All Cards on the Table Dual Diagnoses Are Common in Behavioral Health

Sometimes it takes awhile for common sense to become common practice.

Behavioral health care has always been a complex science, with patients often struggling with multiple demons at once. According to a report published in the Journal of the American Medical Association, 37{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of alcohol abusers and 53{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of drug abusers also suffer from at least one form of serious mental illness. Meanwhile, of all people diagnosed as mentally ill, 29{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} are also abusers of alcohol or drugs.

Yet, for generations, common behavioral health practice was to find out which problem occurred first, or which seems dominant, and focus treatment on that. But over the past decade or so, practitioners have developed some new ideas on how to treat dual diagnoses — or, as doctors in the field call them, co-occurring problems.

“It has definitely evolved,” said Dr. Les Smith, chief medical officer at Providence Hospital. “We used to talk about primary versus secondary diagnosis — in other words, which one occurred first — and then determine if we could reduce the likelihood of one by treating the other.” In other words, if a patient struggled with both depression and drug dependency, a doctor might focus squarely on the addiction and hope the depression diminished over time.

“Historically, the way people have dealt with these things depended on their training,” added Baxter Chandler, manager for Outpatient Behavioral Health at Holyoke Medical Center.

“On the substance-abuse side,” he explained, “a lot of people thought that if you take care of the addiction, the depression will clear up. Meanwhile, others, taking a behavioral health perspective, thought that if you take care of the depression symptoms, that will make the addiction go away or at least get better. But sometimes, in the course of care, we’ve seen the disease not being focused on actually get worse.”

This month, The Healthcare News takes a look at dual diagnoses, and why doctors today are no longer pushing potentially serious problems to the side.

Two Sides of the Same Coin

Chandler said that, in the past, doctors and counselors would approach a patient’s problem based on what he or she checked in for. “If they came in reporting depression, we’d focus on that. If it was drug or alcohol abuse, we’d focus on that,” he said. “But studies strongly suggest that we were underdiagnosing people because mental health and addiction issues often go hand in hand.”

Smith said Dr. Kenneth Minkoff, a Boston-based expert in dual diagnoses, has led the charge to approach co-occurring disorders in a different way.

“Individuals with co-occurring psychiatric and substance disorders,” Minkoff recently wrote, “have long been recognized to be ‘system misfits’ in systems of care that have been designed to treat one disorder only or only one disorder at a time.”

“He has been pushing people to focus on treating existing disorders at the same time,” Smith said, “so that, if someone has a mood disorder or a psychiatric disorder and also happens to have a substance abuse history, we should engage in treatment of both issues simultaneously, and not neglect one in favor of the other.”

It has been an important shift in thinking, behavioral health experts say, considering how common dual diagnoses are.

Doctors have long catalogued the most common psychiatric problems that occur in tandem with drug or alcohol abuse. The short list includes depressive disorders, such as depression and bipolar disorder; anxiety disorders, including generalized anxiety disorder, panic disorder, obsessive-compulsive disorder, and phobias; and other psychiatric disorders, such as schizophrenia and personality disorders.

With this list as a guideline, the National Institute of Mental Health (NIMH) recently studied the relationship between substance abuse and seven major psychiatric disorders. It found that people with antisocial disorder have a 16{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} higher-than-normal risk for substance abuse; for those with manic episodes, it’s 15{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}, and for those with schizophrenia, the increased risk is 10{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}. Meanwhile, patients with panic disorders, manic-depressive episodes, obsessive-compulsive disorders, and phobias show an increased risk of substance abuse on a lesser scale, between 2{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} and 4{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}, depending on the disorder.

NIMH has no definitive answer, however, on the question of what typically arises first, substance abuse or a behavioral disorder. For example, some people with emotional problems may drink or use drugs in an attempt to feel calmer, more peppy, or more cheerful, and this ‘self-medication,’ as doctors call it, can lead to physical or psychological dependency on alcohol or drugs. In other cases, alcohol or drug dependency is the primary condition, and a person with a severe substance abuse problem may develop symptoms of a psychiatric disorder — perhaps episodes of depression, fits of rage, hallucinations, or suicide attempts.

Stimulus and Response

One might think that it’s tough to face up to two problems at once, but Chandler said the recent focus on dual diagnoses has actually been a relief to many patients — for instance, someone who had previously sought treatment in a program that treats only addiction.

“I’ve had people say to me, ‘I didn’t tell them how depressed I am, because they don’t treat that, and I might be screened out,’” he said. “Or someone with post-traumatic stress might say, ‘I didn’t tell them how much drinking I’ve done because I know they screen out people who have addiction.’ So in a way, when people know they can bring it all up, and that we’ll work with them as best we can on all these issues at the same time, there’s a good amount of relief.”

At the same time, he noted, “we certainly get some people who come in to deal with depression, an anxiety disorder, or some other mental health issue, and they’re also abusing alcohol or drugs and don’t want to deal with that. But it’s our job to bring it to their attention and go from there.”

Smith said it’s easier to address issues such as depression today, as opposed to decades past, when it still had a stigma associated with it. He recalled from earlier in his career a fellow alcohol-recovery counselor, a war veteran, who was being treated for depression but didn’t want anyone to know about it. “It was still a little taboo,” Smith said, “but you wouldn’t encounter that much anymore. People are more accepting of the fact that people are treated for more than one disorder simultaneously.”

It can be difficult to accurately make a dual diagnosis upon an initial examination, since many symptoms of severe substance abuse mimic other psychiatric conditions. Therefore, doctors will typically oversee a patient’s detoxification from alcohol or drugs before being able to see all the underlying emotional issues. But once that period has passed, behavioral health experts say, both problems can usually be treated simultaneously.

Depending on the program, rehabilitation for substance abuse can involve individual and group psychotherapy, education about alcohol and drugs, and participation in a recovery program such as Alcoholics Anonymous. Meanwhile, treatment for a psychiatric problem depends upon the diagnosis, but individual and group therapy often accompanies medications and other therapies — leaving room for an integrated program to treat co-occurring problems.

“It’s clear that the more diagnoses you have to treat, the more difficult treatment becomes,” Smith said. “But by focusing on just one, we were almost doomed to failure. Now we’re able to manage more complicated patients in an effective way, and be more empathetic and accepting of the idea that two things can happen at once.”

Only by acknowledging this, he said, can real healing begin.