Comorbid Mental and Substance Disorders among Older Psychiatric Patients David C. Speer, PhD and Kathie Bates, PhD Objective:To investigate the rate and configurations of cur-
rent comorbid mental and substance disorders among older psychiatric patients. Design: A descriptive, retrospective study. Setting:A non-acute, public residential psychiatric treatment facility for adults 55 years of age and older (mean length of stay: 3 months). Patients: 128 patients discharged during a 2-year period. Measures: DSM-111-R diagnoses, demographic and history data. Results: The overall prevalence rate of concurrent mental and substancedisorders during the present treatment episode was 21%. This is comparable to the 6-month rate of 19.8% lthough there is a growing literature on comorbid mental and substance-use disorders among young and middle-aged adults, research on dual diagnosis among the elderly has been neglected, (see also special section on dual diagnosis in Hospital 6 Community Psychiatry, 1989, Volume 40, Number 1O).'-3 Patients with comorbid disorders are now surfacing in the public community mental health services system for the elderly in Florida. These patients are perceived by clinical staff as being manipulative, denying their substance-use problems, resistant to treatment, and generally disruptive of treatment programming. This system was neither intended, funded, nor staffed to provide substance-abuse ~ervices.~ The absence of resources for the treatment of the substance-use disorders creates serious management and treatment problems, in part, because the emerging consensus suggests that both disorders should be treated simultaneously.5-7 Computerized library searches of the Embase, Medline, PsychInfo and PsychLit data bases failed to produce a single reference on dual diagnosis among older adults.' Reasonable initial questions are (1)what is the rate of concurrent dual diagnosis among older mental health patients and (2) what are the most common combinations or configurations of diagnosis among the elderly? Given the lack of studies of older adults, a possible reference point is the psychiatric comorbidity data on adults in general from the Epidemiologic Catchment Area study (ECA).9This study reports that the 6-month prevalence rate of comorbid addictive disorders among adults with any mental disorder, who were receiving treatment, was 19.8%. Unfortunately,
A
From the Florida Mental Health Institute, Department of Aging and Mental Health, University of South Florida, T,ampa, Florida. Portions of this paper were presented at the annual meeting of the Florida Council on Aging, Ft. Lauderdale, FL, .August 1991, and at the annual meeting of the Florida Council of Community Mental Health Centers, Cleanvater, FL, September 1991.
JAGS 40:886-890. 1992 0 1992 by the American Geriatrics Society
found in the Epidemiological Catchment Area Study among adults in treatment (all ages). Nearly 50% of the dually diagnosed subsamplereceived more than two diagnoses, with 60% of the subsample receiving a personality disorder diagnosis. Concurrent affective, alcohol, and personality disorder diagnoses were common. Conclusion:Older patients with comorbid substance-useand mental disorders may differ substantively from comorbid younger patients. Among older patients in an intermediateterm psychiatric facility, the triple occurrence of alcoholism personality disorder and depression was common. J Am Geriatr SOC40886-890,1992
the reported comorbid prevalence rates by specific mental disorders are lifetime rates which will always be larger than 6-month or present comorbidity rates. In a study of young chronic patients, Caton et all0 found that 50% were dually diagnosed, with 22% of the dually diagnosed having depression, 22% schizophrenia, and 27% conduct disorders. In a somewhat older sample of chronic patients, Drake and Wallach" found that about one-third were dually diagnosed, with 58% of these receiving a diagnosis of schizophrenia. A survey of administrators of geropsychiatric residential treatment programs in Florida suggested that 5%-10% of clients in these programs may have comorbid mental and substance-use disorders.' The purposes of the retrospective study reported here are to explore the rates of current comorbid mental and substance disorders and the configurations of dual diagnoses among older mental health patients.
