Dually Diagnosed
(Substance Abuse and Mental Illness)

Jennifer Berryman, Ph.D.
Lisa Blackwell, Ph.D.
Connie Kinch, M.S.
Vigita Reddy, Psy.D.
Greater Binghamton Health Center
New York State Office of Mental Health

Goal 8 of the National Strategy for Suicide Prevention is to improve access to and community linkages with mental health and substance abuse services. It is designed to prevent suicide by ensuring that individuals who are at high risk due to mental health and substance use problems can receive prevention and treatment services.

1. FINDINGS
   1. Overall Rates and Patterns
      • In any given year, approximately 10 million people in the United States have a substance-related disorder and at least one other mental illness. (SAMHSA/NAC, 1997)
      • Approximately two-thirds of suicide completers suffered from either a mood disorder or alcoholism.
      • Approximately one-half of those diagnosed with a psychiatric disorder also have a substance abuse problem (NAMI).
      • 51% of suicide completers have both substance abuse and mood disorders (Suominen et al., 1996)
      • Suicide in alcoholics is largely dependent on the co-occurrence of a depressive episode.
      • In a Veterans Administration study, investigators found 77% of suicide completers who were diagnosed with substance abuse had an additional diagnosis, most commonly, an affective disorder (39%). Of patients who completed suicide, 5% had a co-morbid psychosis and substance abuse; 67% of people with PTSD who completed suicide had a co-morbid disorder, usually an affective disorder or substance abuse. (Lehmann, McCormick & McCracken, 1995)
      • Psychological autopsies have found that over 90% of all completed suicides in all age groups are associated with psychopathology (Shaffer et al., 1996).
   2. Risk Factors

      The risk of suicide is often increased in people with co-occurring disorders who may present with multiple risk factors at any given time. For example, the individual may be non-compliant with medication, be infected with HIV, and experiencing command hallucinations. The individual may be at greater risk for cognitive problems due to extensive substance abuse or lack supportive relationships due to stigma associated with having a psychiatric and substance abuse disorder.

      Typical risks for this population are: trauma history, cognitive/ neurological problems, family history of suicide, history of losses and deaths, history of medication non-compliance, impulsive behavior, history of psychosis, chronic medical problems, chronic pain, difficulty controlling or expressing anger, history of self-injury, and a criminal history.

   3. Precipitating Factors

      This includes losses of many kinds, such as physical health, vocational, financial, psychological, interpersonal (one-third had a relationship loss within six weeks of completing suicide), access to weapons, current medication non-compliance, substance abuse, suicidal ideation, shame, guilt, humiliation, command hallucinations, suicide by friend or family member, pain, hopelessness, recent trauma or abuse, family conflict.

   4. Protective Factors

      Many factors can decrease the risk for suicide by those with a dual diagnosis. Among them are: cognitive flexibility, good coping skills, strong social support, hopefulness, hobbies and interests, short-term plans, ability to develop alternatives to self-harm, good compliance with treatment, hobbies and interests, sobriety, education of primary care physicians, media education, lethal means restriction, screening of at-risk youth, and school-based skills training for students.

   5. The New York Model

      New York State has taken great strides in improving care and treatment for individuals with co-occurring disorders. Some of the evidence of progress is as follows:

      1. Evidence-Based Practices

         The New York Model is a framework for describing symptom severity, locus of care, and level of service integration needed among mental health, substance abuse, and primary health care systems.

         The Model consists of four quadrants with the locus of care for each:

         Quadrant 1
         Less severe mental disorder/less severe substance disorder. Locus of care: primary health care settings.

         Quadrant II
         More severe mental disorder/less severe substance disorder. Locus of care: mental health system

         Quadrant III
         Less severe mental disorder/more severe substance disorder. Locus of care: alcohol and other drug treatment facility

         Quadrant IV
         More severe mental disorder/more severe substance disorder. Locus of care: "No mans land" (joint alcohol and mental health systems).

