JOURNAL OF DUAL DIAGNOSIS, 11(2), 93–96, 2015 C Taylor & Francis Group, LLC Copyright ISSN: 1550-4263 print / 1550-4271 online DOI: 10.1080/15504263.2015.1027125
EDITORIAL
A Call for Creativity in Dual Diagnosis Research Robert E. Drake, MD, PhD,1,2 and Alan I. Green, MD2
Articles in this issue of the Journal of Dual Diagnosis illustrate and elaborate on several research themes that we have identified previously: the complexity and diversity of dual diagnosis; the absence of evidence-based practices in routine mental health settings; the risks of undertreatment or overtreatment; the abundance of correlational studies, which rarely lead to interventions; the relative absence of research on peer support; the potential role of electronic technologies; and the need for creative solutions.
CURRENT PAPERS Klimas, Henihan, McCombe, Swan, Anderson, Bury, Dunne, Keenan, Saunders, Shorter, Smyth, and Cullen studied clinical screening and treatment for problems related to alcohol use in primary care treatment settings. People in these settings often received substance abuse treatments, such as methadone maintenance, but were typically not screened and treated for hazardous, harmful, or dependent drinking. The absence of systematic assessment and comprehensive, individually tailored treatments will continue until health care enters the modern age and adopts technology tools that providers and even patients themselves can use to facilitate routine patient-assisted care algorithms (Marsch, 2015). Two studies addressed the complex relationships among posttraumatic stress disorder (PTSD) symptoms, emotion regulation, and substance abuse. Tripp, McDevitt-Murphy, Avery, and Bracken examined alcohol use and gender 1Dartmouth
Psychiatric Research Center, The Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA 2Department of Psychiatry, The Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA Address correspondence to Robert E. Drake, MD, PhD, Dartmouth Psychiatric Research Center, The Geisel School of Medicine at Dartmouth, 85 Mechanic St., Suite B4-1, Lebanon, NH 03766, USA. E-mail: [email protected]
differences in these relationships. Difficulties with impulse control mediated the relationships in men, while difficulties engaging in goal-directed activities did so in women. Examining similar relationships among incarcerated men who used cocaine, Wahlstrom, Scott, Tuliao, DiLillo, and McChargue found that PTSD symptoms and nonacceptance of emotional responses predicted aggressive behaviors in the prison, with other factors mediating the relationships. Trying to put the two studies together illustrates the finding that correlational studies tend to be specific to population, circumstance, and measures—and why they rarely replicate or lead to robust interventions. Marienfeld and Rosenheck examined veterans with serious mental illness who also received methadone maintenance treatment in comparison with those who had only serious mental illness and those who had only methadone maintenance. The veterans with co-occurring disorders were more likely to have serious psychosocial difficulties, to have additional addictions, and to receive multiple classes of medications. This population is at risk for medical interpretation of social difficulties, leading to polypharmacy and adverse drug-drug interactions (Drake & Wallach, 2007). Treatment algorithms often fail to include the need to evaluate and, where appropriate, to carefully reduce medications. Roush and colleagues contributed two articles on peer support via a program designed specifically for people with co-occurring mental and addictive disorders, Dual Diagnosis Anonymous (DDA; Monica, Nikkel, & Drake, 2010). In the first article, Roush, Monica, Carpenter-Song, and Drake presented the results of focus groups with DDA members: Themes included accepting and understanding co-occurrence; permitting open discussions; and engendering hope for dual recovery. The second article, by Roush, Monica, Pavlovich, and Drake, described the use of community engagement techniques to build multi-stakeholder support and infrastructure for research on DDA. Community engagement research (Clinical and Translational Science Awards Consortium,
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2011) promises to find novel solutions to serious community health problems—approaches other than the usual biomedical treatments that professionals tend to create—thus obviating the common and expensive mistake of providing medical approaches to social problems. Brown, Medoff, Dickerson, Fang, Lucksted, Goldberg, Kreyenbuhl, Himelhoch, and Dixon studied the difficulty of implementing a smoking cessation program for people with serious mental illnesses in community mental health centers. The chief barrier to implementation was patients’ perceived lack of interest in quitting. Other studies have found contradictory results, that is, that patients are interested in smoking cessation (Ferron et al., 2011). Perhaps the