METHOD Setting This study was conducted in the Residential Aging Program (RAP) at the Florida Mental Health Institute.8-12 This JCAHO-accredited, 20-bed program provides residential mental health treatment for persons 55 years of age and older. RAP, like most publicly supported mental health services for older adults in Florida, is not hospital affiliated. Thus, admitted patients must not be at risk for serious or acute medical events requiring extensive medical attention and must be continent and able to self-ambulate. Because the program, in addition to psychiatric treatment, incorporates extensive psychosocial treatment, patients with significant cognitive impairment are generally not admitted. As a result, RAP treats fewer demented patients than some other psychiatric services for older adults. Most referrals are from the acute psychiatric care units of hospitals in the five-county Tampa Bay area. Patients are referred because of a need for more extended treatment than is possible in acute care services that are under a variety
0002-8614/92/$3.50
888
JAGS-SEPTEMBER 1992-VOL. 40, NO.9
SPEER AND BATES
the 24-month period, 27 or 21% received one or more non-substance-use mental disorder diagnoses and one or more substance-use diagnoses. Thus, of the 53 clients who were multiply diagnosed, slightly more than half received comorbid mental and substancedisorder diagnoses. The comorbidity rates of substance-use disorders with the four most frequent non-substance disorders in the RAP sample are as follows: substance-use diagnoses were given to 13% of patients with schizophrenia, 16% of those with major depression, 20% of those with bipolar disorder, and 42% of those with a personality disorder. The frequency distribution of the various configurations of diagnoses among these dually diagnosed patients is presented in Table 2. The single most frequent configuration of comorbid mental and substance substance disorder involved three diagnoses: major depression, alcohol, and personality disorder. Six patients, or 22% of the dually diagnosed, showed this pattern. Overall, 33% of dually diagnosed patients received diagnoses of major depression and alcohol disorders, while 59% were diagnosed as having an affective disorder and an alcohol disorder. In 26 patients, or 96% of this subgroup, the diagnosis was alcoholism, while only two received a drug diagnosis (one client was cross-addicted). Table 2 also indicates that 59% of the dually diagnosed subgroup had a personality disorder. Among these 16 patients, in 10, or 62%, the diagnosis was a personality disorder not otherwise specified (PDNOS). Only two patients received ~ diagnosis of antisocial personality disorder. We tested for differences between the dual diagnosis group and the non-substance-abuse mental disorder group on several demographic and background variables by means of chi-square and ANOVA. The groups TABLE 2. CONFIGURAnONS OF DIA"tNOSES AMONG CLIENTS RECEIVING MENTAL AND SUBSTANCE-USE DISORDER DIAGNOSES = 27)
en
n Schizophrenia and alcohol Schizophrenia, alcohol and personality disorder Schizophrenia, alcohol and other Major depression and alcohol Major depression, alcohol and personality disorder Bipolar and alcohol Bipolar, alcohol and personality disorder Dysthymia and alcohol Dysthymia, alcohol and personality disorder Adjustment disorder and alcohol Adjustment, disorder, alcohol and personality disorder Personality disorder and alcohol Personality disorder and drug Personality disorder, alcohol and drug
2 1
% of DD
7.4 3.7
1
3.7
3 6
11.1 22.2
3
11.1
2
7.4
1 1
3.7 3.7
1 1
3.7 3.7
3
11.1
1 1
3.7 3.7
did not differ significantly by age, marital status, education, number of prior hospitalizations, or age at first hospitalization. The groups did differ significantly on sex (x 2 = 17.45, 1 df, P < 0.0001), with 70% of the dual diagnoses group being male while only 25% of the non-substance-use disorder group were male. DISCUSSION Literature on diagnostic characteristics of older psyamong sites, 15- One source of variation may be whether the setting is an acute-care service or a longer-term treatment facility such as the RAP service described here. For example, the many pressures to stabilize and discharge patients rapidly in acute care settings may lead to a focus on the florid Axis I conditions; the manifestations of personality disorders may often be masked by Axis I symptoms and become apparent only over some longer period of time and after Axis I symptoms have abated. A real and disconcerting issue may simply be the time available for thorough and complete assessment of Axis II conditions. Thus, replication of these findings is needed with attention given to setting differences. The 21 % comorbidity rate of mental and substance disorders among these older residential patients is consistent with the 6-month rate among patients receiving mental health and substance-abuse services reported from the ECA study (19.8%).9 This older adult rate, however, is substantially lower than the rates found among young chronically mentally ill groups (33%50%).10.11 The 21 % RAP comorbidity rate also suggests that dual diagnosis may be underestimated in the florida residential treatment system for older adults." That the comorbidity rates of substance use disorders with schizophrenia and bipolar disorders are so much lower than the lifetime rates reported in the ECA study is striking (47% and 56%, respectively)." This is partly attributable to the fact that current episode rates will always be lower than lifetime prevalence rates. The higher mortality rates for people with schizophrenia and bipolar disorders are also likely factors in the differences between younger and older adults on rates of comorbidity. However, the lower comorbidity rates with bipolar disorder and the relatively high prevalence of personality disorders among older patients with coexisting mental and substance disorders suggest that there may be substantive differences between younger and older dually diagnosed patients. The patterns of diagnoses among these "dually diagnosed" or comorbid older patients are provocative. Nearly half (48%) of the dual diagnosis group were in fact "triply" diagnosed. That alcohol disorders should co-occur at a high rate with affective disorders in general and major depression in particular is not surprising. However, that personality disorders occurred among nearly 60% of patients with comorbid mental and substance disorders is striking. The modal multiple diagnosis pattern among these comorbid mental and substance-disorder patients was tripartite: major depression, alcohol, and a personality disorder. Even among the 16 dually diagnosed patients with affective c~iatricgatients indicates co~si.derable variation
