People like Michael present unique challenges for nurses who work in mental health and substance abuse services, as well as any caregiver who might encounter him in EDs, hospitals, and occupational health clinics. Michael has a co-occurring disorder, or what has been called dual diagnosis — the coexistence of substance abuse or dependency and one or more other independent psychiatric disorders. The term co-occurring disorders has replaced the term dual disorder or dual diagnosis, because the latter term suggests there are only two disorders occurring at the same time, when there may be more. Although “co-occurring disorders” usually refers to the combination of substance abuse and mental disorders, it could also refer to other combinations of disorders such as mental disorders and mental retardation.¹ According to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM IV), a mental disorder is a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress or disability.²

Substance use disorders include substance abuse as well as the more severe diagnosis of substance dependence, for which physiological dependence and tolerance is typical. Both involve continual use of psychoactive substances such as alcohol; opioids; amphetamines; and sedatives, hypnotics, or anxiolytics. Additionally, to be considered a disorder, the illicit drug or alcohol use must cause persistent or recurrent physical, psychological, social, occupational, or family problems. Individuals, like Michael, who meet criteria for substance abuse or dependence and another independent mental disorder, are considered to have co-occurring disorders.

Not all individuals with concurrent substance and psychiatric problems have a co-occurring disorder. An alcoholic whose psychosis clears following detoxification does not have a co-occurring disorder, nor does a cocaine-dependent patient whose depression lifts with the cessation of cocaine abuse. These individuals have substance-induced disorders — psychopathology consistent with the adverse effects of the drugs they abuse. The criteria for co-occurring disorder calls for primary substance and psychiatric disorders that are independent of one another. Although they are invariably interactive, improvement in one is not necessarily associated with improvement in the other.

Taking a Closer Look at Comorbidity

Several large scale studies reveal that approximately half of patients  with alcohol or drug use disorders also suffer from one or more psychiatric conditions, including personality disorders, major depression, schizophrenia, and bipolar disorder.³

There may not necessarily be a direct cause and effect between substance use and mental disorders, but some links seem to exist. For instance, evidence suggests that panic attacks following heavy amphetamine use are the result of a neurobiological effect called kindling. Conversely, mental disorders may lead to the onset of drug abuse. People with conduct disorders and antisocial personality disorders are more inclined to be exposed to drugs in the environment. Additionally, disinhibition, a symptom of bipolar disorder, increases the risk of drug and alcohol abuse in that population. Questions still remain in the complicated biological, genetic, and environmental connections between mental conditions and substance use.³ Compared to singularly diagnosed patients, those with co-occurring disorders have more persistent, severe, and resistant conditions, thus often presenting the greatest treatment challenges.³

Obstacles to Successful Treatment

Many patients with co-occurring disorders move in and out of treatment with caregivers who fail to see the whole diagnostic picture. The traditional separation of mental health and addiction services perpetuates this problem, as specialized clinicians often focus only on those sets of symptoms that are most familiar to them. For example, mental health workers may identify nonsubstance-related mental illness but overlook drug or alcohol problems, while addictions specialists address substance abuse but fail to recognize nonsubstance-related psychiatric symptoms.

When the clinicians do recognize symptoms of both psychiatric and substance-related illnesses, they are sometimes too quick to describe them as cause-and-effect. In the addiction field, psychiatric symptoms are frequently understood as secondary to the primary substance abuse problem, suggesting that successful treatment of addiction will eliminate psychiatric symptoms. A mental health clinician who believes substance use is the patient's way of reducing his own psychiatric distress (the self-medication hypothesis) will expect treatment of the mental disorder to eliminate the need for drug and alcohol abuse, which may result in effective treatment. A growing body of research indicates that programs, which integrate both mental health and substance abuse interventions, manage these patients best.^4,5

Failure to look beyond the medical perspective ignores the influence that the patient's psychosocial and socioeconomic situation has on successful treatment outcomes. Substance use is a social activity for many of the mentally ill that takes place in the communities where they live, since deinstitutionalization placed them outside the protective settings of hospitals. When these individuals leave treatment settings, they are viewed as relapsing into illness rather than merely returning to the norms of their subculture.⁴

People with co-occurring disorders often get the attention of law enforcement. Although deinstitutionalization was meant to be humane, it unfortunately placed many of those with co-occurring disorders into dangerous neighborhoods where they are much more likely to be the victims than perpetrators of violence. With public concern over violence and drug use, individuals with co-occurring disorders can find themselves institutionalized again, but by the criminal justice system.⁴

Inadequate community resources and lack of coordination among the agencies that do exist frequently are contributing factors to poor treatment outcomes. The task of navigating entry into these services can be overwhelming to a patient with multiple problems.⁶