         Individuals located in Quadrant IV are most at-risk and New York State. As such a Quadrant IV Task Force was jointly supported by the NYS Office of Mental Health (OMH) and Office of Alcohol and Substance Abuse Services (OASAS) and it produced a report, Treatment of Co-Occurring Mental Health and Addictive Disorders in New York State: A Comprehensive View (May 2001). The report contains an action plan that addresses problems such as the need for integrated treatment, stigma, funding issues, and staff competency.

      2. Additionally, OMH has directed its psychiatric centers to provide evidence-based treatments (EBT). A SAMHSA Evidence Based Practice Implementation Kit for Co-Occurring Disorders is being developed and will be distributed to adult psychiatric centers. The Kit will include: Fidelity scales, a user's guide, workbook, practice demonstration video tapes, and recipient outcome measures.
      3. Other evidence-based practices being implemented in New York State should also have a positive impact:

         SAMHSA's Wellness Self-Management EBP plan is beginning to be implemented in New York States psychiatric centers. Although the curriculum is not designed specifically for the co-occurring patient, it addresses many risk factors for suicide such as relapse, stress, medication compliance, and relationships. It can be an important part of treatment for those with a co-occurring disorder.

      4. New York State has funded Dual Recovery Coordinators who bring together administrators and service providers from substance abuse, mental health, corrections, and social service agencies to address current issues in the treatment of co-occurring disorders. Action plans are being developed and efforts have already begun to improve services. Issues being addressed include: housing, standardized assessment instruments, funding, training and competencies for both agencies (OMH, OASAS).
      5. Improve training and assessment to increase identification of mood disorders and suicide risk factors.
2. Action Steps
   1. Promote access to mental health and substance abuse treatment. Treatments for mental disorders and substance abuse are increasingly effective. The New York Model is a proven approach to improving care and treatment for individuals with co-occurring disorders. Early interventions that are evidence-based also reduce the need for emergency health care services and costs. Avoided costs could also be expected in law enforcement, corrections, and social services. Most importantly, access to early interventions could prevent pain and suffering among those affected by mental disorders and substance addiction.
   2. Promote greater awareness of co-occurring psychiatric and addictive disorders, and the consequent risk of suicide to this population among providers, law enforcement, corrections, and homeless shelter personnel, general public, emergency room physicians, and family members.
   3. Increased integration and co-operation between substance abuse and mental health services, and between public and private care systems. Poorly coordinated treatment among multiple providers is a real barrier to recovery. Long-term case management is one way to ensure continuity of care involving chronic illnesses like depression and addiction.
   4. Dual recovery coordinators and interagency workgroups can provide integrated treatment that decreases both homelessness and hospitalization for those diagnosed with mental illness and addiction disorders. This involves treatment of both disorders in one setting at the same time. Treatment can consist of outreach, pharmacological treatment, mental health and substance abuse counseling, group treatment, family psycho-education and community-based self-help. Train more individuals in the New York Model and other evidence-based practices; provide more appropriate housing for those not yet abstinent; and assist with transportation and medical needs of the dually diagnosed.
   5. Share the results of the Seeking Safety program developed by Dr. Lisa Najavits at Harvard Medical School/McLean Hospital. It is the first integrated program for persons who, in addition to being dually diagnosed, also suffer from Post-Traumatic Stress Disorder.
   6. Screen chemical dependency patients for depression or mood changes, and violence toward an intimate partner or spouse.
   7. Educate and train family members and community gatekeepers to detect changes in those at suicidal risk outside the clinical care systems. Signs include reduced performance in the workplace and unexplained absences from work or school. Knowing how and where to respond and refer individuals for treatment should be part of the training. Gatekeepers would include health, mental health, substance abuse, social work and human service professionals and lay people including clergy, teachers, correctional workers, coaches, youth workers, nurses' aides, and faith leaders.
   8. Substance abuse is a significant risk factor for suicidal behavior, especially among older adolescent males. Strategies to tighten teenage access to alcohol have successfully decreased youth suicidal behavior. Besides raising the legal drinking age to 21, stricter enforcement of such laws can deter risky behavior, as can increased surveillance.

