Abstract
In this paper, I will cover the issues of treating patients with dual diagnosis. Dual diagnosis is a condition when patients develop two disorders, and most healthcare professionals are not able to assist those patients in treating their conditions. A literature review reveals that lack of proper regulations and specialized treatment models are considered the main causes of low recovery rates among patients with comorbid disorders. Other issues include lack of patient motivation, education, compliance with treatments, etc. The available literature mainly criticizes the contemporary situation in healthcare when it comes to treating patients with comorbid disorders, but some approaches based on combining individual and group therapy are helpful. While some hospitals show efforts to establish working systems in healthcare facilities that will improve treatment outcomes, the current situation indicates that dual disorders are too complex and that only individual-level treatments could prove the most productive and effective.
Keywords: comorbid, comorbidity, dual disorders, mental disorders, substance abuse
Dual diagnosis is defined as a mental state when the patient simultaneously suffers from two psychological disorders. The most common dual diagnoses include substance abuse and psychotic disorders, followed by anxiety disorders and mood disorders (National Institute on Drug Abuse [NIDA], 2011). The literature review on the comorbidity of substance abuse disorders and other disorders indicates that comorbid cases present several issues for healthcare professionals. Three articles were reviewed to find the common issues in treating comorbid cases, future directions, and potential solutions to those issues. The statements found in the literature review correlate exactly to a case study that provides one case of a comorbid disorder and how motivation significantly increases successful treatments. Because motivation appears to be the most influential determinant for positive treatment outcomes, it is questionable if fixed models can fulfil all patients’ needs. Rather than focusing on general healthcare delivery, treatments with patients who suffer from dual disorders should be personalized and highly adaptable.
Literature Review
The article “Psychosocial Treatments for People with Co-occurring Severe Mental Illnesses and Substance Use Disorders (Dual Diagnosis): A Review of Empirical Evidence,” written by Horsfall, Cleary, Hunt, and Walter (2009), analyses the empirical research and treatment proposals for people with dual diagnoses. The authors’ approach is based on categorizing symptoms in compliance with the “Diagnostic and Statistical Manual of Mental Disorders.” Horsfall et al. (2009) are concerned with dual diagnoses because mental illnesses often show high comorbidity rates, so the authors review relevant research to clarify the background and potential treatments for people who live with dual diagnoses. The main focus of the article is the development of comorbid psychiatric disorders and analysing treatment effectiveness.
Horsefall et al. (2009) begin by identifying the four categories of people who are at high risk for developing comorbid mental disorders. To demonstrate the risks of dual diagnoses development, the authors cite a prevalence study by the Epidemiologic Catchment Area (ECA) revealed that 37 percent of people with alcohol abuse disorders and 53 percent with other substance abuse disorders have comorbid mental conditions. Several hypotheses are proposed to explain the correlation between substance abuse and psychosis development, but the main point is that both substance abuse and predispositions to psychosis development work in synergy. The consequences of developing comorbid disorders include high treatment non-compliance rates, treatment relapse, suicidal ideation, social isolation, aggression, and developing several physiological disorders. Most clients fail in their treatments because they lack motivation to reduce substance intake.
The authors analyse individual interventions, group interventions, treatment principles, potential treatments, and empirical evidence that supports positive outcomes of several treatment approaches. Although the authors present a wide variety of approaches and support their statements with credible, specific, and adequate evidence, the evidence for proposed treatments focuses on a broad variety of comorbidity cases. The variety of potential cases does not allow any generalised statements or the development of general treatment models. However, the authors cover each approach in great detail and provide useful information that healthcare professionals can use to develop personalized models and treatment approaches for each patient with dual diagnosis. Furthermore, the article enables healthcare professionals to see that the variety of potential cases requires only personalised treatment models and suggests future directions to engage in testing healthcare delivery models for patients with dual diagnoses.
In the article “Service development: developing a service for people with dual diagnosis,” Whicher and Abou-Saleh (2009), point out the difficulties of curing dual diagnoses, and the main focus is on the comorbidity of substance abuse disorders and other psychiatric conditions because substance abuse disorders show the highest correlations with dual diagnoses cases. The treatment model explained in the article appears to be non-categorical because the authors believe comorbid disorders often overlap and cannot be identified or categorized specifically. The authors focus on describing a service model for patients developed in Richmond, and they focus on treatment quality and solutions rather than explaining the background and development of dual disorders.