JAGS-SEPTEMBER 1992-VOL. 40, NO.9
COMORBID MENTAL AND SUBSTANCE DISORDERS
disorders, nine (56%) also received a personality disorder diagnosis. These findings suggest that about half of older "dually diagnosed" patients have more than two disorders and that over half have personality disorders with their associated difficult prognoses. This is consistent with Kroessler's suggestion that older adults with major depression who do not respond to traditional treatment protocols be assessed for a possible personality disorder." The treatment and prognosis implications of the potential frequency of personality disorders among older clients with mental and substance disorders are sobering. Thompson et ai/I for example, have demonstrated that treatment outcome is much poorer among older patients with major depression who also have personality disorders than among older major depressives without personality disorders. These writers suggest that the optimum time to assess for personality disorder is after Axis I symptoms have mitigated. Nace." however, has suggested that the group therapy approaches appropriate for substance abusers seem also to be effective with personality disordered younger alcoholics. That the modal-specific personality disorder within the dual diagnosis subgroup was personality disorder not otherwise specified (PDNOS) is enigmatic. It is tempting to attribute this to the diagnosis being used as a wastebasket category for difficulty patients. However, a number of writers have commented on the difficulty of placing many personality-disordered patients, and particularly older patients, in specific personality disorder categories because of the frequency with which patients display features of several different personality disorders. 14, 20. 22, 23 The clinical staff in RAP, in fact, use PDNOS to represent the "mixed personality disorder" of DSM-III. Although research has demonstrated the basic stability of personality during aging, Kroessler has argued that because of biologically based behavioral change with aging, the behavioral signs of personality disorders also change as people grow older." He suggests that diagnostic criteria may diffuse with age and, as a result, that older adults fit specific personality disorder categories less clearly than do younger adults. This may be another instance of nosology needing age adjustment. Finally, the dual diagnosis subgroup was characterized by high rates of divorce and prior hospitalization, with first psychiatric or substance-abuse hospitalization occurring during the mid 40's age range. In contrast to non-substance-abusing patients, the dual diagnosis group was largely male. This constellation of characteristics, in the context of alcohol abuse and frequent personality disorders (which by definition are long-standing), is strikingly similar to the phenomenon of early onset (chronic) alcoholism among older adults. 24 - 2 6 This, in turn, suggests a possible significant conceptual overlap of elderly dual diagnosis, early onset alcoholism, and personality disorder, ie, that these may not be distinct and separate phenomena. For example, dual diagnosis may simply be a new label for an older person with a long standing personality disorder and long standing alcoholism who comes to geriatric attention because of major depression or dys-
889
thymia. Although disordered personality and drinking may be the basic problems, we are presented only with the affective problems and, perhaps, some suggestions of a drinking problem. The clinical implication of these preliminary findings is that older patients admitted to acute care psychiatric units with an apparent mood disorder may be stabilized and discharged without a clear understanding of underlying personality problems. The pressures to rapidly alleviate the florid symptoms and discharge the patient to the community are great. Assuming that the alcohol disorder is diagnosed (and this is a big assumption given the frequency with which abusive drinking is successfully hidden among the elderly), a referral to Alcoholics Anonymous or for outpatient alcohol counseling may not be sufficient if the patient also has a personality disorder. Successful treatment of the latter condition usually requires long-term, intensive treatment, perhaps in a restricted setting. If nothing else, these findings suggest that closer diagnostic attention be given to Axis II conditions among elders with mood and substance use disorders. Whether dual diagnosis represents a new and discrete phenomenon or simply a new awareness of the confluence of conditions that have previously been identified in isolation remains to be seen. A better understanding of the interaction of disorders over the life-span is needed. Because of the widespread segregation of mental health and substance-abuse services, and the need for simultaneous treatment, we need a better understanding of the comorbidity of mental and substance disorders among older adults in particular."
