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Development of a Dual Disorders Program

Development of a Dual Disorders Program

In This Special Report:

Schizophrenia With Obsessive-Compulsive Disorder, by Alexandra Bottas, MD

Psychiatric Comorbidity in Persons With Dementia, by Denis Shub, MD and Mark E. Kunik, MD, MPH

Diagnosing Comorbid Psychiatric Conditions, by Johnny L. Matson, PhD and Daniene Neal

Development of a Dual Disorders Program, by Mark D. Green, MD

Comorbidity in Bipolar Disorder, by Doron Sagman, MD and Mauricio Tohen, MD

Integrated dual disorder programs have come about because traditional treatment of co-occurring addiction disorders and psychiatric disorders fail in a large number of people and waste resources. More than 5 million adults in the United States have a serious mental illness and a co-occurring substance use disorder.1 About half of the people who have had a mental disorder in their lifetime have also had a drug or alcohol disorder, and vice versa.2 Many people with dual disorders are treated in expensive, ineffective, and unsatisfying ways—in emergency departments and hospitals, for example—rather than in community settings.3,4 This article emphasizes core philosophies and components of effective dual disorder programs.

Many people curtail the use of damaging drugs and alcohol on their own, and many people with mood and psychotic disorders recover.5 People can change if they believe that change is worthwhile—and if they are ready, willing, and able. But change demands time, vision, and tenacity. People with dual disorders are complex. They can be paranoid, impulsive, or depressed, or they can be withdrawing from a drug or have limited attention and planning capacity. They can also have problems in realms such as financial, legal, housing, or relationships.

How challenging it is for these people to make dramatic behavioral changes! Treatment needs to help them get there, but too often treatment programs demand exactly what people with dual disorders cannot do. If a program is to be effective in such a population, it must be able to grapple with these complexities.

Core values

Core values anchor a team and guide its practice. It helps to make those core values explicit. Ongoing education and supervision can refer to these values, and good practice will flow from them.

Treatment should be integrated. Psychiatric and substance abuse disorders affect each other’s emergence, course, and recovery. Psychiatry clinics commonly fail to assess and treat addictions, and addiction specialists can be poor at detecting and treating psychiatric disorders.6 One still hears comments such as, “You have to treat the addictions before you can treat the mood disorder,” or “She needs to confront the trauma and then she’ll stop using.” Treatment of addictions and psychiatric disorders then occurs in parallel or sequentially—but not in an integrated fashion. Frustrated clinicians blame failure on the other disorder, treatment philosophy, or the patient. Treatment retention is low and relapse and rehospitalization rates are high.

Complex problems cannot be addressed with simplistic solutions. Care should be integrated at the organizational, assessment, and delivery levels.7 Integration ensures that therapists can address the range of challenges facing a participant by using pharmacotherapeutic, motivational, and behavioral interventions.8 Assessments need to be comprehensive and cover substance use and psychiatric symptoms, risk level, and both internal and external challenges to recovery. Obtaining a chronology enables these challenges to be understood in the person’s narrative, reveals repeating patterns (eg, escalating psychosis after relapse to drinking and stopping medications), and suggests priorities on which to focus.

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