inconsistency reflects the robust finding that professionals and patients have different perspectives and opinions (Woltmann, Wilkniss, Teachout, McHugo, & Drake, 2011; Roe, Gelkopf, Baloush-Kleinman, & Shadmi, in press). In a classic understatement, Brown and colleagues called for more creative solutions. CENTRAL THEMES Before suggesting new approaches, we will review key themes. Dissecting each of these themes may lead to innovative and practical interventions. The Complexity and Diversity of Dual Diagnosis The term dual diagnosis is itself a misnomer because people with two disorders often have multiple disorders complicated by multiple socioenvironmental stressors. The potential combinations of disorders, levels of severity, and contextual issues are legion. Further, the enterprise of reifying diagnoses and expanding polypharmacy reflects one of the many adverse effects of the process of periodically revising and reproducing the Diagnostic and Statistical Manual on Mental Disorders, often referred to as the DSM process (Drake & Wallach, 2007). Because of complexity, developing a medical typology without examining underlying social determinants is parlous. Yet the appropriate level of analysis for developing interventions remains unclear. Interactions may involve genetic, neurological, developmental, biochemical, social, ethnic, environmental, and cultural domains. Can we expect that similar treatments or even treatment principles will span such heterogeneity? Socioenvironmental interventions are most likely to be generic, as all people with dual diagnosis have needs for safe housing, social supports, meaningful activities, and psychological coping strategies. Pharmacological, neurological and, in the future, genetic interventions may be highly specific, as neuroscience continues to identify mechanisms, but for the present these factors need considerable clarification. The Absence of Evidence-Based Practices in Routine Mental Health Settings Another ubiquitous dilemma is that existing evidence-based treatments are rarely used (Drake & Essock, 2009). ImpleJournal of Dual Diagnosis
menting them successfully, providing universal access, and sustaining fidelity to evidence-based models would exceed current capacity by several orders of magnitude, especially in the context of high staff turnover, fluctuating state mental health budgets, and poor alignment between evidence-based practices and payment mechanisms (Goldman et al., 2001). For example, even wealthy states cannot afford regular face-to-face fidelity consultations for an expanding number of evidencebased practices. As we discuss below, technology may provide workable solutions.
The Risks of Undertreatment and Overtreatment While many people with dual diagnosis receive no treatment, those who are in treatment often receive overmedication and polypharmacy. It’s easy to see why: People want immediate improvements, pharmaceutical advertising suggests incorrectly that miraculous cures are available, and doctors are paid for prescribing medications but not for providing psychosocial interventions. We have created a therapeutic map on which many roads lead to overtreatment, with the result that treatment can at times produce more harm than benefit (Watts, 2012). This tragic outcome becomes even more likely when diagnoses are complex and interactive and when contextual issues, like poverty and homelessness, overwhelm other factors.
Correlational Studies of Psychological Mechanisms Correlational studies, especially of complex relationships that include moderators and mediators, tend not to be replicated for a variety of reasons, including many idiosyncratic characteristics of clients, programs, and contexts (Simmons, Nelson, & Simonsohn, 2011). Perhaps these studies can help to refine cognitive behavioral treatments and other psychotherapies, but at this juncture the field needs pragmatic intervention studies more than further elaborations of complex psychological models. Further, intervention studies should focus on ecologically meaningful outcomes, rather than on putative internal states and second-order correlates (McHugo et al., 2006). The analogous problem in pharmacology is treating laboratory values rather than focusing on outcomes that patients value.
The Inattention to Peer Support Clinical researchers, consistent with their training, tend to focus on pharmacological and psychotherapeutic interventions and often ignore nonmedical interventions, such as housing, employment, families, religions, cultural traditions, and most importantly peer support (Drake, Wallach, Alverson, & Mueser, 2002). At the same time, the fields of public mental health, addiction treatment, and dual diagnosis need simple, inexpensive interventions that can spread rapidly, attract
Editorial
people who avoid specialty care, and be sustained (Drake, 2013). Peer support presents such an alternative, one that has been underused and understudied. The story of DDA should inspire intervention researchers.
