Double jeopardy

For mentally ill substance abusers, treatment has often targeted either their illness or their addiction -- with the result that neither is cured. Massachusetts is working on ways to help.

Cityscape by Sarah McNaught

The police receive a call that a whacked-out man is harassing people on Boston Common. When they arrive, officers find a middle-aged male, clean but somewhat disheveled, pacing back and forth. He unloads disjointed and almost incoherent bits of wisdom on anyone who walks by. It's the kind of scene that's not uncommon in Boston.

A brief search reveals a small bag of white powder in the man's coat pocket. Another junkie vagrant disturbing the peace, the cops figure; they cuff him, throw him in the back of the cruiser, and take him to jail. He receives a court date and fails to show up, which doesn't really surprise anyone at the courthouse. To them, he is just an addict on the run.

But is he? Though it's easy to blame his behavior on drugs alone, it's not unlikely that he also suffers from a mental illness -- one he can't control, and one that both mimics and amplifies the symptoms of his addiction. Schizophrenia and manic depression, for example, can cause people to become agitated, delusional, paranoid, and even violent -- much like crack, cocaine, and other drugs. Now, thanks to a grant from the Substance Abuse and Mental Health Services Administration (SAMHSA), Massachusetts is developing a treatment plan to help people with both mental-health and substance-addiction problems.

Of the 700,000 Massachusetts residents suffering from some form of mental illness, no one is sure exactly how many are also struggling with drug or alcohol addiction. Nationally, an estimated 7.2 million people between the ages of 18 and 54 suffer from so-called co-occurring disorders, according to the National Co-Morbidity Survey, funded in 1996 by the National Institute of Mental Health. Fifty percent of those being treated for mental illness by the Massachusetts Department of Mental Health have substance-abuse problems, according to Ken Minkoff, medical director of Boston's Arbour Fuller Hospital, which helps such patients. Similarly, about 40 percent of those being treated by the Department of Public Health for less-severe psychiatric disorders, such as phobias, are substance abusers. And 30 percent of substance abusers receiving treatment in Massachusetts have some sort of psychiatric condition.

It seems like common sense that people suffering from co-occurring disorders need treatment for both mental illness and addiction. Yet for a variety of reasons, such patients often do not get the help they need. Sometimes one disorder or the other is ignored or overlooked because the symptoms overlap. Even when both conditions are diagnosed, addressing them simultaneously has proved difficult: for many years, substance-abuse specialists have regarded patients' mental illness as merely a symptom of their addiction, while mental-health experts have seen substance abuse as a symptom of mental illness. And treatment models for drug rehabilitation and mental illness are so different that each may undermine the other. "Differences between the types of treatments offered to substance abusers and the mentally ill perpetuate the gaps in services and eliminate the dually diagnosed from existing services," says Kathleen Sciacca of Sciacca Comprehensive Service Development for Mental Illness, Drug Addiction, and Alcoholism, who is responsible for launching dual-diagnosis programs in New York.

When patients are treated for only one of their disorders, their risk of relapse becomes much greater. People suffering from both addiction and mental illness are more likely to become homeless, to need emergency services, or to commit suicide. They are more prone to violence, as a result of which some end up in the prison system. In addition, according to SAMHSA, there are the social costs of treating, housing, and providing financial support for those whose dual illnesses leave them unable to work. Treatment costs for psychiatrically disabled drug abusers are nearly 60 percent higher than costs for nonabusers, according to a Harvard Medical School study published in 1996.

In Massachusetts, the Department of Public Health and the Department of Mental Health teamed up to work on this problem for the first time in 1973. Unfortunately, research suffered from minimal funding and inadequate support from the medical community. But last year, Massachusetts received one of 21 grants awarded nationally by SAMHSA's Center for Mental Health Services. The grant will allow the Department of Public Health, the Division of Medical Assistance, and the Massachusetts Behavioral Health Partnership to spend the next five years implementing a treatment plan for mentally ill substance abusers.

