1. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 32Clients with a Dual Diagnosis

2. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins According to a report published by Journal of the American Medical Association, 37% of persons who abuse alcohol and 53% of persons who abuse drugs also have at least one serious mental illness. Of all persons diagnosed with a mental disorder, 29% abuse either alcohol or drugs. —Mental Health America, 2009

3. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Chemical dependency is a serious public health problem. For people with mental illness, comorbid chemical dependency can be a catastrophic life problem. —Vaccaro, 1999

4. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Learning Objectives After studying this chapter, you should be able to Discuss the term dual diagnosis Explain the acronyms: MICAA, MICA, and CAMI Differentiate the two main theories related to the development of a dual diagnosis Recognize the defining characteristics of clients with a dual diagnosis Articulate the barriers to effective treatment of a client with a dual diagnosis

5. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Learning Objectives (cont.) Interpret the four categories that have been developed to describe the dually diagnosed client Describe why it is difficult to assess a client with a dual diagnosis Summarize the following phases of treatment for clients with a dual diagnosis: acute stabilization, engagement, prolonged stabilization, and rehabilitation and recovery including continuum of care Explain why evaluation of a dually diagnosed client’s progress is an ongoing process

6. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Etiology of Dual Diagnosis Vulnerability model –Drug use contributes to mental illness. –Other factors increase the risk for mental illness. Alcohol personality subtypes Self-medication hypothesis –Individuals with psychiatric disorders use drugs to help them alleviate symptoms. –Self-medication leads to drug dependency.

7. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Clinical Symptoms and Diagnostic Characteristics Four major categories Primary diagnosis is mental illness; secondary diagnosis, substance-related disorder. Primary diagnosis is substance-related disorder; secondary diagnosis, mental illness. Mental illness and substance-related disorder coexist. Substance-related disorder and mood disorder co-occur.

8. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

9. The Nursing Process Assessment Nursing diagnoses Outcome identification Planning interventions Implementation Evaluation

10. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment Identify the relative contribution of the most common coexisting diagnoses: anxiety disorders, depressive disorders, personality disorders, and schizophrenia Sources of data include the following: –Substance-related disorder assessment tools –Mental status exam –Laboratory testing –Review of court records, medical records, previous treatment records –Interview of social worker familiar with the client’s history –Observation of the client in the clinical setting –Assessment of the client’s motivation to seek treatment, desire to change behavior, and understanding of diagnosis

11. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Diagnoses Ineffective health maintenance Disturbed thought processes Impaired social interaction Ineffective coping Noncompliance Situational low self-esteem

12. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Outcome Identification Outcomes focus on the following: Willingness to participate in treatment Development of positive coping skills Verbalization of feelings of increased self-worth Development of appropriate social skills Desire to establish and maintain contact or relationship with a professional in the community Desire to socialize in drug- and alcohol-free environments

13. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Planning Interventions Interventions are based on the individual’s needs considering the following: The type of substance-related disorder involved The presence or absence of cognitive impairment The ability to process abstract concepts Motivation for treatment The availability of social support The necessary treatment setting to address clinical symptoms

14. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Implementation Acute stabilization Engagement Prolonged stabilization Rehabilitation and recovery

15. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Evaluation Evaluation focuses on the following: Compliance by the client Stated outcomes Effectiveness of interventions Progress the client is making

16. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Key Terms CAMI Dual diagnosis MICA MICAA Persuasion Self-medication hypothesis Vulnerability model

17. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Reflection Reflect on the chapter-opening quote by Vaccaro. Explain your interpretation of the phrase “catastrophic life problem.” ? What nursing challenges do you think you would encounter if you were to develop a nursing plan of care for such a client? Do you feel adequately prepared to provide care for such a client? Explain your answer.