REFERENCES 1. Brown VB, Ridgely MS, Pepper B et al. The dual crisis: Mental illness and substance abuse. Am PsychoI1989;44:565-69. 2. Caragnonne P, Emery B. Mental illness and substance abuse: The dually diagnosed client. Rockville, MD: National Council of Community Mental Health Centers, 1987. 3. Teague GB, Schwab B, Drake RE. Evaluation of services for young adults with severe mental illness and substance use disorders. Alexandria, VA: National Association of State Mental Health Program Directors, 1990. 4. Speer DC O'Sullivan M, Schonfeld L. Dual diagnosis among older adults: A new array of policy and planning problems. J Ment Health Admin 1991;18:43-50. 5. Evans K, Sullivan JM. Dual Diagnosis: Counseling the Mentally III Substance Abuser. New York: Guilford Press, 1990. 6. Lehman AF, Myers CP, Corty E. Assessment and classification of patients with psychiatric and substance abuse syndromes. Hosp Community Psychiatry 1989;40:1019-1025. 7. Minkoff K. An integrated treatment model for dual diagnosis of psychosis and addiction. Hosp Community Psychiatry 1989;40:1031-1036. 8. Speer DC. Comorbid mental and substance disorders among the elderly: Conceptual issues and propositions. Behav Health Aging 1990;1:163-170. 9. Regier DA, Farmer ME, Rae OS et al. Comorbidity of mental disorders with alcohol and other drug abuse. JAMA 1990;264:2511-2518. 10. Caton CLM, Gralnick A, Gender S et al. Young chronic patients and substance abuse. Hosp Community Psychiatry 1989;40:1037-1040. 11. Drake RE, Wallach MA. Substance abuse among the chronically mentally ill. Hosp Community Psychiatry 1989;40:1041-1046. 12. Patterson RL. Overcoming Deficits of Aging. New York: Plenum Press, 1982. 13. Dupree LW, Broskowski H, Schonfeld L. The gerontology alcohol project: A behavioral treatment program for elderly alcohol abusers. Gerontologist 1984;24:510-516. 14. American Psychiatric Association Committee on Nomenclature and Statistics. Diagnostic and Statistical Manual of Mental Disorders, 3rd Ed, Revised. Washington, DC: American Psychiatric Association Press, 1987. 15. Conwell Y, Nelson C, Kim C et al. Elderly patients admitted to the psychiatric unit of a general hospital. J Am Geriatr Soc 1989;37:35-41.
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SPEER AND BATES
16. Goldstrom ID, Bums BJ, Kessler LG et al. Mental health services use by elderly adults in a primary care setting. I Gerontol 1987;42:147-153. 17. Simson S, Wilson LB. Meeting the mental health needs of the aged: The role of psychiatric emergency services. Hosp Community Psychiatry 1982;33:833-836. 18. Speer DC, William J, West H et al. Older adult users of outpatient mental health services. Community Ment Health J 1991;27:69-76. 19. Thienhaus 01, Rowe C, Woellert P, Hillard JR. Geropsychiatric emergency services: Utilization and outcome predictors. Hosp Community Psychiatry 1988;39:1301-1305. 20. Kroessler D. Personality disorder in the elderly. Hosp Community Psychiatry 1990;41: 1325-1 329. 21. Thompson LW, Gallagher D, Czirr R. Personality disorder and outcome
22. 23. 24. 25. 26.
in the treatment of late-life depression. J Geriatr Psychiatry 1988;21:133146. Nace EP. Substance abuse and personality disorder. In D. F. O’Connell, ed. Managing the Dually Diagnosed Patient: Current Issues and Clinical Approaches. New York Haworth Press, 1990. Sadavoy J. Character pathology in the elderly. J Geriatr Psychiatry 1987;20(2):165-178. Atkinson RM, Tolson RL, Tumer JA. Early versus late onset problem drinking in older men. Alcoholism Clin Exp Research 1990;14:574-579, Schonfeld L, Dupree L. Antecedents of drinking for early- and late-onset elderly alcohol abusers. J Stud Alcohol 1991, in press. Schuckitt MA. A clinical review of alcohol, alcoholism, and the elderly patient. J Clin Psychiatry 1982;43:396-399.
