By Jeanene Swanson
Statistics don’t lie: co-occurring mental disorders and addiction - also called dual diagnosis - go hand in hand. In fact, according to several long-standing epidemiological studies, 50% of general psychiatric patients also have a substance use disorder. That's a harrowing 8.9 million adults, with only 7.4% of individuals receiving treatment for both conditions, this according to The Substance Abuse and Mental Health Services Administration (SAMHSA).
Addiction treatment specialists are well aware of the fact that drug and alcohol abuse can also cause symptoms of a mental disorder - in other words, if you take away the drugs and alcohol, the mental problems ease up or go away entirely. But that’s not always the case. Substance use can trigger latent mental disorders and often make them worse.
Treatment for dual diagnosis is never straightforward. And while treatment facilities over the past several decades have glommed onto the idea of “integrated” modalities that focus on treating both disorders simultaneously, the system has a long way to go before it can say that treatment for dual diagnosis is truly integrated.
One typical patient, Matthew Peters, was drinking regularly by the time he was 13, and finally went to a local substance abuse clinic near his home in North Carolina. He was diagnosed with major depressive disorder - “which was good,” he says. “What is less good is that I was given a prescription for Valium to treat my insomnia.” Unfortunately, this was only the beginning of several failed attempts at getting treatment.
“The most difficult part of finding successful treatment was going through all the failed attempts to treat one condition without treating the other,” he says. “I have been through countless detoxes and rehabs, and a few psychiatric wards over the years. Most of these treated either alcoholism or depression, but seldom both at once.”
While dual diagnoses can run the gamut, Dr. R. Andrew Chambers, who is director of the Addiction Psychiatry Training Program at the Indiana University School of Medicine in Indianapolis, says that research shows “horrific” rates of co-morbidity among patients with schizophrenia, bipolar disorder, PTSD, and personality disorders. Dr. Joshua Smith, the outpatient director of the Center for Drug and Alcohol Programs at the Medical University of South Carolina, says he sees a lot of patients with co-occurring depression, dysthymia (chronic low-grade depression), generalized anxiety disorder, social anxiety disorder, panic disorder, PTSD, and bipolar disorder. Less common are OCD and eating disorders.
Chambers believes that both addiction and mental disorders are aggravated by what he calls “this pesky self-medication dogma...Addiction is not self-medication - it is the opposite of self-medication.” Matthew Peters agrees. “Having a dual diagnosis differs in that it’s not just about refraining from alcohol, or taking anti-depressants,” he says. “It is a synergistic condition where one illness exacerbates the other.”
Chambers has built a career investigating the connection between mental illness and substance use disorders - primarily in a rat model of schizophrenia. “They’re the same disease,” he says. Both his addiction studies (which focus on cocaine and nicotine addictions) and epidemiological studies have shown that if you have mental illness, you are more susceptible to becoming an addict. The regions of the brain that are compromised in schizophrenia - the hippocampus, the nucleus accumbens, the frontal cortex - are also the regions that make people more likely to abuse drugs and alcohol. Additionally, mentally ill addicts suffer more, as shown by higher suicide rates among addicts with mental illness.
Public health studies have shown that addiction occurs across many types of mental illness, and that it’s not specific to any one drug. “If there’s any common denominator, it’s severity,” Chambers says. “The relationship is between addiction and mental illness, not between the drug and mental illness.” And while severity of mental illness might be the biggest predictor of a dual diagnosis, one can’t exclude the fact that a hallmark of mental illness - as well as addiction - is impulsiveness. Addicts with mental health disorders are facing a neurological double whammy, all while being led to believe that their self-medicating is part of the solution.
IS "INTEGRATED TREATMENT" WORKING?
Integrated programs have gained traction in recent years, with so-called “dual diagnosis” clinics having popped up all over the country. According to MUSC’s Smith, screening and treating for co-occurring disorders “is so wedded to what we do, it’s natural for us to look at those things.”
John Tsuang, director of the Dual Diagnosis Treatment Program at the Harbor-UCLA Medical Center, runs an intensive outpatient program. Tsuang says the initial intake includes a full assessment by a therapist to see if the patient is eligible. Patients must have some type of psychiatric disorder - he typically sees people with depression, anxiety, bipolar, and personality disorders -along with a drug or alcohol problem within the previous six months. Entry must be voluntary on the part of the addict.
“A lot of patients, even after they get sober, continue to have a lot of psychiatric issues that haven’t been addressed,” he says. “Just telling people to stop using, it’s really not appropriate without looking at [their] issues.” Typically, his patients who show co-morbid disorders enter outpatient detox. If they’re actively psychotic, Tsuang prescribes medication. For depression, he will assess its severity and usually will wait two months before prescribing anything. The same for anxiety with the exception, he says, that they’re “pretty aggressive in terms of insomnia meds.” He gives antihistamines like Benadryl and Trazodone, but avoids benzodiazepines and addictive sleep aids like Ambien.
“Drugs and alcohol can cause psychiatric symptoms,” Tsuang says. “If you can stop [addicts] from using drugs and alcohol, some of these will go away, and some will not. The trick is to find out whose will go away and whose will not” and then use appropriate follow-up treatment. Tsuang says they offer a full range of group therapies at Harbor-UCLA, including 12-step, nutrition, healthy habits, prevention, cognitive behavioral therapy (CBT), psychopharmacology education, and others.