Three-Pronged Assessment

Patients with co-occurring disorders require a comprehensive assessment that includes a physical examination and medical history, a drug and psychiatric profile, and urine and breathalyzer testing. Evaluation of substance abuse in these patients should address —

• Currently used substances, such as alcohol, nicotine, illicit drugs, prescription and over-the-counter medication, and herbal remedies
• Patterns of drug use and abuse, assessing when the activity began, periods of abstinence, current patterns of abuse, rituals, and route of administration
• Withdrawal risk and pattern of previous withdrawal episodes
• Past treatment episodes, including detoxification, rehabilitation, outpatient treatments, methadone maintenance, and self-help group participation
• Family history of drug and alcohol abuse

It is important to identify treatment approaches that were effectve in the past (“I did well on methadone, it calmed my nerves and helped me to think straight.”) along with unsuccessful modalities (“I couldn’t stay locked up in detox for more than a day. People were talking about me constantly, the TV made me nervous, and I didn’t feel safe.”). Quite often, a patient’s response to this inquiry gives indications of a nonsubstance-related psychiatric disorder.

The psychiatric evaluation should be equally detailed assessing —

• Mood and affect, cognitive ability, insight, judgment, and orientation
• Current psychiatric symptoms and onset (did they precede or follow substance abuse, what makes them better or worse, how are symptoms during periods of use and abstinence), previous psychiatric care and other hospitalizations, medication use and responses, and past suicide attempts
• Suicidal ideation, plan, intent, and means (the risk for suicide is high in patients with co-occurring mental and substance use disorders, particularly in those with bipolar disorder)⁵
• History of abuse or trauma
• Family history of psychiatric disorders and treatment

A comprehensive assessment should also include an evaluation of patients’ psychosocial and socioeconomic needs, including housing, employment, finances, family issues, and legal concerns. Interventions that fail to concurrently address problems in these areas are unlikely to be successful. A 60-minute intake assessment instrument, the Addiction Severity Index, is available to rate patients’ needs for services across these domains.⁷

Finally, the clinician needs to decide if the patient’s psychopathology is related to the coexistence of a substance use disorder and another independent mental disorder, or if it is an expected effect of currently abused substances. Differentiating between depressive, anxious, or psychotic symptoms and those that are substance-induced is often difficult. However, noting the progression of symptoms over time may be helpful in formulating an accurate diagnosis.⁸ For example; symptoms that abate with detoxification may reflect a purely substance-induced problem.

The Role of Medication

Contrary to common clinical thinking, the use of medication is often the cornerstone of effective treatment for patients with co-occurring disorders, particularly those with mood, anxiety, and thought disorders. A long held rule that patients must be abstinent from drugs before starting treatment for depression is no longer standard practice. Improved screening tools have helped clinicians distinguish alcohol-related depressive symptoms from clinical depression.⁹ Both disorders must be treated aggressively.¹⁰

In many cases, medications allow these patients to participate fully in recovery activities. For example, in Michael’s case, his depression is manifested by severe sadness, social isolation, and an inability to engage in activities of daily living. Treatment with an antidepressant could enable him to participate in counseling and 12-step meetings, to work, and to regain the motivation needed to make lifestyle changes consistent with recovery. As an integral part of treatment, psychiatric medication may be initiated before abstinence is secured if the severity of psychiatric symptoms warrants.^9,11 In all cases where psychiatric medication is used to manage symptoms in patients with co-occurring disorders, structure, education, monitoring, and support are necessary to maximize effectiveness and maintain the patient’s mental health and safety.¹²

Clinicians need to select psychiatric medications carefully and monitor patients for abuse, misuse, or diversion of these agents. Patient education that addresses both illicit drugs and therapeutic medications should accompany the initiation of pharmacotherapy. Patients need to understand that the very drugs that make them feel good, such as cocaine, have the negative effects of worsening depressive, anxious, and psychotic symptoms. On the other hand, the medications prescribed to assist patients in feeling better may have no pleasure-producing effects, but produce unpleasant adverse effects, such as dry mouth, constipation, sedation, or sexual dysfunction. Patients also need to know that the notion of drug and alcohol tolerance — needing more substance to feel an effect — does not usually apply to psychiatric medication; more is not better, but may be harmful. Be aware that for some patients, taking any medications may conflict with the drug-free philosophy espoused in many community-based recovery groups. If this issue is not appropriately addressed, nonadherence and poor outcomes may ensue. Twelve-Step groups, such as Double Trouble in Recovery and Dual Recovery Anonymous, are tailored to people with co-occurring disorders, recognizing the need for psychotropic medications and offering support in coping with both chemical and mental illnesses.¹³ There has been an increase in the number of empirical studies showing the effectiveness of 12-step programs for co-occurring disorders.¹⁴

