Dual treatment best in co-occurring disorders: optimal approach is for addiction psychiatrists to focus on treatment, leave monitoring to primary care.
There are 14.9 million adults in the United States who meet criteria for a substance use disorder, and 19.4 million who meet criteria for serious psychological distress; 5.2 million meet criteria for both, according to the 2005 National Survey on Drug Use and Health.
"Of this 5.2 million, a remarkably small amount are coming into our treatment services," said Charlene E. Le Fauve, Ph.D., clinical psychologist and chief of the Co-Occurring and Homeless Activities Branch at the Substance Abuse and Mental Health Services Administration.
Almost half (48%) of this co-occurring disorder (COD) group gets no treatment at all. Approximately 5% get substance use treatment only, and about 6% get treatment for both substance use and a mental health disorder. Another 41% get treatment only for mental health problems, "but how many have positive, long-acting outcomes while treating one disorder and ignoring the other?" Dr. Le Fauve asked.
All individuals presenting for treatment for substance use should be screened for mental health problems and vice versa, Dr. Le Fauve said, because the presence of one type of disorder puts an individual at higher risk for developing the other type. For example, mood disorders, especially anxiety and depression, are very common in the addiction population.
Relationships between mental health and substance use disorders are often complex and challenging, Dr. Le Fauve said. Acute and chronic substance use can create psychiatric symptoms; substance withdrawal can cause psychiatric symptoms; and/or substance use can mask psychiatric symptoms. Consequences of substance use in patients with untreated psychosis include decreased compliance in all categories, increased psychotic symptoms, frequent use of health care services, increased tardive dyskinesia, violent behavior, and early mortality, Dr. Le Fauve said.
"We've talked to the primary care docs, and they don't have much time. The screening instruments have to be brief," Dr. Le Fauve said. Ongoing assessment of the person with CODs is another essential component. Always check on compliance and reasons for noncompliance, ask how their medications are affecting them, and acknowledge that they have a right not to take medications, she said.
Conduct a very extensive interview about all substances, including age at first use, patterns over time, periods of abstinence, and consequences of use, Dr. Le Fauve said. "We have people bring in everything. This gives you the opportunity to look at bottles, how much is left, and who prescribed it. You will be amazed at what you find out. Amazed."
Homeless people with CODs are a particular challenge to treat, and they are at higher risk for adverse outcomes, Dr. Le Fauve said. Once homeless, people with CODs require more services and are more likely to remain homeless than are other types of homeless people, she said. In addition, among homeless veterans, one-third to one-half have co-occurring mental illnesses and substance use disorders. "I say this right now in the context of our current war situation, but it's always an important issue."
Therefore, access to psychiatric care is necessary for clients presenting for treatment in substance use programs, Dr. Le Fauve said. Also, treatment will be more effective if clients have a sense of control and ownership over the treatment process. "This sounds preachy and canned, but it's true," she remarked.
ARTICLES BY DAMIAN MCNAMARA
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|Title Annotation:||Addiction Psychiatry|
|Publication:||Clinical Psychiatry News|
|Date:||Oct 1, 2007|
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