“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.

Works Cited

Anderson, Michael. PhD. Telephone interview. 17 Nov. 2011

“Dual diagnosis.” Mental Health Practice May 2011: 10. Psychology Collection. Web. 12 Nov.

2011.

Drake, R.E. Mueser, K.T. Clark, R.E. Wallach, M.A. “The Course, Treatment and Outcome of

Substance Disorder in Persons with Severe Mental Illness”. American Journal of

Orthopsychiatry 66. 1996 42-51. Print.  

Hurlock, Kay Psy.D. and Bordini, Ernest J.  Ph.D. “Dual Diagnosis Frequently Asked Questions.”  Clinical Psychology Associates of North Central Florida. n.d. Clinical Psychology Associates of North Central Florida n. pag. Web. 12 Nov. 2012

McGovern, M.P. Matzkin, A.L. Giard, J. “Assessing the Dual Diagnosis Capability of Addiction Treatment services: The Dual Diagnosis Capability in Addiction Treatment (DDCAT) Index.” Journal of Dual Diagnosis. 3.2 (2007) 111 – 123. Substance Abuse & Mental Health Services Administration. Web. 12 Nov. 2011

Mueser, K. et al.  Integrated Treatment for Dual Disorders: a Guide to Effective Practice. New York: Guilford, 2003. Print.

 “Grading the States 2009.” National Alliance on Mental Illness. 2011. NAMI.org. Web. 12 Nov. 2011.

Ohlms, David, PhD. “Dual Diagnosis Treatment Protocols: Which Illness Should Be Treated First.” NAMI St. Louis Newsletter. Jan.-Mar. 2008. NAMI.org. Web. 24 Nov, 2011.

Osher,F.C. & Drake,R.E. “Reversing a History of Unmet Needs: Approaches to Care for   Persons With Co-occurring Addictive and Mental Disorders.” American Journal of Orthopsychiatry. 66 (1996): 4-11. Web 12 Nov, 2011.

 United States. Department of Health and Human Services. Substance Abuse and Mental Health Service Administration. The Dual Diagnosis Capability in Addiction Treatment (DDCAT) Toolkit. Rockville, MD. 26 Jul. 2011. Web 12 Nov. 2011

Sciacca,K., “On Co-occurring Addictive and Mental Disorders: A Brief History of the Origins of

Dual Diagnosis Treatment and Program Development: Published Letter to the Editor.”

American Journal of Orthopsychiatry. 3 Jul. 1996: 66. Web. 12 Nov, 2011.

Sundram, CJ, Platt, IL, Cashen, JA, “The Multiple Dilemmas of the Multiply

Disabled.” Albany, NYS Commission on Quality of Care for the Mentally Disabled Report. Sept. 1986. Web. 12 Nov. 2011.

http://www.medicinenet.com/bacterial_vaginosis/article.htm

Let’s see if I’m enough of a writer to let something ooze that isnt of today.

Saw her just the other day                                                                         D D7

With blue eyes and her fairest way                                                        A Am

Oh my lord I think I’m going to miss her                                             G 

Said she’d always be a friend to me                                                        D D7

But she had to move west, she had to be free                                    A Am

& my lord I know I’m going to miss her                                               G

When she’s coming home, baby I don’t know                        DMaj7/9aug

What I’m  going to do with myself when tomorrow comes DMaj7/9aug

I’ll tell myself a lie when that moment arrives                            C dim Em

I think of that last look as you were lying there                C dim AmDim

Goes  to an Am7 sumtin’ sumtin’… This change + storyline has a change of feel here; I need to be fresh and think outside of the box(that means I’m done for tonight)

 All of the notes will still be there tomorrow!

#4

• The literal meaning of the name
• The sentimental meaning.
   

• When a word entered a language
• What source the word came from
• How the word’s form and meaning have changed over time.
   

http://baby-names.emedtv.com/baby-names/middle-name-meanings.html

The perception of time is all in our minds and does the meaning of life come at the end, or is it merely so ingrained a part of our id we stumble over it again and again?  A blink of the eye and you’re at nine… two more to middle age.  Life may be a trip in the hit parade, or is it better just to be humble, than to live in vain?  The aspirations of mankind seem so askew from what is in mind, to possess what can’t be taken, to pit man against man, to multiply as custom and horde as a rule.  The moment of desperation is at hand, the age of the world surpassing the evolution of man; what conceit to believe that it is possible to kill the land, for after we have ruined this place in which we reside, the world will still spin, blood will return to soil, the sky will filter the air, the meaning of life will then be too clear, as the world is at peace once again.

DMB revised7/12/2010

May 12, 2010 DMB