Mental Health Industry Treatment of Addictive Disorders

Introduction

Physical and mental health reflects the personality of a person. For increasing productivity, happiness in a human being’s life health is a major and important factor. A person is considered mentally healthy, only if he/she possesses good physical and mental equilibrium. This is because there is a clear and distinct nexus between mind and body and each buttress the other about human work activities.

During the earlier period, people did not attach much importance or give that much attention to mental health. But with societal development with concomitant mental stress and its impact on both body and mind, it is now considered an important issue. A person to be considered healthy should satisfy certain minimum conditions. A mentally healthy person is always ready to accept his strengths and limitations, as they are, and possesses the ability to control his feelings and emotions. He is aware of his roles and responsibilities in life in terms of their obligations to society. If a person is not mentally healthy, it may mean that he may have some illness that needs to be treated and cured.

Most psychological studies consider this stage a psychiatric disorder. According to the book, A Short Text Book of Psychiatry by Niraj Ahuja, the psychiatric disorder is defined as a “disturbance of i. Cognition (i.e, Thought), or ii. Conation (i.e. Action), or iii. Affect (i.e. Feeling), or any disequilibrium between the three domains.” (A short textbook of psychiatry by Niraj Ahuja, 2006, p.1).

Psychiatric disorder is not an unfamiliar term in the modern world. There is no age limit for occurring psychiatric disorders. It may happen in kids and elder people. There are many contributory aspects of psychiatric disorders, like depression and anxiety. Even use of drugs, alcoholic addictions, etc., could be prime reasons for psychiatric disorders.

Addiction is defined as “A chronic relapsing condition characterized by compulsive drug-seeking and abuse and by long-lasting chemical changes in the brain.” (Definition of addiction, 2009). Like psychiatric disorders, addiction is a common word in this period. Addiction means obsession, engrossment, or extreme psychological dependence on one or more specific things. In this kind of person, normal functioning of the body and maintenance of mental equilibrium depends upon regular supply and intake of such substances to which he is addicted. Many people are addicted to things like drugs, alcohol, computer and video game, work, etc.

Research Hypothesis

This research study concerns itself as to whether there exists any relationship between psychiatric disorders and addictions.

A relationship lies between psychiatric disorders and addiction. There is a possibility for persons having psychological disorders to become addicted to the drug, alcohol, and chemical dependency and abuse, and it is also possible that chemically dependent people may degenerate to psychiatric cases. But it is not a must. It may take place independent of each other. It is also possible that psychiatric disorders can occur without addiction, and/or substance abuse. Psychiatric disorder condition may be arising without the presence of addiction or a person become addicted to a certain substance without psychiatric disorder. There is a high probability for psychiatric disorders to occur without addiction and the reverse effect is also not implausible. At the time of treatment for this kind of people, this factor also needs to be considered. Otherwise, it will lead to a more dangerous situation. In this state of affairs, dual diagnosis and its treatment are very important. For understanding the relationship between these two factors a detailed study about psychiatric disorders and addiction is essential.

Psychiatric disorders are mainly in six types. They are “anxiety disorders”, “depressive disorders”, “personality disorders”, “behavioral disorders”, “eating disorders” and “psychotic disorders”. (Types of psychiatric disorder, 2009).

These could also be subdivided into kinds of anxiety disorders manifesting strange, pathological fears and nervousness. Panic disorder, social phobia, obsessive-compulsive disorder, etc. come under this category. (Anxiety disorder, 2009).

Depressive disorder is closely related to a person’s state of mind, body, and thoughts, and imaginations passing through his mind. “Depression”, “bipolar disorder” and “dysthymia” are occurred due to “depressing disorder”. Personality disorder means an abnormal condition in behavior, thought, wishes, etc. Conduct disorder, paranoid personality disorder, avoidant personality disorder, etc come under this group. “Behavioral disorders” influence one’s mental and public behavior. Drugs, alcohol abuse, compulsive gambling, unnatural sexual fantasies, bestiality, incest, etc. are examples of behavioral disorders. Primary symptoms of eating disorders are changes in physical appearance like weight and eating manner. “Anorexia nervosa” is a disorder related to eating. Delusion and paranoia are indicative of the presence of psychotic disorder. Schizophrenia and delusion disorder also come under this class. (Types of psychiatric disorders, 2009).

Like psychiatric disorders addictions have many categories. They are “Alcoholism, Drug, Food addiction, Gambling, Internet, Nicotine, Prescription Drugs, Sex-Porn, Shopping and Work addiction.” (Types of addictions and treatments, 2009).