According to Whicher and Abou-Saleh (2009), the main issues when treating dual diagnosis are the complex interactions between substance abuse and other mental disorders. It is often difficult to identify the primary disorder to engage with proper treatment. Furthermore, patients with multiple conditions often do not fit among popular frameworks and general psychiatric services. Those issues often result in poor treatment choices that fail to engage the patients’ problems adequately. In response to the criticism of existing service models, the authors focus on a service model being developed at Richmond specifically for dual diagnoses patients. While exploring mainly the mechanics behind the institution operations, mission statements, training the staff, and linking with other services, the authors outline the basic approach to patients with comorbid disorders. Those stages include, assessment, education, brief interventions, formal addiction interviewing, and relapse prevention. The model covers all needs of patients with comorbid disorders and helps them with physiological detoxification, motivation building, and psychological support.
The topic is adequately covered by the authors. Although it lacks practical examples that would illustrate the practical application of the proposed model, that is understandable because the model is still in the early stage of development. Whicher and Abou-Saleh (2009) claim that there is still not enough data to analyse the disadvantages and suggest potential improvements of the model developed at Richmond. Other than lack of criticism, which currently cannot be objective and complete, the article focuses on one specific model, so it allows the authors to focus on explaining that model in great detail. While the article lacks practical examples, the authors identify the issues behind existing treatment models effectively and describe the mechanics behind the new proposed model in Richmond in great detail.
Edward and Munro (2009) present information about nursing and monitoring patients with dual diagnoses in their article “Nursing Considerations for Dual Diagnosis in Mental Health.” The article is based purely on literature review, and the authors take a practical approach rather than elaborate on patient care models in theory. The authors confirm the popular issues in treating patients with dual diagnoses. The main issues include lack of comprehensive care that often leads to patient relapse, non-compliance, lack of motivation, multiple admission, homelessness, and legal issues. The main focus of the article is to suggest implications for nursing practices when treating patients with dual diagnoses, but the article fails to address potential solutions to the problems.
The authors provide the background, epidemiology, trajectories of illnesses development, screening, assessment, and obstacles for treating dual disorders. However, the article indicates that the authors mainly criticise the existing models of care and point out the issues those models fail to solve. Those issues are well-known in healthcare. Rather than providing reinforcement through various sources, the authors should have focused on future directions for improving treatments. Other than general suggestions throughout the article, such as increase staff education, allocate more nursing resources, or improve existing treatment models, the authors fail to make specific statements that could clarify their vision of an acceptable dual diagnoses care in modern healthcare.
The scope of the topic does not match the length, depth, and concise writing style of the article. For example, the section dealing with screening and assessment indicates that several contemporary screening tools can be effective, and that certain knowledge and skills can assist healthcare professionals. However, those few sentences fail to describe such approaches, and they fail to address some of the common issues in diagnosing comorbid disorders. For example, the difficulty of determining the primary disorder is not addressed by the authors. Rather than suggesting specific issues, addressing their backgrounds, and suggesting or proposing solutions, Edward and Munro (2009) simply point out general issues, such as lack of employee expertise and non-timely diagnoses. The article only points out various issues without thoroughly discussing solutions proposed by empirical studies and healthcare facilities. It also does not give specific instructions for future directions in developing healthcare models, so it does not contribute to the advances in psychiatric treatment of people with comorbid disorders.
Discussion
It is possible to notice that there are several consistent statements in the literature review. Furthermore, it is almost impossible to notice any contradictions. All perspectives presented in existing literature related to dual diagnoses patients are consistent in criticising existing healthcare delivery models and the complexity of treatments. However, the authors do not provide adequate focus on solutions in their articles, and they cannot propose absolute conclusions because research evidence supports the dynamic nature of treating patients with dual diagnoses.
