Academic journal article Alcohol Health & Research World

The Challenge of Dual Diagnosis

Academic journal article Alcohol Health & Research World

The Challenge of Dual Diagnosis

Article excerpt

Researchers have made great strides in understanding and treating alcoholics with co-occurring psychiatric disorders. Improved diagnostic criteria are available, and research has demonstrated that both disorders must be addressed if the dually diagnosed patient is to have the best chance for a good outcome. The best type of treatment program is an integrated approach, assuring that treatments will be coordinated for best effect. Additional research is needed to match optimum treatment approaches with cost-effective reimbursement practices. KEY WORDS: dual diagnosis; AOD dependence; comorbidity; behavioral and mental disorder; diagnostic criteria; prevalence; etiology; diagnosis; health care delivery; treatment program; treatment outcome

The traditional view that psychiatric disorders are unrelated to alcohol and other drug (AOD)use problems' has hampered effective treatment of patients who exhibit both types of disorder (Ries 1993; Miller 1994). Psychiatric and AOD disorders produce many similar symptoms and often coexist in the same patient, where one disorder can influence the course and treatment outcome of the other. The existence of two or more different disorders in the same patient is referred to as comorbidity. Patients with comorbid AOD and psychiatric disorders are said to have dual disorders, or a dual diagnosis.2

Research indicates that patients with dual diagnoses are more disabled and require more services than patients with a single disorder. In addition, they are more prone to suicide (Cornelius et al. 1995) and have higher rates of homelessness and legal and medical problems as well as more frequent and longer hospitalizations (see Center for Substance Abuse Treatment [CSAT] 1994).

Patients with dual disorders may be misdiagnosed and improperly treated, often "falling through the cracks" in the health care system (Merikangas and Gelernter 1990; Minkoff 1989; Ries 1993). For example, alcoholics with psychiatric disorders may be rejected by both alcoholism programs and mental health programs (National Institute on Alcohol Abuse and Alcoholism 1991). This article explores some problems in diagnosing and treating alcoholics with dual diagnoses.

HOW COMMON IS DUAL DIAGNOSIS?

Two large epidemiologic studies have provided data on the prevalence of dual diagnosis in the general population. The Epidemiologic Catchment Area (ECA) study sought data on psychiatric disorders and their treatment from more than 20,000 residents of households, group homes, and long-term institutions in five sites across the United States (Regier et al. 1990). The ECA found that 13.5 percent of respondents had experienced an alcohol-use disorder at some time in their lives, 6.1 percent had experienced other drug-use disorders, and 22.5 percent had experienced non-AOD psychiatric disorders (Regier et al. 1990). Lifetime prevalence for any psychiatric or AOD disorder was 34 percent (Helzer and Pryzbeck 1988). Overall, the lifetime prevalence for any psychiatric disorder was 44 percent among people with an alcohol disorder and 64.4 percent among people with other drug-use disorders (Regier et al. 1990).

More recently, the National Comorbidity Study (NCS) administered structured psychiatric interviews to more than 8,000 respondents ages 15 to 54 in the noninstitutionalized civilian population of the United States. The NCS found higher rates than the ECA for any or all lifetime disorders (i.e., 48 percent) (Kessler et al. 1996). As in the ECA, the NCS found most mental disorders to be more common among persons with a current or lifetime AOD diagnosis than among those who had never experienced AOD problems (Kessler et al. 1996).

The NCS also found that most disorders had their onset prior to the onset of the AOD disorder. A significant exception to this general finding was mood disorders (e.g., depression) among male alcoholics, which usually developed after the onset of the alcoholism (Kessler et al. …

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