Management of Chronic Mental Illnesses and Substance Use Disorders

Introduction

During the period following deinstitutionalization in 1950’s, psychiatrists started focusing on patients with chronic mental disorders who left institutions and were in the process of getting rehabilitated in the community. By the late 1980s, mental health professionals began to attend to this new younger population of persons with severe mental illness leading to the emergence of the concept of co-occurring disorders or dual diagnosis (Ridgely et al., 1987). As a consequence of deinstitutionalization along with other risk factors like poverty, poor education, poor social skills, lack of vocational skills and opportunities, and residence in drug-infested neighborhoods, such patients experienced a high rate of regular exposure to psychoactive substances and of social pressures to use them. Exposure of these patients with severe mental illness to the drug culture in the community led to the development of another entity of patients having co-morbid substance abuse with psychiatric disorders. Such individuals were discussed under the rubric of dual diagnosis but were also called mentally ill chemical abusers or substance-abusing mentally ill persons (Drake & Wallach, 2000).

There is no single form of dual diagnosis. There are numerous types of psychiatric illness along with different patterns of alcohol or drug abuse. Most of these patients would fall within the following four categories:

• 1.

  Those who are severely disabled by comorbid mental health and substance use disorders and will require a coordinated and integrated approach by both mental health and drug and alcohol services,

• 2.

  Those who are severely disabled by mental health disorders and adversely affected by problematic substance use disorders

• 3.

  Those who are disabled by substance use disorders and adversely affected by mental health problems

• 4.

  Those who are mildly disabled by mental health disorders and substance use disorders and who will be treated primarily by a general practitioner but may also require access to either mental health or substance abuse services at various times (Burnam & Watkins, 2006; Drake et al., 2001; Todd et al., 2004).

It is therefore necessary to be clear that dual diagnosis is not a diagnosis in itself. Instead it simply implies that a person has both psychiatric and substance use issues. Among dual-diagnosis patients, substance-use disorders range from single drug abuse to a cocktails of substances, whereas mental health problems can include a wide array of disorders, from those defined as “high-prevalence and low- impact therapeutic”, such as anxiety and depression, to those defined as “low prevalence, high-impact therapeutic”, such as psychosis and major mood disorders (Canaway & Merkes, 2010). Although the “low impact” group is the most represented among dual-diagnosis patients, the “high impact” group, even if smaller, requires more intensive and expensive treatment programs.