Alcoholism means persistent sickness occurring due to habitual drinking of alcohol. In many situations, alcoholism is the root cause of physical and mental addiction. This negatively influences the smooth working of the nervous system of the human body. It either partially or fully damages an individual’s conscious mind. Alcoholism also affects the working of the brain, liver, heart, etc. A person becomes either physically or mentally or both ways dependant on drugs like heroin, marijuana, and other prescription drugs. Commonly drug-addicted people may become prone to criminal tendencies than normal people, since certain types of drugs react to reasoning and logical thinking faculties of the brain, and render these areas inert. People who eat too much or are too much worried about food preparation or are abnormally fussy about matters connected with food can be considered as food addicted. Nicotine addiction occurs through the usage of cigarettes and chewing tobacco. According to United States government statistical survey report, approximately 440,000 premature deaths occurred in the US each year due to smoking. (Nicotine- tobacco- cigarette smoking addiction, 2009).

Nowadays many people especially adults and teens show a tendency for abusing prescription drugs in the form of painkillers and other medications. This tendency is called “prescription drug addiction”. Another type of addiction is “sexual addiction”. People who have sexual addiction most probably become public nuisances. Other kinds of addiction like shopping, the Internet, and gambling are not relevant in this study.

Co-occurring disorders: – Co-occurring disorder means the presence of more than one disorder in a single person, that is, the presence of psychiatric disorder and addiction. According to the website called new method wellness “co-occurring disorders is when an individual is suffering from two or more mental, emotional or physical disorders at the same time.” (Dual diagnosis programs and co-occurring disorders treatment, (n.d.)).

In this period, the number of people who are suffering due to co-occurring disorders is increasing year by year. It is not a positive indication. One reason for

the co-occurring disorder is one disorder can be the root cause of another disorder. For example, a person who has a psychiatric disorder like anxiety or depression may abuse or show a tendency for addiction to drugs or alcohol. In such a case, if the person gets treatment for depression or anxiety, it will not provide relief from drug or alcohol addiction. This kind of person after treatment will show a psychiatric disorder like depression due to the usage of drugs or alcohol. According to a survey report in the US in 1997 around 10 million people had co-occurring disorders. (Lowa PIC focus: Co-occurring disorders, 2001).

This report indicates that psychiatric problems and alcohol or drug addiction have a nexus. According to a Report of Mental Health Association of Southeastern Pennsylvania, 37 percent of alcohol-addicted people and 53 percent of drug-addicted people have at least one psychiatric disorder. On the other side, almost 29 percent of psychiatrically disordered people are addicted to substance abuse. This report also says that people who have psychiatric disorder has three to six times more probability of drug abuse than people without psychiatric disorder. But it is difficult to say which problem occurs first out of the two. In some cases, people with mental illness use drugs or alcohol to overcome their difficulties. In medical terms, it is called self-medication. Self-medication slowly moves to the usage of drugs and alcohol. It may occur vice versa, that is, a person who is an alcohol or drug addict may gradually develop symptoms of the psychiatric disorder like depression, suicide tendency, delusion, etc. (Co-occurring disorders, (n.d.)).

Co-occurring disorders are seen in all kinds of people; children, adults, students, employees, etc. If people have either psychiatric disorders or addiction, such people may bring a negative influence on the family and society. If a person has these two problems at the same time, its aftereffect will be all the more. In an APA report, six out of 10 individuals who have an addiction to drug or alcohol also has a mental illness. (Bettesworth, 2009).

It also states that there is an increased chance of people with mental illness or addiction contracting other diseases compared to normal people. According to, the Director of the National Institute of Drug Abuse, Nora Volkow “people with depression are 40 percent more likely to develop lung cancer than the average person, while schizophrenics are at double the risk. In addition, 60 percent of deaths of those with co-morbid disorders occur due to poisoning when attempting to self-medicate.” (Bettesworth, 2009, para.4). From this statement, it is clear that the presence of psychiatric disorders, alcohol and drug abuse, or co-occurring disorders will increase the chance for other severe diseases and death.

Dual Diagnosis: – Dual diagnosis and co-occurring diseases cannot be considered as extremely different situations. They are almost the same. Mental Health America (MHA) defines dual diagnosis as “A person who has both an alcohol or drug problem and an emotional/psychiatric problem is said to have a dual diagnosis.” (Fact sheet: Dual diagnosis, 2009).

Dual diagnosis facility is common in servicing centers that provide treatment for mental health and alcohol and drug addiction. When one falls into this stage treatment or management of one of the problems, either psychiatric disorder or mental illness is extremely difficult. A major reason for that is they show multiple symptoms which overlap. This increases the difficulty of diagnosing the problem and identifying the proper treatment. In this condition, the patient requires treatment for both problems. Depressive disorders and anxieties are common syndromes for dual diagnosis patients. It is difficult to identify which disorder develops first since both symptoms may be present simultaneously. Here the treatment for co-occurring disorders starts at the same time. The treatment section is started with detoxification and it continues with treatment for dual diagnosis.

From the above paragraph, it is clear that identification of dual diagnosis is a difficult task and its major reason is the mimic of systems in more than one disorder. For example, a person who is addicted to drugs or alcohol shows symptoms like anger and hallucination in the same way as people with mental illness. Another reason is that in many situations family members cannot find the mental illness in substance abusers. People who are distressed due to dual diagnosis may have many other problems which are not related to medical, psychological, and psychiatric disorders. But such people usually opt for mental health services for solving their problems. Their problems may relate to family, society, culture, law, etc. In this circumstance, they need something other than medical treatment. They need treatment or relaxation for their body and mind. So for solving or tackling these problems, joined approach from a different direction is essential.

