present often results in a diagnosis of schizophrenia for treatment resolve after or unspecified psychotic disorder,22 despite a month of abstinence.27 A similar time Current Psychiatry the fact that this symptom can occur during course for resolution has been noted for Vol. 17, No. 9 27 Table 3 disorders is lacking. In addition, medica- Tips for clarifying the presence tions for both CODs often remain inacces- of dual disorders sible to patients with dual disorders for 3 reasons: Determine the sequential onset of SUDs • SUDs negatively impact medication and other mental disorders as well as the adherence among patients with dual dis- persistence of symptoms during previous periods of sobriety through: orders, who sometimes point out that “it Dual diagnosis • open-ended interviewing says right here on the bottle not to take this patients • thorough chart review medication with drugs or alcohol!” • collateral history • Some self-help groups still espouse blanket opposition of any “psychotropic” Monitor symptoms during prospective trials of sobriety while deferring pharmacotherapy medications, even when clearly indicated (eg, antidepressants, , mood for patients with COD. Groups that rec- stabilizers) pending diagnostic clarity and ognize the importance of pharmacother- completion of acute withdrawal apy, such as Dual Diagnosis Anonymous SUDs: substance use disorders (DDA), have emerged, but are not yet Clinical Point widely available.30 Although the • Although there are increasing options for FDA-approved medications for SUDs, ‘self-medication’ anxiety, distress, fatigue, and depressive they are limited to the treatment of alco- hypothesis is often symptoms among individuals with cocaine hol, , and use disorders31; invoked, this theory dependence.28 These findings support the are often restricted due to hospital and has not been well guideline established in DSM-IV that symp- health insurance formularies32; and remain toms persisting beyond a month of sobriety underprescribed for patients with dual supported in studies “should be considered to be manifestations disorders.11 of an independent, non-substance-induced Although underutilization of pharma- ,”29 while symptoms cotherapy is a pitfall to be avoided in the occurring within that month may well be treatment of patients with dual disorders, substance-induced. Unfortunately, in real- medication overutilization can be just as world clinical practice, and particularly in problematic. Patients with dual disorders outpatient settings, it can be quite difficult are sometimes singularly focused on resolv- to achieve the requisite period of sobriety ing acute anxiety, depression, or psychosis at for reliable diagnosis, and patients are often the expense of working towards sobriety.33 prematurely prescribed medications (eg, Although the “self-medication hypothesis” an antidepressant, antipsychotic, or mood is frequently invoked by patients and cli- stabilizer) that can confound the cause of nicians alike to suggest that substance use symptomatic resolution. Such prescriptions occurs in the service of “treating” underly- are driven by compelling pressures from ing disorders,34 this theory has not been well patients to relieve their acute suffering, as supported in studies.35-37 Some patients may well as the predilection of some clinicians pledge dedication to abstinence, but still to give patients “the benefit of doubt” in pressure physicians for a pharmacologic assessing for dual diagnoses. However, solution to their suffering. With expand- whether an inappropriate diagnosis or a ing legalization of for both rec- prescription for an unnecessary medication reational and medical purposes, patients represents a benefit is debatable at best. are increasingly seeking doctors’ recom- mendations for “medical marijuana” for a Pharmacotherapy wide range of complaints, despite the fact A third real-world challenge in managing that data supporting a therapeutic role for patients with dual disorders involves opti- cannabis in the treatment of mental illness mizing pharmacotherapy. Unfortunately, is sparse,38 whereas the potential harm in because patients with SUDs often are terms of either causing or worsening psy- excluded from clinical trials, evidence- chosis is well established.39,40 Clinicians must Current Psychiatry 28 September 2018 based guidance for patients with dual be knowledgeable about the abuse potential of prescribed medications, ranging from sleep aids, analgesics, and muscle relaxants Related Resources to antidepressants and antipsychotics, while • Substance Abuse and Mental Health Services Administration. Co-occurring disorders. https://www.samhsa.gov/disorders/ MDedge.com/psychiatry also being mindful of the psychological co-occurring. meaningfulness of