Assessment and Treatment of Patients with Co-Occurring Psychiatric and Substance Abuse Disorders

Annelle B. Primm, M.D., MPH, Director – Community Services, Johns Hopkins Medicine

Recent epidemiologic surveys show that more than 10 million Americans have co-existing substance-related and mental health disorders (SAMHSA Report, 1996). Several researchers pointed out that patients with comorbidity have poorer outcomes than those with single diagnoses, such as increasing psychiatric symptoms, homelessness, higher risk for relapse, institutionalization, worse compliance, difficulties in managing their lives (Drake and Wallach, 1989), lower satisfaction with familial relationships (Dixon et al., 1995), and increasing rehospitalization rates (Leon et al., 1998; Gupta et al., 1996; Stanislav et al., 1992), and greater risk for mortality (Felkcr et al., 1996).

Upon recognizing the existence of patients with co-occurring psychiatric and substance use disorders, the treatment of these individuals became a great challenge for professionals. An additional challenge has been the poor fit between dually diagnosed patients and the traditional treatment system. In the traditional treatment system, the earliest model of treatment is the serial model, in which the clients are treated only for one type of disorder at a time. Once one type of disorder is under control, the patients are referred to another agency for treatment of the co-occurring disorder. Another traditional approach is separate, parallel treatment, where two agencies work with the clinicians at the same time, each treating one type of disorder in a parallel fashion. Many clinicians working within this model have difficulty coordinating treatment and understanding comorbidity. In addition, the clients often become lost between the two systems. In an effort to solve these problems, addiction treatment and psychiatric programs have developed a variety of mechanisms and moved toward integrated treatment services. Integrated treatment programs serve people with severe mental illness and substance abuse and treat both types of disorders simultaneously at one site. The effectiveness of integrated treatment programs has been discussed in several studies (Ahrens, 1998; Bachrnann eta!, 1997; Bebout et al, 1997; Drake et al, 1997; Drake et a!, 1998; Hoffman, 1993). The authors have reported some reduction of substance abuse, psychopathology, and time spent hospitalized; improvement in treatment, functional status, quality of life, housing stability, and awareness of the disorders; progress in recovery, medication compliance and linking with self-help groups; and greater satisfaction and remission.

In recent years, there has been an improvement in knowledge about treatment of dually diagnosed patients, but barriers still exist for effective services delivery. Grella and Hser (1997) assessed mental health service delivery in drug treatment programs in Los Angeles County and found that the majority of addiction programs had restrictions on admission of dually diagnosed clients and nearly half did not serve patients with comorbidity. In traditional addiction programs, the confrontational approach, restriction of use of medications, and use of former clients as counselors (Rohrer and Schonfeld, 1990) do not fully meet the needs of dually diagnosed patients.

In addition to a lack of appropriate integrated treatment programs there are other problematic issues with respect to the treatment of dually diagnosed patients. For example, professionals often miss the second diagnosis. In fact, some of the patients who present with psychiatric illness in mental health settings are not diagnosed as having substance use disorder by psychiatrists (Breakey et al., 1998; Lin et al., 1998), and patients who present with substance use disorders and attend traditional addiction treatment programs, often do not get diagnosed or treated for their psychiatric problems. Lehman and colleagues (1995) reported that dually diagnosed persons with independent mental disorders were more likely to be referred for mental health treatment and less likely to receive substance abuse treatment and follow-up.

In order to improve outcomes of dually diagnosed patients, adequate assessment and treatment have to be provided. The appropriate assessment gives information about, 1) severity of psychiatric and substance use disorders, 2) conditions, associated with occurrence and maintenance of these disorders, 3) psychosocial needs and problems, including cultural issues, 4) treatment motivation, and, 5) areas for treatment intervention. The treatment goals are based on the severity of the symptoms and the leading needs. Recent guidelines for treatment of dually diagnosed patients suggested improvement in three areas: assessment (Table 1), level of coordination, and location of care (Table 2).

Assessment of dually diagnosed patients is based on a detailed history of psychiatric and substance abuse symptoms. Important information on psychiatric status includes: chief complaint/presenting symptoms, family history, personal history, medical history, psychiatric history, history of present illness, and mental status exam. Important information on substance abuse includes: types of drugs, age of onset, amount now, maximum amount, frequency, route, last used, maximum clean time, number of detoxes, history of DT’s and withdrawal. It is useful to place the results of the evaluation in one of the following categories:

Table 1:


Low-Low Category 2

Low-High Category 3

High-Low Category 4


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