A community project, known as “The Wall”, undertaken by mental health consumers in southwestern Sydney, in conjunction with the Fairfield Alcohol and Other Drug Counseling service, allowed patients to express their own reasons for drug use. Some of these include wanting to escape the voices, the depression, the fear and the phobias brought on by schizophrenia. Other patients reported feeling bored and lonely as their old social networks broke down, and wanting a sense of belonging, even if it is with a social group whose activity is based on drug use.
In older patients, drug use may be due to their downward “social drift”. Trapped in a poverty cycle, they move into inner city areas, where drug predators are rampant [3].
Substance abuse complicates every aspect of schizophrenia, causing greater suffering for the patient, as well as making the health professional’s task more difficult. It has important implications for GP’s are responsible for the first recognition of the disease, as drug use often masks the earliest symptoms of psychosis, causing it to be confused with a drug-induced psychosis. Conversely, the patient may abuse drugs covertly, since many of the telltale signs of substance misuse, being similar to schizophrenia’s positive symptoms, are pre-existing [6].
Drugs may trigger or aggravate a psychotic episode. It leads to a more severe illness course, with more acute crises, more symptoms, more medication non-compliance, suboptimal response to pharmacological treatment, and more hospitalizations [1, 6]. Patients suffer more medication side effects, and are at risk of HIV and hepatitis C. And because of their need for a peer group’s acceptance, patients are less compliant with drug and alcohol counseling [6]. They are more likely to become seriously socially impaired, suffer severe depression and attempt suicide [1, 6]
Substance abuse places extra burden- physically, emotionally and financially- on an already strained family, who may resent the patient for “adding to the problem”, or for stealing from them to fund their drug habit.
Dual diagnosis patients suffer greater social stigma, have more difficulty in securing residential placement, and are at a higher risk of homelessness [8]. Homeless patients have poor access to mental and physical health services, and in a vicious cycle, become more disorganized and unwell physically [9].
Disturbed behavior, violence to self and others is also more prevalent in patients with co-morbidity, and many patients find themselves trapped in the criminal justice system [1].
As such, there are many problems and issues faced by patients with a dual diagnosis, not least of all is the failure of current services to meet their highly complex needs, especially in acute crises. According to one carer, public hospital emergency rooms are the worst in such situations, with patients not receiving help unless they’re obviously at a danger to themselves or to others.
In busy public hospitals such as Liverpool, which are already pressed for staff to deal with life-threatening cases, it is not surprising that patients presenting with a mental illness rate rather low on the triage list. Clearly, an alternative system for crisis management is needed.
Understaffing is a significant problem for long-term management also, with only one dual diagnosis coordinator in SWS, and case managers assigned to patients have a high workload. Some patients seek help from their general physician instead, but they often fail to recognize the concurrent conditions, or they possessed little time or the training to deal with such complex problems and issues.
In Australia and most other developed nations, the health care system revolves around specialization, with areas of professional expertise clearly mapped out. This demarcation becomes a problem when two or more diagnoses run concurrently. Many agencies label patients as being “too complex”, or impose stringent conditions on admittance. The patient is then repeatedly “turfed” between the two departments, receiving little help from either, and management resemble a game of human ping-pong. While treatment agencies are engaged in these demarcation disputes, the victims of an inflexible health care system falls between the gaps, failed by professionals who, in their drive for sophisticated specialization, have lost sight of the crux of the picture- that there is a patient out there who is desperate for just some understanding and any kind of help.
The philosophy behind traditional treatment programs is also inappropriate for patients with a dual diagnosis. Mental health services treat patients as “sick”, and health professionals assert management for the person [6]. On the other hand, the most drug and alcohol counseling programs are confrontational, as they center on the idea of a “motivated” patient, someone who “wants to change” [10]. Operating at opposite ends of a psychological spectrum, neither of these approaches is suited to patients with co-morbidity, and they serve only to cause emotional jolting and confusion to someone who really has little control over the direction of their life.