seeking, prescribing, and • National Alliance on Mental Illness. Dual diagnosis. https:// not prescribing medications.41 www.nami.org/Learn-More/Mental-Health-Conditions/ Related-Conditions/Dual-Diagnosis. Although the simultaneous treatment of • Foundations Recovery Network. Dual diagnosis support groups. patients with dual disorders that includes http://www.dualdiagnosis.org/resource/ddrn/self-help- pharmacotherapy for both SUDs and CODs support-groups/support-groups. • Substance Abuse and Mental Health Services is vital for optimizing clinical outcomes, Administration. Integrated treatment for co-occurring clinicians should strive for diagnostic accu- disorders evidence-based practices (EBP) KIT. https:// store.samhsa.gov/product/Integrated-Treatment-for-Co- racy and use medications judiciously. In Occurring-Disorders-Evidence-Based-Practices-EBP-KIT/ addition, although pharmacotherapy often SMA08-4367. is necessary to deliver evidence-based treat- • Substance Abuse and Mental Health Services Administration. Substance abuse treatment for persons with co-occurring ment for patients with dual disorders, it is disorders. https://store.samhsa.gov/shin/content/SMA13- inadequate as standalone treatment and 3992/SMA13-3992.pdf. should be administered along with psycho- Clinical Point social interventions within an integrated, Be knowledgeable multidisciplinary treatment setting. clients admitted to substance use treatment programs in a U.S. national sample. Drug Alcohol Depend. 2017;175: about the abuse 157-163. potential of 5. Brunette MF, Muesner KT. Psychosocial interventions for The keys to optimal outcomes the long-term management of patients with severe mental all prescribed illness and co-occurring substance use disorder. J Clin The treatment of patients with dual disor- Psychiatry. 2006;67(suppl 7):10-17. medications ders can be challenging, to say the least. 6. Tiet QQ, Mausbach B. Treatments for patients with dual diagnosis: a review. Alcohol Clin Exp Res. 2007;31(4): Ideal, evidence-based therapy in the form 513-536. of an IDDT program can be difficult for 7. Kelly TM, Daley DC, Douaihy AB. Treatment of substance abusing patients with comorbid psychiatric disorders. clinicians to implement and for patients to Addict Behav. 2012;37(1):11-24. access. Best efforts to perform meticulous 8. Tsuang JT, Ho AP, Eckman TA, et al. Dual diagnosis treatment for patients with schizophrenia who are substance clinical assessment to clarify diagnoses, use dependent. Psychatr Serv. 1997;48(7):887-889. pharmacotherapy judiciously, work col- 9. Rosen MI, Rosenheck RA, Shaner A, et al. Veterans who may need a payee to prevent misuse of funds for drugs. Psychiatr laboratively in a multidisciplinary setting, Serv. 2002;53(8):995-1000. and optimize treatment given available 10. Substance Abuse and Mental Health Services Administration. Key substance use and mental health resources are keys to clinical success. indicators in the United States: results from the 2016 National Survey on Drug Use and Health. HHS Publication No. SMA 17-5044, NSDUH Series H-52. References Rockville, MD: Center for Behavioral Health Statistics 1. Regier DA, Farmer ME, Rae DS, et al. Comorbidity of mental and Quality, Substance Abuse and Mental Health disorders with alcohol and other drug abuse. Results from Services Administration. https://www.samhsa.gov/ the epidemiologic catchment area (ECA) study. JAMA. data/sites/default/files/NSDUH-FFR1-2016/NSDUH- 1990;264(19):2511-2518. FFR1-2016.pdf. Published September 2017. Accessed 2. Drake RE, Mercer-McFadden C, Muesner KT, et al. August 7, 2018. Review of integrated mental health and substance abuse 11. Rubinsky AD, Chen C, Batki SL, et al. Comparative treatment for patients with dual disorders. Schizophr Bull. utilization of pharmacotherapy for alcohol use disorder 1998;24(4):589-608. and other psychiatric disorders among U.S. Veterans Health 3. Horsfall J, Cleary M, Hunt GE, et al. Psychosocial Administration patients with dual diagnoses. J Psychiatr treatments for people with co-occurring severe mental Res. 2015;69:150-157. illness and substance use disorders (dual diagnosis): 12. McGovern MP, Lambert-Harris C, McHugo GJ, et al. a review of empiric evidence. Harv Rev Psychiatry. Improving the dual diagnosis capability of addiction and 2009;17(1):24-34. mental health treatment services: implementation factors 4. Krawczyk N, Feder KA, Saloner B, et al. The association of associated with program level changes. J Dual Diag. psychiatric comorbidity with treatment completion among 2010;6:237-250. continued on page 44 Bottom Line Ideal treatment of patients with dual disorders consists of simultaneous, integrated interventions delivered by a multidisciplinary team. 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