Some psychiatric medications have a potential for abuse and, when possible, other alternatives should be used. For example, providers often prescribe benzodiazepines to treat the anxiety that accompanies posttraumatic stress disorder. In a person with a co-occurring disorder, the best selection may be an anxiolytic such as buspirone (BuSpar), which is nonaddicting, or a selective serotonin reuptake inhibitor (SSRI) antidepressant with anxiolytic qualitites such as paroxetine (Paxil).¹⁵

With some patients, however, a benzodiazepine is necessary, and those with a low-abuse potential, such as oxazepam (Serax), are preferred. While the risk of abuse of benzodiazepines is widely recognized, other agents, such as benztropine mesylate (Cogentin) have abuse potential. Medication adherence can often be evaluated through the patients’ refill patterns, assessment of their working knowledge of their medication schedules, and, when appropriate, monitoring therapeutic blood levels of such drugs as lithium or valproic acid (Depakote).

The potential for harmful drug interactions must be taken into account when treating patients who may be taking illicit drugs or alcohol and prescription medications. For example, both alcohol intoxication and withdrawal can disturb the fluid electrolyte balance in the body and can lead to lithium toxicity. And the anticholinergic effects of marijuana can lead to atropine psychosis when combined with an anticholinergic medication, such as benztropine mesylate (Cogentin).¹¹

Care must be exercised when adjusting a patient’s regime. For instance, neuroleptic agents may be needed to keep psychotic symptoms at bay during voluntary detoxification from high doses of methadone. Tricyclic antidepressants (i.e., Elavil, Norpramin,Tofranil) lower the seizure threshold and, if possible, should not be used in patients who are withdrawing from alcohol or sedative hypnotics. Further, they should not be used in patients with significant histories of suicidality, because they are lethal in overdose. Though they can have sexual side effects, the SSRIs, such as fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil) are safer choices.¹⁶

Some patients may be on addiction treatment medications as well as psychotropic medication. Medications that reduce cravings and the psychological reward from substance use help increase abstinence rates. Methadone and Suboxone (a combination of buprenorphine and naloxone) are used to treat opiate dependence. Disulfiram (Antabuse), acamprosate (Campral), and topirimate (Topamax) have been used for alcohol cravings.¹⁷

Multifaceted Intervention

Comprehensive treatment of patients with co-occurring disorders includes:

• Evidenced-based psychosocial intervention (e.g., cognitive behavioral therapy, motivational interviewing, relapse prevention techniques)
• Drug counseling
• Education
• Family therapy
• Twelve-step referral 
• Regular follow-up with a psychiatrist or clinician with expertise in psychotropic medications⁵

These therapeutic modalities assist patients to develop a better understanding of their coexisting diseases and to recognize early signs of relapse. Multifaceted therapy can provide patients with effective relapse-prevention skills and support them as they practice adaptive coping responses to stress and negative emotional states. Within the context of these modalities, patients can improve their social skills and attain a higher level of independent functioning.

People with co-occurring disorders often need the management of many of the same acute and chronic medical conditions that bring other patients to medical facilities. They may be hypertensive, diabetic, or epileptic; they could be living with cancer or a debilitating disease, anticipating surgery, or recovering from its effects. Special populations present their own unique requirements. Women need protection from sexual and physical violence, help with parenting, and treatment settings that provide for children. The greater risk of violent behavior among those with co-occurring disorder raises community safety issues as well as the possibility of incarceration.⁵ The coexistence of a substance-use disorder and another psychiatric disorder, which can contribute to risky behaviors such as multiple sex partners or needle sharing during periods of intoxication, make this population particularly vulnerable to contracting viral hepatitis, HIV, and other sexually transmitted diseases. In order to support their addictions, some patients engage in high-risk sexual practices that have been linked to the transmission of disease. Other homeless or incarcerated patients incur the risk of tuberculosis due to crowded living space. For these individuals, the coordination of routine physical examination and health screening, direct clinical management of disease, and teaching to reduce risk and promote health are vital.

A model of care

To achieve the most desirable outcomes for patients with co-occurring disorders, clinicians need to address the problems of substance abuse and additional psychiatric illness simultaneously. Ideally, healthcare providers should be cross-trained in both addiction theory and mental health concepts to produce an integrated model of care. Collaboration is needed to provide comprehensive services and maintain continuity of the integrated treatment for the duration of therapy.

