Dual Diagnosis: Chronic Mental Illness and Addiction

Recently, there was a suicide by a patient who was treated for mental illness, as reported in the Washington Post.  He had abused drugs and one of the psychiatrists reporting about the incident stated that this was the choice of the patient. Other psychiatrists and mental health experts reacted harshly, reminding all of us that those individuals affected by psychotic illnesses do not make rational choices, especially when abusing drugs.

The story reminded me of my past experiences working with the severely mentally ill.

During the 1990's I worked at a psychiatric Day Hospital. The patients were people who were recovering from a psychiatric hospitalization for acute psychotic episodes. most were diagnosed with things such as Paranoid Schizophrenia, Bipolar Disorder with Psychotic Symptoms, Schizoaffective disorder and other types of psychoses that severely interfered with their lives.

Patients lived either at home with their families or at specific psychiatric residences staffed by mental health experts who closely monitored their lives. The patients could live at the residences on the condition that their time was spent either at the day hospital or a continuing day treatment facility. Day hospital patients took the subway system and public transport to attend day hospital.

The Day Hospital ran like a school with patients being given their medications, attending a variety of groups ranging from psychotherapy to medication management, socialization and vocational counseling. They were also provided with psychoe-ducation about their specific illnesses, how to manage their symptoms and how to reduce stress in their lives in order to prevent relapse. Each patient also had a psychotherapist with whom they met on a weekly basis or as emergency and crisis situations emerged.

The program was successful for many patients. However, the most successful of these people were the ones who were compliant with program recommendations and did not use alcohol or other drugs.

One of the most serious of problems affecting our patients and that staff would discuss at many of our meetings was the phenomenon of Dual Diagnosis. Some of the older staff would talk about the fact that the days of treating people who suffered purely from schizophrenia were over because of insidious impact of drug abuse. In fact,patients were referred to as CAMI, or the Chemically Abusive Mentally Ill.

Then as now, there are a large number of the chronically mentally ill whose symptoms are aggravated by drugs such as marijuana, crack cocaine, alcohol and many other substances. While these patients naturally want to be normal and make the same choices as other people who do not suffer from these mental illnesses, the facts are that these substances not only undermine their medications but aggravate and elevate such things as auditory and visual hallucinations, delusional thinking and impulsive and dangerous behaviors.

Sadly, we constantly witnessed patients who, after their inpatient hospitalization, emerged into the day hospital community and started on a course of recovery. Of course, there is no cure for schizophrenia. However, symptoms would abate enough so that they could be prepared to either work on a part time basis or return to college classes.

Then, the day would come when many of them would enter the day hospital, sometimes after a weekend, looking regressed and symptomatic. All too often, they had spent the weekend having abused substances.

People who do not suffer from a severe mental illness can become dangerously impulsive under the influence of certain drugs and alcohol. For those suffering from one of the psychotic illnesses that impulsiveness can quickly turn to suicide during an episode of intoxication.

We knew back during the 1990's about the high correlation between mental illness and drug abuse. It is about time that the world awoke to the fact that those suffering from these illnesses must be treated for their addiction as well as for their mental illness.

Your comments and questions are welcome

Allan N. Schwartz, PhD