When discussing dual diagnosis one of the main questions is why people with mental illness tend to substance abuse and vice versa. According to the opinion of G. Hussein Rassool “The mentally ill may experience down the drift to poor inner-city areas (social drift hypothesis) where drug availability is increased.” (Rassool, 2002, p.5).

Normally, people with psychiatric disorders may possess weak minds. So their thoughts and imaginations will also be haphazard and not have clear thinking. Although part of their mind may suggest that their actions are wrong, the addictions are so deep-rooted and hedonistic that they may find it difficult to overcome their limitations and their bodies give way to their chemical dependency needs. For that, they go by the wrong notion that the usage of drugs or alcohol will give them the power to overcome their disabilities. So, at the time of treating this kind of co-occurrence disorder, it is necessary to consider these factors. It is entirely different from treatment for people with substance abuse who is physically fit or treatment of a person with a psychiatric disorder who is not addicted to drug or alcohol.

For the treatment of dual diagnosis involvement of the family with the treatment is a crucial factor. For that family members have to be aware of the stage of the patient. In such cases, more than medical treatment, the patient must be provided with moral support, which will help in avoiding a relapse. Hospital treatment is not a must for all dual diagnosis patients. Hospital treatment is prescribed based on the severity of the condition of the patient. Family members and friends must support patients during their duel with dual diagnosis. Understanding the family members will increase the chances of recovery for the patient. When treating someone some factors should be kept in mind. It is crucial for considering dual diagnosis treatment. It is that when treating co-occurring disorders, it should be ensured that treatment of one problem does not increase the intensity of another disease. If It may occur, it will be advisable to go for a middle path between these two problems.

“The suggested strategy of AA to put aside all other problems and focus only on the alcohol, or the suggested strategy of AA to put aside all other problems and focus only on the alcohol develop a plan.” (Diclemente, 2003, p.155).

From the above, it is clear that the possibility for the co-occurring disorder is very high in psychiatrically disordered people and addicted people. Besides their mental state, family atmosphere, society, culture, etc can be reasons for their developing into dual diagnosis patients. Dual diagnosis patients’ psychology is different from others. They have a different kinds of complexes in their mind. To overcome these kinds of complexities they find substance abuse as a solution. In the case of people with substance abuse or people with continuous usage of drugs or alcohol, their brain and nerve system get ruined. So they lose their thinking capacity. Consequently, they may lose their mental balance.

One cannot place the blame squarely on patients for the responsibility of acquiring or living with dual diagnosis. One’s environment, society, laws, and other factors are involved in this. Cooperation from all these aspects is important for the treatment and recovery of the people who are suffering due to dual diagnosis. Otherwise, they may become a problem to the family and society.

Treatment of Dual Diagnosis

In the case of co-occurring disorders, one among the substance abuse or psychiatric disorder is considered as the primary problem. The treatment of Dual Diagnosis generally involves the determination of the primary problem. But it is a difficult task because many symptoms of severe substance abuse are similar to that of mental disorders. Moreover, it is also seen that a line of treatment for one condition may also need to take cognizance of the other and vice versa and the consumption of conflicting drugs for treatment may aggravate or exacerbate the situation. This is more palpable in chronic cases where it becomes necessary to first arrest the conditions before starting the actual line of treatment. Prolonged use of drugs may often render the symptoms temporarily invisible and yet may flare up again if remission occurs.

Many experts believe that the diagnosed patient must undergo treatment for withdrawal from drugs or alcohol before assessing the possibility of any underlying psychiatric problem. Even though both problems are to be treated simultaneously, the first step of the treatment process is usually what is termed detoxification. This process, which is done under medical supervision and professional monitoring, allows the body to clean itself from the harmful effects of drugs or alcohol. For many patients, detoxification could be a painful experience and the withdrawal symptoms may be agonizing. But nowadays, doctors can help the patients to manage this without many painful effects, through current pain management systems, counseling, and other psychiatric interventions in the best interests of patients and early recovery.

The detoxification process leads to the intervention on substance abuse and psychiatric disorder. There are rehabilitation centers for people suffering from substance abuse and psychiatric settings for the treatment of mental disorders. The rehabilitation of substance abuse consists of medication and also psychotherapy which aims at bringing about behavior changes needed to cure addiction. Other therapeutic methods such as counseling and group work are also found to be effective in the treatment. The patients are often encouraged to join

self-help groups such as Alcoholics Anonymous (AA) that provides them a platform to share their experiences and to discuss the problem with other patients. The treatment of psychiatric disorders involves usual procedures of medication and therapy suitable for different disorders. The web article entitled ‘Fact sheet: Dual diagnosis’ in the ‘Mental Health America website’ makes this clear by putting it as, “Adjunct treatment, such as occupational or expressive therapy, can help individuals better understand and communicate their feelings or develop better problem-solving or decision-making skills.” (Fact sheet: Dual diagnosis, 2009).