Healthcare providers have a responsibility to address the range of clients needs, so there will no longer be a “wrong-door policy,” but that every door can be the “right door.”¹⁸ The government Substance Abuse and Mental Health Services Administration’s Co-occurring Center for Excellence (http://coce.samhsa.gov ) advocates an integrated system for the delivery of mental health and substance abuse treatment services through a variety of agencies and behavioral health settings, while preserving the strength of the traditional focus on only one disorder.¹

Programs must also be culturally sensitive, and special effort should be made to engage those individuals who are not yet willing to participate.¹⁹ Working with people who have co-occurring disorders can be challenging. Employing a recovery perspective in treatment of co-occurring disorders has been found to be effective. Recovery emphasizes empowering the client to be an active participant in the treatment process. Recovery will have different meaning for each individual, but generally it is a process that maximizes functioning within the constraints of the disorders.¹⁸ Working in the recovery perspective requires understanding of stages of change.¹⁸ (See Figure 1.)

The clinician needs to be aware of the patient’s stage for change and be able to individualize treatment accordingly. People may be in different stages of change for their mental disorder and their substance use.

Motivational interviewing is an evidence-based counseling approach showing promise in treatment for co-occurring disorders.²⁰ Motivational interviewing (MI) is a client-centered, directive method that can enhance a person’s inner motivation to change by exploring and resolving ambivalence.²¹ This involves accepting the patient’s level of motivation, whatever it is, as the starting point for treatment. Often, patients experience ambivalence when they are starting the process for behavioral changes. Recent studies indicate people with co-occurring disorder, who receive individual MI participate more actively in treatment and reduce their substance use than those not receiving MI.²²

Often, clinicians see the goal for their patients as being drug- or alcohol-free, even though the patients may have different goals. They may not be interested in changing drinking or drug habits, but seeking help to be eligible for something else, such as a housing voucher. The clinician need not be confrontational or argumentative, but open to the patient’s needs and desires. The clinician can roll with resistance, attempting to establish rapport and trying to elicit the patient’s assessment of how drinking or drug use impacts their goals and helping them to identify concrete ways to change. Building a therapeutic relationship has been found to be the most effective predictor for positive outcomes in treatment.²¹

Case management techniques, developed as a treatment strategy to meet the needs of the chronically mentally ill,²³ can make it possible to coordinate the variety of services necessary to address the medical and psychosocial problems that typically accompany people with co-occurring disorders, particularly when they are receiving simultaneous treatments for co-occurring disorders at separate settings. Case management also makes it possible to monitor and treat patients with co-occurring disorders experiencing psychiatric, substance-related, and medical crises.⁵

Case management includes assessment, referral, coordination of resources, health teaching, crisis intervention, and medication monitoring.²³ Through specialized education and training, nurses can develop the skills necessary to fulfill these roles. As case managers, nurses can systematically assess symptoms of substance-use disorders and additional psychiatric disorders to aid in diagnosis and plan strategies of care. Additionally, nurses have experience with multidisciplinary collaboration and coordination of patient care services; an understanding of medication management, including an ability to assess efficacy and side effects; skills in crisis intervention and individual and group supportive therapies; knowledge of anatomy and physiology to assist in the management of medical illness; and an expertise in patient teaching. These skills place nurses in a unique position to be effective case managers.

A co-occurring disorder is a common but often undetected occurrence in psychiatric and substance abuse settings. As patients with co-occurring disorders do not respond well to either traditional psychiatric or substance abuse treatment alone, clinicians must make an accurate diagnosis so that treatment can target the special needs of these patients. Assessment based solely on patients’ initial presentation and complaints alone may be incomplete; therefore, the evaluation of medical, psychiatric, and substance abuse problems should be both comprehensive and ongoing to ensure accurate diagnosis.

Finally, providers need to evaluate psychosocial problems such as homelessness, family discord, and legal difficulties that so often complicate the lives of patients with co-occurring disorders in order to plan and implement successful treatment.

Nurses who are cross-trained in addiction and mental health theory are uniquely suited to participate in the multifaceted treatment and case management of patients with co-occurring disorders. Professional nurses bring skills in assessment, care planning and intervention, patient education, crisis management, and interdisciplinary collaboration. Nurses also bring a tradition of empathy and compassion that is basic to establishing therapeutic relationships. Although working with people with co-occurring disorders can be challenging, rewarding outcomes for these patients are possible. For some, success is measured by psychiatric stabilization or reduction in the use of drugs or alcohol, suicidal gesturing, or hospitalizations. For others, it may be a job, a home, or a reunited family. Their successes may be individually measured, yet universally profound. For nurses, they are professionally satisfying.