Dual Diagnosis In India

Dual diagnosis is the co-occurrence of substance use disorder and other psychiatric disorder.

Dual diagnosis is the co-occurrence of substance use disorder and other psychiatric disorder when at least one disorder of each type can be established independent of the other and is not simply a cluster of symptoms resulting from [a single] disorder. ~Center for Substance Abuse Treatment (2005)

The study conducted by Department of Psychiatry, Postgraduate Institute of Medical Education & Research, Drug De-addiction and Treatment Centre, Chandigarh, was aimed to study the profile of patients with dual diagnosis form an integrated Dual Diagnosis Clinic(DDC). 

“Till date the existence of integrated dual diagnosis clinic (DDC) in India is not known. The Drug De-addiction and treatment center of our hospital has initiated one of the first such clinics in India in October, 2009. This clinic was started after an 11 year retrospective data from our centre which showed that the prevalence of dual diagnosis is 13.2% and there has been a very high attrition rate and favorable outcome in those who were retained in the treatment”, Basu D, Sarkar S, Mattoo SK (2013)  Journal of Dual diagnosis 9: 23-29. Dual diagnosis counseling and active surveillance by the psychiatric social workers are the forms psycho-social interventions considered in the clinic.

Out of 1929 patients registered over a span of 28 months, 1907 (98.8%) records were traceable. Amongst these, 287 (15%) had a comorbid non-substance psychiatric disorder.  The figure was much less than those found in other studies from India (50-75%) and the US (50-60%).

When the pattern of psychiatric disorders in the clinically confirmed dual diagnosis cases was analyzed, mood disorders were the commonest (141, 49.1%) amongst all dual diagnoses. Psychotic disorders (65, 22.6%) were the second most prevalent diagnosis followed by anxiety and stress related disorders (58, 20.2%), organic disorders (6, 2%) and other mental disorders (22, 7.7%). This trend is comparable with the existing literature from our centre, other studies in India and the US [58]. Alcohol was the primary substance of use in both psychotic (30.8%) and non-psychotic (47.3%) co-occurring disorder. This perhaps reflects the treatment seeking pattern in the de-addiction centres of India [9]. However, cannabis use is relatively more prevalent (23%) in the psychosis group. This finding is also in line with the literature across the world [1012]. Opioid (nonpsychotic- 26% and psychotic-28%). and nicotine (non-psychotic-16% and psychotic-15.6%) use was equally prevalent in both the groups. Mean duration of outpatient follow up was 2.6 months. There has been a high attrition rate (24%) following detailed evaluation (after the first 2 visits). Those who remained in the treatment net, significant proportion (45.7%) of patients were improved. High dropout rate has also been observed in the studies from the US and the rate of dropout after first contact is as high as 42%. Half of the subjects were failed to be engaged in the treatment because of their short follow up duration.

A PGIMER spokesperson disclosed, “A recent study published in a peer reviewed journal from our centre showed that one in every third person visiting our centre is a case of Dual Diagnosis.” She pointed that the PGIMER has been running a weekly Dual Diagnosis Clinic since 2011and more than 660 patients had been registered in this clinic.

The study was carried out on 179 patients that came as outpatients to the Drug De-addiction and Treatment Centre at the PGIMER between April 10, 2013 and June 28, 2013 from across the region.

“The prevalence of Dual Diagnosis was 58 (32.4%). Duration of use and dependence (in months) of alcohol, opioids and nicotine was was shorter and of cannabis and benzodiazepines was longer in Dual Diagnosis group. This study screened the largest number of substance use disorders patients visiting a tertiary care centre in India using a sound methodology. The prevalence reported in our study is lower than reported in some western hospital based and community based studies,” says the abstract of the study.

It needs to be pointed out that PGIMER is seen as the second most important health medical facility in the country after AIIMS in Delhi.

The study further points out that in the group that showed Dual Diagnosis alcohol was the predominant substance (50 %) followed by opioid (41.4%). The next was cannabis (6.9%) and nicotine (1.7 %). The most common opioid used by this group was heroin (31.9%). This was followed by synthetic opioids.

The PGIMER recently held a special continuing medical education programme on the “Dual Diagnosis: Facing the Reality and the Challenges” aiming at capacity building for enhancing the diagnostic and management skills of psychiatry trainees and young psychiatrists. More than 150 delegates from different parts of India attended the programme where experts comprising guest faculty addressed queries of the delegates about identifying and management of Dual Diagnosis. The focus was on management of cases in the clinical practice.

 Furthermore, A PGIMER spokesperson disclosed, “A recent study published in a peer reviewed journal from our centre showed that one in every third person visiting our centre is a case of Dual Diagnosis.” She pointed that the PGIMER has been running a weekly Dual Diagnosis Clinic since 2011and more than 660 patients had been registered in this clinic.