All authors agree that current service models are not suitable for patients with dual diagnoses, but they approach the issue from different perspectives (Edward & Munro 2009; Horsfall et al. 2009; Whicher & Abou-Saleh 2009). Whicher and Abou-Saleh (2009) address the potential solutions by offering potential models implemented in healthcare facilities. On the other hand, Horsfall et al. (2009) address the interventions used on individual and group levels, so they mainly focus on measured outcomes of cognitive-behavioural therapy (CBT), motivational interviewing (MI), and self-help groups. The article by Edward and Munro (2009) is the least helpful article for understanding issues and potential solutions to treating patients because only broad statements and issues are presented without adequate elaborations on the topic. However, all authors indicate that inadequate healthcare resources and staff education for dealing with patients who suffer from comorbid disorders.
Jason Craig has a 10-year medical history of substance abuse and psychotic disorders. Craig’s case is an example of the most common comorbidity between substance abuse and other psychiatric disorders (Horsfall et al. 2009). His constant readmission to the PECC unit and acute mental care hospitals indicates one of the issues presented by Edward and Munro (2009) for patients with dual diagnoses. Furthermore, it supports the statements that treatments are often ineffective because patients lack motivation and refuse to give up their old habits (Horsfall et al. 2009; Whicher & Abou-Saleh 2009). It also indicates the necessity for new healthcare delivery models that motivate and simultaneously engage different issues the patients suffer from (Whicher & Abou-Saleh 2009). Craig’s solution to the problem was his desire to engage in self-help groups. While the main issue with dual diagnoses patients is lack of motivation to leave undesired behaviours and non-compliance with treatments (Horsfall et al. 2009), Craig’s girlfriend and their expected child acted as sufficient motivational factors that encouraged Craig to leave his old habits behind and seek professional help. Craig’s path to recovery was triggered by a random situation, and that indicates the lack of motivational abilities of healthcare professionals for most patients with comorbid disorders.
Conclusion
Although research shows that substance abuse is the most common comorbid disorder, a report by the National Health Service (2009) in England indicates that many patients, who suffer from dual diagnosis, suffer from anxiety and depressive disorders. The type of treatment would depend on both disorders and identifying the primary issue. Because the patients’ motivation cannot be influenced by generic environmental factors, so only an adaptable and personalized approach can help.Medication therapies for people with comorbid disorders still lack clinical research and support (NIDA, 2011), so treatments should omit medication intake for now and focus on individual therapy. The main concern is to start early interventions with MI because lack of motivation is the leading cause of low recovery rates from dual disorders. Group therapy did not prove effective because patients often feel that one aspect of their needs is neglected in group therapies that focus on one disorder, but patients are encouraged to seek self-help group counselling to address one aspect of their issue (Vogel et al. 1998). However, healthcare professionals should focus only on individual therapies and personalize treatment approaches that constantly monitor each patient’s progress and set realistic goals in compliance with individual backgrounds of each patient.
References
Edward, K., & Munro, I. 2009, ‘Nursing considerations for dual diagnosis in mental health’, International Journal of Nursing Practice, vol. 15, no. 2, pp. 74-9.
Horsfall, J., Cleary, M., Hunt, G. E., & Walter, G. 2009, ‘Psychosocial treatments for people with co-occurring severe mental illnesses and substance use disorders (dual diagnosis): a review of empirical evidence’, Harvard Review of Psychiatry, vol. 17, no. 1, pp. 24-34.
National Health Service 2009, Mental health network fact sheet, The NHS Confederation, London, viewed 11 March 2012 < http://www.nhsconfed.org/Publications/Documents/ MHN_factsheet_August_2009_FINAL_2.pdf>
National Institute on Drug Abuse 2011, Comorbidity: addiction and other mental disorders, National Institutes of Health, Bethesda, MD, viewed 11 March 2012, < http://www.drugabuse.gov/sites/default/files/comorbidity.pdf>.
Vogel, H. S., Knight, E., Laudet, A. B., & Magura, S. 1998, ‘Double trouble in recovery: self-help for people with dual diagnoses’, Psychiatric Rehabilitation Journal, vol. 21, no. 4, pp. 356-364.
Whicher, E. V., & Abou-Saleh, M. T. 2009, ‘Service development: developing a service for people with dual diagnosis’, Mental Health and Substance Use: Dual Diagnosis, vol. 2, no. 3, pp. 226-34.
