There are three major models in which dually diagnosed patients are treated: sequential, parallel, and integrated treatment. Each is discussed below.
In sequential treatment, the more acute condition is treated first, followed by the less acute co-occurring disorder. The same staff may treat both disorders, or the less acute disorder may be treated after transfer to a different program or facility. For example, a manic patient with a cocaine use disorder needs mood stabilization before initiating substance abuse treatment. Conversely, a patient with major depression and alcohol withdrawal delirium is not in a position to discuss treatment adherence to antidepressant medication. Instead, this issue is best addressed when the patient is more stable. Although sequential treatment has the advantage of providing an increased level of attention to the more acute disorder, a typical disadvantage of this model is that patients are often transferred to a different treatment team to address the less acute disorder, and the interrelationship between the two disorders may never be adequately addressed.
In parallel treatment, both disorders are treated simultaneously, but not by the same treatment team. For example, a patient may receive treatment for an SUD in an addiction treatment program and for a psychiatric disorder in a mental health clinic. Typically, staff members of each program are very wellversed in their own area of expertise, but not in the other. However, major cross-training efforts on dual diagnosis have improved this situation in the past decade. The different treatment programs may also have different treatment philosophies, which may be confusing to the patient (Mueser, Bellack, & Blanchard, 1992; Ridgely, Goldman, & Willenbring, 1990). For example, in substance abuse treatment programs, clinicians may attribute psychiatric symptoms (e.g., depression and anxiety) to substance use; when a patient attempts to obtain relief, they may view this as "drug-seeking" behavior. Alternatively, staff in psychiatric programs may tend to minimize the importance of substance use and not stress its potential negative consequences.
Unfortunately, patients treated in parallel or sequential programs often receive different experiences based on the treatment settings they enter. The two different programs may provide patients with different feedback on the relationship between their substance use and psychological symptoms. Patients in these situations are then left to attempt to integrate these sometimes disparate approaches themselves. In these circumstances, patients may be accused of "manipulating" and "splitting staff' when they present information obtained in one program that is contradictory to the other.
In integrated treatment, the management of both disorders occurs in one treatment setting, and the same clinicians, or team of clinicians, manage both illnesses. Integrated treatment has received increasing interest of researchers and clinicians, fostered by the belief that it is more effective than the other treatment models described earlier.
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