The treatment methods for psychiatric disorders such as depression, mood disorders, and personality disorders that co-occur with addiction vary according to their nature and severity. The care and support and understanding of family members are instrumental in the recovery of patients. The family of the patient also needs support from the community and should be made aware that substance abuse is a disease and not a matter of disgrace to the family. Another effective element in the prevention of recovery and relapse of co-occurring disorders is the formation of self-help groups of families affected by this disorder. This helps in sharing their grief and also in widening their knowledge about the problem and possible treatments.

Addiction and depression

Substance abuse and addiction are major health problems in America and when coupled with mental illness the situation is much more serious which would pose great risks to safety and health, become an economic burden and the recovery and success in treatment will be difficult to achieve. The prevalence of depression in the United States is high. If depression lasts long, there is the possibility that it may become chronic. The major symptoms are persistent sadness, lack of interest in daily activities, thinking about suicide, lack of self-esteem, and physical symptoms such as loss of weight and sleep disorders. Among the different co-occurring disorders the common dually diagnosed problems are addiction and depression. When speaking about the connection between depression and addiction Dennis C. Daley refers to the words of Regier, et al, when he says, “almost one-third of individuals with depression had a co-existing substance use disorder at some point in their lives.” (Daley, 2007, para.3).

The author of the above article, Dennis C. Daley, Ph.D.; holds the view that there is a difference in the occurrence of addiction and depression in men and women. In the case of men, the addictive disorder develops first and this is followed by depressive episodes, but generally, in the case of women instead of addiction, depression manifests at the beginning which may pave the way to the development of addiction. Many people use drugs and alcohol to get temporary relief from grief, anger, or similar feelings. Some others who feel depressed or alone often turn to alcohol and drugs for comfort. There is evidence that connects the use of cocaine to psychiatric problems which often results in hallucinations, anxiety, or similar psychological disorders.

The effect of this dual disorder has multiple dimensions. Children of the patients often face stigma, abuse, and neglect, and the chance of developing conduct disorders and personality problems is high among them. “Children of depressed mothers are at increased risk for a psychiatric disorder; the prevalence of ‘multi-problem’ children is over eight times higher among families with a depressed parent (Yapko, 1999).” (Daley, 2007, para.6).

Treatment of addiction and depression

In the treatment of this dual disorder, the first stage is assessing which problem appeared first. If it is an addiction then helping the patient to stop substance abuse, using behavior therapies, counseling, and if necessary with medication may reduce the level of depression. If depression is a serious issue then it has to be treated with special counseling therapies and proper anti-depressant medication. An integrated treatment approach should be adopted to help the patient to recover from and manage disorders and to make changes in his or her social and family life. The generally accepted approach in the treatment is to adopt the combined therapy of medication with interventionist therapy that addresses the co-occurring disorders. Familial support and participating in self-help programs are also not detrimental in the treatment of co-occurring addiction and depression. Though recovery from a combination of these two problems is hard to achieve, a good dual diagnosis, understanding of the link between disorders, and an integrated treatment will make recovery possible.

Referring out

Referring patients to better or more specialized care is needed in many acute cases. In the areas of dual diagnosis, referral of patients is inevitable, because the patient is affected by different kinds of disorders and medical experts from diverse fields are required to ensure an integrated treatment. Addicted patients are to be treated in Rehabilitation Centers, while the psychiatric problems need a mental hospital for proper care.

Referring to self-help groups is also an important step in the treatment of dual disorders. The pertinent and vexing issue about referring dual diagnosed patients is that a community provides treatment of addiction at one particular center, and treatment services for psychiatric problems are available in another center.

This often results in referring the patients back and forth between these centers thus making the integrated treatment difficult for patients and physicians as well. This repeated referral between mental health and addiction services is called “the ping pong effect.” (Griffin, Campbell, McCaldin, & McAuley, n.d.).

What is needed in the treatment of Dual Diagnosis is adopting an integrated approach or hybrid programs that can effectively address both problems together.

Personality disorders

The explanation of personality disorders provided by the National Institute of Health is that they “are long-term patterns of thoughts and behaviors that cause serious problems with relationships and work.” (Personality disorders, 2009).

According to them, people having personality disorders often find it very difficult to deal with problems of daily life and to cope with stressful experiences. Their relationship with others is also found to be troublesome and maintaining lasting relationships with others may also be challenging and a difficult proposition.

People with personality disorders may have rigid attitudes and not flexible attitudes and may lack the ability to show proper responses to people and situations.

Their outlook of the world is very narrow and so social life is very difficult for them, even though they feel that their behavior may be normal.