rent comorbid mental and substance disorders among older psychiatric patients. Design: A descriptive, retrospective study. Setting:A non-acute, public residential psychiatric treatment facility for adults 55 years of age and older (mean length of stay: 3 months). Patients: 128 patients discharged during a 2-year period. Measures: DSM-111-R diagnoses, demographic and history data. Results: The overall prevalence rate of concurrent mental and substancedisorders during the present treatment episode was 21%. This is comparable to the 6-month rate of 19.8% lthough there is a growing literature on comorbid mental and substance-use disorders among young and middle-aged adults, research on dual diagnosis among the elderly has been neglected, (see also special section on dual diagnosis in Hospital 6 Community Psychiatry, 1989, Volume 40, Number 1O).'-3 Patients with comorbid disorders are now surfacing in the public community mental health services system for the elderly in Florida. These patients are perceived by clinical staff as being manipulative, denying their substance-use problems, resistant to treatment, and generally disruptive of treatment programming. This system was neither intended, funded, nor staffed to provide substance-abuse ~ervices.~ The absence of resources for the treatment of the substance-use disorders creates serious management and treatment problems, in part, because the emerging consensus suggests that both disorders should be treated simultaneously.5-7 Computerized library searches of the Embase, Medline, PsychInfo and PsychLit data bases failed to produce a single reference on dual diagnosis among older adults.' Reasonable initial questions are (1)what is the rate of concurrent dual diagnosis among older mental health patients and (2) what are the most common combinations or configurations of diagnosis among the elderly? Given the lack of studies of older adults, a possible reference point is the psychiatric comorbidity data on adults in general from the Epidemiologic Catchment Area study (ECA).9This study reports that the 6-month prevalence rate of comorbid addictive disorders among adults with any mental disorder, who were receiving treatment, was 19.8%. Unfortunately,
A
From the Florida Mental Health Institute, Department of Aging and Mental Health, University of South Florida, T,ampa, Florida. Portions of this paper were presented at the annual meeting of the Florida Council on Aging, Ft. Lauderdale, FL, .August 1991, and at the annual meeting of the Florida Council of Community Mental Health Centers, Cleanvater, FL, September 1991.
JAGS 40:886-890. 1992 0 1992 by the American Geriatrics Society
found in the Epidemiological Catchment Area Study among adults in treatment (all ages). Nearly 50% of the dually diagnosed subsamplereceived more than two diagnoses, with 60% of the subsample receiving a personality disorder diagnosis. Concurrent affective, alcohol, and personality disorder diagnoses were common. Conclusion:Older patients with comorbid substance-useand mental disorders may differ substantively from comorbid younger patients. Among older patients in an intermediateterm psychiatric facility, the triple occurrence of alcoholism personality disorder and depression was common. J Am Geriatr SOC40886-890,1992
the reported comorbid prevalence rates by specific mental disorders are lifetime rates which will always be larger than 6-month or present comorbidity rates. In a study of young chronic patients, Caton et all0 found that 50% were dually diagnosed, with 22% of the dually diagnosed having depression, 22% schizophrenia, and 27% conduct disorders. In a somewhat older sample of chronic patients, Drake and Wallach" found that about one-third were dually diagnosed, with 58% of these receiving a diagnosis of schizophrenia. A survey of administrators of geropsychiatric residential treatment programs in Florida suggested that 5%-10% of clients in these programs may have comorbid mental and substance-use disorders.' The purposes of the retrospective study reported here are to explore the rates of current comorbid mental and substance disorders and the configurations of dual diagnoses among older mental health patients.
