Dual Diagnosis Should Not Be A Reason To Refuse Treatment

I talk to a great many people in a great many areas and fields.  In California, a lot of the mental health treatment programs are having “Obamacare-it is.”

While consumers who tried to use the official website to get enrolled for insurance had their “challenges” – to put it politely – the facilities expected to treat patients are having to do some major adjustments.

If you aren’t aware (especially you, Rip Van Winkle), “Obamacare” is what people lovingly call The Patient Protection and Affordable Care Act (PPACA).

I use the term “Lovingly Call” in the same manner people called homeless camps during the Great Depression “Hoovervilles” – blaming President Herbert Hoover for ruining the US economy and leading to the stock market crash.  Many feel Pres. Obama has done something similar to health care.

The government is an upside-down world (they call it “spin”).  The Affordable Care Act is not really making healthcare more affordable. In fact, many people lost the only insurance they could afford because companies could afford to offer such plans anymore!

This is reminiscent of other Government Spin program names such as:

The “Clear Skies Initiative” of 2002 to cut power plant emissions (which basically exempted new power plant constructions from installing modern pollution controls, and thereby increasing pollution).

“No Child Left Behind Act” of 2002 (NCLB) – which takes funding away from, (or closes) schools that aren’t doing well and gives more funding to schools that are doing very well – essentially leaving a heck of a lot of children behind.

Likewise, The Patient Protection and Affordable Care Act (Obamacare) is right on track – depriving patients of protection and making healthcare unaffordable.

I recently gave a sympathetic ear to a contact who wanted me to go help a struggling county mental health agency.  One of the biggest problems in community health programs is treating the patient who is a substance abuser and also has a mental illness – called “dual diagnosis.”

Addiction is a serious problem.  Sometimes it causes symptoms that look like mental illness.  Often it is concurrent with mental illness, as a patient is “self-medicating” to alleviate symptoms.

You just can’t accurately diagnose which problem it is until the addiction problem is taken away.

Addiction is considered a medical problem rather than a mental health problem. A patient who undergoes detoxification is at risk of seizures and other serious complications – many of which could be fatal.

Some facilities combine the medical and psychiatric treatments under the “dual diagnosis” banner.

The problem that a lot of clinics are having with Obamacare, my friend told me, is that under the new law, clinics will not be allowed to turn away patients who are also addicts.

Score one for Obamacare — I believe this is a GOOD thing (as Martha Stewart would say).

Overall, I believe Obamacare is a mess — a God-awful mess — for a lot of reasons.  Not the least of these is people who have had insurance and are losing it and all kinds of individual case “glitches” that seem lost in piles of prose that are variously interpreted according to one’s partisan politics of origin.

Now I don’t care a fig about partisan politics — I never have — but I do care about people being refused treatment because they are addicted to something.  They are harder to treat, to be sure, but there is something wrong — dreadfully wrong — if somehow physicians considering themselves on a moral high road compared to patients are part of making decisions.  Or maybe the physicians simply do not know what to do next, since these patients often are a mess.

Like I explained to my friend at the agency, people who are having a hard time in life simply do not walk up to a psychopharmacologist and say “Hello sir or madam.  I believe I have a chemical imbalance and am seeking correction of that.”  Hell, no.  Usually, they are in extremis so they would not show up at all unless they were in misery.  Turning away people who are in misery is just not what I happen to be in this business to do.

I ran a dual diagnosis clinic, once — for several months, in the middle of the downtown of a large central California city.  One of the therapists who worked with me became a close friend and still remains in touch after many years through social networks even though she moved away to a different region of the country (Hi Sylvia!  Best to Ed!).

Unfortunately, a great deal of what is written on the internet about dual diagnosis is rubbish.  Psychiatrists have an amazing capacity to be opinionated without a reasonable review of the data they have gathered.  Sometimes they become academicians and try to standardize things for their colleagues whom they seem to believe are intellectually challenged (not my problem guys).  Once a theoretical framework has been chosen, that colors everything else that is seen, and felt.

These folks start with the different theoretical frameworks — does the addiction problem cause the mental disorder, does the mental disorder cause the addiction problem, or is the addiction problem a misguided attempt to self-treat?

