A great deal of research has been conducted regarding the dual diagnosis of mental illness and substance use disorders. It has been observed that occurrence of substance use disorders among patients with mental illness is a common occurrence. In a study by Weaver et al (2003) more than 40% of patients suffering from mental illnesses were observed to be suffering from substance use disorders as well. Co-existence of these two disorders can cause numerous problems, which can have significant adverse effect on the overall outcome and quality of life of these patients and lead to increased health care costs (Bartels, Drake, & Wallach, 1995).
Presence of mental illness in an individual suffering from substance abuse disorders also causes an increase in the rates of violence and crime in the society (Swartz et al, 1998). Treatment of substance abuse disorders among the patients with dual diagnosis is likely to improve long-term outcome in these patients. Thus treatment and prevention of relapse of substance use disorders among these patients forms an important aspect of health care. In this paper I shall be briefly reviewing treatment options and strategies for preventing relapse of substance use disorders among patients with dual disorders. Relapse Preventive Strategies
One main problems associated with treatment of dual disorders is that accurate diagnosis of dual disorders is not possible (Hu, Kline, Huang, & Ziedonis, 2006). Unless the presence of the dual disorders is identified, effective treatment cannot be started. The study by Hu et al (2006) emphasized the need for implementation of improvised and standardized mental health screening systems for detection of mental illness among patients with substance abuse disorders. Another major problem associated with the treatment of dual disorders, which has been observed among these patients is the high relapse rate of substance abuse disorders.
The results of the study by Rollins, O’Neill, Davis and Devitt (2005) showed high relapse rates of about 33% among the patients with dual diagnosis within first six months of completing treatment. With the passage of time, the frequency of relapse was observed to reduce considerably. It is highly important to identify the possible risk factors and the time at which they are most likely to occur. This knowledge would help the government and health care professionals to formulate strategies targeted towards such high-risk situations at the time when the relapse is most likely to occur in order to prevent their occurrence.
The study by Rollins et al (2005) suggests that the maximum efforts for preventing relapse should be made in the first six months following remission. The review of literature by Drake, Wallach, & McGovern (2005) highlighted the importance of social factors in triggering relapse of substance use disorders among patients with dual diagnosis. Social factors like peer pressure and involvement in drug-abusing social networks were identified by Drake et al (2005) to be the most important factors responsible for relapse of substance abuse disorders among these patients.
The studies by Rollins et al (2005) and Xie et al et al (2005) showed that patients who were employed at the time of undergoing treatment were able to maintain high rates of remission. Patients living in independent households after attaining abstinence were also observed to show high relapse rates (Drake et al, 2005; Rollins et al, 2005; Xie et al, 2005). Lack of sufficient facilities for treatment of substance use disorders was observed to be another factor for triggering relapse (Xie et al, 2005). Patients who had a greater access to social support were associated with sustained remission (Rollins et al, 2005).
Thus provision of adequate housing facilities, employment opportunities, individualized treatment facilities, and social support would prove to be helpful in preventing relapse (Drake et al, 2005; Rollins et al, 2005; Xie et al, 2005). Xie et al (2005) further highlighted the importance of encouraging these people to be constantly involved with substance abuse treatment programs. Individuals belonging to younger age groups (? 24 years), having male sex and lower levels of education were also found to be associated with higher relapse rates (Rollins et al, 2005, & Xie et al, 2005).
Thus authors of these studies suggested that relapse prevention strategies should be especially directed towards young (<24 years of age), male patients, who have low levels of education. In order to increase chances of remission among these patients, it is also very important to assess the severity of substance use disorder and to evaluate whether the individual is just abusing drugs or is dependent on them (Bartels et al, 1995). Drug abuse and dependence are the two ends of the spectrum of substance use disorders.
Drug dependence is associated with psychological and physical dependence of an individual on drugs and is thus associated with compulsive use of drugs. In the study by Bartels et al (1995) it was shown that patients who suffered from drug abuse at the time of admission showed a remission rate of 54% whereas those who had been suffering from drug dependence, showed a much lower remission rate of 31%. This implies that patients with dual diagnosis who show physical or psychological dependence towards drugs are more likely to experience relapse in comparison to those individuals, who just abuse drugs, but are not dependent on them.
Thus relapse preventive strategies should be specifically targeted towards individuals who are dependent on drugs. Type of treatment Strategies The two disorders, i. e. mental illness (schizophrenia etc) and substance use disorders are completely different from one another and exhibit different treatment requirements. Thus, traditionally, treatment of patients with dual disorders had been carried out by two different sets of physicians, who simultaneously treated the two disorders separately.