The symptoms of this disorder begin to appear in adolescence and continue in adulthood, which will become less apparent during the middle age period of patients. The exact reason for this disorder is not yet known and some believe that genetic factors and bitter experiences in childhood may be the primary cause for personality disorders.

Types of personality disorders

There are many types of personality disorders and are classified mainly as

• cluster A: Odd or eccentric behavior
• cluster B: Dramatic, emotional, or erratic behavior
• cluster C: anxious, fearful behavior. (Fact sheet: Personality disorders, 2009).

The most important ones among each cluster in the context of comorbidity with substance abuse are the following.

Cluster A consists of Schizoid personality disorder where people are highly introverted, alone, and have no intimacy with others; Paranoid Personality disorder is characterized by untrusting and unforgiving behavior and shows unjustifiable emotional outbursts and are often jealous; Schizotypal personality disorder is characterized by eccentricity in speaking or dressing, inappropriate responses and anxiety in social situations.

Cluster B includes antisocial personality disorder where people are hesitant to obey social rules, have aggressive and violent relationships, and show no respect and consideration to others. The article about personality disorder on the Mental Health America website suggests that the people suffering from this type of disorder are often addicted to drugs and alcohol because it helps them to escape from tension and boredom. (Fact sheet: Personality disorders, 2009).

Borderline personality disorder shows unstable relationships, moods, and behavior, indulging in self-injury and perceiving things in extremes, experiencing the chronic feeling of emptiness, etc.; narcissist personality disorders are characterized by people with exaggerated self-image and self-admiration and becoming oversensitive to failure.

Cluster C comprises of avoidant personality disorder- people who are hypersensitive to rejection and afraid of criticism, timid and unwilling to engage in social or work activities; Dependant personality disorder- people lacking self-confidence, rarely taking initiative, and always depending on others for advice and decision making, Obsessive-Compulsive personality disorder- people who need perfection and never feel satisfied with their success. They pay attention to minute details and often repeat their actions awkwardly several times to seek perfection in them. This habit makes them leave most tasks uncompleted.

Co-occurrence of personality disorder and addiction

It is estimated that the Axis II personality disorders in the DSM classification are the most common co-occurring disorders in treated substance abusers. The median prevalence of Axis II is high among treated opiate and cocaine-dependent patients with 79% and 70% respectively. (Magnavita, 2004, p. 400).

Studies indicate that the Cluster B disorders such as Antisocial and Borderline described above are the most prevalent among all personality disorders. The research conducted by Bridget F. Grant as part of the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions in the United States makes it clear where the author says, “among individuals with a current alcohol use disorder, 28.6 percent had at least 1 personality disorder, and 47.7 percent of those with a current drug use disorder had at least 1 personality disorder.” (Alcoholics more likely to have personality disorders, 2009).

Self-medicating

The voluntary use of mainly non-prescription drugs forms the rubric of self-medication and is considered lethal since there may not be any medical justifications or evidence for its administration or use. Even overdose or non-prescription use of prescription drugs constitutes self-medication, which could cause wanton damages to the user’s physical health and mental equilibrium. Self-medication, a dangerous precedent, is the use of alcohol or drugs to alleviate symptoms of a mood disorder or to alleviate pain or distress. It is usually associated with bipolar or mood disorders. Self-medication often helps a depressed person to elevate his mood and to forget the grief which would lead to the feeling of happiness, though short-lived. Sometimes people suffering from anxiety disorders consume alcohol to escape from the anxiety to face social situations. For many, the use of drugs and alcohol provides relief to the suffering of anxiety or pain.

But the relief derived from the use of drugs or self-medication is short-lived. People often fail to notice that the symptoms of mood disorders are aggravated with self-medication. Though self-medication can provide relief to some symptoms of mood swings or non-transient disorders, it may evoke symptoms of other types of mental illnesses that are latently present in the person.

The long-term use of the drugs may cause addiction and dependence which would worsen the condition of the patient. The theory is known as the ‘self-medication hypothesis’ states that self-medication for alleviating symptoms of existing bipolar disorder causes addiction or dependence. The theory put forward by Khantzian, & Duncan is thus, “The self-medication hypothesis proposes that addiction to alcohol and other drugs results from their use for relief from dysphoria resulting from an underlying disorder or condition — such as stress.” (Khantzian, & Duncan, 1974).

Mental disorders associated with specific drugs

Many drugs cause or induce different types of psychiatric disorders. Some common drugs and the effects they can produce are described here. Cocaine is a widely abused substance. The web article named ‘Cocaine and related disorders’ explains the harmful effects of this drug according to which the possible problems associated with the use of cocaine are the occurrence of many psychiatric disorders such as delusions and hallucinations, mood disorder, anxiety disorder, sexual dysfunction, and sleep disorder. (Cocaine and related disorders, 2007).

Another drug that induces mental disorder is LSD which results in extreme changes in behavior and mood, severe depression and disorientation of time; amphetamine which causes similar disorders associated with LSD and sleep disorder; and Ketamine, which was first clinically tested in animals and the wide abuse nowadays may lead to cognitive and memory problems.

