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173 Presentation SERIAL, PARALLEL, AND INTEGRATED MODELS OF DUAL-DIAGNOSIS TREATMENT RICHARD K. RIES, M.D. Acting Chief of Psychiatry Director, Inpatient Psychiatry Dual-Diagnosis Disorders Program Medical Director, Chemical Dependence Project Harborview Medical Center 325 Ninth Avenue Seattle, WA 98104 Agréât DEAL of interest has recently developed in the area of dual diagnosis, which is defined here as a co-occurrence of mental disorder and substance-use disorder. Much of the focus on dual diagnosis has come from the public mental health system, which is confronted with increasing numbers of young chronically mentally ill patients who also have problems related to substance use. Research shows that the dual disordered population has poor treatment compliance, is hospitalized more frequently than are psychiatric patients, and has poor outcome in both psychiatric1 and chemical dependency treatment.2 A number of programs have been developed to address dual disordered patients. These include outpatient programs3, case-managed programs4 , and inpatient programs.5"8 There are relatively few outcome studies in the area, probably due to several factors: 1. dual diagnosis is a relatively new area of interest; 2. dual-diagnosis programs and clinics have developed only in the last few years; Journal of Health Care for the Poor and Underserved, Vol. 3, No. 1, Summer 1992 174 Serial, Parallel, and Integrated Models 3. the boundaries of dual diagnosis are unclear;* 4. the heterogeneity of disorders and patient types makes clean scientific study difficult. While several outcome studies by the National Institute on Drug Abuse (NIDA) and the National Institute of Mental Health (NIMH) are underway, clinicians and administrators have been forced to design and implement treatment programs for dual disordered populations without the results of outcome studies. The pressure to introduce services has been caused by the high prevalence of dual disordered patients and the amount of services they consume .9 Though controlled outcome studies are largely unavailable, models for treating the dual disordered patient can be developed empirically by using established treatment models for each disorder, which exist independently in the mental health and chemical dependency systems, then examining the potential for therapeutic intervention. The interactions between the two treatment systems can be conceptually viewed as serial (one treatment follows the other), parallel (the two treatments remain separate, but are given concurrently ), and integrated (the two treatments are merged both in time and concept). While the fields of mental health and chemical dependency feature diverse treatment models, the models rarely overlap between the two fields. Further, deep schisms between state bureaucracies, funding sources, personnel, and geographic location of treatment resources have historically given patients only two options: chemical dependency treatment or mental health treatment.10 This separation of both treatment models and systems has led to the model of serial treatment. Serial treatment In serial treatment, a bipolar patient with alcoholism would be first either stabilized on a psychiatric unit, then transferred to a chemical dependency unit, or vice versa. This model allows the chemical dependency system and the mental health system to operate in separate spheres. It neither requires personnel to learn new skills nor change basic concepts, and it separates the billing, administration, and treatment facilities of the two systems. Thus, serial treatment is consistent with the separation that has characterized mental health treatment and chemical dependency treatment in this country for many years. * For example, a long-term care facility might interpret "dual diagnosis" to mean a patient with chronic mental illness, such as schizophrenia or bipolar disorder. On the other hand, a psychiatric treatment unit that largely handles panic disorders and anxiety disorders might view dual diagnosis from a different set of interests. ______________________________Ries___________________________175 While this model facilitates administration, it fails miserably to address individual patient needs. Under the serial model, a bipolar alcoholic who is too manic for a chemical dependency unit or too intoxicated for a psychiatric unit might not be admitted to either. Thus, dual disordered patients often fall between the cracks.10 Further, since philosophical concepts and explanatory models in the fields of mental health and chemical dependency are quite different, patients are often given contradictory information, explanations, and therapies.11 A psychiatric unit may tell a bipolar alcoholic to make sure he continues...

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