However, most of the recent studies dealing with the treatment of patients with dual disorders highlight the importance of the integrated treatment approach in treatment of these patients. In the integrated treatment approach, the treatment for both mental illnesses and substance use disorders is provided by the same clinician or team of clinicians in a coordinated manner to ensure that the patient receives more consistent and efficient form of treatment (Drake, Mercer-McFadden, Mueser, McHugo, & Bond, 1998).
Drake et al (1998) in their study observed that comprehensive integrated treatment programs; especially those, which provided assertive outreach facilities and motivational strategies to the patients were significantly able to increase the rate of remission. Motivational strategies help the patient to remain motivated to abstain from drugs. On the other hand, the assertive outreach approach involves direct delivery of mental health services to the patients in their own environment, rather than their treatment in the hospital environment.
Motivational strategies and support by the family has been advocated by Barrowclough et al (2001) as effective relapse prevention strategies. Rollins et al (2005) also observed that integrated treatment strategies, which offered protective housing programs along with social support, professional counseling, and group activities, were found to be associated with lower rates of relapse. Studies by both McGovern, Wrisley, & Drake (2005) & Barrowclough et al (2001) show the importance of including cognitive behavioral therapy (CBT), a psychological therapy, during the various phases of treatment in a person suffering from dual disorders.
This psychological therapy is believed to motivate the patient to remain abstinent, helps them in fighting against the withdrawal symptoms, and preventing relapse. Mcgovern et al (2005) emphasize in their study that CBT should be employed both during the stages of initial treatment as well as the stage of recovery. Each stage of treatment usually comprises to two phases, i. e. the action phase and the maintenance phase. In the action phase, CBT helps in encouraging and motivating the individual to curb his initial urge for consuming drugs and helps in achieving initial abstinence.
When the individual reaches the maintenance phase, the individual has already learnt to abstain from drugs. Thus in this phase, CBT would help the individual to focus on changing his lifestyle, improving his relationships with family and friends, and coping with other psychological changes. Monitoring and care of the patient is often ignored in the maintenance phase as the patient has already attained abstinence when he reaches this stage. However McGovern et al (2005) suggested that dual diagnosis is a chronic disorder similar to other chronic medical conditions like hypertension etc.
Thus continuous monitoring and care of the patient should be especially continued during the maintenance phase in order to prevent relapse. Conclusion From the above discussion it can be seen that simultaneous occurrence of mental illnesses and substance use disorders in patients can have a significant adverse impact on their quality of life and lead to considerable utilization of resources and health care services. Thus treatment and prevention of relapse of substance use disorders among patients suffering from dual diagnosis is of prime importance.
A complex interaction between social, biological and clinical factors is responsible for development of relapse among these patients. Thus combinations of psychological, social, pharmacological, and clinical interventions incorporated in form of “integrated treatment approach” should be implemented. Since needs of each individual are different from one another, the therapy needs to be highly individualized. References Barrowclough, C. , Haddock, G. , Tarrier, N. , Lewis, S. W. , Moring, J. , O’Brien, R. et al. (2001).
Randomized controlled trial of motivational interviewing, cognitive behavior therapy, and family intervention for patients with comorbid schizophrenia and substance use disorders. American Journal of Psychiatry, 158, 1706 -1713. Bartels, S. J. , Drake, R. E. , & Wallach, M. A. (1995). Long-term course of substance abuse disorders among patients with severe mental illness. Psychiatric Services, 46, 248-251. Drake, R. E. , Mercer-McFadden, C. , Mueser, K. T. , McHugo, Q. J. , & Bond, Q. R. (1998). Review of integrated mental health and substance abuse treatment for patients with dual disorders.
Schizophrenia Bulletin, 24, 589–608. Drake, R. E. , Wallach, M. A. , & McGovern, M. P. (2005). Special Section on relapse prevention: Future directions in preventing relapse to substance abuse among clients with severe mental illnesses. Psychiatric Services, 56 (10), 1297 – 1302. Hu, H. M. , Kline, A. , Huang, F. Y. , & Ziedonis, D. M. (2006). Detection of co-occurring mental illness among adult patients in the New Jersey substance abuse treatment system.
American Journal Public Health, 96, 1785–1793. McGovern, M. P. , Wrisley B. R. , Drake, R. E. (2005). Relapse of substance use disorder and its prevention among persons with co-occurring disorders. Psychiatric Services, 56, 1270–1273. Rollins, A. L. , O’Neill, S. J. , Davis, K. E. , Devitt, T. S. (2005). Substance abuse relapse and factors associated with relapse in an inner-city sample of patients with dual diagnoses. Psychiatric Services, 56, 1274–1281. Swartz, M. S. , Swanson, J. W. , Hiday, V. A. , Borum, R. , Wagner, H. R. , & Burns, B. J. (1998). Violence and severe mental illness: The effects of substance abuse and non-adherence to medication. American Journal of Psychiatry, 155 (2), 226-31.