Thomas A. M. Kramer, MD

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In This Article

Introduction

Patients who present to us with so-called "dual diagnoses" of a primary psychiatric disorder and a substance abuse disorder represent some of the most difficult challenges clinicians can face. Often, the substance abuse precludes in some way the treatment for the psychiatric disorder. For example, attendance and compliance may be compromised or the direct effects of the substance abuse may negate or reverse the effects of the treatment. When clinicians look to the literature for guidance in dealing with these difficult situations, they find virtually no data. Evidence-based medicine is not much help when there is little evidence being collected. Most research studies examining the clinical efficacy of a treatment exclude substance-abusing patients because the substance abuse often confounds the data. Similarly, most studies looking at the efficacy of substance abuse treatments exclude patients with any primary psychiatric disorders for similar reasons.

One of the difficulties in dealing with this patient population is the inherent paradox in the message that we give them as we treat them. Essentially, what we say to them is "take drugs," that is, comply with the psychopharmacological treatment that we have prescribed, but "don't take drugs," that is, avoid all illicit substances that are not being prescribed. While this paradox might not be difficult for a high functioning patient to navigate, for the more severely ill patients who may have some cognitive impairment as a function of their illness and for whom taking medication is all the more critical, a careful clear and supportive method of presenting this message is absolutely essential.

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