Development of a Dual Disorders Program
Development of a Dual Disorders Program
Methodology for Better Outcomes
By Mark D. Green, MD |
March 19, 2009
Dr Green is medical director of WestBridge Community Services of the Cambridge Hospital in Cambridge, Mass, and a lecturer on psychiatry at Harvard Medical School in Boston. The author reports that he has no conflicts of interest concerning the subject matter of this article.
Morbidity and mortality are high among people with dual disorders, in part because of lifestyle issues (eg, smoking, poor diet, little exercise, sleep disorders, unsafe sex, possible suicide ideation, and medication-related adverse effects). Programs need to educate patients and offer them strategies for change. Smoking cessation should be provided in all programs. Safe injection practices, advice about driving while intoxicated, safer sex practices, and dietary guidance should be routine. Manuals can guide this process, and the team nurse plays a central role.35
Systems issues and anatomy of the team
The development of an effective dual disorders team requires time, commitment, and investment. Blending psychiatry and addiction teams can be difficult because of differing philosophies about confrontation, spirituality, and peer involvement. Integration must occur at financial and management levels and include multiple agencies to ensure multiple points of entry to care for people who may not know their problem a priori.36,37 Staff needs extensive and ongoing training to maintain a high fidelity to evidence-based practice models to ensure better outcomes.38 Involvement of peers who are advanced in their own recovery inspires hope, transfers expertise, and keeps the focus on patient goals; they are highly effective.39 A team approach with daily meetings provides a holding environment, coordinates care, and diffuses tensions. The use of group supervision can redefine the frustrations resulting from clashes between staff and patient agendas and suggests evidence-based solutions. While some specialization is necessary, all staff members should be skilled in most services. Care managers may have a closer relationship with their assignees, but ideally the patients should feel an alliance with the team rather than a particular individual. Staff members must be flexible, cooperative, patient, and respectful.
Not everyone needs all the components of care outlined here, but complex problems need complex solutions. Before a program is set up, it must be determined which patients it will help. Time, support, and structured treatment are needed, and this can be costly. If the investment is not made, however, the bill gets picked up by criminal justice, acute hospitals, or welfare services. Thus, the decision of whether to invest in effective dual disorder programs is one for health care systems and, ultimately, society. We have learned a lot about which programs work, and there are many patient “success stories” to show us how worthwhile these efforts are.
Also in this Special Report
Drugs Mentioned in This Article
Naltrexone (Depade, ReVia)
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