Addiction or psychiatric illness

Diagnosing a primary problem in co-occurring disorders and treating them accordingly is highly important in the treatment of dually diagnosed diseases. Determining whether addiction or psychiatric illness is predominant will eventually lead to forming an appropriate treatment plan to effectively address both problems. In some cases, withdrawal from addiction is found to have adverse effects on existing psychiatric conditions. Experts think that depending on the psychiatric disorder present in the patient as part of the dual diagnosis, he or she may receive treatment for the co-occurring disorders. “If the psychiatric disorder is a chronic mental illness such as schizophrenia, then a psychiatric milieu is preferable; whereas anxiety, depressive or personality disorders are better treated in an addiction milieu.” (Miller, 1994, p. 2).

Parity in healthcare improvements

During the current milieu of rapid advancement and improvement in mental health improvement, co-occurring disorders are diagnosed more reliably and a variety of treatment options is available for them. But many do not go for treatment because of the high cost of care and existing disparity in insurance coverage for mental disorders compared to general diseases. Only comprehensive legislation that stands for parity between benefits to mental health and general health can address this issue effectively.

The highly welcomed Mental Health Parity and Addiction Equity Act of 2008 is a major step that will lead to ensuring parity in health care in the United States. This legislation tries to end discrimination in mental health insurance by making it mandatory for insurance providers to cover mental diseases as they do with general illnesses. The law can protect nearly 113 million people in the United States. It covers mental health and substance use disorder benefits which provide benefits to services for mental health conditions and substance use disorders.

In the context of a dual diagnosis, ensuring parity in health care is a vital factor since the patient suffers from multiple symptoms of different disorders and they should be treated, aiming at holistic improvement. The support from the family should be coupled with care and support from State machinery.

Treatment of Dual Diagnosis: Case Management

Dual diagnosis may present itself in many ways, and challenge the wisdom, experience, and diligence of some of the best health professionals in the game.

The first aspect that needs to be tackled is the patient himself- his personality type, previous case history if any, and the precipitating causes for the conditions to arise.

Where medical records are available, they need to be thoroughly studied before any line of intervention is suggested. If no records are available, it would become necessary to construct them, to address future treatment and medication needs. Doctors need to familiarize themselves with patients to gain in-depth knowledge of the case and its various ramifications.

“Reorganizing practice might better meet the needs of clients with co-occurring disorders by providing a broader array of services, less fragmentation, more outreach, and closer follow-up.” (Study of women with co-occurring disorders and lifetime histories of interpersonal trauma, 2004, P.2, Discussion and recommendations, para. 6).

While the matter of which symptoms need to be medically addressed first is best left to professional mental health care community and chemical dependency specialists to act in tandem, which kind of intervention would best serve the patient’s interests and be the best form of treatment needs to be evaluated by concerned persons. While one cannot be ignored in favor of another, it is best if both symptoms and pathological undercurrents are identified and steps taken for remedial actions.

It would not be wrong to suggest that a detailed case workout plan needs to be chalked out throughout treatment, including all aspects concerning the patient, including lifestyle during treatment, diet, exercises, and social contacts. The detox regime needs to be strictly adhered to, to bring about the desired results through disciplined efforts and conforming to medical norms and regulatory precepts.

The main issues would be in terms of the length of time the conditions were persisting, the line of treatment that has been followed so far, reasons for its discontinuance or change of treatment modes, and its impact on the conduct of the patient. Thus, besides the routine and banal features, several other items need to be considered like the health records, income groups, racial characteristics (some races may be more susceptible to certain kinds of dual diagnosis than others), and other socio-economic and demographic considerations.

The main aspect is the twin challenge that evolves from comorbidity and the presence of addiction of any kind. Whether the psychic disorders are a manifestation of addiction or the cause of it or the latter results from it are issues that confront the mental health care professionals almost regularly.

In other words, the attending doctors need to find out whether mental ill-health is the cause or the result of addiction. Thus, the choice has to be made whether the patient needs to be treated in a drug or chemical dependency unit for addiction or psychiatric wards for mental illness, or both. In most cases, when such combined ill manifestations present themselves, the doctors need to address the de-toxification first, reducing the blood levels or liver dysfunction or chemicals in the system, and then proceed towards the treatment of the psychic aspect. This is based on the notion that the physical aspects need to be arrested and controlled first and then, the more difficult phase of treatment, the mental one, ensues. Nevertheless, there are practical difficulties. However, these are easier said than done. For one thing, most clinical settings have separate units for mental and addiction disorders and, for another, it is seen that due to past failures and experiences many psychiatrists do not wish to treat patients, symptomatic of dual diagnosis ailments. It is even seen that these fears are also shared by chemical dependency treatment centers, which fear that the complications may present major challenges for which they are not trained nor experienced. (Evans, & Sullivan, 2001).

“Individualized treatment vs. group therapy is among the key differences in approach between mental health practitioners and substance abuse treatment counselors.” (Inaba, 2008).

