Charl Els, MBChB, FCPsych, MMedPsych1
(Can J Psychiatry 2007;52:167-169)
For centuries, mental illness was viewed as an invasion by evil spirits that had to be exorcised. Later practices dictated sending the afflicted away to asylums, and eventually the custodial model gave way to a trend of deinstitutionalization. Despite its deficits, this translated into an increased potential for societal involvement and interaction that changed the mental health landscape. In the context of addiction, the last few decades have yielded a body of evidence confirming the formerly disavowed disease of addiction as a group of bona fide mental disorders. Although this disease concept is endorsed by most contemporary psychiatrists, many health care systems' models have not successfully escaped the "moral management archetype" holding addiction hostage. What does this mean, and how does this affect patient care? There are more questions than answers, and easy solutions are evasive, making the challenges at a systems level at least as intractable as the problem of addiction itself.
Addictionology, or the study of addictions, has emerged as a distinct and useful subspecialty,1 and despite the multifaceted presentation of addictive disorders, it is described with remarkable similarity in major global mental health taxonomy systems.2 Additionally, although the diagnoses in this category have achieved sufficient construct validity and internal consistency of criteria on a systems level, addiction is often not recognized as such and is neglected when public health policy and fiscal priorities are determined. Could patients be falling through the cracks as a result of our health care system's failure to adequately endorse addiction as a chronic, relapsing mental disorder? Is it possible that some policy-makers' views of addiction as a personal choice (or a social phenomenon responsible for undesirable behavior, crime, and immorality) have not been replaced by a more enlightened stance? The prevailing policies separating addiction from mainstream psychiatry certainly do not speak to the contrary. Addiction may, at last, be coming out of the shadows, but it is certainly not in from the cold.
Although addiction is a complex disease involving physiological, psychological, genetic, behavioural, and environmental factors, it is fundamentally a disease of the brain,3-5 and like many other chronic mental disorders, it is amenable to treatment. In what amounts to a historical anomaly, the mental health community was (and in many jurisdictions still is) disenfranchised as the primary and rightful custodian for the treatment of this disease. Would it be considered a leap of faith to suggest that the treatment of this chronic mental disorder could be best directed by the discipline dedicated to the study and treatment of other chronic disorders of the brain?
Addiction is the most common psychiatric disorder and the most prevalent comorbid condition in individuals with other mental illnesses. It costs the Canadian economy an estimated $40 billion annually,6 which is greater than the economic impact of all other mental illnesses combined. Further, for several plausible reasons, the prevalence and costs of addiction are increasing and have possibly not yet reached a plateau. Nevertheless, despite the devastating economic impact of addictions, a dire need for solutions, and the confusing panoply of available (but not necessarily effective) treatment options, most addicted individuals remain untreated. In treatment-seeking cases, the health care system often finds itself ill-equipped, yet compelled to deal with complications arising from addictions. In a system where there is no universal expectation to meet evidence-based standards, many addicted individuals seeking treatment fail to find an appropriately matched modality. In this diluted and fragmented system, so-called addicts may find themselves stigmatized, disenfranchised, homeless, impoverished, destitute, or drifting in and out of psychiatric facilities, the criminal justice system, emergency departments, and faith-based settings. …