Absence of Health Information Technologies People with mental illnesses and substance use disorders use contemporary technologies in a manner similar to the general population (Ben-Zeev, Davis, Kaiser, Krzsos, & Drake, 2013). For example, at least 80% of people with schizophrenia access the Internet regularly, use e-mail, and access social networking websites, online forums, chat rooms, and blogs. Moreover, they already use a host of digital resources for mental health reasons: to obtain information about mental disorders and treatments; to search for resources related to their mental illnesses or substance use disorders; to connect with peers with similar conditions; to manage their disorders; and to engage with online communities and supports. Web-based interventions, mobile health supports, wearable sensors, and virtual reality interactions increasingly provide interventions directly, in the privacy of people’s residences, and at times and intensities of their choice. The Health Information for Economic and Clinical Health (HI-TECH) Act (U.S. Department of Health & Human Services, 2009) will facilitate broad adoption and meaningful use of technologies to improve health care. Thus far, however, little research has been done on technology tools for people with dual diagnoses. The challenge will be to develop tools that will be applicable in different types of settings for different populations. Health technologists may be needed to help other professionals use the technologies optimally and to provide continuous motivational coaching, practical training, ongoing technical support, and problem solving to patients (Ben-Zeev, Drake, & Marsch, 2015).
The Need for Creative Solutions Current research approaches to comorbidity have not produced simple, effective, inexpensive solutions. Notwithstanding possible breakthroughs from basic science or clinical research, how can we develop useful, accessible, affordable interventions? Perhaps, as we describe next, by considering new approaches.
FUTURE INTERVENTIONS First, we must prioritize basic needs and social services. The medical construction of the term dual diagnosis privileges biomedical research and treatments, while ignoring political, economic, social, and environmental realities. People who are poor, who have a serious illness, or who have significant social disadvantages are denied opportunities, suffer high burdens
95
of cumulative adversity, and are shunted into dangerous and drug-infested neighborhoods as well as jails and prisons. Hospitalization and community-based health care, safe and decent housing, and basic social resources are unavailable to the poor in many parts of the U.S. For example, in northern Manhattan, wealthy residents have access to an inordinate number of psychiatrists, while people with co-occurring serious mental illness and substance use disorder can rarely find any psychiatrist or any effective treatments (Drake et al., 2011). Moreover, when people with social disadvantage and behavioral health disorders do access health care, they tend to receive multiple medications rather than the psychosocial services they prefer (Carpenter-Song, in press). Applying medical solutions to social problems is expensive and ineffective. Nevertheless, the DSM process has inexorably increased the number and prevalence of diagnoses and eliminated traditional concepts of diversity and even normality (Frances, 2013); pharmaceutical advertising and the hope for rapid cures have shifted mental health budgets toward medications (Substance Abuse and Mental Health Services Administration, 2010); states’ prioritizing of medications has reduced human services and housing (Assessing the State, 2013); and the increasing economic inequalities in the U.S. has worsened these trends. For those who are poor and disadvantaged, medication alone does not work. The underlying socioenvironmental realities need to be addressed—by focusing on education, jobs, housing, and basic social services. Research shows that helping poor people to find housing in middle-class neighborhoods changes their housing choices and raises their expectations regarding neighborhood, housing, and schools (Darrah & Deluca, 2014). Second, we should make use of resources that are readily available and less costly than professional medical interventions. Consider the potential of family supports, peer supports, education in community colleges, employment in the open market, and technology tools on smart phones. These interventions are inexpensive, yet they are essentially ignored by current research. The success of DDA should inspire us to seek Walmart rather than Saks Fifth Avenue solutions for common problems. Third, new ideas are more likely to come from new sources rather than traditional health care researchers (Johnson, 2012). Many patient forums on the Internet could offer ideas, perhaps in response to prizes for crowdsourcing proposals. We could also extend the community engagement approach to this field. The DDA experience illustrates how a diverse group of stakeholders can overcome bureaucratic inertia to solve problems in a cost-effective manner. And we could invite our colleagues from other fields—anthropology, social policy, sociology, economics, engineering, computer science, and so on—to contribute to innovation. Dual diagnosis research teams should include much broader representation: people with dual disorders; family members; business leaders; community members; computer companies; diverse disciplines; and many others. The complexity of dual 2015, Volume 11, Number 2
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diagnosis entails much more than medical comorbidities, and successful interventions are likely to require much more than traditional medical approaches. Fourth, we must recognize that medicine is the last major industry to adopt information technology extensively. The pace has been slow, the resistance from professionals and other industries has been great, and well-researched tools have yet to enter the market place. Nevertheless, over 50,000 mobile health tools are currently available, and the number increases daily. Well-researched tools will soon be available (Marsch, 2015). Patients are connecting with each other on the Internet, using technology tools, and taking control of their health care. Technology will be the key to overcoming poor access to services, low-quality services, lack of patient-centeredness, and stigma—all of which plague the field of dual diagnosis today. Finally, we should remember that our goal is not so much treating disease as enabling well-being—the reasons that make life meaningful. As Atul Gawande (2014, p. 260) recently wrote, “whatever we can offer, our interventions, and the risks and sacrifices they entail, are justified only if they serve the larger aims of a person’s life.”