Who cares, when the patient is in front of you is crying, pounding your desk, and/or threatening suicide (yes, all three really happened)?

For current references, I went to the National Library of Medicine.  I mean, you have got to realize that this is a place I pretty much live when I am writing or cogitating.  It is thus perhaps more my web address than the home pages my loving husband has put up for me.

First problem is just the great volume of pages of results when looking up dual diagnosis patients.  There are case studies.  There are demographic studies.  The research looks, quite frankly, as if nobody knows who the hell these people are.  Trying to focus on how people actually treat dual diagnosis patients is tough but possible when I learn (the hard way) that most people in most other specialties also seem to have things they call dual diagnosis (things like AIDS and opportunistic infections and cardiovascular disease and God knows what).

Research on how to treat dual diagnosis patients is pretty rare.

Some dedicated folks in  Boston at Massachusetts General Hospital published their dual-diagnosis research.  In their second published study — larger than their first — with acamprosate (a modified amino acid) there was a little less drinking with that drug added to the antidepressant, but really not statistically significant.

Aauugghh!

Another one looking at adolescents is even scarier.  It basically says that Ritalin might improve substance abuse outcomes in ADHD (attention deficit disorder with hyperactivity) patients.  Of course, even shrinks and shrink-pharmacologists other than me have questioned the accuracy and nature of the ADD diagnosis, and some have even discussed Ritalin as a gateway drug. Welcome to the cloudy picture that is psychopharmacology.

But wait.  There’s more.

One thing that I agree with most clinicians known to me about (stranger than fiction)is simply:  People need to address both their substance abuse issues and their mental illness issues simultaneously.

I did recently visit an outpatient institution that had two separate tracks, one for substance abuse and one for mental illness.  They had actually gone to the trouble of making sure that both tracks, both led by credentialed mental health professionals, did not meet at the same time.  They could thus require that dual diagnosis patients attend both if they were willing to attend either.  I actually was present at a team meeting where a patient was fired for deciding he wanted to attend the mental health track and did not consider the addiction track “helpful.”

Most institutions just do not have the luxury of two tracks, and tell a patient to go to Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) according to the precise nature of their infirmity.  The general public (and the legal system) is under the mistaken impression that these programs are actually treatment. They are not – they are merely support groups.

This is what Obamacare is trying to avoid.  The clinics cannot shove-off the patient to a support group because it is afraid of not being paid for treatment.

One of the best things about my substance abuse rotation during my training as a psychiatrist in the heartland was that I was required to go to be the only physician present in one such meeting (mine was AA with some NA stragglers who had both sets of issues) for many weeks.  Had it not been for the training, I would never have set foot in any such meeting.  For whatever problems I have had in my life, and I do remain convinced I have had at least my share, I have not had addiction kind of problems.

The first thing that I learned was how to avoid covering my face or ducking out of shame when the self introductions came around the circle to me.

“My name is Estelle and I am a doctor…”

I had originally planned to tell them I was on substance abuse rotation and a psychiatry resident, but I never got that far into my sentence.  Instead, I got fiery responses like:

“A doctor is the one who got me addicted to drugs.  I’ll be working on that one all my life.”

“I would trust you more if you were an alcoholic.”

“Jesus!  Who let you in here?”

Before I could respond ‘It wasn’t my idea; it was a training requirement …” I also got:

“Do you smoke? Maybe you are addicted to food or something….”

(I was pretty chubby then…)

The woman who had been contacted by the director of my substance abuse rotation, a doctor who was actually very clever and knowledgeable and told me he could never, ever, look at a piece of chalk with its dust without craving cocaine, tried to quiet them down and explained my status, while I held my face in my hands in desperation.

You may wonder how I remember things that happened so many years ago in such excruciating detail.  The answer, of course, is that it was traumatic.  I was really hurt. I wondered about who and what I was if such a simple elucidation of my status could evoke such emotional negative effects.

