Psychiatrists frequently encounter dual-diagnosis patients (Box) and may often wonder which to treat first—the substance abuse or the psychiatric comorbidity. Five principles can help you counsel dual-diagnosis patients more effectively. Briefly, they are to:
- appreciate this population’s heterogeneity
- adopt a longitudinal treatment approach, reassessing patients’ progress and adjusting interventions as needed over time
- be empathic rather than confrontational
- realize that treatment often proceeds in stages—not on a smooth, linear path
- recognize the importance of medication compliance.
ASSESSMENT
Different patients, different problems. All counseling of dual-diagnosis patients begins with a thorough assessment aimed at making an accurate diagnosis and understanding the relationship between the co-existing disorders. Although some people refer to “dual-diagnosis patients” as a single entity, these patients differ according to:
Dual-diagnosis patients: Twice the clinical challenge
The National Institute of Mental Health’s Epidemiologic Catchment Area study documented high rates of substance use disorders in patients with psychiatric disorders.1 Lifetime prevalence of co-occurrence was 61% for bipolar disorder (the highest of any Axis I disorder),47% for schizophrenia, and 36% for panic disorder.
Dual-diagnosis patients face a more bleak prognosis than those with a single disorder, including higher rates of relapse, hospitalization, violence, incarceration, homelessness, and serious infections such as hepatitis and HIV.2 Unfortunately, these findings have not always led to effective treatments.
These patients represent a heterogeneous group and require individualized treatment. For example, abstinence from alcohol or drugs may worsen psychiatric symptoms in a patient with posttraumatic stress disorder and substance abuse. On the other hand, abstinence would be expected to improve the symptoms of a patient with comorbid major depressive disorder and substance abuse.
- diagnosis, with a myriad of potential combinations of substance use and psychiatric disorders
- severity of disorder, with some having a predominant psychiatric or substance use problem and others experiencing severe courses of both problems
- causes of their substance abuse and psychiatric disorders, based in part on which problem is primary and which is secondary
- level of motivation for treatment and their treatment goals.
Primary versus secondary disorders. How to distinguish “primary” from “secondary” disorders in dually diagnosed patients has prompted much research and debate.
A psychiatric disorder is typically called primary when it can be viewed as independent from the substance use disorder. The term “secondary psychiatric disorder” connotes that the substance use disorder is causing the psychiatric symptoms. For example, alcohol-dependent patients in detoxification programs often have depressive symptoms, some of which abate with abstinence. They are frequently diagnosed as having “secondary depression,” or—in DSM-IV diagnostic terms—substance-induced mood disorder.
Unfortunately, distinguishing primary from secondary disorders is sometimes difficult because of patients’ poor memory, recall bias, and inadequate periods of sobriety (“I’ve been drinking for a long time and have been depressed for a long time, so I don’t remember what I was like when I was sober”). Thus, the diagnostic assessment is generally accomplished over time, rather than in a single interview.
Our research3 and clinical experience have taught us that patients’ recall about the relationship between their substance use and psychiatric symptoms often changes over time. Determining the “primary” disorder may also have limited validity in predicting treatment response.4
Stages of Change model. The Stages of Change model5,6 is useful for assessing a dually diagnosed patient’s motivation to change, although its use in addictive disorders has been challenged.7,8 According to the transtheoretical model developed by Prochaska et al (Table 1),5 people generally make behavioral changes in stages defined by their level of willingness to make these changes.
When counseling the dually diagnosed patient, it is useful to assess readiness to change and to suggest behavioral steps the patient is able and willing to make. Thus, it would not be appropriate to discuss drug refusal methods with a patient who does not see his substance use as a problem. Rather, addressing this patient’s ambivalence would be more useful.
Table 1
5 stages of change: The transtheoretical model of behavior change
| Stage of change | Patient behavior |
|---|---|
| Precontemplation | No intention to change behavior in the foreseeable future; little or no awareness of problems |
| Contemplation | Aware that a problem exists; seriously thinking about overcoming it but no commitment to take action |
| Preparation | Intends to take action within the next month; has tried unsuccessfully to take action in the past year |
| Action | Modifies behavior, experiences, or environment to overcome problems |
| Maintenance | Works to prevent relapse and consolidate gains attained during action stage; for addictive behaviors, maintenance extends indefinitely from 6 months after the initial action |
| Source: Prochaska JO. Transtheoretical model: Stages of Change. Cancer Prevention Research Center, University of Rhode Island. http://www.uri.edu/research/cprc/TTM/StagesOfChange.htm | |
It is important to note that many patients move back and forth between stages of readiness to change. For example, a patient in the action stage (entering treatment and pursuing a goal of abstinence) may revert to contemplation and again question whether he or she has a serious substance abuse problem. We recommend that clinicians reassess patients regularly and continue to match interventions with the current level of motivation.