It often happens that youngsters need to be treated more for dual diagnosis. There have been cases when young persons suffering from mental and emotional instability or other mental conditions and being treated for it play truant to avoid such treatment and indulge with friends to use drugs or alcohol.

Under such influences, they commit crimes for which they are arrested and put behind the prison. If the crimes are serious, they would be treated by the rules applicable to psychiatric patients in prison settings and if minor, they are released after they serve their sentences. It is quite possible that guardians of such children having a dual diagnosis would need to provide intensive care in exclusive psychiatric settings/ detox centers to get rid of these habits. In most scenarios, the detox centers would need to rid of the drug habit and upon its stabilization, such patients need to be psychiatrically evaluated and treated. However, symptomatically, it is often seen that drug habits may precipitate mental disorders and, therefore, it would be necessary to address mental illness first.

A lot would, therefore, depend upon what is felt by the concerned health care professionals and their expert opinions on the matter. It is most essential that, in the case of youngsters, both of the two aspects, mental disorder and also chemical dependency are fully treated; otherwise other symptoms like suicidal tendencies, depression, aggressive behavior, and social withdrawals may most likely result. Also, there are chances of relapses, more powerful than the earlier ones that may cause undue distress to the patients, carers, etc.

Since both conditions are interrelated and linked, mental HCPs may not find it easy or simple to separate both aspects before commencing treatment for patients with DD. Another aspect would be the fact that often unconventional intervention systems need to be resorted to while treating such patients. It is also seen that case management needs to take a holistic view of the case before commencing interventional programs, or medication.

Research has proved that adolescent with the alcoholic problem has higher chances of contracting another mental ailment and this could be still higher as the morbidity rates go up.

Another major aspect is that symptomatically, both diseases tend to imitate or overlap each other and, therefore, unless a proper and thorough investigation is done after a successful detox, there are very little hopes that the condition could be arrested or even alleviated. Thus, the diagnostic tools used need to be appropriate and effective, in line with the patient’s versions and complaints.

However, it is also seen that many drug and mental disorder patients may not be coherent or may not correctly identify their symptoms, thereby making the doctors’ work more burdensome. If doctors base intervention and line of treatment on wrong or untrue symptoms provided by patients, it would aggravate the situation, and finally may have to be hospitalized for a thorough check-up and investigation before a line of treatments is opened up. The major ways in which Dual Diagnosis could be addressed could be seen as follows:

1. Medical detox centers 2. Long-term rehabilitation and residential interventions. 3. Co-morbidity management centers. 4. limited use of hospital facilities and infrastructure 5. Institutional visit to patients’ status 6. Intensive care management systems. (Dual Diagnosis, 2008).

Of course, it is seen that a lot would depend upon the facts and intensity of the case for the attending health care professionals to decide on which option to take care of, and the team of psychiatrists, nursing community, detox specialists, and social scientists to be actively involved in the recovery and rehabilitation process of DD patients. It is also to be seen that it is a concerted and integrated approach that can best serve the patients’ welfare needs.

(Dual diagnosis, 2008).

Coordination of Care

The level and intensity of care is also an important aspect in that often the services of a team of hcp would be required- like psychiatrists, drug specialists, detox professionals, neuro physicians, and brain specialists need to be in attendance besides social scientists, workers and community leaders who contribute to better living for patients. The coordination and co-operation need to be extended between the chemical substances experts and mental care doctors, besides others who are actively involved in the treatment and intervention methods of patients. This could also be seen in terms of better understanding of each other’s perspectives and suggesting and implementing the best options available under the circumstances which could be in the best treatment alternatives available to the patients. On the one hand, this could be in terms of outpatient services, available 2-3 days a week, for 2-4 hours and it could also be in terms of in-patient partial hospitalization that takes care of the illnesses and the possibility of relapse.

What needs to be kept in mind is an integrated and comprehensive program that could cater to meet the challenges offered by both ailments, psychic and physical with the best results in both cases. It needs to be considered that there are many aspects, including a past line of treatment and what kind of interventions were administered and its efficacy, and the need for a new line to be sought.

Other aspects that need to be considered are the community services required to be ensured. It is not wrong to believe that often mental disorders are socially tabooed and, as such, most patients are reluctant or loath to speak about it, whereas physical ailments may be discussed with greater earnestness. Now, taking the case of DD patients, the psychic aspects may dominate the physical ones, thus rendering it rather difficult to chalk out an integrated patient management system that could effectively address both ailments and symptomatic representations. Therefore, in such acute cases, it is best to have investigations and probes done in clinical or hospital settings, so that accurate and appropriate lines of treatment and intervention as applicable and prescribed by doctors may be taken up.

In such cases, the support by family and relatives emotionally and mentally is of great solace for patients to regain their health and well-being.