References

Clark, D.C. & Goebel-Fabbri, A.E. (1999). Lifetime risk of suicide in major affective disorders. In D.G. Jacobs (ed.), The Harvard Medical School Guide to Suicide Assessment and Intervention, pp.300-310, San Francisco: Jossey-Bass/Pfeiffer.
Dalton, E.J., Cate-Carter, T.D., Mundo, E., Parikh, S.V. & Kennedy, J.L. (2003). Suicide risk in bipolar patients: The role of co-morbid substance abuse disorders. Bipolar Disorders, 5, pp. 58-61.
Drake, R.E. & Mueser, K.T. (2001). Co-occurring alcohol use disorder and schizophrenia. Retrieved on 6/16/03 from http://www.niaaa.nih.gov/publications/arh 26-2/99/102/text.htm.
Jamison, K.R. (1999). Suicide and manic depressive illness: An overview and personal accounts. In D.G. Jacobs (ed.), The Harvard Medical School Guide to Suicide Assessment and Intervention (pp.251-269), San Francisco: Jossey/Bass/Pfeiffer.
Lehmann, L., McCormick, R.A., & McCracken, L. (1995). Suicidal behavior among patients in the VA health care system. Psychiatric Services, 47(10), 1069-1071.
Marzuk, P.M. & Mann, J.John. (1988). Suicide and substance abuse. Psychiatric Annals, 18, 639-645.
McHugh, G.J., Mueser, K.T., & Drake, R.E. (2001). Treatment of substance abuse in persons with severe mental illness. In H.D. Brenner, W. Boewker, et al. (eds.) The Treatment of Schizophrenia: Status and Emerging Trends, (pp. 137-152). Kirkland, WA, Hogrefe and Huber Publishers.
Mueser, G.J., Drake, R.E., & Noordsy, D.L. (1998). Integrated mental health and substance abuse treatment for severe psychiatric disorders. Journal of Practical Psychology and Behavioral Health, May, 129-139.
Murphy, G.E., Armstrong, J.W., Jr., Hermele, S.L. et al., (1979). Suicide and Alcoholism: Interpersonal loss confirmed as a predictor. Archives of General Psychiatry, 36, 65-69.
Najavits, L.M. (2002). Seeking Safety: A Treatment Manual for PTSD and Substance Abuse. New York: Guilford Press.
Pirkis, J. & Burgess, P. (1998). Suicide and recency of health care contacts: A systematic review. British Journal of Psychiatry, 173, 462-474.
Regier, D.A., Farmer, M.E., Rae, D.S. et al., (1990). Co-morbidity of mental disorder with alcohol and other drug abuse: Results from the Epidemiologic Catchment Area (ECA) study. Journal of the American Medical Association, (JAMA), 2511-2518.
Rich, C.L., Fowler, R.C., Fogarty, L.A. & Young, D. (1988). San Diego suicide study: III Relationships between diagnoses and stressors. Archives of General Psychiatry, 45, 589-592.
Shaffer, D.A., Gould, M.S., Fisher, P. et al. (1966). Psychiatric Diagnosis in Child and Adolescent Suicide. Archives of General Psychiatry, 53, 339-348.
Suominen, K., Henriksson, M.M., Suokas, J. et al., (1996). Mental Disorders and co-morbidity in attempted suicide. Acta Psychiatrica Scandinavica, 94, 234-240.
Weiss, R.D., & Hufford, M.R. Substance abuse and suicide. In D.G. Jacobs (ed.) The Harvard Medical School Guide to Suicide Assessment and Intervention. (pp. 300-310). San Francisco: Jossey-Bass, Pfeiffer.