Any honest doctor or anyone else who makes it to my advanced stage of life has to question if they have made the right choices, if they have done it “right.”  This was only one of many times I have wondered, really wondered about medicine.  I spent an irrationally large amount of time and effort getting those two magic letters “MD” plastered after my name.  (I even spent time practicing my signature with them, now a rounded squiggle after my whole signature or even my initials.)

Now, I am glad I have the authority that goes with that moniker, even if observations of medicine over the passage of time has me wondering more and more about the assumptions, logic, and aspects of the practices of such profession.

The second thing I learned impacted not so much on me personally as it did on the treatment of patients with “dual diagnosis” difficulties.

It is virtually impossible to find a group of NA or AA that endorses the use of psychiatric medications.  Most of them figure that psychiatric medications are just another kind of chemical of dependence or abuse.

Now I can see how some might feel that way, and everyone is entitled to their opinion, but people who “sponsor” or counsel others take some responsibility for what those other folks do.  In a world where professionalism and remuneration are unknown, and malpractice does not exist, I wish knowledgeable accountability did.  I have gotten releases and talked to sponsors, clergy people, parents, anybody, and fared poorly.  It has gotten to the point where the minute I hit a new city or institution, I ask personnel if they know and AA/NA group that endorses psychiatric drugs, or will at least tell a patient to try and find one.

There is one website that seems to discuss treatment alternatives in a more contemporary and realistic way than some, but it is far from perfect.  Me, I still believe in the Thomas Jefferson affirmation that an enlightened public is the best insurance that people will do the right things.  The patient has got to educate themselves as much as possible.  If the literature seems mired in technical jargon, direct questions to treating personnel become even more important.

One current belief that I cannot endorse strongly enough is that both substance abuse treatment and mental illness (perhaps behavioral treatment) must be pursued simultaneously.

If anyone still thinks that substance abuse treatment is stigmatizing, such beliefs have to be abandoned.  Confidentiality and anonymity prevent telling detailed stories on this one, but please believe me when I say that people have obtained employment and met lovers through AA and NA type connections.  People in Hollywood have even faked substance abuse problems just to get into AA and NA meetings and make deals that have become jewels of the silver screen.  Yes, really.

Moreover, people who have been treated for substance abuse and now abstain from substance abuse have been shown, in older studies that blew my socks off during training, to actually be more “honest” and “loyal” than other folks.  Yes, the frequent AA/NA admonition to “get real” or to “get rid of the big ‘I'” actually seems to work.

As for the “mental health part,”  I am hearing more and more people with problems like anxiety or mood disorders call them “behavioral problems,” they find to have less stigma than expressions like “mental illness.”  (Schizophrenia may be more incapacitating and require more support, and may need a different set of rules…)

Indeed the politically-correct government systems have renamed almost all county, state and federal mental health programs “behavioral health.”  Likewise, patients are “consumers,” and treatment is “assistance.”

I have had many patients over the years who protest against any label – especially “bipolar.”  They refuse to acknowledge their illness or their need to take medicine because of the stigma (they perceive) attached.  “I don’t give a damn if you call it ‘kumquat.’  Just take the damned pills, please,” is my standard response.

I sometimes offer prayer or getting down on my knees or begging, but that usually gets laughs which is fine as long as they take the damned pills.

Sometimes I end up explaining what a kumquat is (a small member of the citrus family) but that is all right, too.  I do not mind if laughs at me are on the way to the coveted value of compliance.

There is, of course, one thing I always come back to, like the springtime, no matter what illness I happen to be talking about.  Everybody and everything has to be reviewed on a case by case basis.

For example, the literature on acamprosate (or oral naltrexone) and alcohol abstinence in dual diagnosis patients is small and equivocal at best.  I could find a patient I think it would help.  I could recommend an over the counter amino acid in addition to psychiatric medications.  I could say to find and AA group that will not verbally clobber the patient every time they do a self-introduction.  It depends on the person, and their needs and what they say and maybe even on their blood tests, and what they are willing to do.

I wish they did not call it “practicing” medicine, as if the years I have spent knowing the exquisite loneliness and responsibility are supposed to be part of an asymptotic approach to perfection.  I’m just trying to do the best I can, one patient at a time.

 

THE END