While treatment progress is real, some specialists, Chambers included, believe there is a long way to go. Chambers argues that keeping addiction and mental health in separately-funded research and treatment “silos” has led to a public health disaster. To address this, he’s developed a fully integrated dual diagnosis outpatient treatment center in Indianapolis. “The concept is that when you come in, you’re going to get it all treated here, under one roof, [and] we’re going to deploy the highest standard of care for either syndrome. This is what we think should be the standard of care” for all so-called integrated dual diagnosis treatment in the U.S.
Even with the best care, however, co-occurring disorders are simply difficult to treat, in part because of the abusers themselves. Karl Shallowhorn, author of Working on Wellness: A Practical Guide to Mental Health, spent most of a decade treating his co-occurring bipolar disorder and drug addiction. Initially hospitalized in college for a “psychotic break,” Shallowhorn says he was discharged and went back to using drugs and alcohol. “I did not see the connection between my mental illness and my addiction,” he points out. Eventually, he was diagnosed with bipolar disorder and underwent intensive outpatient treatment. Meanwhile, he continued using drugs and was hospitalized once every year for the next decade.
“For years I was in complete denial of my illness despite the negative consequences,” he says. “I was relatively compliant with taking my meds; however, my recovery was impeded by my substance abuse. I found that once I stopped the drug use I was able to recognize my bipolar symptoms and address them with the help of my psychiatrist and therapist.”
Denial is common among dual diagnosis patients. Also commonly, seeking help is their last resort not the first action. Smith suggests that patients start by looking for help in their circle of family, friends, or clergy. Opening up to someone they trust, like their general practitioner, can help connect them to suitable treatment. “If they’re scared or not convinced, those are obstacles” to getting healthy, he says.
How do you find a treatment center if you don’t have a GP or family member’s recommendation? I tried finding a dual diagnosis treatment facility starting with an online search, as Shallowhorn advises. It led me to the National Association of Addiction Treatment Providers’ (NAATP) web site. Founded in 1978, NAATP is a membership organization for for-profit and non-profit private treatment facilities. According to NAATP president and CEO Michael Walsh, while you can sort member facilities for dual diagnosis, “the descriptions are done by the members themselves so I cannot tell you exactly how many say they offer dual diagnosis as opposed to who really does it and to what level of expertise. I have found that there are all kinds of variations, and even professionals in our field don’t really know how to assess programs or patient needs properly.”
NAATP is attempting to shed light on these issues and educate their membership and the general public. They are about to publish a “How to" guide to finding a treatment center, one that will suggest questions to ask - how much individual vs. group therapy is offered, and by what level of clinician experience, for example. “Members need to be state licensed but I have found enforcement of standards is more difficult and less effective as budgets have been slashed in most states for these agencies,” Walsh says. “Education and information is key to raising the bar for our industry.”
Even if you do find a suitable treatment facility, many centers don’t know how to treat both. “Very few are capable of treating both under one roof,” according to Chambers. Smith adds, “The addiction treatment centers have been quicker to adopt [treating] co-occurring disorders than the other way around [psychiatric clinics adding substance abuse treatment],” he says. “For most health care providers who are not substance abuse-trained, it’s like a black box.” For his part, Peters notes that the most effective treatment program he found was close to home at the UNC Alcohol and Substance Abuse Program, which, he says, "takes a comprehensive approach to substance abuse that involves education and group therapy as well as one-on-one sessions with therapists. The thing I would change [about current treatment strategies] is that in the presence of one of these conditions, an aggressive effort be made to determine whether the other is present.”
Peters adds that it’s important to have relapse prevention strategies in place as well. While many of these involve 12-step programs, it’s essential for addicts with mental disorders to realize that they are different from “regular” addicts. “I would proceed with great caution when it comes to 12-step programs,” Peters says. “Some of these groups tend to be anti-medication, and some people really need to be on medicine to help control their mental health symptoms.” In other words, he argues, find a rehab that embraces individualized treatment plans and evidence-based approaches.
Tsuang at Harbor-UCLA is a firm believer in CBT plus medication. Unfortunately, many patients battle the stigma of taking drugs, even though the Big Book bible of 12-step doesn’t preclude taking them in recovery from alcohol addiction. Patients are “taking meds but they’re afraid to talk about it because of the stigma,” he says. Tsuang sees the need for more education about the biological condition of depression, as well as for non-addictive medications like SSRIs, the most frequently prescribed antidepressants, which are non-addictive. “You’re not taking it to get high or get happy, you’re taking it to get stabilized.”
Successfully completing treatment may be somewhat of a misnomer. Shallowhorn notes: “In the end I believe it has to do with a person’s quality of life - are they doing better than when they first entered treatment?” Research has shown that individuals who have some kind of post-treatment care tend to be more successful, and this is where mutual support groups (AA, NA, Dual Recovery Anonymous) or local recovery clubhouses can be useful, he adds. “It is so important that people have some kind of a safety net once they complete treatment. We can’t do it alone.”