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198 Presentation THE CHALLENGE OF DUAL DIAGNOSIS EVELYN C ROBERTSON, Jr. Commissioner Tennessee Department of Mental Health and Mental Retardation 706 Church Street Nashville, TN 37243-0675 AYOUNG man, let's call him James, had a history of mental illness and alcohol abuse. A friend of mine, a recovering alcoholic, told me that his first encounter with James was at a local Alcoholics Anonymous (AA) group. James had been directed to AA by the psychiatrist at a community mental health center. When James shared with the AA group that he was taking medication for his mental illness, he was told that in order to recover from alcoholism he must abstain from any and all mood-altering drugs. Several meetings later, James said that his doctor insisted that he remain on his medication. For months, James struggled to reconcile his doctor's orders with the rules of AA. Then, suddenly, he no longer appeared at meetings. One day my friend was visiting the Middle Tennessee Mental Health Institute, and there was James, who was now a patient at the hospital. My friend wondered, "Did this young man wind up in a mental institution because the alcoholic support group didn'tknow how, or were unwilling, to deal with his mental illness, or was it because the mental health treatment people didn't know how or were unwilling to deal with his alcoholism?" The case of James raises the subject of dual diagnosis. Now be it understood that I claim no substantial expertise in dual diagnosis. I am an administrator, not a clinician. However, as the Commissioner of the Department of Mental Health and Mental Retardation, the subject of dual diagnosis gives me cause for concern. I have become aware of the prevalence of dual diagnosis, the complications it poses to effective treatment, the difficulties confronting clients in seeking treatment, and the substantial costs that patients with dual diagnosis contribute to the health care system. Journal of Health Care for the Poor and Underserved, Vol. 3, No. 1, Summer 1992 Robertson 199 Yet the facts are that you are the professionals and the direct care givers in the fields of mental health and alcohol and drug abuse services. You are the experts. You are the people who have first-hand knowledge of the issues presented by dual diagnosis. You are the people who can make a difference. Thus, my purpose in making these remarks is to encourage you to make that difference. In this presentation, I will attempt to raise some of the issues surrounding dual diagnosis. I hope that as a result of focusing the issues, an ensuing discussion will give rise to research, new ideas, greater understanding, and most important, better treatment results. Definition The first issue is the definition of dual diagnosis. Is there actually such a phenomenon? If so, is there a precise definition so that we can all know exactly about what we are talking? Dr. David Knott, the Program Director of the Alcohol and Drug Unit at Memphis Mental Health Institute, has reviewed that unit/ s experience with dual diagnosis. He defines dual diagnosis as "a substance dependence diagnosis plus an additional Axis I [clinical syndromes] diagnosis." Dr. Knott does not include Axis II [developmental disorders] diagnoses under the rubric of dual diagnosis because he believes that to do so would produce a number of confounding variables that would only lead to confusion in diagnosis and treatment. The issue of definition becomes confused, however, when the matter of "primary diagnosis" arises. Drs. Wolfe and Sorensen, in an article titled "DualDiagnosis Patients in the Urban Psychiatric Emergency Room," noted that a serious difficulty in securing reliable data on dual diagnosis patients was related to the fact that administrative forms included space for only one major psychiatric diagnosis. This format reflected an earlier fiscal reality that substance abuse services were not funded by the community mental health section of the local health department.1 This limitation may give rise to an either/or situation: Either the patient has a primary diagnosis of mental illness which is exacerbated by substance abuse, or the patient has a primary diagnosis of substance abuse which is complicated by a form of mental illness...

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