The Conceptual Framework of Dual Disorders and Its Flaws

Abstract

<jats:p>When psychiatric illness and substance use disorder coexist, the clinical approach to the patient is, unsurprisingly, awkward. This fact is due to a cultural context and, more directly, to the patient’s psychiatric condition and addiction behaviors—a situation that does not favor a scientific approach. In dual disorder facilities, several types of professionals work together: counselors, social workers, psychologists, and psychiatrists. Treatment approaches vary from one service to another and even within the same service. It is crucial to provide dual disorder patients with multiple treatments, comprising hospitalization, rehabilitative and residential programs, case management, and counselling. Still, when treating dual disorder (DD) heroin use disorder (HUD) patients, it is advisable to follow a hierarchical algorithm. First, we must deal with addiction: by detoxification, whenever possible. This means starting most patients on anti-craving pharmacological maintenance, though aversion therapy may be appropriate for a few of them. Opiate antagonists may be used with heroin-addicted patients as long as those patients are only mildly ill. In contrast, agonist opioid medications, i.e., buprenorphine and methadone suit moderately and severely ill patients, respectively. Achieving control of mood instability or psychotic episodes is the next step, to be followed by a prevention strategy to counteract residual cravings and dominate mood disorders or psychotic episodes through long-term pharmacological maintenance that is focused on a double target.</jats:p>

Clinical care of patients with dual disorders in India: diverse models of care delivery

“…Both these scenarios undermine the assumption that the country's appropriate management of dual disorder is a norm. Similar concerns about limited attention to patients with dual disorders by the general practitioners have also been cited from other countries (Pacini et al, 2020).…”

“…In addition, some of the facilities engage occupational therapists, child psychologists and counsellors. While psychiatrists, physicians, psychologists and counselors have been listed as key care providers in SUD treatment settings, other professionals’ roles have also been acknowledged (Pacini et al , 2020). The treatment offered includes a combination of pharmacological and non-pharmacological interventions.…”

“…There is no nationally approved framework for setting up such services. Differences in approaches to managing dual disorders within the same service and between services have also been highlighted from other countries (Pacini et al , 2020).…”

“…In India, among medical professionals, the treatment for SUD and other mental disorders is offered mainly by psychiatrists. This arrangement circumvents certain challenges experienced in settings where there is a dichotomy of the service providers for SUD (referred to as addictologist, narcologist in some settings) and other mental disorders (Kealy-Bateman et al , 2019; Sterling et al , 2011; Pacini et al , 2020). This prevents the patients from falling through the cracks as seen in settings where the services are fragmented (Chi et al , 2006).…”

Special Issue: Diagnosis and Management of Addiction and Other Mental Disorders (Dual Disorders)

“…Finally, two contributions focus on the current state of the clinical evaluation and management of DD patients. Pacini and colleagues [ 15 ] developed a specific hierarchical algorithm to be followed for treating DD in heroin use disorder patients, a complex comorbidity that with different consumption patterns has shown an emerging state in recent years. The review on the quality of the clinical recommendation management guidelines, carried out by Hakobyan et al [ 16 ], suggests the use of the NICE guideline to better meet the standards although it shows a clear need to improve the evidence-based recommendations for integrated treatment in DDs.…”