DISCLOSURES Dr. Drake reports no financial relationships with commercial interests. Dr. Green reports research grant support over the past three years from Janssen and Novartis. He currently serves as a consultant to Otsuka and Alkermes (unpaid) and on a data safety monitoring board for Eli Lilly studies, and he has two pending patents on the treatment of substance abuse. During the past three years he has owned shares of stock in Johnson & Johnson, Pfizer, and Mylan.
REFERENCES Assessing the State of America’s Mental Health: What We Can Do Now. (2013) (testimony of Michael F. Hogan). Retrieved from http://www.help.senate.gov/imo/media/doc/Hogan.pdf Ben-Zeev, D., Davis, K. E., Kaiser, S., Krzsos, I., & Drake, R. E. (2013). Mobile technologies among people with serious mental illness: Opportunities for future services. Administration and Policy in Mental Health and Mental Health Services Research, 40, 340–343. doi:10.1007/s10488-012-0424-x Ben-Zeev, D., Drake, R. E., & Marsch, L. (2015). Clinical technology specialists: Who needs them? We do. British Medical Journal, 350, h945. doi.org/10.1136/bmj.h945 Carpenter-Song, E. (in press). Putting meaning into medicine: Why context matters in American psychiatry. Epidemiology and Psychiatric Science. Clinical and Translational Science Awards Consortium. (2011). Principles of community engagement (2nd ed.). Bethesda, MD: U.S. Department of Health and Human Services. Darrah, J., & Deluca, S. (2014). “Living here has changed my whole perspective”: How escaping inner-city poverty shapes neighborhood and housing choice. Journal of Public Policy Analysis and Management, 33, 350–384. doi:10.1002/pam.21758
Journal of Dual Diagnosis
Drake, R. E. (2013). Cost-effective and scalable approaches to address the need for dual diagnosis services. Journal of Dual Diagnosis, 9, 267. doi:10.1080/15504263.2013.806688 Drake, R. E., Caton, C., Xie, H., Gorroochurn, P., Hsu, E., Samet, S., & Hasin, D. (2011). A prospective 2-year study of emergency department patients with early-phase primary psychosis or substanceinduced psychosis. American Journal of Psychiatry, 168, 742–748. doi:10.1176/appi.ajp.2011.10071051 Drake, R. E., & Essock, S. M. (2009). The science-to-service gap in real-world schizophrenia treatment: The 95% problem. Schizophrenia Bulletin, 35, 677–678. doi:10.1093/schbul/sbp047 Drake, R. E., & Wallach, M. A. (2007). Is comorbidity a psychological science? Clinical Psychology: Science and Practice, 14, 20–22. doi:10.1111/j.1468-2850.2007.00058.x Drake, R. E., Wallach, M. A., Alverson, H. S., & Mueser, K. T. (2002). Psychosocial aspects of substance abuse by clients with severe mental illness. Journal of Nervous and Mental Disease, 190, 100–106. doi:10.1097/00005053-200202000-00006 Ferron, J. C., Brunette, M. F., He, X., Xie, H., McHugo, G. J., & Drake, R. E. (2011). Course of smoking and quit attempts among clients with cooccurring severe mental illness and substance use disorders. Psychiatric Services, 62, 353–359. doi:10.1176/ps.62.4.pss6204 0353 Frances, A. (2013). Saving normal: An insider’s revolt against out-of-control psychiatric diagnosis, DSM-5, Big Pharma, and the