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Assessment and management of dual diagnosis--that is, the comorbidity of substance use disorder in persons with mental illness--is a major challenge for clinicians, especially in the emergency department (ED). It is widely accepted, but perhaps less well appreciated in the clinical realm, that substance abuse comorbidity is more the rule than the exception in persons with serious mental illness.
The comorbid relationship between substance use disorder and mental illness is being increasingly recognized by health care planners across the nation and has also received prominent attention in the final published report of the President's New Freedom Commission on Mental Health. The New Freedom report emphasizes that most patients who have both a substance use disorder and a mental illness are treated for one or the other, but rarely receive treatment for both. The report also makes a strong pitch for integrated dual diagnosis treatment services.
In this issue, Dr Maviglia's overview article and case studies provide us with practical insights into the complex presentation of dual diagnosis in the ED. The diagnostic conundrum is most evident in the ED setting and is often coupled with an inadequate source of collateral patient history. Because patient presentation usually is at night or during the weekend, mental health specialists in dual diagnosis may not be as readily available to assist their ED colleagues in assessment, triage, and placement of these patients. The vignette introducing the additional pitfalls in cultural competence among ED staff adds a further dimension of complexity.
The case highlighting the shortcomings of the American Society of Addiction Medicine (ASAM) criteria1,2 in actual implementation is also illustrative. The ASAM criteria have gained increasing attention in planning services and in assessment. However, as the third case illustrates, these criteria may lead clinicians to choose less immediate interventions and thereupon lose the "window of opportunity" when the patient presents in crisis and is "motivated" to receive care.
As the overview article highlights, there is a conspicuous lack of uniformity on the assessment tools chosen to evaluate patients with substance use disorder comorbidity. The extent to which any one measure can be applicable across a variety of patient populations and service systems (ie, mental health, substance abuse, correctional services) is unknown. Although this may appear to be less of a concern in the ED setting, it is an important structural issue for health care planning services in this arena.
The Substance Abuse and Mental Health Services Administration (SAMHSA) has invested both money and considerable effort in promoting statewide dual diagnosis initiatives. Choosing a reliable and user-friendly assessment tool has been a major challenge and, even within this SAMHSA initiative, a diversity of approaches to the assessment of patients with dual diagnosis still exists. The CAGE questionnaire3,4 is just one measure, and it is not particularly helpful in the diagnosis of substance abuse in patients with serious mental illness.
Another important point worth amplifying beyond Dr Maviglia's article is the extent to which patients present with polysubstance abuse rather than abuse of a single agent. This is relevant particularly to understanding the interaction between drugs and alcohol, which makes assessment even more difficult, and certainly resonates with clinicians in the ED. The second vignette in Dr Maviglia's case presentations illustrates this point well.
Dr Maviglia also describes the potential for "a clash of ideologic viewpoints" in the management of patients with dual diagnosis who present to the ED. Depending on the patient's ideologic orientation--as well as the philosophy of the institution to which a patient may have been exposed--the ED physician may be in step or out of step with the patient's therapeutic inclination. Because the ED is a place for quick decisions and triage, appreciation of the meaning and context of the patient's addictive behavior may not be a priority for there and then; yet the manner in which the clinician approaches the patient will influence the patient's decision of whether or not to engage in treatment.
In response to the burgeoning interest in dual diagnosis among a broad array of health care professionals, a new journal entirely dedicated to this topic was launched last year. The Journal of Dual Diagnosis (JDD) is a quarterly, peer-reviewed publication, now on its fifth issue. The JDD publishes high-quality, original scientific contributions as well as scholarly reviews and perspectives that are relevant to the basic mechanisms of dual diagnosis, including clinical and therapeutic aspects. The interest in dual diagnosis is growing and, as Dr Maviglia's article and case presentations exemplify, dual diagnosis continues to present a complex dilemma for clinicians. *
1. Gastfriend DR, ed.
Addiction Treatment Matching: Research Foundations of the American Society of Addiction Medicine (ASAM) Criteria
. Binghamton, NY: Haworth Press, Inc; 2003.2. Rosack J. Revised criteria guide placement of patients in addiction treatment.
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2001;10:319-326.4. Volk RJ, Cantor SB, Steinbauer JR, Cass AR. Item bias in the CAGE screening test for alcohol use disorders.
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