|
Many individuals with chronic mental disorders such as bipolar illness, recurrent major depression, dysthymia, borderline personality or schizophrenia and other psychotic disorders also have substance-use disorders ("dual disorders"). Some have recurrent psychiatric disorders with occasional episodes and little or no residual disability and are able to function well during periods of remission. However, those with chronic mental disorders experience repeated episodes of psychiatric illness with significant residual disability. Or, they experience persistent symptoms that are almost always present and may wax and wane periodically.
While alcohol, cocaine and cannabis are the most common substances of abuse for these patients, many abuse multiple substances. The addition of a substance use disorder complicates recovery from chronic mental illness, creates a burden for the family and often causes frustration among caregivers that have to manage the clinical and psychosocial crises commonly encountered with these disorders. Such patients are at high risk for poor adherence to medications, psychotherapeutic treatments, self-help groups, which increase vulnerability to suicidality, psychiatric and/or substance use relapse and subsequent hospitalization. They have the most difficult course of recovery, and some are more prone to adverse effects of substances. For example, symptoms of a psychotic disorder can sometimes be exacerbated by even small amounts of a substance.
Dual Disorders: A View from the Inside Out
One of the best ways to fully understand dual disorders is to look at the experience from the inside out in order to gain insight on what it is like for the patient as well as the family. Since many mental and substance use disorders are chronic conditions, the adverse effects on the patient and family are many and far-reaching. Senator George McGovern wrote a deeply personal and eloquent book about one of his daughters entitled Terry. Terry, a mother of two daughters, was a chronic alcoholic with severe depression who tragically froze to death after getting drunk and passing out in the snow at the age of 45. Senator McGovern said of her disorders, "Terry was dealt a double cruel hand: the companion demons depression and alcoholism." In a letter to her mother several weeks before her death, Terry spoke about her struggles with relapse and her desire "to be a daughter to you and dad - not a source of worry, anger and sorrow."
A patient who relapsed to addiction and mania following ten years of sobriety said, "After my mania got out of control, I decided to move to the basement of my house away from my wife of 25 years. I told her not to bother me and to ensure privacy; I removed the steps from the kitchen to the basement. At the time, I didn't think this was bizarre at all. My family had to ... commit me for psychiatric care because I refused help, insisting I was fine." Another patient with schizophrenia and addiction worked hard to manage her dual disorders and did fairly well for a considerable period of time. She said, "Following a few days of smoking marijuana, I became psychotic, stopped taking my medications and got real sick again. ... My parents took me to the hospital where I got back on track." What all these cases have in common is that both patients and families were affected in numerous ways.
A Challenge for Clinicians and Researchers
The challenge for mental health clinicians is to become competent in addressing substance use disorders in order to know when to refer to substance abuse services or when to provide integrated care to those suffering from dual disorders who seek care in a mental health treatment system. Treatment in two separate systems is often difficult and cumbersome for the dual-disordered patient who is usually best treated in the same facility or program. However, there will be times in which treatment in separate systems may be necessary. For example, we sometimes refer psychiatric patients to substance abuse rehabilitation programs, which are able to provide addiction treatment while being sensitive to psychiatric recovery issues.
While there is increasing research and clinical literature on chronic mental disorders and co-occurring substance use disorders, insufficient attention is paid to the substance-related disorders. For example, the recent edition of a major comprehensive textbook on psychiatry included over 230 pages of text on schizophrenia and over 1000
sub-topics of schizophrenia in the index. However, the index listed fewer than a dozen references on substance-use disorders and schizophrenia, and the text included just a few pages on it. Given the high rates of substance-abuse
co-morbidity among patients with schizophrenia (47 percent), this seems inadequate and is representative of an attitude that must be changed.
The challenge for researchers is to develop, test and identify empirically based treatments that are most effective for dual-disordered patients.