medicalization of ordinary life. New York, NY: Harper Collins. Gawande, A. (2014). Being mortal: Medicine and what matters in the end. New York, NY: Metropolitan Books. Goldman, H. H., Ganju, V., Drake, R. E., Gorman, P., Hogan, M., Hyde, P., & Morgan, O. (2001). Policy implications for implementing evidence-based practices. Psychiatric Services, 52, 1591–1597. doi:10.1176/appi.ps.52.12.1591 Johnson, S. (2012). Future perfect: The case for progress in a networked age. New York, NY: Riverhead Books. Marsch, L. A. (2015). Envisioning the future: Transformation of healthcare systems via technology. In L. A. Marsch, S. E. Lord, & J. Dallery (Eds.), Behavioral healthcare and technology: Using science-based innovations to transform practice (pp. 317–328). New York, NY: Oxford University Press. McHugo, G. J., Drake, R. E., Brunette, M. F., Xie, H. Essock, S. M., & Green, A. I. (2006). Enhancing validity in co-occurring disorders treatment research. Schizophrenia Bulletin, 32, 655–665. doi:10.1093/schbul/sbl009 Monica, C., Nikkel, R. E., & Drake, R. E. (2010). Alcohol & drug abuse: Dual Diagnosis Anonymous of Oregon. Psychiatric Services, 61, 738– 740. doi:10.1176/ps.2010.61.8.738 Roe, D., Gelkopf, M., Baloush-Kleinman, V., & Shadmi, E. (in press). Implementing routine outcome measurement in psychiatric rehabilitation in Israel. International Review of Psychiatry. Substance Abuse and Mental Health Services Administration. (2010). National expenditures for mental health services & substance abuse treatment: 1986–2005. Retrieved from https://store.samhsa.gov/shin/ content/SMA10-4612/SMA10-4612.pdf Simmons, J. P., Nelson, L. D., & Simonsohn, U. (2011). False-positive psychology: Undisclosed flexibility in data collection and analysis allows presenting anything as significant. Psychological Science, 22, 1359–1366. doi:10.1177/0956797611417632 U.S. Department of Health & Human Services. (2009). Health Information Technology for Economic and Clinical Health (HI-TECH) Act. Retrieved from www.hhs.gov/ocr/privacy/hipaa/administrative/ enforcementrule/hightechenforcementifr.html Watts, G. (2012). More psychiatrists attack plans for DSM-5. British Medical Journal, 344, e3357. doi:10.1136/bmj.e3357 Woltmann, E., Wilkniss, S. M., Teachout, A., McHugo, G. J., & Drake, R. E. (2011). Trial of an electronic decision support system to facilitate shared decision making in community mental health. Psychiatric Services, 62, 54–60. doi:10.1176/ps.62.1.pss6201 0054
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EDITORIAL
A Call for Creativity in Dual Diagnosis Research Robert E. Drake, MD, PhD,1,2 and Alan I. Green, MD2
Articles in this issue of the Journal of Dual Diagnosis illustrate and elaborate on several research themes that we have identified previously: the complexity and diversity of dual diagnosis; the absence of evidence-based practices in routine mental health settings; the risks of undertreatment or overtreatment; the abundance of correlational studies, which rarely lead to interventions; the relative absence of research on peer support; the potential role of electronic technologies; and the need for creative solutions.
