Academic journal article Indian Journal of Psychiatry

Psychosocial Interventions in Patients with Dual Diagnosis

Academic journal article Indian Journal of Psychiatry

Psychosocial Interventions in Patients with Dual Diagnosis

Article excerpt

Byline: B. Subodh, Nidhi. Sharma, Raghav. Shah

Management of patients with dual diagnosis (Mental illness and substance use disorders) is a challenge. A lack of improvement in either disorder can lead to a relapse in both. The current consensus opinion favours an integrated approach to management of both the disorders wherein the same team of professionals manages both the disorders in the same setting. The role of pharmacotherapy for such dual diagnosis patients is well established but the non-pharmacological approaches for their management are still evolving. After stabilization of the acute phase of illnesses, non-pharmacological management takes centre stage. Evidence points to the beneficial effect of psychosocial approaches in maintaining abstinence, adherence to medication, maintenance of a healthy life style, better integration in to community, occupational rehabilitation and an overall improvement in functioning. Psychosocial approaches although beneficial, are difficult to implement. They require teamwork, involving professionals other than psychiatrists and psychologists alone. These approaches need to be comprehensive, individualized and require training to various levels that is difficult to achieve in most Indian settings. In this article we provide a brief review of these approaches.


The concept of dual diagnosis dates back to time immemorial, but the term dual diagnosis was formally outlined in 1994. The National Library of Medicine (NLM) introduced a new Medical subject heading (MeSH) as ' Diagnosis, Dual (Psychiatry) ' defined as 'the co-existence of a substance use disorder with a psychiatric disorder. The diagnostic principle was based on the fact that it has been found often that chemically dependent patients also have psychiatric problems of various degrees of severity' (MeSH, NLM, 1994). Ries (1995) listed the various terms being used to address the co-morbid severe mental illness and substance use disorders and among these, dual diagnosis seems to have emerged as the favoured term[1]. 3238 references are listed under the MeSH (Medical subjects headings) in Pubmed database in December, 2017.

SUDs are highly comorbid with borderline and antisocial personality, bipolar, psychotic, depression, and anxiety disorders[2]. In USA, around half of the people seeking treatment for SUD are diagnosed as having a co-occurring mental health disorder[3]. The Epidemiological catchment area study in USA showed a lifetime prevalence of comorbid SUD in patients with Schizophrenia to be around 47% and in patients with Bipolar disorder to be around 61%[4]. There are no nationally representative studies of prevalence of dual diagnosis in India. A recent well-conducted study from a clinic in North India showed that one-third (32.4%) of patients seeking treatment for SUD were diagnosed as having a co-occurring mental health disorder. Majority of the cases had affective disorder (12.3%), anxiety disorder (11.2%) and psychotic disorder (5%)[5]. Most patients with BPAD (affective disorders) report improvement in mood symptoms upon using substances[6]. Patients with Dual Diagnosis have high rates of mortality and morbidity[2],[3],[5],[6].

The need for a comprehensive and individualized management was recognized since a long time, but various conflicting models of management have evolved. Among these, the integrated model of management is now accepted as a norm. The integrated model refers to the focus of treatment on two or more conditions simultaneously and to the use of multiple treatments, such as the combination of psychotherapy and pharmacotherapy[7].

The pharmacological treatments are mainly directed towards the neurobiological changes associated with mood disorders, anxiety disorders and psychotic disorders, management of acute episodes and exacerbations and maintenance treatment for prevention of relapse. Psychosocial treatments are not a stand-alone treatment for dual diagnosis patients. …

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