The study was carried out on 179 patients that came as outpatients to the Drug De-addiction and Treatment Centre at the PGIMER between April 10, 2013 and June 28, 2013 from across the region.

“The prevalence of Dual Diagnosis was 58 (32.4%). Duration of use and dependence (in months) of alcohol, opioids and nicotine was was shorter and of cannabis and benzodiazepines was longer in Dual Diagnosis group. This study screened the largest number of substance use disorders patients visiting a tertiary care centre in India using a sound methodology. The prevalence reported in our study is lower than reported in some western hospital based and community based studies,” says the abstract of the study.

It needs to be pointed out that PGIMER is seen as the second most important health medical facility in the country after AIIMS in Delhi.

The study further points out that in the group that showed Dual Diagnosis alcohol was the predominant substance (50 %) followed by opioid (41.4%). The next was cannabis (6.9%) and nicotine (1.7 %). The most common opioid used by this group was heroin (31.9%). This was followed by synthetic opioids.

The PGIMER recently held a special continuing medical education programme on the “Dual Diagnosis: Facing the Reality and the Challenges” aiming at capacity building for enhancing the diagnostic and management skills of psychiatry trainees and young psychiatrists. More than 150 delegates from different parts of India attended the programme where experts comprising guest faculty addressed queries of the delegates about identifying and management of Dual Diagnosis. The focus was on management of cases in the clinical practice.

Reference:

https://www.esciencecentral.org/journals/profile-of-patients-with-dual-diagnosis-experience-from-an-integrated-dualdiagnosis-clinic-in-north-india

http://www.catchnews.com/health-news/alcoholics-and-drug-addicts-have-a-higher-probability-of-mental-disorders-55760.html

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Dual Diagnosis: A Clinical Challenge

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The literature concerning dual diagnosis has largely identified and defined the mental health “element”of this phenomenon as the presence of a functional psychotic illness(such as schizophrenia, bipolar disorderdelusional disorder, schizo-effective disorder, or depressive illness with psychotic symptoms), but is less specific when identifying the substance use “element” of the dual diagnosis (Phillips, 1998; Phillips & Johnson,2001)

From a clinical perspective it can be argued that this definition is excessively narrow since it excludes those patients with non-psychotic mental health problems(such as personality disorder, depressive illness, anxiety, or phobic or eating disorders) from the potential benefit of any specialist help or evidence based intervention available to those with substance use disorders and functional psychotic illness. This is especially pertinent since the presence of non-psychotic mental health problems is well established among those with substance use disorders (Baker et al.,2004; Farrell et al., 2003)

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Dual diagnosis is a term for when someone experiences a mental illness and a substance abuse problem simultaneously. Dual diagnosis is a very broad category. It can range from someone developing mild depression because of binge drinking, to someone’s symptoms of bipolar disorder becoming more severe when that person abuses heroin during periods of mania. Either substance abuse or mental illness can develop first. A person experiencing a mental health condition may turn to drugs and alcohol as a form of self-medication to improve the troubling mental health symptoms they experience. Research shows though that drugs and alcohol only make the symptoms of mental health conditions worse. Abusing substances can also lead to mental health problems because of the effects drugs have on a person’s moods, thoughts, brain chemistry and behavior.

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Why Do Some People Develop a Co-occurring Disorder While Others Don’t?

Researchers continue to search for a definitive answer to this question. Currently, the belief is that dual diagnoses come about as a result of a combination of variables. Chief among them are genes, stressful or traumatic events, and early drug exposure, all of which can overlap and interact with each other at various times in someone’s life.1

Which psychiatric illness comes first – substance abuse or the other co-occurring disorder – depends on the person and their circumstances. Sometimes substance abuse can lead to mental illness. For example, the onset of depression is common among those whose relationships, careers and/or health have deteriorated as a result of substance abuse. Conversely, mental illness can bring on drug abuse. Anxiety, for example, can lead people to abuse alcohol and other drugs to find relief from their symptoms.

It can be difficult to determine which illness came first and which is responsible for the other. This is why seeking professional help from trained clinicians and medical experts is a vital component of successful treatment. Determining in what ways one or more psychological disorders are interacting with a drug use disorder can be extremely beneficial to one’s recovery.

While most people with concurrent disorders get better with treatment, there are some factors that can inhibit or slow down their progress.

  • Most important is an undetected co-occurring mental illness. Undetected illnesses pose a risk to treatment dropout and relapse.
  • Those who develop a mental illness before a substance use disorder may be at higher risk of enduring a difficult treatment process.
  • Severe, co-occurring major depression and/or post traumatic stress disorder (PTSD) may also provide additional strain and hinder treatment progress.
  • And, lastly, recent evidence suggests that continued use of tobacco during treatment can be a risk for post-treatment relapse.