CURRENT PAPERS Klimas, Henihan, McCombe, Swan, Anderson, Bury, Dunne, Keenan, Saunders, Shorter, Smyth, and Cullen studied clinical screening and treatment for problems related to alcohol use in primary care treatment settings. People in these settings often received substance abuse treatments, such as methadone maintenance, but were typically not screened and treated for hazardous, harmful, or dependent drinking. The absence of systematic assessment and comprehensive, individually tailored treatments will continue until health care enters the modern age and adopts technology tools that providers and even patients themselves can use to facilitate routine patient-assisted care algorithms (Marsch, 2015). Two studies addressed the complex relationships among posttraumatic stress disorder (PTSD) symptoms, emotion regulation, and substance abuse. Tripp, McDevitt-Murphy, Avery, and Bracken examined alcohol use and gender 1Dartmouth
Psychiatric Research Center, The Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA 2Department of Psychiatry, The Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA Address correspondence to Robert E. Drake, MD, PhD, Dartmouth Psychiatric Research Center, The Geisel School of Medicine at Dartmouth, 85 Mechanic St., Suite B4-1, Lebanon, NH 03766, USA. E-mail: [email protected]
differences in these relationships. Difficulties with impulse control mediated the relationships in men, while difficulties engaging in goal-directed activities did so in women. Examining similar relationships among incarcerated men who used cocaine, Wahlstrom, Scott, Tuliao, DiLillo, and McChargue found that PTSD symptoms and nonacceptance of emotional responses predicted aggressive behaviors in the prison, with other factors mediating the relationships. Trying to put the two studies together illustrates the finding that correlational studies tend to be specific to population, circumstance, and measures—and why they rarely replicate or lead to robust interventions. Marienfeld and Rosenheck examined veterans with serious mental illness who also received methadone maintenance treatment in comparison with those who had only serious mental illness and those who had only methadone maintenance. The veterans with co-occurring disorders were more likely to have serious psychosocial difficulties, to have additional addictions, and to receive multiple classes of medications. This population is at risk for medical interpretation of social difficulties, leading to polypharmacy and adverse drug-drug interactions (Drake & Wallach, 2007). Treatment algorithms often fail to include the need to evaluate and, where appropriate, to carefully reduce medications. Roush and colleagues contributed two articles on peer support via a program designed specifically for people with co-occurring mental and addictive disorders, Dual Diagnosis Anonymous (DDA; Monica, Nikkel, & Drake, 2010). In the first article, Roush, Monica, Carpenter-Song, and Drake presented the results of focus groups with DDA members: Themes included accepting and understanding co-occurrence; permitting open discussions; and engendering hope for dual recovery. The second article, by Roush, Monica, Pavlovich, and Drake, described the use of community engagement techniques to build multi-stakeholder support and infrastructure for research on DDA. Community engagement research (Clinical and Translational Science Awards Consortium,
94
Editorial
2011) promises to find novel solutions to serious community health problems—approaches other than the usual biomedical treatments that professionals tend to create—thus obviating the common and expensive mistake of providing medical approaches to social problems. Brown, Medoff, Dickerson, Fang, Lucksted, Goldberg, Kreyenbuhl, Himelhoch, and Dixon studied the difficulty of implementing a smoking cessation program for people with serious mental illnesses in community mental health centers. The chief barrier to implementation was patients’ perceived lack of interest in quitting. Other studies have found contradictory results, that is, that patients are interested in smoking cessation (Ferron et al., 2011). Perhaps the inconsistency reflects the robust finding that professionals and patients have different perspectives and opinions (Woltmann, Wilkniss, Teachout, McHugo, & Drake, 2011; Roe, Gelkopf, Baloush-Kleinman, & Shadmi, in press). In a classic understatement, Brown and colleagues called for more creative solutions. CENTRAL THEMES Before suggesting new approaches, we will review key themes. Dissecting each of these themes may lead to innovative and practical interventions. The Complexity and Diversity of Dual Diagnosis The term dual diagnosis is itself a misnomer because people with two disorders often have multiple disorders complicated by multiple socioenvironmental stressors. The potential combinations of disorders, levels of severity, and contextual issues are legion. Further, the enterprise of reifying diagnoses and expanding polypharmacy reflects one of the many adverse effects of the process of periodically revising and reproducing the Diagnostic and Statistical Manual on Mental Disorders, often referred to as the DSM process (Drake & Wallach, 2007). Because of complexity, developing a medical typology without examining underlying social determinants is parlous. Yet the appropriate level of analysis for developing interventions remains unclear. Interactions may involve genetic, neurological, developmental, biochemical, social, ethnic, environmental, and cultural domains. Can we expect that similar treatments or even treatment principles will span such heterogeneity? Socioenvironmental interventions are most likely to be generic, as all people with dual diagnosis have needs for safe housing, social supports, meaningful activities, and psychological coping strategies. Pharmacological, neurological and, in the future, genetic interventions may be highly specific, as neuroscience continues to identify mechanisms, but for the present these factors need considerable clarification. The Absence of Evidence-Based Practices in Routine Mental Health Settings Another ubiquitous dilemma is that existing evidence-based treatments are rarely used (Drake & Essock, 2009). ImpleJournal of Dual Diagnosis
menting them successfully, providing universal access, and sustaining fidelity to evidence-based models would exceed current capacity by several orders of magnitude, especially in the context of high staff turnover, fluctuating state mental health budgets, and poor alignment between evidence-based practices and payment mechanisms (Goldman et al., 2001). For example, even wealthy states cannot afford regular face-to-face fidelity consultations for an expanding number of evidencebased practices. As we discuss below, technology may provide workable solutions.
