Until very recently, mental health professionals viewed mental health as clearly distinct from alcohol and substance abuse problems. Faced with a person with both mental health and substance abuse problems, the first step was often a referral for substance abuse treatment. Some mental health professionals even refused to treat individuals with co-occurring mental health and substance abuse problems until the substance abuse problem had been successfully treated.
      Even more problematic, many mental health professionals failed to ask their patients about substance abuse problems. Not surprisingly, patients with mental health and substance abuse problems, often referred to as individuals with "dual disorders," frequently failed treatment that was divided and only addressed one set of problems. The following case vignette illustrates the problem.
      Jenny is a 30-year-old married computer programmer. She lives with her husband and 3-year-old son. During college, Jenny had problems with binge drinking until her senior year when she left school for a semester and successfully stopped drinking on her own. Soon after the birth of her son, Jenny began to suffer mood swings. She began to drink again as she tried to take the edge off her frequent irritable moods. After a sleepless spending spree, Jenny was diagnosed with bipolar disorder in a manic phase. Her doctor failed to inquire about alcohol problems. She was prescribed medication, with a warning not to drink any alcohol with the medication. By her next appointment, Jenny was severely agitated and confused and her doctor increased her medication, not realizing that she was not taking the medication that he had prescribed.
      A week later, Jenny's husband urgently called the doctor, saying that he had found empty wine bottles concealed in the home and multiple pill bottles unopened. The doctor told the husband that he was revising his diagnosis and now felt the correct diagnosis was alcoholism. He referred Jenny for alcohol rehabilitation treatment, saying he would see her once her alcoholism was resolved.
      In retrospect, Jenny had a dual disorder, bipolar disorder and alcohol dependence, and the lack of recognition of the alcohol problem clearly thwarted successful treatment, as is all too often the case. Fortunately, many mental health and substance abuse professionals now recognize the common co-occurrence of mental health and substance abuse disorders and have developed highly successful integrated treatment programs, programs that treat both problems.
      Several recent community-based studies have demonstrated the high prevalence of dual disorders. A University of Michigan study found that nearly 30 percent of the U.S. population had a current mental health or substance use disorder. Roughly one-fifth of these individuals had a co-occurring mental health and substance abuse disorder. Subsequent studies have found that a high proportion of individuals with dual disorders receives no treatment of any sort and very few receive combined mental health and substance abuse treatment. Among severely mentally ill individuals, e.g. those with schizophrenia, schizoaffective, bipolar, or other disorders, co-occurring alcohol and substance abuse, dual diagnoses are particularly problematic.
      Investigators estimate that 50 percent or more of persons with severe mental illness also have an alcohol or substance abuse problem that interferes with treatment. For these particularly vulnerable individuals, alcohol or substance abuse may complicate treatment by leading to nonadherence with medication, interfering with the effects of prescribed medication, disinhibiting behavior or by exposing these individuals to crime-ridden and violence-prone environments. A recent study at Duke University found that severely mentally ill individuals with substance abuse problems were often non-compliant with medication and had an increased risk of serious violent behavior.
      Among seriously mentally ill individuals, alcohol and substance abuse is a potent risk factor for a host of adverse outcomes, including homelessness, treatment failure, increased vulnerability to HIV infection, increased family burden, and increased treatment costs. Despite the growing recognition that many patients in public mental health programs suffer from dual disorders, many states and communities have been slow to integrate mental health and substance abuse treatment. One barrier to integration has been separate public funding for these disorders. In addition, mental health and substance abuse professionals have often dealt with these patients with conflicting approaches to treating these disorders. For example, the confrontational style of some substance abuse treatment is ineffective and often harmful for severely mentally ill individuals. However, new integrated treatment programs have been shown to be highly effective, even with severely ill patients. In North Carolina, while considerable progress has been made in developing integrated mental health and substance abuse disorders treatment programs, few public mental health programs have adequate resources to treat patients in need of this approach. In the face of mounting financial pressures, some public programs have even scaled back or eliminated innovative programming. North Carolina's efforts to improve its system of care must make treatment services for dually diagnosed individuals a key priority.