"There have been many national efforts to publicize the idea that dual diagnosis does in fact exist and to bring to light the importance of treating these separate illnesses in one individual," says Paul Barreira, deputy commissioner of clinical and professional services for the Massachusetts Department of Mental Health, who has headed up the initiative in this state. "But there remains the need to establish facilities and train staff on the proper way to diagnose, assess, and treat both disorders at the same time."

Results of a national study funded by the National Institute of Mental Health brought the need for such treatment to the forefront last year. The report found that 47 percent of people with schizophrenia abuse alcohol or drugs. According to the study, the odds of a schizophrenic abusing alcohol or drugs are four and a half times greater than for someone in the general population. Among people with affective disorders such as depression and phobias, 32 percent also suffer from substance abuse. And 55 percent of those suffering from bipolar disorders (manic depression) are addicted to either drugs or alcohol.

The relationship between the two types of disorders is complex. One illness may cause the other: for instance, according to SAMHSA, cocaine use may provoke such mental symptoms as panic attacks, psychotic episodes, and depression. At the same time, mental illness may lead indirectly to substance abuse: people who suffer from panic attacks or depression often self-medicate with alcohol so that they can function socially. Even when the two disorders develop independently -- as with a patient who drinks obsessively as a teenager and then, in later years, develops schizophrenia -- their effects become so intertwined that they must be treated together, according to Barreira. And, finally, specialists believe that severe childhood trauma may trigger both mental illness and substance abuse.

The key to the model being developed in Massachusetts is that it integrates existing treatments for substance abuse and mental illness. "The basis of the treatment," Barreira says, "is the acknowledgment that there are fundamental differences between mental-health and addiction treatments and that both must be adopted in order for dual treatment to work."

Mental-health specialists, for example, often use medication to control patients' symptoms; in addiction recovery, on the other hand, the emphasis is on ridding the body of all drugs. Drug rehabilitation relies heavily on self-help support groups, which are less appropriate for those with mental illnesses because such patients often have trouble discussing their symptoms. Finally, substance abusers can behave normally when they are not using drugs or alcohol; as a result, they may deny that they have a problem. People with mental illness, on the other hand, have no control over when their symptoms will strike and often cannot be fully cured. Whereas drug treatment focuses on abstinence and recovery, mental-health treatment aims for stability and rehabilitation.

The first step of the dual-diagnosis model is to determine whether a patient suffering from a mental illness is, in fact, addicted to drugs or alcohol. In some treatment programs, such as Sciacca's program at Harlem Valley Psychiatric Center in New York, a clinician looks into family history to determine whether the patient is at high risk for chemical dependency. The clinician then contacts the substance-abuse group at the facility to devise a treatment program.

Before actual treatment can begin, specialists must stabilize the patient's addiction and related emotional distress, whether through detoxification or group therapy. Once that is achieved, patients are educated on the effects of substance abuse, the symptoms of their particular mental disorder, and how they affect each other.

"It is not currently explained to patients that the depression they feel leads them to drinking, which, in turn, causes them to feel depressed," says Barreira. "It sounds basic, but the only way to keep a reluctant patient involved is to fill them in."

Whether patients are receiving residential or outpatient treatment, group therapy aimed at substance abuse is integrated into their mental-health care. Because many individuals who suffer from mental illness are not comfortable attending groups such as Alcoholics Anonymous or Narcotics Anonymous, speakers from both AA and NA are invited to speak to patient groups.

Once patients are sober, they "feel more independent and they are in more control of their lives, something that both substance abuse and mental illness can rob them of," explains Barreira. "The truth is, there are many people who can live functional, fulfilling lives if they could only see how one illness feeds off the other. Until recently, there was no way for them to understand that correlation when those of us treating them were still somewhat in the dark. With the development of new treatments and our own education, we can change that."

Sarah McNaught can be reached at smcnaught[a]phx.com.