The Risks of Undertreatment and Overtreatment While many people with dual diagnosis receive no treatment, those who are in treatment often receive overmedication and polypharmacy. It’s easy to see why: People want immediate improvements, pharmaceutical advertising suggests incorrectly that miraculous cures are available, and doctors are paid for prescribing medications but not for providing psychosocial interventions. We have created a therapeutic map on which many roads lead to overtreatment, with the result that treatment can at times produce more harm than benefit (Watts, 2012). This tragic outcome becomes even more likely when diagnoses are complex and interactive and when contextual issues, like poverty and homelessness, overwhelm other factors.
Correlational Studies of Psychological Mechanisms Correlational studies, especially of complex relationships that include moderators and mediators, tend not to be replicated for a variety of reasons, including many idiosyncratic characteristics of clients, programs, and contexts (Simmons, Nelson, & Simonsohn, 2011). Perhaps these studies can help to refine cognitive behavioral treatments and other psychotherapies, but at this juncture the field needs pragmatic intervention studies more than further elaborations of complex psychological models. Further, intervention studies should focus on ecologically meaningful outcomes, rather than on putative internal states and second-order correlates (McHugo et al., 2006). The analogous problem in pharmacology is treating laboratory values rather than focusing on outcomes that patients value.
The Inattention to Peer Support Clinical researchers, consistent with their training, tend to focus on pharmacological and psychotherapeutic interventions and often ignore nonmedical interventions, such as housing, employment, families, religions, cultural traditions, and most importantly peer support (Drake, Wallach, Alverson, & Mueser, 2002). At the same time, the fields of public mental health, addiction treatment, and dual diagnosis need simple, inexpensive interventions that can spread rapidly, attract
Editorial
people who avoid specialty care, and be sustained (Drake, 2013). Peer support presents such an alternative, one that has been underused and understudied. The story of DDA should inspire intervention researchers.
Absence of Health Information Technologies People with mental illnesses and substance use disorders use contemporary technologies in a manner similar to the general population (Ben-Zeev, Davis, Kaiser, Krzsos, & Drake, 2013). For example, at least 80% of people with schizophrenia access the Internet regularly, use e-mail, and access social networking websites, online forums, chat rooms, and blogs. Moreover, they already use a host of digital resources for mental health reasons: to obtain information about mental disorders and treatments; to search for resources related to their mental illnesses or substance use disorders; to connect with peers with similar conditions; to manage their disorders; and to engage with online communities and supports. Web-based interventions, mobile health supports, wearable sensors, and virtual reality interactions increasingly provide interventions directly, in the privacy of people’s residences, and at times and intensities of their choice. The Health Information for Economic and Clinical Health (HI-TECH) Act (U.S. Department of Health & Human Services, 2009) will facilitate broad adoption and meaningful use of technologies to improve health care. Thus far, however, little research has been done on technology tools for people with dual diagnoses. The challenge will be to develop tools that will be applicable in different types of settings for different populations. Health technologists may be needed to help other professionals use the technologies optimally and to provide continuous motivational coaching, practical training, ongoing technical support, and problem solving to patients (Ben-Zeev, Drake, & Marsch, 2015).
The Need for Creative Solutions Current research approaches to comorbidity have not produced simple, effective, inexpensive solutions. Notwithstanding possible breakthroughs from basic science or clinical research, how can we develop useful, accessible, affordable interventions? Perhaps, as we describe next, by considering new approaches.
