Dual diagnosis was not an acknowledged theme of the 13th annual meeting of the American Academy of Addiction Psychiatry last month in Las Vegas. Yet in presentation after presentation, the "double-d word" kept popping up.
Clearly, for the meeting’s nearly 320 attendees, dual-diagnosis patients—specifically those with both a substance abuse and another Axis I mental disorder—are a driving force of their practices. Whether it was adult or adolescent patients that were the topic of discussion, the majority of presentations at the meeting addressed the concept of dual diagnosis, proclaiming it to be "the norm," "the majority of our patients," or "the only thing I see."
Many presenters detailed research supporting the co-occurrence of substance use disorders and mental disorders. Yet not nearly the same level of agreement was reached on how to treat these often complex clinical cases.
Data from the National Institute of Mental Health’s Epidemiologic Catchment Area program, cited many times during the AAAP meeting, indicate that dual diagnosis in adults is not the exception, but the rule. Researchers have estimated that as many as 50 percent of adult general psychiatry patients also have a substance abuse disorder.
The numbers are equally alarming in the opposite direction: 37 percent of adults with an alcohol-abuse disorder are estimated to have another mental disorder, and 53 percent of adults with a drug-related disorder also have another mental disorder.
The co-occurrence of disorders makes diagnosis complicated, and treatment is difficult, even when a psychiatrist is willing to take on the challenge—which few appear to be, according to several meeting presentations.
John Tsuang, M.D., an associate clinical professor of psychiatry at the UCLA—Harbor Medical Center, and Timothy Fong, M.D., an addictions research fellow at UCLA, presented a workshop on dual-diagnosis patients that focused on pharmacological management.
"Nearly 50 percent of persons with schizophrenia have a substance use disorder," Tsuang said. "Around 34 percent have a co-occurring alcohol problem, and 27 percent of persons are abusing drugs."
The overlap is not quite as pronounced with unipolar depression patients, about 27 percent of whom have a substance use disorder, Tsuang said. For those with bipolar I disorder, however, 61 percent have a substance use disorder, which most commonly appears during a manic phase. Overall, a patient with anxiety disorder has about a 33 percent chance of abusing or being addicted to drugs or alcohol, he added.
In adolescents, similar trends have been found, according to Paula Riggs, M.D., an associate professor of psychiatry at the University of Colorado School of Medicine.
"Around 90 percent of teens experiment [with drugs and/or alcohol] but don’t progress to substance abuse disorders," Riggs said. Studies have estimated that anywhere from 3 percent to 9 percent do progress to drug abuse or dependence, and 5 percent to 8 percent will go on to abuse or be dependent upon alcohol. "It’s the so-called ‘vulnerable experimenters’ who progress," Riggs said. "But what makes some vulnerable and others not?"
An emerging model, Riggs said, indicates that many factors converge to cause the dual diagnoses.
"It is the culmination of biopsychosocial vulnerabilities and substance use that exacerbates pre-existing dysregulation," she explained. "It modulates the vulnerable adolescent’s motivation and ends up increasing his or her vulnerability and reactivity to environmental stressors. It impacts their self-esteem and their self-efficacy."
Regardless of the model used, data indicate that conduct disorders in children and adolescents invariably begin before substance abuse does, while depression is roughly split—half of depression begins before substance abuse, half follows the onset of substance abuse.
With bipolar disorder, Riggs said, there appears to be a variable onset in relationship to substance abuse. She presented data indicating that if bipolar disorder arises in a patient as an adolescent, the risk of a comorbid substance use disorder is eight times that of the general population. Yet there are some data to indicate, she added, that when children are treated for what appears to be bipolar disorder, the risk of comorbid substance abuse may actually decrease.
"But it really doesn’t matter when the comorbidity started or why or how," Riggs emphasized. The important message is that "the research favors an integrated treatment approach rather than a sequential approach."
Riggs, Tsuang, and Fong pointed out, however, that regardless of the research and their collective clinical experience favoring an integrated approach to dual-diagnosis treatment, the reality is far different.
"Clinicians are reluctant to treat comorbidity in adolescents with active alcohol/substance use disorders," Riggs said. "They refer to substance use treatment first—using the sequential model—and impose an abstinence contingency for treating the comorbid psychiatric disorder. While on the opposite side of the coin, treatment of a comorbidity alone does not treat the substance use disorder. The untreated substance use then interferes with treating the comorbidity. But you can’t engage a patient in substance treatment if the comorbidity is not addressed."
Indeed, Tsuang detailed data from one study indicating that integrated treatment actually can decrease the number of hospitalization days, as well as reduce illness severity.
In their workshop, Tsuang and Fong detailed pharmacologic approaches to dual-diagnosis patients. But Fong stressed that "medications only lay the groundwork for therapy. The focus must be on symptom relief and initial crisis management."
In addition, he said, many clinicians often change medications frequently in dual-diagnosis patients because side effects of the medications may appear to be identical to those of intoxication. "Many of the meds we use day to day commonly cause sedation, dry mouth, agitation, fine motor tremor, et cetera. All these could make the clinician think the patient is drinking or using [drugs] again, when they aren’t. As a result, the treatment medications are changed, and the patient destabilizes further."
Despite the difficulty of treating dual-diagnosis patients, the three presenters agreed that persistence, adherence to a systematic treatment approach, and close management are key to stabilizing patients with dual diagnoses.
More information on the AAAP meeting presentations, including presentation materials, is posted on the Web at http://aaap.org/meetings/2002am/handouts/handouts.html. ▪