One of the greatest efforts of the medical industry is to diagnose, treat and promote the healing of diseased members within its society. Medical breakthroughs and newfound technologies aid medical professionals in the treatment of illnesses and afford afflicted individuals with the opportunity to live normal, healthy lives; however, in all of its command there are instances in which modern medicine struggles to prevail over the infirmity. Unlike many diseases, those within the mental health field termed as “psychological disorders” are dissimilar from other diseases which manifest on a physical level, because of the absence of anatomically related symptoms or dysfunction. Additionally, the nature of psychological disorders or personality disorders, otherwise known as mental illness, is such that the diagnosis and treatment of patients is often subjective at best and becomes exacerbated by the lack of direct measure of anatomic response to therapy and or medication. The psychological disorder that is least effectively treated and understood of all mental illnesses, is in effect, co-occurring disorders referred to as “dual diagnosis”. As these synonymous afflictions, co-occurring disorder and dual diagnosis might suggest, they are characterized by the simultaneous presence of two dysfunctions within an individual, one being an active chemical dependency interdependent of any other “non-specific” psychological disorder(s). One of the greatest hindrances in the treatment dual diagnosis stems from the fact that the relational component between chemical dependence and mental disorders has only been identified and treated accordingly for approximately 25 years, hence, inadequate treatment models continually require development and update as expertise of treatment evolves. Due to the dynamics within dual diagnosis, in all of its perplexities, proper treatment for patients who suffer from co-occurring disorders is not as likely to be obtained, as for patients suffering from more traditional or “singular” occurrences of psychological disorders. The history of dual diagnosis is short lived by comparison to any other mental disorder and the true origin and development of this diagnosis has not been completely documented, although the first application of the term “dual diagnosis” began in the early-mid 1980’s. The term was seemingly shared by psychiatric colleagues on the east and west coasts of the United States at that time. Kathleen Sciacca, M.A., Executive Director, Sciacca Comprehensive Service Development for Mental Illness, Drug Addiction and Alcoholism, in her invited response “On Co-occurring Addictive and Mental Disorders: A Brief History of the Origins of Dual Diagnosis Treatment and Program Development”, gives account of the difficulties faced by the professionals in New York who were initially involved with treating and ultimately identifying dual diagnosis as an interdependence of addictive and psychological disorders.
“To The Editor, The opening article of the Journal’s special section (Osher & Drake, Reversing a history 4-11) which traces the history of separating mental health and addictive services is an important contribution to the literature on dual disorders. Since we are now in the early stages of the evolution of dual diagnosis services, however, I believe it is important to provide a more complete and detailed account of the previous initiatives in this field. In response to the article The Course, Treatment and Outcome (Drake et al. 49), which states: “Ten years ago the only treatment options available for people with co-occurring substance abuse and severe mental illness were parallel treatments in separate programs.” the record requires correction. Dual diagnosis treatment interventions and “integrated” programs that truly adapted to the needs of Mentally Ill Chemical Abusers (MICA) began in 1984.”
Sciacca further explains that in September, 1986, the New York State (NYS) Commission on Quality of Care (CQC) presented the results of eighteen months of research. In its report there was description of the negative outlook and deterioration of dually diagnosed patients who were handed off between different systems with no definitive locus of responsibility. Resulting was Governor Cuomo’s order which “designated the NYS Office of Mental Health as the lead agency responsible for coordinating collective efforts for this population.” (qtd in Sundram, Platt, Cashen). CQC continued to review the dual diagnosis programs developed in 1984, and found that the treatment interventions, training, and integration between programs to be effective remedies in treating the disorder. TIME magazine became aware of the CQC findings, and CQC suggested that TIME magazine research these efforts. A reporter attended treatment groups, spoke with consumers and the director, and was afforded access to related training clinics. The story Bad Trips for the Doubly Troubled, Christine Gorman, was published containing a national dual diagnosis statistics report; hence, [doubly troubled] became common knowledge to the general public contributing to the awareness and support of treating the dually diagnosed. As a result of the efforts of NYS, CQC, the New York Office of Mental Health and Governor Cuomo’s office formed the MICA Training Site for Program and Staff Development. Unfortunately, the program closed in 1990 due to budgetary cuts. MICA programs, models and groups originating out of the MICA initiative, to this day, continue to be an important source of the present services utilized by mental health professionals nationally and internationally. The adaption of treatment models cross training of mental health service providers and interagency program development resulting from such models prove to deliver marked improvement of results in the treatment of dually diagnosed patients versus a much lowered success rate of more homogenous treatment approaches. (Sciacca)
Despite the efforts over the last decades, treatment design continues to be a factor which deters the medical community from properly treating and prevents dually diagnosed clients from obtaining a manageable level of mental health due to the inability of professionals within the scope of addiction and psychiatric treatments to uniformly treat the co-occurring disorders simultaneously, without prejudice.