Continuation of care

One of the major aspects of DD is that of relapse, which could be quite daunting. Thus, it is necessary that doctors need to reduce the risk and occurrences of relapses to the minimum and, therefore, take the most appropriate route of treatment negating the possibility of any kind of relapses, either mental or addictive. It is imperative that patients visit the health care centers as often as is required, take proper medication and course of treatment as prescribed and for the duration directed. It is also necessary for them to take such measures, either on their own or through HCP, to avoid or even eliminate the chances of any relapses or recommencement of alcoholism, drug habit, or others. Once the detox program is over, it is the responsibility of HCP to ensure that proper follow-ups and rehabilitation techniques are undertaken by the patients in their interests. Mostly, “This relapse prevention treatment program usually meets 3-5 days a week, 4-6 hours/day and is for people who require medical monitoring on an outpatient basis.” (Dual diagnosis, 2008).

The main areas of concern are the reappearance of mental disorders due to the resumption of drugs and alcohol tendencies which need to be avoided. Any such precipitation could be disastrous for the patient who has just recovered from drug abuse. Thus, it is of utmost importance that necessary steps be taken to avoid such situations.

Co-morbidity – Is Psychiatric disorder a cause of substance abuse or its result?

One of the main challenges that mental health care professional or a chemical dependency specialist would need to tackle is the fact of whether the psychiatric disorder is a cause of substance abuse or the result of it. In most cases, it may be the result of it.

In several conducted types of research, especially in the context of young people, with no previous records of psychiatric illnesses, it is seen that drug, alcohol, or substance abuse has led to a variety of mental ailments, ranging from aggressive behavior, suicidal tendencies, unprovoked sexual conduct, and even homicidal and destructive attitudes. Thus, it would not be wrong to suggest that in the case of co-morbidity, as is often the case, the chemical dependency needs to be arrested first, before psychiatrist treatment is provided to such victims.

However, the real danger occurs if chemical dependency relapses before the mental illness is cured, or while it is in progress, which may show symptoms of mental illness and treated as such, in which case the clear case of dual diagnosis is present, almost full blast.

In such cases, where both manifestations compete with each other in degree and intensity, it would be urgent to institute inpatient intensive management programs, not only to avail of medical technology but also to control and perhaps alleviate the disorders through professional mental care interventions and prolonged course of treatment that could address both issues, simultaneously and successfully.

Yet another factor could be in terms of the fact that medication for both manifestations needs to be compatible and co-existent, for the situation could be exacerbated if prescribed medication is on a collision course with each other.

In such cases, the best interests of the patient would lie in stopping the treatment and adopting a wait-and-watch attitude till a valid medical conclusion is derived.

The wide range of implications and health care impacts of co-morbidity has ensured that many mental HCP and chemical dependency professionals do not take up these challenges, based either on lack of exposure, experience, training, or simply because they have been deterred by past unpleasant experiences, or rank failures while dealing with such cases of co-morbidity. However, it would be myopic on the part of mental HCP to be deterred by past experiences since modern medical technologies and infra-structure do offer a wide-ranging broad spectrum of health care interventions ranging from inpatient care systems, medication, specialized counseling and therapy sessions, and committed professionals who may be competent enough to address major issues with aplomb and success. While time is essentially a major factor, successful treatment options are not, and positive care, both within the health care center milieus and at home could ensure that the patients have reasonable recovery rates and could lead quite normal lives afterward.

Conclusions

From the above deliberations, it has been proved beyond reasonable doubt that there exists a positive correlation or nexus between mental disorders and drug or substance abuse. It is seen that each disorder underpins the other and it would thus be necessary to implement an integrated patient management program that could address both problems and find cures for both. Although this may sound like a difficult proposition, it is not unachievable, especially in the present context of wide-ranging medical interventional techniques and state-of-the-art sophisticated and remarkable medical technology that could be used for these problems.

It would not be wrong to assume also, that in future years, applied science and medical breakthroughs could usher in remarkable progress in the containment and cure of dual diagnosis, much to the relief of millions of patients, carers, and medical professionals all over the world.

It could also be instrumental in reducing mortality rates in countries worst affected by such ailments and bringing in better healthcare options and health facilities for ailing millions, who are trapped by such kind of dual diagnosis, with presently no relief or solution from their predicament.

Attention should be given to discovering support groups for people with co-occurring disorders that can provide assistance to strengthen significant issues such as opportunities to mix with people, have access to recreational activities, and develop peer relationships. Participation in groups that deal with education and awareness of dual diagnosis issues could resolve and help in medication management, life skills, and improvement in activities of daily living, which are all very important and also helpful in dealing with such issues on a long term basis. (Dual diagnosis, 2008).

A final word needs to be said in terms of the presence of co-morbidity. Conducted research into areas of psychic disorders pooled with drug or substance abuse have led to the conclusion that simple and well structured clinical trials could be an effective way of dealing with substance misuse and a combination of simultaneously addressing clinical psychic disorders and substance dependency may not serve the purpose on all occasions. (Lev, Jeffery, McLaren, & Sieqfried, 2008).

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