METHOD Setting This study was conducted in the Residential Aging Program (RAP) at the Florida Mental Health Institute.8-12 This JCAHO-accredited, 20-bed program provides residential mental health treatment for persons 55 years of age and older. RAP, like most publicly supported mental health services for older adults in Florida, is not hospital affiliated. Thus, admitted patients must not be at risk for serious or acute medical events requiring extensive medical attention and must be continent and able to self-ambulate. Because the program, in addition to psychiatric treatment, incorporates extensive psychosocial treatment, patients with significant cognitive impairment are generally not admitted. As a result, RAP treats fewer demented patients than some other psychiatric services for older adults. Most referrals are from the acute psychiatric care units of hospitals in the five-county Tampa Bay area. Patients are referred because of a need for more extended treatment than is possible in acute care services that are under a variety
0002-8614/92/$3.50
888
JAGS-SEPTEMBER 1992-VOL. 40, NO.9
SPEER AND BATES
the 24-month period, 27 or 21% received one or more non-substance-use mental disorder diagnoses and one or more substance-use diagnoses. Thus, of the 53 clients who were multiply diagnosed, slightly more than half received comorbid mental and substancedisorder diagnoses. The comorbidity rates of substance-use disorders with the four most frequent non-substance disorders in the RAP sample are as follows: substance-use diagnoses were given to 13% of patients with schizophrenia, 16% of those with major depression, 20% of those with bipolar disorder, and 42% of those with a personality disorder. The frequency distribution of the various configurations of diagnoses among these dually diagnosed patients is presented in Table 2. The single most frequent configuration of comorbid mental and substance substance disorder involved three diagnoses: major depression, alcohol, and personality disorder. Six patients, or 22% of the dually diagnosed, showed this pattern. Overall, 33% of dually diagnosed patients received diagnoses of major depression and alcohol disorders, while 59% were diagnosed as having an affective disorder and an alcohol disorder. In 26 patients, or 96% of this subgroup, the diagnosis was alcoholism, while only two received a drug diagnosis (one client was cross-addicted). Table 2 also indicates that 59% of the dually diagnosed subgroup had a personality disorder. Among these 16 patients, in 10, or 62%, the diagnosis was a personality disorder not otherwise specified (PDNOS). Only two patients received ~ diagnosis of antisocial personality disorder. We tested for differences between the dual diagnosis group and the non-substance-abuse mental disorder group on several demographic and background variables by means of chi-square and ANOVA. The groups TABLE 2. CONFIGURAnONS OF DIA"tNOSES AMONG CLIENTS RECEIVING MENTAL AND SUBSTANCE-USE DISORDER DIAGNOSES = 27)
en
n Schizophrenia and alcohol Schizophrenia, alcohol and personality disorder Schizophrenia, alcohol and other Major depression and alcohol Major depression, alcohol and personality disorder Bipolar and alcohol Bipolar, alcohol and personality disorder Dysthymia and alcohol Dysthymia, alcohol and personality disorder Adjustment disorder and alcohol Adjustment, disorder, alcohol and personality disorder Personality disorder and alcohol Personality disorder and drug Personality disorder, alcohol and drug
2 1
% of DD
7.4 3.7
1
3.7
3 6
11.1 22.2
3
11.1
2
7.4
1 1
3.7 3.7
1 1
3.7 3.7
3
11.1
1 1
3.7 3.7
did not differ significantly by age, marital status, education, number of prior hospitalizations, or age at first hospitalization. The groups did differ significantly on sex (x 2 = 17.45, 1 df, P < 0.0001), with 70% of the dual diagnoses group being male while only 25% of the non-substance-use disorder group were male. DISCUSSION Literature on diagnostic characteristics of older psyamong sites, 15- One source of variation may be whether the setting is an acute-care service or a longer-term treatment facility such as the RAP service described here. For example, the many pressures to stabilize and discharge patients rapidly in acute care settings may lead to a focus on the florid Axis I conditions; the manifestations of personality disorders may often be masked by Axis I symptoms and become apparent only over some longer period of time and after Axis I symptoms have abated. A real and disconcerting issue may simply be the time available for thorough and complete assessment of Axis II conditions. Thus, replication of these findings is needed with attention given to setting differences. The 21 % comorbidity rate of mental and substance disorders among these older residential patients is consistent with the 6-month rate among patients receiving mental health and substance-abuse services reported from the ECA study (19.8%).9 This older adult rate, however, is substantially lower than the rates found among young chronically mentally ill groups (33%50%).10.11 The 21 % RAP comorbidity rate also suggests that dual diagnosis may be underestimated in the florida residential treatment system for older adults." That the comorbidity rates of substance use disorders with schizophrenia and bipolar disorders are so much lower than the lifetime rates reported in the ECA study is striking (47% and 56%, respectively)." This is partly attributable to the fact that current episode rates will always be lower than lifetime prevalence rates. The higher mortality rates for people with schizophrenia and bipolar disorders are also likely factors in the differences between younger and older adults on rates of comorbidity. However, the lower comorbidity rates with bipolar disorder and the relatively high prevalence of personality disorders among older patients with coexisting mental and substance disorders suggest that there may be substantive differences between younger and older dually diagnosed patients. The patterns of diagnoses among these "dually diagnosed" or comorbid older patients are provocative. Nearly half (48%) of the dual diagnosis group were in fact "triply" diagnosed. That alcohol disorders should co-occur at a high rate with affective disorders in general and major depression in particular is not surprising. However, that personality disorders occurred among nearly 60% of patients with comorbid mental and substance disorders is striking. The modal multiple diagnosis pattern among these comorbid mental and substance-disorder patients was tripartite: major depression, alcohol, and a personality disorder. Even among the 16 dually diagnosed patients with affective c~iatricgatients indicates co~si.derable variation