It is a problem not only the consumers of mental healthcare and their families who pay out of frustration and anguish for the inadequacies within mental health industry, but also it continues to be noted by mental health industry officials that this form of co-occurring mental disorder, if not properly treated, is the greatest cost to mental healthcare providers and tax payers alike. It is uncertain as to exactly how many individuals are inflicted with dual diagnosis disorder, and the accuracy and parameters of studies conducted account widely varied results. The United States Substance Abuse and Mental Health Services Administration (SMHSA), released figures that in 2006 that approximately 5.6 million adults over the age of 18 had both a mental health disorder and a drug or alcohol addiction, of which, nearly half went without treatment. (Hurlock and Bordini, Dual Diagnosis Frequently Asked Questions). More recent data leads researchers to believe that up to 50% of the mentally ill population suffers from a substance abuse problem.
The National Institute for Health and Clinical Excellence (NICE) has disclosed information to promote the identification and effective treatment of those individuals who are addicted to substances and diagnosed with a mental disorder. As reported by NICE, 40 percent of those who are diagnosed with some form of psychosis have abused drugs at some point in their lives, which is double that of those people within the general population. Fergus Macbeth, NICE’s Director at the center for clinical practice stated, “When these two conditions co-exist, patients can spend twice as long in hospital as those who do not misuse substances. They also experience poorer physical health, are less likely to take prescribed medication and are more likely to drop out of services.” (Mental Health Practice, 10).
According to Dr. Michael Anderson of the Metropolitan St. Louis Psychiatric Center, the greatest difficulty in treating patients who suffer from co-occurring disorders happens on a case-by-case basis of how to treat both ailments simultaneously. Anderson claims that, “it would be easier if the disorders could be separated and dealt with individually, but due to the connectedness of the disorders, isolation and treatment individually becomes counterproductive”. When the question of best treatment aid and the most valuable tool at the clinician’s disposal was posed, Anderson responded, “The best aid in treating dual diagnosis is experienced, well-trained clinicians… The most valuable tool at the clinician’s disposal would be use of the proper theoretical perspective as required by the individual needs of the patient example: psychodynamic vs. cognitive behavioral perspective, and other types of theoretical perspectives.” Anderson points out that the greatest lapse in the medical health field in the regard of treatment of dually diagnosed patients is the “health care system”. Anderson continued to explain that insurance companies do not cover the “addictive” side of the mental disorder dollar for dollar, if at all, as it would a non-substance related psychological disorder. “It is difficult to treat a disorder that is equally as critical in treating for the successful outcome of the patient…if that part of the treatment plan cannot be billed for,” Anderson expresses. (Anderson interview).
The sentiment conveyed by Anderson regarding the monetary aspect of treatment is echoed in an article published by National Alliance on Mental Illness (NAMI), wherein Missouri received a grade of C propagated by state budget cuts in its Medicaid program and mental health care systems. In 2009, the state continued to receive a C; but, in many respects, the overall situation seems worse. “Missouri is the recipient of a federal transformation grant and can be commended for its desire to transform its mental health care system and openness to new ideas. Unfortunately, the state’s delivery is not matching its vision, and in some cases, it is creating its own problems.” reported NAMI.
It seems as though there is another hurtle standing between consumers’ mental health and treatment of co-occurring disorders as expressed by Dr. David Ohlms, Medical Director of Chemical Dependency Services at Center Pointe Hospital in St. Charles, MO. Ohlms points out that, increasingly, those in the medical profession including psychiatrists view chemical addiction as a symptom of another illness rather than a diagnosis by itself. Ohlms cautions mental health providers from hasty diagnosis and pharmacological treatment of a mental illness and urges mental health professionals to promote a patients’ abstinence from drugs and alcohol for 30 days or longer before assigning a DSM-IV psychiatric diagnosis. Proceeding without that check may perpetuate an existing addiction by misprescribing substance(s) for someone whose primary diagnosis is (and secondary symptoms are a result of) addictive disease.(Ohlms Dual Diagnosis Treatment Protocols: Which Illness Should be Treated First).
