Co-occurring psychiatric disorders pose additional challenges for persons recovering from substance use disorders (SUDs). Psychiatric comorbidity (commonly referred to as “dual diagnosis”) involves having a psychiatric disorder in addition to a SUD. Investigations have shown they’re not uncommon though prevalence rates of comorbidities vary across studies due to research factors (e.g., design, methods, scope of inquire). Investigations typically have some limitations, and in psychiatric comorbidity research this would include limiting the scope of inquiry to a number of specified psychiatric diagnoses/ categories, whether participants currently (and/or historically) met diagnostic criteria, identifying matches in terms of substance use type (e.g., alcohol use disorder) to another mental disorder (e.g., major depressive disorder), and assessing psychiatric problem severity regardless of diagnosis. It is likely that empirical investigations and other contextual factors inform clinical assessment to some degree.
For instance, in the United States, managed care organizations (MCOs) were created to ensure the highest quality of care by making treatment providers more accountable in order to receive insurance reimbursement. MCOs grew considerably since the 1980s, resulting in treatment providers having to justify their services on a frequent basis. This provided for a checks and balances system to prevent fraud while ensuring consumers were receiving quality care. However, this ultimately created a system where MCO agents (usually possessing a bachelor’s degree and no advanced clinical training or extensive experience) had significant influence on patient assessment/treatment by informing clinicians what would (and what would not) be reimbursed on a case-by-case basis.
Before long, standards of care and hierarchies of disorders (in terms of what was reimbursed) were established. By the early 1990s, benefits were limited to “carve-out” plans and pre-set conditions imposed by MCOs. Benefits for persons seeking treatment for SUDs had been reduced. Some have argued that the lack of comprehensive services available to those seeking SUD treatment created the “revolving door” pattern of service utilization, including those with psychiatric comorbidity. Unfortunately, controlled studies on the cost, quality, and outcomes for SUD treatment that were sanctioned by a managed care system were absent.
Changes in reimbursement policies implied SUDs (and personality disorders, that no longer were reimbursed by most insurance companies) were not bona fide mental disorders. It didn’t take long for some clinicians to erroneously (or intentionally) look for evidence to suggest patients seeking treatment for SUDs had a “severe mental illness” (SMI) in order to meet the threshold for insurance coverage. In short, a zeitgeist emerged where SUDs were minimized, SMI such as major depressive disorder, bipolar disorder, and schizophrenia was considered more serious than SUDs, and clinicians were looking for signs/symptoms of SMI -that might not have really existed- among their patients.
We (the authors) have worked in various capacities with persons with SUDs since the late 1980s, and have learned anecdotally that many seeking SUD treatment were told things at intake such as, “You really don’t have depression, but I have to mark this down in your chart in order to admit you.” or “We can’t treat you unless you’re hearing voices or feel like harming yourself,” as a way of scripting patients. Likewise, we have observed questionable documentation from patient records (and from colleagues disclosures) in terms of inflated global assessment of functioning scores (under previous DSM systems), diagnostic histories that were incredulous, and the practice of not documenting personality disorders in charts out of fear that doing so would disqualify reimbursement for services.
The implementation of MCOs in recent decades created a contextual backdrop that influenced assessment. We argue that in the U.S., persons seeking recovery from SUDs:
1) Have been susceptible to misdiagnosis as a way to pay for treatments;
2) Went through a revolving door system of service delivery because services were not comprehensive as they once were, and in some cases;
3) Were led to believe that they had a co-occurring disorder that didn’t exist. Certainly, some had comorbidity. But others displayed signs/symptoms that intake workers and practitioners suspected (if not hoped) would fit diagnostic criteria for some other-than-SUD disorder to meet managed care thresholds.
There is a dearth of empirical support to guide clinicians in the assessment/diagnostic formulation for this population, particularly in the area of differential diagnosis (i.e., distinguishing the best diagnosis among others that would appear to fit the symptoms). However, some investigations during the height of MCOs’ influence have implications for assessing persons with SUDs who present symptoms that are truly indicative of co-existing disorders versus those that are substance-induced. In addition, the Diagnostic and Statistical Manual of Mental Disorders (DSM-V; APA, 2013) provides clear criteria for engaging in a differential diagnosis when working with persons who present with substance use. We urge clinicians to be acutely mindful of, and accountable for, signs/ symptoms that suggest the presence of:
1) substance-induced disorders
2) substance/medication-induced mental disorders when assessing persons who present with any recent substance use, including prescribed medications.
Likewise, we question the practice of prescribing medications to persons with SUDs. There must be sound basis to warrant their use, especially medications that have possible psychoactive effects (i.e., altering one’s mood/mind), within the first 30 days of abstinence. Prescribed “substances” might alleviate some symptoms, but they can and do create other symptoms that have great potential to sustain an erroneous diagnosis. Assessment is suspect when diagnostic symptoms are a consequence of medication.
Medicating patients in their first month of abstinence increases the risk of iatrogenic (healer-induced) psychopathology. Clinicians prescribing medications to persons with SUDs within the first 30 days of abstinence must exercise expert judgment and have strong basis to guide and substantiate this intervention. It is rather interesting that pharmacological interventions have been popularized by marketing strategies while the risk of misdiagnosis has increased over the past couple decades. Nonetheless, clinicians who prescribe medications should highly consider these contextual factors, and also consider the highly litigious context of U.S. society in that the burden of proof will fall upon them to justify their practices in legal matters resulting from suspected malpractice.
John M. Majer, Ph.D. received his Doctorate in Clinical Psychology
(community emphasis) at DePaul University, Chicago, IL. He started
his career working with persons with SUDs in the late 1980s and
shifted his interests in serving this population as a researcher and
consultant. Presently, he is a Professor of Psychology at Harry S.
Truman College, one of the City Colleges of Chicago in addition to
providing consultation in both research and legal matters. Dr. Majer’s
ongoing consultation with DePaul’s Center for Community Research
was instrumental in the awarding of a participatory action research
grant by the Center on Minority Health and Health Disparities. He has
over 35 publications in peer-reviewed (not open-access contingent)
scholarly outlets and serves as a reviewer and consulting editor for
a number of journals. His areas of research include persons with
substance use disorders (and those with psychiatric comorbidity), 12-
step involvement, and the Oxford House model of residential care.
Ted J. Bobak, B.A. earned his undergraduate degree in Psychology
at Governors State University, University Park, IL. Presently, he is
a graduate student in DePaul University’s Community Psychology
doctoral program. He has been active in the field of treatment/recovery
from SUDs for over 6 years. His research interests include