Current mental health care services involve families poorly. There is little social support for families in the southwestern Sydney area- no counseling services, no support groups where carers may share their experiences. This is unfortunate, since family support can mean everything in terms of positive and negative influences, and may even dictate the outcome of a person’s disease.
It is obvious then, that effective intervention for dual diagnosis is in need of much improvement. There need to be better recognition of the condition by health professionals, especially in young people, where prevention of the complications of co-morbidity is the key to a better illness outcome. Harm minimization should also be a goal, aiming to reduce the problems associated with illicit drug use. And, more importantly, there need to be improved integration of services for patients with a dual diagnosis.
General physicians, the ones who are in the closest contact with patients, should be better educated in terms of illness recognition and the services available for patients with dual diagnosis, so that they may establish a good referral network, and can more effectively liaise between patients and treatment agencies.
Effective intervention should be based on a holistic approach, rather than opting for a single solution, due to the many medical and non-medical needs of the dual diagnosis patient. Every aspect of care need to be accounted for, but at the same time, the care plan should actively involve the patient, as well as his/her family and friends. Service providers should become familiar with the patient and his/her problems, and be willing to respond to times of acute crisis. Through this method, the patient may be able to regain some organization in his/her illness management, and ultimately reclaim control over their lives.
Such an approach is exemplified in a “continuous care team” scheme, trailed in New Hampshire, USA, where case workers help patients plan activities such as including re-training in employment skills, organizing financial management, engaging the patient in a drug use reduction program, arranging for family support and visiting those living in residences [3].
In Australia, some initiatives are made in improving health care for patients with co-morbidity. An action plan, formulated in October 1998, aim to have Area Health Services develop models which collaborate between mental health other services, devise management guidelines, assess and establish future directions in their training programs for health professionals [11].
In March 2000, a National Co-morbidity Workshop was held, and the agenda of the conference focused on three main points: the definition and epidemiology of the disease, the implications it has for patients’ disease outcomes and response to intervention, and methods of treatment and prevention.
In southwestern Sydney, the MIDAS program (mental illness with problematic drug and alcohol use), managed by a clinical nurse consultant who acts as an area coordinator, provides a number of services for consumers and carers [12], including patient information, contribution to schizophrenia fellowship meetings and motivational group sessions for patients to inform them on how dual diagnoses influence each other, encourage them to explore the “positive” and negative aspects of drug use, and ultimately allow consumers to regain control over their lives. These sessions involve workers from mental health and drug and alcohol counseling, allowing cross-verbalization of ideas and techniques.
Community mental health teams, consisting of nurses and psychologists, are established to assess patients’ home and social situations, in order to improve treatment compliance, as well as to respond to acute crises [12].
Rehabilitation teams in the SWSAHS work in conjunction with MIDAS to provide cognitive rehabilitation to rebuild patients’ planning functions, and in vocational retraining, which aim to prevent patients from becoming trapped in a relapse-drug use cycle and in a downward spiral of social deterioration.
MIDAS also organizes a number of community initiatives, one of which is “The Wall”, a creative project that engaged consumers in the development of more effective service provision for dual diagnosis. Another is the “Midas Touch” quarterly newsletter and website, which covers issues in dual diagnosis, and summaries of the latest research and publications.
In the area of professional education, MIDAS operates workshops which educates on the epidemiology of dual diagnosis, methods of screening for high-risk patients and effective interventions and treatments. It helps institutions such as the Australian College of General Practitioners to provide training in specific areas. There is also a nursing training manual, which gives guidelines on effective service provision for patients.
MIDAS also consults with the Probation and Parole Board to suggest policy and procedures, with youth services to co-ordinate programs for peer support education, and meets with staff from hospital emergency departments to offer guidelines regarding management approaches and appropriate referrals of dually-diagnosed patients.
Dual diagnosis causes much morbidity and suffering in schizophrenic patients, but in many cases, these effects can be overcome and prevented. With continued efforts at understanding the disorder, in improving its recognition and management, a better outcome may be achieved for those affected by this chronic disabling illness.