Progress in Dual Diagnosis Research: Innovation and Controlled Trials

This issue of the Journal encompasses intriguing progress. In addition to further defining heterogeneity and implementation issues, the papers address creative clinical approaches and some present controlled trials. These trends herald the growth of the Journal and the dual diagnosis field more broadly.

Arranz, Safont, Corripio, Ramirez, Dueñas, Perez, Alvarez, and San studied gender differences in a small sample of patients with early psychosis. Men were more likely to use several substances regularly and cannabis early in life. Bennett, Brown, Li, Himelhoch, Bellack, and Dixon reported a randomized controlled trial of two smoking cessation interventions for people with serious mental illness. Most participants cut down and tried to quit, but the overall abstinence rate was low and did not differ between interventions. Segalà, Vasilev, Raynov, Gonzalez, and Vassileva studied the history of childhood attention deficit hyperactivity disorder (ADHD) and measures of current impulsivity in adults with heroin use disorder, finding that self-reported childhood ADHD did not correspond strongly with impulsivity scores. Rebgetz, Hides, Kavanagh, and Choudhary conducted a qualitative study of people with psychosis who quit using cannabis without treatment. Quitters cited awareness of adverse effects, presence of social supports, use of multiple coping strategies, and ability to resist peer pressure as keys to their success.

Tang, Chen, Chung, Kuo, Huang, and Tsai studied alcohol use in patients with bipolar disorder and found that alcohol users had more rapid cycling as well as greater alcohol-related medical problems. Hellem, Sung, Shi, Pett, Latendresse, Morgan, Huber, Kuykendall, Lundberg, and Renshaw reported positive results on a small open-label pilot study of creatine treatment for women with depression and methamphetamine use. Weibel, Lalanne, Riegert, and Bertschy described a patient with alcohol use disorder and bulimia who responded to high-dose baclofen with reduced alcohol craving but not food craving.

Bernard, Ninot, Cyprien, Courtet, Guillaume, Georgescu, Picot, Taylor, and Quantin reported a small controlled trial of exercise and counseling versus health education for smokers with depression. The study was underpowered but suggested that the exercise and counseling intervention may be helpful. McCallum, Mikocka-Walus, Turnbull, and Andrews reviewed the literature on continuity of care to clarify definitions and types of continuity. Elmquist, Shorey, Anderson, and Stuart studied patients in residential treatment for substance use disorders and determined that eating disorder symptoms predicted discharges against medical advice.

Myers, Browne, and Norman studied outpatient treatment engagement among women with co-occurring alcohol use disorder and posttraumatic stress disorder, using a controlled trial of two psychosocial interventions, Seeking Safety and facilitated 12 step. Treatment assignment did not predict engagement, but younger age, having dependents, and severity factors predicted poor engagement. Goodman, Milliken, Theiler, Nordstrom, and Akerman presented a pregnant patient with opiate use disorder and posttraumatic stress disorder as background for a review of this increasingly prevalent group of patients.

Taken together, these papers highlight several aspects of dual diagnosis research that indicate important developments in the field.

First, the heterogeneity of dual diagnosis populations continues to be refined (Green & Drake, 2015). This issue identifies that the early use of cannabis by men poses specific dangers, that young women with dependents and co-occurring disorders as well as those with eating disorders and alcohol use disorders are difficult to engage in treatment, that pregnant women with opiate addiction and posttraumatic stress disorder present multiple complexities, and that the relationship between bipolar disorder and alcohol use may be related to rapid cycling. These studies emphasize the need to tailor outreach and multidisciplinary treatments for specific populations and specific individuals. In 1987 the initial federal review of dual diagnosis emphasized heterogeneity and the need for specific approaches (Ridgeley, Osher, & Talbott, 1987). Yet we have made minimal progress over nearly 30 years. Few programs truly integrate mental health and substance abuse treatments and even fewer offer specialized services for the subgroups identified in this issue. Heterogeneity has profound implications for education, training, service organization, and research.

Second, smoking cessation in people with dual diagnosis remains a ubiquitous problem. Evidence-based treatments can be effective (Tidey & Miller, 2015), but people in public-sector programs have difficulty accessing and engaging in these treatments. The rate of smoking therefore remains extremely high among those with dual diagnosis, and smoking is the primary cause of their early mortality. Large-scale smoking cessation programs have not yet demonstrated effectiveness (Williams, Stroup, Brunette, & Raney, 2014). Reducing smoking among the poor, the disadvantaged, those with mental illness or addiction, and those with dual diagnosis should be a major public health priority.

Third, current neuroscience research aims to identify problems in brain reward and self-regulation in addiction. In general, the brain reward system is mediated by a common set of pathways, while self-regulation shows great individualization (Kelley, Wagner, & Heatherton, 2015). As in this issue, the separation of craving experiences may enhance understanding of these pathways.

Fourth, the dual diagnosis field needs innovative treatments (Drake & Green, 2015). One source of ideas may be natural recovery. People often quit using psychoactive substances after experiencing psychosis, and no clear evidence shows that addiction treatment enhances the natural process (Wisdom, Manuel, & Drake, 2011). The explanation could be education regarding substance use, treatment for psychosis, or reaction to the trauma of experiencing psychosis. Also in this issue of the Journal, creatine treatment and exercise represent novel approaches that may enhance or substitute for traditional interventions.

Fifth, integrated treatment remains an elusive goal. Perhaps an emphasis on continuity of care could enhance integration and improve outcomes for patients with dual disorders. Many groups—people who are young, homeless, incarcerated, pregnant, caring for dependents, immigrating, and on and on—need outreach and other supports to engage in dual diagnosis treatment. The outreach and interventions must be tailored by group and individualized by person. The task is daunting, the field remains inchoate, and the opportunities for research-based solutions are legion. The challenge should energize us all.

DISCLOSURES

Dr. Drake reports no financial relationships with commercial interests. Dr. Green reports research grant support over the past 3 years from Janssen and Novartis. He currently serves as a consultant to Otsuka and Alkermes (unpaid) and on a data safety monitoring board for Eli Lilly studies, and he has two pending patents on the treatment of substance abuse. During the past 3 years he has owned shares of stock in Johnson & Johnson, Pfizer, and Mylan.