Dual Diagnosis: Dilemmas in Assessment and What’s New in the Revised ASAM Patient Placement Criteria

David Mee-Lee, M.D., Assistant Clinical Professor, University of California at Davis School of Medicine, Department of Psychiatry

Dilemmas and disagreements about the assessment of persons with dual psychiatric and substance-related disorders frequently revolve around whether to approach the person as suffering from an addiction disorder or a mental health disorder or both. The challenge is to be guided by assessment principles that see the ?dual? in dual diagnosis not as further opportunity to fragment the field and allow clients to fall through the cracks; but as an opportunity to uphold the importance of? both mental and substance-related disorders. A common language of multidimensional assessment that crosses the psychiatric and addiction treatment systems barriers can promote better integrated care. Those with dual issues need no longer bounce between systems of care that have been too ready to shift responsibility to the other side of the fence.

Diagnostic Guidelines The Substance-Related Disorders chapter of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSMTV) on page 177 has a helpful one page table that summarizes effectively the various substances of abuse cross referenced with the variety of Substance Use Disorders and Substance Induced Disorders with which patients can present. Such a chart supports the importance of a careful assessment. To begin treatment based solely on the appearance of psychiatric symptoms denies the person accurate diagnosis to distinguish between substance use disorder, substance-induced problems, self medication of a primary mental disorder, or true dual diagnosis.One reason for careful assessment rather than reactive treatment of presenting symptoms is the recognition that pharmacological and psychosocial aspects of addiction can mimic psychiatric disorders. What can appear to be a significant major depression can dissipate decisively with abstinence and recovery if the depression is secondary to a substance dependence problem. However, it is equally important to avoid persistent admonition to not drink and ?go to meetings? if there is a primary depressive disorder, which the client attempts to self medicate with alcohol.Using a decision tree to assess for either a substance-related disorder, a mental disorder or both involves at least two principles:

Take good history A definitive psychiatric diagnosis by history requires the psychiatric symptoms to have occurred during drug-free periods of time and/or to have preceded the beginning of addiction problems. If an accurate history is not available or credible, another principle involves something easier said than done.

Observe the client for a sufficient time drug-free ?Shorter time for objective, psychotic symptoms; longer for subjective, affective symptoms. Clients are encouraged to try non-drug ways of coping such as active involvement in a recovery program that incorporates self/mutual help meetings, tools, techniques, and a wide variety of non-drug coping responses to help clients deal with the stresses of everyday living.This provides opportunities for relief not possible when substances and medications are so readily available. If there is evidence of a documented co-occurring mental disorder, then no drug-free period is necessary.

Criteria for Co-Occurring Mental and Substance-Related Disorders The Second Edition of the Patient Placement Criteria of the American Society of Addiction Medicine (ASAM PPC-2) has been revised and will be published later in 2000 (PPC-2R). Criteria will be presented in two formats – Level of Service format and a Matrix Structure of Criteria:

  • The original guidelines were broadened to incorporate criteria and service development more responsive to a wider range of ?dual diagnosis? patients. This traditional format provides guidelines to existing programs on how they might modify their current service. The goal is to improve the assessment process, staff expertise, and service design to better meet the needs of the dual diagnosis population.
  • A ?future directions? Matrix Structure of Criteria takes a significantly different approach to assessment, treatment planning and placement. This approach provides criteria and risk rating descriptions; specifies types of services and modalities needed; and indicates the intensity of services and levels of service and settings where the patient?s needs can best be met. The goal is to promote improved assessment and treatment of ?dual diagnosis? clients through a multidimensional approach that matches specific needs to services, rather than matching just to level of care.

Multidimensional Assessment Because psychiatric and substance disorders are biopsychosocial disorders, assessment must be comprehensive and multidimensional to plan effective care. The common language of the six assessment dimensions of the ASAM Patient Placement Criteria (with modifications in italics for mental disorders) can be used to determine clinical severity for both mental and addiction disorders.

Description of Services The ASAM PPC-2R defines program capabilities as being of three types: those that offer Addiction-Only Services (AOS), those that are Dual Diagnosis Capable (DDC), and those that are Dual Diagnosis Enhanced (DDE). Program capabilities are defined as follows:

1 Programs that offer Addiction-Only Services (AOS) Some addiction treatment programs cannot accommodate patients with psychiatric illnesses that require ongoing treatment, however stable the illness and however well functioning the individual. Such programs are said to provide Addiction-Only Services (AOS). 2 Dual Diagnosis Capable (DDC) Programs Dual Diagnosis Capable (DDC) programs routinely accept individuals who have co-occurring mental and substance-related disorders. DDC programs can meet such patient?s needs so long as their psychiatric disorders are sufficiently stabilized and the individuals are capable of independent functioning to such a degree that their mental disorders do not interfere with participation in addiction treatment. 3 Dual Diagnosis Enhanced (DDE) Programs DDE programs can accommodate individuals with dual diagnoses who may be unstable or disabled to such an extent that specific psychiatric and mental health support. monitoring and accommodation are necessary in order for the individual to participate in addiction treatment. Such patients are not so acute or impaired as to present a severe danger to self or others, nor do they require 24-hour, intensive psychiatric supervision.

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