JAGS-SEPTEMBER 1992-VOL. 40, NO.9
COMORBID MENTAL AND SUBSTANCE DISORDERS
disorders, nine (56%) also received a personality disorder diagnosis. These findings suggest that about half of older "dually diagnosed" patients have more than two disorders and that over half have personality disorders with their associated difficult prognoses. This is consistent with Kroessler's suggestion that older adults with major depression who do not respond to traditional treatment protocols be assessed for a possible personality disorder." The treatment and prognosis implications of the potential frequency of personality disorders among older clients with mental and substance disorders are sobering. Thompson et ai/I for example, have demonstrated that treatment outcome is much poorer among older patients with major depression who also have personality disorders than among older major depressives without personality disorders. These writers suggest that the optimum time to assess for personality disorder is after Axis I symptoms have mitigated. Nace." however, has suggested that the group therapy approaches appropriate for substance abusers seem also to be effective with personality disordered younger alcoholics. That the modal-specific personality disorder within the dual diagnosis subgroup was personality disorder not otherwise specified (PDNOS) is enigmatic. It is tempting to attribute this to the diagnosis being used as a wastebasket category for difficulty patients. However, a number of writers have commented on the difficulty of placing many personality-disordered patients, and particularly older patients, in specific personality disorder categories because of the frequency with which patients display features of several different personality disorders. 14, 20. 22, 23 The clinical staff in RAP, in fact, use PDNOS to represent the "mixed personality disorder" of DSM-III. Although research has demonstrated the basic stability of personality during aging, Kroessler has argued that because of biologically based behavioral change with aging, the behavioral signs of personality disorders also change as people grow older." He suggests that diagnostic criteria may diffuse with age and, as a result, that older adults fit specific personality disorder categories less clearly than do younger adults. This may be another instance of nosology needing age adjustment. Finally, the dual diagnosis subgroup was characterized by high rates of divorce and prior hospitalization, with first psychiatric or substance-abuse hospitalization occurring during the mid 40's age range. In contrast to non-substance-abusing patients, the dual diagnosis group was largely male. This constellation of characteristics, in the context of alcohol abuse and frequent personality disorders (which by definition are long-standing), is strikingly similar to the phenomenon of early onset (chronic) alcoholism among older adults. 24 - 2 6 This, in turn, suggests a possible significant conceptual overlap of elderly dual diagnosis, early onset alcoholism, and personality disorder, ie, that these may not be distinct and separate phenomena. For example, dual diagnosis may simply be a new label for an older person with a long standing personality disorder and long standing alcoholism who comes to geriatric attention because of major depression or dys-
889
thymia. Although disordered personality and drinking may be the basic problems, we are presented only with the affective problems and, perhaps, some suggestions of a drinking problem. The clinical implication of these preliminary findings is that older patients admitted to acute care psychiatric units with an apparent mood disorder may be stabilized and discharged without a clear understanding of underlying personality problems. The pressures to rapidly alleviate the florid symptoms and discharge the patient to the community are great. Assuming that the alcohol disorder is diagnosed (and this is a big assumption given the frequency with which abusive drinking is successfully hidden among the elderly), a referral to Alcoholics Anonymous or for outpatient alcohol counseling may not be sufficient if the patient also has a personality disorder. Successful treatment of the latter condition usually requires long-term, intensive treatment, perhaps in a restricted setting. If nothing else, these findings suggest that closer diagnostic attention be given to Axis II conditions among elders with mood and substance use disorders. Whether dual diagnosis represents a new and discrete phenomenon or simply a new awareness of the confluence of conditions that have previously been identified in isolation remains to be seen. A better understanding of the interaction of disorders over the life-span is needed. Because of the widespread segregation of mental health and substance-abuse services, and the need for simultaneous treatment, we need a better understanding of the comorbidity of mental and substance disorders among older adults in particular."
