by Carol Lang-Wermuth, B.S.N., R.N.
Bryn Mawr Hospital - Department of Psychiatry

Historically, co-occurring substance abuse and psychiatric disorders have had different models of treatment.  The National Comorbidity Survey indicated that approximately 51% of people with mental disorders also suffer from substance abuse disorders.  Dually diagnosed clients have a decreased response to treatment if one of the disorders goes untreated.  New approaches to treatment integrate both models with cross-referrals, consultations, and program systems to meet the needs of this population.  A concept of recovery for these two models is a significant paradigm in the psychiatric field.  Treatment success requires health care providers to develop evidence-based interventions for stabilization and positive outcomes for both disorders.

Clinical assessment for dual diagnosis is difficult because chemical abuse can mask psychiatric symptoms, distort diagnosis, or activate psychiatric crisis.  The health care provider must evaluate for both mental health and substance abuse problems.  Indicators for substance abuse include:  self-medicating, misuse of prescription drugs/OTC's, use of drugs with negative consequences, progression of chemical dependency, previous detox/rehab, high tolerance, symptoms of withdrawal, and drug seeking behavior.  Identifying both disorders require a team approach, which may include family, friends, caseworkers, doctors, nurses, labs, urine drug screens, and medical conditions secondary to drug abuse.

Physiologic dependency on drugs such as alcohol, sedative/barbiturates, and hypnotics require detox protocols and pharmacologic interventions.  They should never be stopped abruptly and detoxification requires supervision by a doctor.  Focus is on meeting approximate tolerance levels with certain class drugs and slowly reducing these over a given period.  A safe detox is imperative to avoid seizures, arrhythmias, excitation of the central nervous system, and delirium tremens.  The mixed use of detox drugs and psychiatric medications require caution for synergistic effects.  A large percentage of psychiatric medications can mask withdrawal symptoms.  Stabilization of mental disorders may be impossible if clients continue abusing substances.  Use of habit-forming drugs for symptom control of mental disorders require caution and alternative medications should be considered for efficacy.

The concept of recovery targets not only stabilization of symptoms, but leads the person into positive life outcomes.  This starts with identifying dual diagnosis and providing "a path" to recovery.  This may include:  self-help/coping skills, preventive self-care/relapse, counseling, education, sponsorship, and 12 step programs for the client and significant others.  Dually diagnosed clients generally desire positive life outcomes like independent living (a place to call home), job/education, personal growth, meaningful relationships, and avoiding the spirit-breaking experience of relapse and hospitalization.

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