Basics of Managing the Dual Diagnosis Patient
By Dr. Paul F. Giannandrea – Clinical Director – The Bergand Group
Patients with both a psychiatric diagnosis and chemical dependence are common in the treatment population at the Bergand Group. In general, 47% of schizophrenics, 32 % of mood disordered and 60% of bipolar disordered patients abuse substances. Likewise, 84 % of psychiatric inpatients and 8.7-17.1% of psychiatric outpatients are substance dependent. In fact, the overall rate of mental illness in substance dependent patients is 53%; this represents 4.5 times the rate of dependence in the general population.
Unfortunately, diagnosing and treating the dual diagnosis patient is complex and sometimes confusing. Traditionally, one must meet the full DSM V diagnostic criteria in order to be considered a “truly dually diagnosed” patient. However, it is not that simple for a couple of reasons. One, most substances of abuse cause symptoms very similar to psychiatric diagnoses such as major depression and anxiety disorder. These drugs may also cause various problems such as sexual dysfunction and nutritional problems such that various medical and psychiatric problems may be diagnosed erroneously. I call these patients “pseudo dually diagnosed” patients. In addition, psychiatric patients may utilize substances of abuse and cause them problems but they do not meet full criteria for a substance dependency. One such example is the schizophrenic who uses marijuana and this triggers their psychosis. Another example is a substance dependent patient who blames their use on a “psychiatric condition” that they do not have but have symptoms of one during its use. I call these patients “false dually diagnosed” patients.
Another complexity in diagnosing and treating dual diagnosis patients is that their diagnoses can change over the time of observation. For example for almost half of patients who are admitted with both depression and alcoholism, after two weeks of abstinence, their “depression” resolves completely. Even more confusing, is the fact that one fourth of those alcoholics whose depression does resolve in those two weeks, when followed and monitored for a year after discharge, do ultimately meet full criteria for major depression!
So what is the optimal way to accurately diagnose and treat the potentially dual diagnosis patient?
- Since confusion about the diagnosis can delay intervention, achieving clarification, through a comprehensive evaluation, is the first order of business after safety is addressed.
- Although abstinence is a critical factor in recovery, it is not the only factor. Regular psychosocial treatments for substance dependence are relevant so long as the patient is behaviorally manageable and not psychotic or delirious.
- Patient-treatment matching should be done on an individual basis, depending on the patient’s needs, the recourses available, and the skills and preferences of the clinicians involved.
- Dual diagnosis clinics that specialize in substance dependent patients who have comorbid psychiatric illness play an important role when there is diagnostic confusion or when the patient does not respond to routine psychiatric treatment (or has not responded to treatment in the past).
At the Bergand Group, we believe in following the chemically dependent patient for a prolonged period of time, both during prolonged periods of abstinence and during the period of establishing significant periods of abstinence. We recurrently assess patients for the existence of other psychiatric diagnoses. We have specialists in various psychiatric conditions and who apply a variety of treatments for them. We have a collective experience of over 100 years of doing so.
Dr. Paul F. Giannandrea
Clincal Director – The Bergand Group
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