FUTURE INTERVENTIONS First, we must prioritize basic needs and social services. The medical construction of the term dual diagnosis privileges biomedical research and treatments, while ignoring political, economic, social, and environmental realities. People who are poor, who have a serious illness, or who have significant social disadvantages are denied opportunities, suffer high burdens
95
of cumulative adversity, and are shunted into dangerous and drug-infested neighborhoods as well as jails and prisons. Hospitalization and community-based health care, safe and decent housing, and basic social resources are unavailable to the poor in many parts of the U.S. For example, in northern Manhattan, wealthy residents have access to an inordinate number of psychiatrists, while people with co-occurring serious mental illness and substance use disorder can rarely find any psychiatrist or any effective treatments (Drake et al., 2011). Moreover, when people with social disadvantage and behavioral health disorders do access health care, they tend to receive multiple medications rather than the psychosocial services they prefer (Carpenter-Song, in press). Applying medical solutions to social problems is expensive and ineffective. Nevertheless, the DSM process has inexorably increased the number and prevalence of diagnoses and eliminated traditional concepts of diversity and even normality (Frances, 2013); pharmaceutical advertising and the hope for rapid cures have shifted mental health budgets toward medications (Substance Abuse and Mental Health Services Administration, 2010); states’ prioritizing of medications has reduced human services and housing (Assessing the State, 2013); and the increasing economic inequalities in the U.S. has worsened these trends. For those who are poor and disadvantaged, medication alone does not work. The underlying socioenvironmental realities need to be addressed—by focusing on education, jobs, housing, and basic social services. Research shows that helping poor people to find housing in middle-class neighborhoods changes their housing choices and raises their expectations regarding neighborhood, housing, and schools (Darrah & Deluca, 2014). Second, we should make use of resources that are readily available and less costly than professional medical interventions. Consider the potential of family supports, peer supports, education in community colleges, employment in the open market, and technology tools on smart phones. These interventions are inexpensive, yet they are essentially ignored by current research. The success of DDA should inspire us to seek Walmart rather than Saks Fifth Avenue solutions for common problems. Third, new ideas are more likely to come from new sources rather than traditional health care researchers (Johnson, 2012). Many patient forums on the Internet could offer ideas, perhaps in response to prizes for crowdsourcing proposals. We could also extend the community engagement approach to this field. The DDA experience illustrates how a diverse group of stakeholders can overcome bureaucratic inertia to solve problems in a cost-effective manner. And we could invite our colleagues from other fields—anthropology, social policy, sociology, economics, engineering, computer science, and so on—to contribute to innovation. Dual diagnosis research teams should include much broader representation: people with dual disorders; family members; business leaders; community members; computer companies; diverse disciplines; and many others. The complexity of dual 2015, Volume 11, Number 2
96
Editorial
diagnosis entails much more than medical comorbidities, and successful interventions are likely to require much more than traditional medical approaches. Fourth, we must recognize that medicine is the last major industry to adopt information technology extensively. The pace has been slow, the resistance from professionals and other industries has been great, and well-researched tools have yet to enter the market place. Nevertheless, over 50,000 mobile health tools are currently available, and the number increases daily. Well-researched tools will soon be available (Marsch, 2015). Patients are connecting with each other on the Internet, using technology tools, and taking control of their health care. Technology will be the key to overcoming poor access to services, low-quality services, lack of patient-centeredness, and stigma—all of which plague the field of dual diagnosis today. Finally, we should remember that our goal is not so much treating disease as enabling well-being—the reasons that make life meaningful. As Atul Gawande (2014, p. 260) recently wrote, “whatever we can offer, our interventions, and the risks and sacrifices they entail, are justified only if they serve the larger aims of a person’s life.”
DISCLOSURES Dr. Drake reports no financial relationships with commercial interests. Dr. Green reports research grant support over the past three years from Janssen and Novartis. He currently serves as a consultant to Otsuka and Alkermes (unpaid) and on a data safety monitoring board for Eli Lilly studies, and he has two pending patents on the treatment of substance abuse. During the past three years he has owned shares of stock in Johnson & Johnson, Pfizer, and Mylan.
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Journal of Dual Diagnosis
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