Integrated Treatment for Dual Disorders
Integrated treatment can be provided in specialized
dual-diagnosis inpatient, partial hospital or outpatient programs or within the context of the current treatment plan by a mental health or substance abuse professional or team. Treatment interventions include providing education and support, encouraging self-disclosure of substance use and related behaviors, motivating the patient to engage in treatment and recovery, facilitating transition from one level of care to another, facilitating treatment adherence, engaging the patient's family or significant others, helping the patient understand the relationships between the various disorders, linking the patient with self-help programs and teaching recovery skills. Of course, the effectiveness of the caregiver is dependent on his/her ability to develop a therapeutic alliance with the patient. Negative attitudes and perceptions of substance abusers will impede progress while empathy; understanding and optimism about the patient's ability to change will enhance progress and the professional's ability to "connect" with the patient.
Studies conducted by numerous investigators show that integrated treatment is effective in improving psychiatric and substance use outcomes. Most studies involve a combination of pharmacotherapy and psychosocial treatment. Both individual and group therapies have been or are currently being used in these various studies.
The Impact on the Family and Children
While not all families or members within a family are affected in the same way by exposure to dual disorders, the burden is often great. The actual effects are mediated by the severity of the disorders, support systems available to the family member and personal factors. Clinicians should be accessible, sensitive to the concerns and issues of family members and should view the families as allies, guarding against labeling family members as codependent or dysfunctional. There will be some instances, however, in which family members may hinder recovery of the
dual-disordered member.
I conducted a survey with over 100 dual-diagnosis patients in my clinic and asked them to rate and describe the adverse effects of their disorders on their family. On average, they rated the negative effects of both disorders as "severe" and identified the following specific problems: emotional burden on the family through worry, anger, fear or distrust (91 percent), neglect of their families (84 percent), irresponsibility of patient (74 percent), verbal abuse (70 percent), financial problems (64 percent), physical abuse (45 percent), childcare problems (37 percent) and arrest for domestic violence (27 percent). The written responses of patients indicated that they were quite aware of their behaviors and how these affected their families in a multiplicity of negative ways. These responses also showed the guilt and shame they felt. One patient said, "I've had depression for years but always managed to take care of my kids. But when I started using crack cocaine, I went downhill real fast. ... I got reported to Children and Youth Services after getting arrested and ended up losing my kids to a foster home."
Families often provide poignant descriptions of their experiences as well. A husband of a dual-diagnosis patient said, "I'm so damn tired. For years I was a nervous wreck because I always worried about my wife. When she was depressed I tried to lift her up. When she was getting high, I tried to make her want to stop using. ... I got real angry because she wasted so much money on drugs. We were always behind on bills and deep in debt. Plus, it took away from our kids." An eleven-year-old girl, when asked to describe the worst thing that happened to her as a result of her mother's problems stated, "Mom hit me, she punched me, she slapped me, but the very worst thing was she died."
Clinicians can help patients by engaging them in discussions of the impact of their disorders on their family, facilitating family involvement in their treatment, encouraging them to talk with their family regarding their disorders and recovery plan and introducing them to use the making amends steps of the twelve-step program of AA or NA. Clinicians can help families by providing education on dual disorders, exploring their concerns, questions and experiences and linking them with self-help groups. Administrators can help families by ensuring that their clinicians develop a philosophy of treatment including the family perspective and offering family services.
Research Initiatives
Our research group has conducted numerous clinic surveys and empirical studies during the past ten years. A brief review of some of this work follows:
- We compared inpatient service utilization and
aftercare adherence between psychiatric patients with (P+)
and without (P-) a concurrent substance use disorder. We
found that P+ patients had more current DSM-IV
diagnoses, twice as many psychiatric hospitalizations
and days in the hospital, significantly lower aftercare
treatment entry and attendance rates, higher aftercare
dropout rates and higher re-hospitalizations at one-
year follow-up.
- A single Adherence Therapy session with an
outpatient clinician prior to the patient's discharge
from the hospital almost doubles the adherence rates
with the initial aftercare session.
- Four sessions of Motivational Therapy provided during
the first month of outpatient care to discharged
inpatients led to improved adherence and completion
rates, clinical outcomes and lower rehospitalization
rates.
- Combining naltrexone (Revia) with antidepressants
for depressed alcoholics reduces alcohol consumption.
- Dual-diagnosis patients who were diagnosed with both
alcohol and cocaine dependence show high rates of
suicidal and homicidal ideation and behavior.
- Almost one-third of dual-diagnosis patients show high
rates of social anxiety and avoidant behavior, which
often interfere with their ability to participate in group
therapy and self-help programs.
