In psychiatry, dual pathology is considered to exist when someone presents an addictive disorder and simultaneously a mental disorder (Szerman and Martinez-Raga, 2015), both can develop at the same time or first one and then the other.
Dual patients are patients who present greater psychopathological and psychosocial severity, are admitted more, present more suicidal risk (Szerman et al, 2013), tend to drop out of treatment earlier and have more health and social needs. This justifies increasing efforts, not only at the level of care, but also at the level of design and management of specific resources, to improve the approach and care of these patients.
Most common disorders in dual pathology
All psychiatric disorders can present a high percentage of substance use and therefore would be dual disorders. Specifically, according to data from the Spanish Society of Dual Pathology, between 70 and 80% of patients with schizophrenia, 60% of bipolar patients, more than 70% of severe personality disorders and around 30% of patients with depression, anxiety and attention deficit hyperactivity disorder (ADHD) also present substance abuse.
If we consider patients who already have addictions, the most recent studies indicate that most people who develop addictive disorders had a mental vulnerability that favors it prior to addiction.
Causes of addiction in patients with mental disorders
There is no single clear cause that explains the association between addictive disorders and other mental disorders, although genetic, neurobiological and environmental factors have been identified as contributing to the development of dual disorders (Volkow, 2004 and 2007; Arias et al, 2013).
Greater difficulty in detection and treatment with dual pathology
Dual pathology entails greater difficulties in its detection, diagnosis and treatment and therefore requires greater use of resources. An incomplete or non-specialized approach will make it very difficult to achieve success.
In many cases a complete initial evaluation of the patient is not performed, and the diagnosis focuses only on the detection of one of the two disorders, mental or addictive. This prevents the identification of the dual disorder and the establishment of a specific approach and may even lead to the establishment of an inadequate therapeutic plan for the patient.
The assessment of dual pathology should begin as soon as possible by the psychiatric specialist, without waiting for the patient to be abstinent and without the obligation of prior psychiatric stabilization (Minkoff, 2001) so that treatment is complete from the outset. In this sense, the system designed should be accessible, integrated, have continuity and be specialized, in accordance with the demands and knowledge of the current state of science based on evidence.
In the public health system, the approach to mental health and addictions is carried out separately, so that if dual pathology is detected, a parallel treatment model is usually offered, on the one hand treatment from the mental health network and on the other from drug addiction resources. This model can be ineffective due to the difficulties of coordination between the two teams and the lack of specificity with respect to dual disorders.
Person-centered model for dual mental pathology
The best alternative is to offer person-centered treatment.
The person-centered model, according to the Picker Institute, consists of the following characteristics:
- Respect for the values, preferences and needs of ill persons.
- Receiving services in a coordinated and integrated manner
- Having relevant information available in a clear and understandable manner
- Achieving the highest possible quality of life
- To have emotional support
- Involve family and friends in the process to the extent appropriate.
- Receive ongoing care (regardless of the point of care)
- To obtain the maximum possible accessibility
That is why we currently propose an integrated treatment model, in which both mental disorder and substance use disorder are treated together, from an integrative perspective with multidisciplinary teams, with follow-up and long-term goals (Szerman et al, 2013; Kessler et al, 1994; Szerman et al, 2014).