The increasing knowledge of co-occurring disorders, the demand for viable treatment options and fiscal pressures on the healthcare industry has further created the need for industry and government cooperation in the mission for treatment of the dual diagnosis populous. SAMHSA (Substance Abuse and Mental Health Services Administration), a division of The Department of Health and Human services has implemented, since 2003, the Dual Diagnosis Capability in Addiction Treatment (DDCAT) index. The DDCAT, based on the American Society of Addiction Medicine’s (ASAM) program dual diagnosis model was studied within a series of psychometric vignettes. The map below reflects the widespread implementation in various stages of the DDCAT as well as two parallel instruments, the Dual Diagnosis Capability in Mental Health Treatment (McGovern, Matzkin, & Giard, Assessing the dual diagnosis capability of addiction ).
The DDCAT index was created by by Dr. Mark McGovern, member of The Dartmouth Psychiatric Research Center and Associate Professor of Psychiatry at Dartmouth Medical School. The DDCAT was first tested in Connecticut, Louisiana, and New Hampshire and was eventually implemented in a number of states, Native American tribes, and internationally. The Dual Diagnosis Capability in Addiction Treatment Index is a gauging tool for assessing addiction treatment program services, specifically for persons with co-occurring mental health and substance use disorders. The DDCAT is based upon a fidelity assessment methodology. Fidelity scale methods simply put are used to evaluate a treatment program’s ability to adhere to, and its competence in the application of evidence-based practices. Methodology in this context is been used to value mental health treatment facilities implementation of the Integrated Dual Disorder Treatment (IDDT) model. IDDT is an evidence-based practice for patients with dual diagnosis disorders in mental health settings, and who suffer from severe and persistent mental illnesses (Mueser, Norrdsy, Drake. Integrated Treatment for Dual Disorders.) Both DDCAT and the IDDT Fidelity Scale utilize similar methodology, but DDCAT has been specifically developed for addiction treatment service settings. The DDCAT measures 35 aspects of a treatment program that are subdivided into seven sub-categories as follows:
1) The first dimension is Program Structure. This dimension measures general organizational factors which foster or inhibit the development of integrated treatment.
2) Program Milieu is the second dimension, and it focuses on the setting or environment and whether the staff and physical setting are welcoming to patients.
3-4) The third and fourth dimensions are called Clinical Process dimensions-(Assessment and Treatment). These dimensions investigate whether specific clinical goals are achieved within integrated assessment and treatment.
5) The fifth dimension is Continuity of Care, which examines the long-term treatment and after care support commonly connected with persons who have co-occurring disorders.
6) The sixth dimension is Staffing, which examines Staff and internal relations operations that support integrated assessment and treatment.
7) The seventh dimension is Training, which measures the level and type of training in support of the facility’s capacity of staff to treat persons with co-occurring disorders.
The DDCAT is contingent on the taxonomy of addiction treatment services as indicated by the American Society of Addiction Medicine (ASAM). This methodology provided brief definitions of Addiction Only Services, Dual Diagnosis Capable and Dual Diagnosis Enhanced. The DDCAT utilizes these categories and developed observational methods (fidelity assessment methodology) and objective methods in order to determine the dual diagnosis capability of addiction treatment services for persons with co-occurring disorders as stated by the SAMHS. The DDCAT may serve as a useful tool in gauging a programs’ comparative performance in theory; nevertheless, every city and town, every agency, clinic or hospital, every policy and healthcare regulation provides for variants whereby the values or proportions used in determining the relationship of a provider’s capability to treat dually diagnosed patients and the relative level of treatment success is not accordant.
In conclusion, the difficulty in treating co-occurring psychological disorders stems from a number of variables related to the disorder. From the clinicians’ standpoint, dual diagnosis disorder is considered to be one of the mental healthcare industry’s greatest challenges because of the difficulties in treating this disorder due to its masked and varying manifestations. Additionally, the nature of treating a disorder with both addictive and psychological attributes has been unsuccessful until at which point both conditions are treated simultaneously and cessation of the addiction has occurred. The treatment model that has been developing from the mid 1980’s, a hybrid adaption of treatment approaches, resulting from cross training of mental health service providers and medical communities and interagency program development, has stagnated as a result of the inability to create a universal treatment paradigm and treatment is further pushed towards disrepair as a result of deteriorating economic factors and related healthcare lapses. Individuals addicted to substances and diagnosed with mental disorders, thus resulting in the treatment of dual diagnosis continues to be an uphill battle for clinicians; however, focused treatment of patients on a case by case basis continues to be the single most effective aspect of treatment for dually diagnosed patients at this time.
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