REFERENCES 1. Brown VB, Ridgely MS, Pepper B et al. The dual crisis: Mental illness and substance abuse. Am PsychoI1989;44:565-69. 2. Caragnonne P, Emery B. Mental illness and substance abuse: The dually diagnosed client. Rockville, MD: National Council of Community Mental Health Centers, 1987. 3. Teague GB, Schwab B, Drake RE. Evaluation of services for young adults with severe mental illness and substance use disorders. Alexandria, VA: National Association of State Mental Health Program Directors, 1990. 4. Speer DC O'Sullivan M, Schonfeld L. Dual diagnosis among older adults: A new array of policy and planning problems. J Ment Health Admin 1991;18:43-50. 5. Evans K, Sullivan JM. Dual Diagnosis: Counseling the Mentally III Substance Abuser. New York: Guilford Press, 1990. 6. Lehman AF, Myers CP, Corty E. Assessment and classification of patients with psychiatric and substance abuse syndromes. Hosp Community Psychiatry 1989;40:1019-1025. 7. Minkoff K. An integrated treatment model for dual diagnosis of psychosis and addiction. Hosp Community Psychiatry 1989;40:1031-1036. 8. Speer DC. Comorbid mental and substance disorders among the elderly: Conceptual issues and propositions. Behav Health Aging 1990;1:163-170. 9. Regier DA, Farmer ME, Rae OS et al. Comorbidity of mental disorders with alcohol and other drug abuse. JAMA 1990;264:2511-2518. 10. Caton CLM, Gralnick A, Gender S et al. Young chronic patients and substance abuse. Hosp Community Psychiatry 1989;40:1037-1040. 11. Drake RE, Wallach MA. Substance abuse among the chronically mentally ill. Hosp Community Psychiatry 1989;40:1041-1046. 12. Patterson RL. Overcoming Deficits of Aging. New York: Plenum Press, 1982. 13. Dupree LW, Broskowski H, Schonfeld L. The gerontology alcohol project: A behavioral treatment program for elderly alcohol abusers. Gerontologist 1984;24:510-516. 14. American Psychiatric Association Committee on Nomenclature and Statistics. Diagnostic and Statistical Manual of Mental Disorders, 3rd Ed, Revised. Washington, DC: American Psychiatric Association Press, 1987. 15. Conwell Y, Nelson C, Kim C et al. Elderly patients admitted to the psychiatric unit of a general hospital. J Am Geriatr Soc 1989;37:35-41.
890
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16. Goldstrom ID, Bums BJ, Kessler LG et al. Mental health services use by elderly adults in a primary care setting. I Gerontol 1987;42:147-153. 17. Simson S, Wilson LB. Meeting the mental health needs of the aged: The role of psychiatric emergency services. Hosp Community Psychiatry 1982;33:833-836. 18. Speer DC, William J, West H et al. Older adult users of outpatient mental health services. Community Ment Health J 1991;27:69-76. 19. Thienhaus 01, Rowe C, Woellert P, Hillard JR. Geropsychiatric emergency services: Utilization and outcome predictors. Hosp Community Psychiatry 1988;39:1301-1305. 20. Kroessler D. Personality disorder in the elderly. Hosp Community Psychiatry 1990;41: 1325-1 329. 21. Thompson LW, Gallagher D, Czirr R. Personality disorder and outcome
22. 23. 24. 25. 26.
in the treatment of late-life depression. J Geriatr Psychiatry 1988;21:133146. Nace EP. Substance abuse and personality disorder. In D. F. O’Connell, ed. Managing the Dually Diagnosed Patient: Current Issues and Clinical Approaches. New York Haworth Press, 1990. Sadavoy J. Character pathology in the elderly. J Geriatr Psychiatry 1987;20(2):165-178. Atkinson RM, Tolson RL, Tumer JA. Early versus late onset problem drinking in older men. Alcoholism Clin Exp Research 1990;14:574-579, Schonfeld L, Dupree L. Antecedents of drinking for early- and late-onset elderly alcohol abusers. J Stud Alcohol 1991, in press. Schuckitt MA. A clinical review of alcohol, alcoholism, and the elderly patient. J Clin Psychiatry 1982;43:396-399.