There are a number of different talk therapies, but the following have been shown to be especially effective in treating a number of dual diagnoses:

  • Cognitive-behavioral therapy (CBT) involves recognizing and changing thoughts and behaviors that encourage drug use and negative thinking.
  • For people with self-harm and impulsive tendencies, Dialectical Behavioral Therapy (DBT) may be particularly helpful.  
  • Some individuals prefer group therapy, which can also improve social skills and provide a support group.  
  • Exposure therapies are especially helpful for individuals suffering from severe anxiety and panic attacks, as well as post-traumatic stress.  
  • Therapeutic communities are designed to help those suffering from domestic violence or homelessness.
  • Assertive Community Treatment targets those with severe mental illness such as schizophrenia.  
  • There are also separate facilities that treat dual diagnoses in adolescents.  

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The following posts have some case studies and their results. Care, read and share to help!

Reference:

http://www.mentalhelp.net

http://www.nami.org/Learn-More/Mental-Health-Conditions/Related-Conditions/Dual-Diagnosis#sthash.JIApDy05.dpuf

 

Substance Abuse Disorder 

 Drugs are here to stay; you need to choose your way

Drugs are fascinating because they change our awareness. The basic reason people take drugs is to vary their conscious experience. Of course there are many ways to alter consciousness, such as listening to music, dancing, exercising, day dreaming … and participating in religious rituals. The list is probably endless, and suggests that changing consciousness is something people like to do

               (Weil and Rosen in Saunders and O’Connor 1994:8)


Substance use disorder (SUD), also known as drug use disorder, is a condition in which the use of one or more substances leads to a clinically significant impair mentor distress (National Alliance on Mental Illness). Being a complex brain disease, it includes alcoholism and drug addiction, along with dependence and intense as well as uncontrollable cravings which leads to compulsive behavior to obtain the substance.

Commonly used term, addiction, is a condition in which the body must have a drug to avoid physical and psychological withdrawal symptoms. The first stage is dependence. It is termed as a disease by several medical associations, including the American Medical Association and the American Society of Addiction Medicine. Like diabetes, addiction is caused by a combination of behavioral, environmental and biological factors

These substances are drugs which are chemicals, natural or synthetic, that change a person’s mental state and used repeatedly for the effect. Legally or illegally obtained, these psychoactive drugs that changes brain functioning resulting into alteration of consciousness include:

  • Depressants – They slow down the nervous system. For e.g.-alcohol, tranquilizers, heroin, and other opiates, cannabis (marijuana in small doses).
  • Stimulants – They excite the nervous system. For e.g.-nicotine, amphetamines, cocaine, caffeine.
  • Hallucinogens – They distort how things are perceived. For e.g.- LSD, mescaline, ‘magic mushroom’, cannabis (high doses).
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The effects of drugs depend on drugs, person and environment. (Photo by  Imagens Evangelics)

A person does not choose to indulge, rather has certain reasons to not stop using drugs; these can include pleasure, company, liking, relief, loneliness, coping mechanism, dependency, ill after-effects, courage booster. People can feel caught between what their parents and elders say is important and the pressures and promises that western culture seems to offer. Community stress, boredom, frustration and peer pressure can draw people into drug using lifestyles.

The effects of any drugs depend on drugs, person and environment. A person does not choose to indulge, rather has certain reasons to not stop using drugs; these can include pleasure, company, liking, relief, loneliness, coping mechanism, dependency, ill after-effects, courage booster. People can feel caught between what their parents and elders say is important and the pressures and promises that western culture seems to offer. Community stress, boredom, frustration and peer pressure can draw people into drug using lifestyles.

The following diagram shows the three major influences on an individual’s decisions about drug use. Addressing drug-related harm needs to consider the links between these different factors.

When you watch, you follow, you know? When somebody do things, see them and you follow their example. They drink, well, you drink too! You get in there with them, they share you ‘hey, come on, come on here, drink here!’ And you drink. That’s it. The grog gets hold of you.   (Brady 1993:405)

There are many signs, both physical and behavioral, that indicate drug use. Each drug has its own unique manifestations, but there are some general indications that a person is using drugs:

  • Sudden change in behavior
  • Mood swings; irritable and grumpy and then suddenly happy and bright
  • Withdrawal from family members
  • Careless about personal grooming
  • Loss of interest in hobbies, sports and other favorite activities
  • Changed sleeping pattern; up at night and sleeping during the day
  • Red or glassy eyes
  • Sniffing or runny nose

In this blog, we will be talking about this topic as well as many case studies in detail. Don’t forget to read, share and care. 

~Aastha Sethi

Reference: Wikipedia and https://health.nt.gov.au/Health_Promotion