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Dealing With a Dual Diagnosis

Many addicts and alcoholics also suffer from mental health problems. Here are 12 suggestions to guide a treatment strategy.

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Dr. Robert M. Lichtman photo via

People who suffer from both mental health and substance use disorders present the clinician with a unique set of challenges. Only in recent decades have we begun to accurately identify and effectively treat such co-occurring conditions. But after a slow start, progress is finally being made.

In the mid-1990s mental health agencies and treatment providers for addiction recognized that patients presenting with co-occurring disorders required clinical services beyond their existing capabilities. At the point of entry to public and private facilities, many patients were literally “falling through the cracks.” On the one hand, mental health services were challenged by patients whose primary disorders were schizophrenia, bipolar disorder, and major depressive disorders at the “high end” and adjustment disorders at the “low end.” However, the clinical presentations of many patients suffering from these problems were compounded by secondary—and equally serious—substance use disorders that mental health facilities were ill equipped to treat. On the other hand, facilities for alcoholism and addiction treatment found that entry-level patients met their criteria for admission, but mental health issues were interfering with accurate assessment and “best practices” therapy. 

The research and literature were literally in their “infancy.” Evidenced-based treatment was just beginning to show results. An effort to bridge the gap between mental health treatment and substance abuse treatment was in order. Collaboration between the clinical and the administrative components of agencies providing services to these two distinct medical conditions was necessary.

Over the next decade both types of agencies slowly began to change in order to meet the needs of patients with co-occurring disorders. Now there is widespread recognition that this challenging population requires its own tailored treatment. Yet some “hard-liners” still resist these changes, holding onto old practices or not fully implementing new guidelines. They fail to accept the evidence of many epidemiological studies that mental health disorders and substance use disorders are not separate issues but “co-exist” in a large segment of the population that we treat.

The following list condenses my long experience assessing and treating people with co-occurring mental health and substance use disorders into 12 principles that every clinician needs to know.

Mental health and substance use disorders are not separate issues—they “co-exist” and often interact synergistically.

1. Staff in both OMH and OASAS agencies needs cross-training that synthesizes the symptoms and behavioral outcomes of both mental health and substance use disorders. The effect of one on the other presents an entirely different picture than either one alone.

2. Prescribed medications, such as antidepressants or antipsychotics, for patients with serious and persistent mental illness may be the only way to stabilize mental status.

3. When patients self-medicate with alcohol and drugs, a stabilized mental status can easily be compromised. (Some may also turn to substances of abuse to ward off the side effects of their prescribed medications.)

4. Abstinence from substance use is sometimes a long-term goal rather than a requirement for admission. Harm reduction has to be considered.

5. We have little control over nonresidential patients’ need to self-medicate other than random urine a/o blood analysis. Threats of losing privileges, being dropped from a program or being hospitalized are of little consequence when their drug of choice and the gratification of getting high are immediately available.

6. An inpatient diagnosis of “Polysubstance Dependence in Remission in a Controlled Environment” is a red flag to keep an eye on the patient and their visitors. Dependence means that their “dependent state is their comfortable state.” Without their drug(s) of choice they are uncomfortable, and our prescribed medications cannot compete with their self-prescribed ones.

7. One of the central predicaments of this patient population is that they have little in life to depend on or to get high on other than the immediate effects of substances of abuse.

8. When faced with life-threatening physical illness and concomitant pain, many times such patients will turn to virtually anything for relief.

9. Due to limited funds, our patients seek out the least costly, which unfortunately are often the most dangerous, drugs. (In ascending order of cost: nicotine, alcohol, marijuana and crack-cocaine.)

10. Unable to afford popular brands of cigarettes, many patients turn to Cheyenne’s, $1.50 a pack. The nicotine content of these “cigarettes” is far greater than the branded ones. The mentally ill who smoke have become a target of specific marketing campaigns by cigarette companies. The diagnosis of nicotine dependence has high rates in co-occurring disordered populations.

11. The Stages of Change model and Motivational Interviewing have provided the backbone for many programs.

12. The US Department of Health and Human Services: Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment website has many publications available free of charge. Tip 42 —substance abuse treatment for persons with co-occurring disorders—is especially helpful. Of particular importance is the “Quadrant of Care Model,” which categorizes and prioritizes where the focus of treatment should concentrate.

In addition to his public sector position, Dr. Robert M. Lichtman, CASAC, CAS, MAC, FAPA, teaches a graduate course called “Chemical Dependency and Mental Health." He is a past president and founding member of the Addictions Division of the New York State Psychological Association. 

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