Recovery Skills for Dual Disorders
"Recovery" is a term that refers to the process of teaching patients to manage their disorders and abstain from substances or reduce their harmful substance use. While abstinence is the ideal goal, caregivers must come to appreciate small steps that patients make, particularly since many do not initially embrace sobriety or abstinence as a desired goal. Patients must accept their disorders and learn (and sometimes relearn) how to manage their illnesses through the acquisition of recovery skills. Some of the more common recovery skills include learning to:
- overcome periods of low
motivation
- manage desires to drink
alcohol or ingest drugs
- monitor major symptoms
of psychiatric illness
- reduce negative and
improve positive thinking
- deal with high-risk people, places and events
- improve ability to communicate (to doctors, clinicians,
family, friends)
- deal with pressures to stop taking psychotropic
medications
- refuse offers of drugs or alcohol
- structure time and reduce boredom
- manage distress and upsetting feelings (anger, anxiety,
depression, guilt)
- develop a recovery support system and utilize
self-help groups
- manage persistent symptoms of illness
- identify and manage relapse warning signs for
psychiatric and substance-use disorders
- anticipate and deal with setbacks
Final Thoughts
Substance use disorders are so common among patients with chronic mental disorders that clinicians must understand how to assess and treat both disorders and know when to refer the patient to another treatment program. Without treatment that focuses on both disorders, patients will not get the optimum benefit from treatment. There is much evidence that dual-diagnosis patients have more symptoms, diagnoses and problems than those with single disorders do and are more prone to poor adherence with treatment. There is also evidence that providing integrated treatment with a dual focus does lead to greater clinical improvement.
Dennis C. Daley is Associate Professor of Psychiatry, Chief of Drug and Alcohol Services and Director of the Center for Psychiatric and Chemical Dependency Services at Western Psychiatric Institute and Clinic (WPIC) of the University of Pittsburgh Medical Center in Pittsburgh, PA. He is a Principal and Co-Principal Investigator on several research studies sponsored by the National Institute on Drug Abuse and National Institute on Alcohol Abuse and Alcoholism related to treatment of individuals with substance-use disorders and mood disorders. Dr. Daley is a consultant to two federally funded research projects at Harvard Medical School and Spalding University. In addition, he has consulted with numerous treatment programs in the U.S. and Europe, presenting workshops and lectures in over 30 States, Canada and Europe. Dr. Daley is Co-Director of the Education Core for the Veteran Administration's Mental Illness Research, Education and Clinical Care project.
Dr. Daley developed several dual-disorder treatment programs and has been involved in providing services to patients and families, program development and management for over twenty years. He has over 200 publications including books, recovery guides, journal articles and educational films on dual disorders, relapse prevention and recovery from chemical dependency. He has also written over thirty educational videos for patients and families. His practical recovery materials are used in many treatment programs in the U.S. and other countries, and several of his books have been translated to foreign languages. You may contact Dr. Daley by calling 412/ 383-2710 or e-mail at: Daleydc@msx.upmc.edu
References
Daley, D.C., Moss, H.B. & Campbell, F. Dual Disorders: Counseling Clients with Chemical Dependency and Mental Illness. 2nd Ed. Center City, MN: Hazelden, (1993).
Daley, D.C. & Thase, M.E. Dual Disorders Recovery Counseling: Integrated Treatment for Substance Use and Mental Health Disorders. 2nd Ed. Independence, MO: Independence Press, (2000).
Daley, D.C. Dual Diagnosis Workbook: Recovery Strategies for Substance Use and Mental Health Problems. 2nd Ed. Independence, MO: Independence Press, (2000).
Daley, D.C. & Zuckoff, A. Improving Treatment Compliance: Counseling & Systems Strategies for Substance Abuse & Dual Disorders. Center City, MN: Hazelden, (1999).
Montrose, K.A. & Daley, D.C. Celebrating Small Victories: A Primer of Approaches for Helping Clients with Dual Disorders. Center City, MN: Hazelden, (1995).
Ryglewicz, H. & Pepper, B. Lives at risk: Understanding and Treating Young People with Dual Disorders. NY: The Free Press, (1996).
|
