The Carroll County Health Department is trying to help a population that has frequently fallen through the cracks of the public health system -- individuals who suffer from both chronic mental illness and drug or alcohol abuse.
This month, the department's mental health bureau began a program to treat the "dually diagnosed" by combining elements of mental health and substance abuse therapies.
"Often treatment is focused on one [problem] or the other," said Howard Held, director of the mental health bureau. "Folks who have a dual problem conceivably can get lost between the cracks of these differences."
Treatment of the dually diagnosed population is complex and often unsuccessful. They make up a large percentage of longtime mental hospital patients, the homeless and the inmate population, Mr. Held said.
About one-third of the patients seen in the health department's adult mental health services section have a substance abuse problem that needs attention, said Suzan Sigmund, director of the county's adult mental health services programs.
"Traditional substance abuse programs aren't set up to handle these kinds of people," said Dr. Joel Hassman, a staff psychiatrist with the county health department. "We're hoping the dual diagnosis program will get them into treatment for both problems simultaneously."
Although therapists have been aware of the unique problems of the dually diagnosed for at least a decade, it has only been within the past five years that money has become available to develop programs to treat this population, health officials say.
The Carroll County Health Department received $139,000 in a federal mental health block grant to develop its program. The federal funds are distributed through the state Mental Hygiene Administration.
The dual diagnosis program staff includes Dr. Hassman, a psychologist, a social worker and a clerk/secretary. Each will devote 20 hours a week to the program. Also, a therapist from the county's addiction bureau will help lead group sessions.
All new patients will be evaluated by Dr. Hassman, who will assess what type of treatment program is best suited to the patient.
Program components will include group sessions to educate patients about the complexities of treating chronic mental illness and substance abuse, group and individual sessions, and careful monitoring of patients' medications.
Jo Riley-Kauer, director of the health department's addictions bureau, hopes the dual diagnosis program will meet the needs of patients whose problems can't be addressed by addictions therapy alone.
At any given time, Ms. Riley-Kauer said, at least 25 percent of the addiction bureau's clients have had mental illness episodes, been on medications for a mental illness or at one time were patients at Springfield Hospital Center.
Ms. Riley-Kauer points out that even the addiction bureau's patients who don't have a mental illness are generally "noncompliant," uncooperative to treatment.
"They have low incomes, poor job skills, come from dysfunctional families; they don't have a lot of support," Ms. Riley-Kauer said.
"If you couple that with someone who hears voices as well, you're talking about a lot more noncompliance."
The Carroll County dual diagnosis program will be modeled after program in Montgomery County developed to treat mentally ill chemical abusers. It was one of the first public programs in the state to address simultaneous treatment of mental illness and substance abuse, said Zrinka Tomic, director of adult mental health services in the Montgomery County Health Department.
Before introduction of the program in 1990, mentally ill substance abusers were sent to local addictions programs for treatment.
In general, Ms. Tomic said, mentally ill patients don't respond well to traditional addiction programs because they have difficulty adhering to the rules and guidelines.
"They'd end up coming back to us [the mental health bureau] not being properly served," Ms. Tomic said.
The Montgomery program stressed educating patients about the connection between mental illness and addiction and ways in which each illness aggravates symptoms of the other.
In addition to individual and group psychotherapy, "peer activity" groups encourage patients to socialize and participate in expressive therapies, such as art and music.
Ms. Tomic said that they stress peer interaction because "the majority of these people are very lonely, and their social life is only related to people who use drugs or alcohol."
The program is more flexible than traditional addiction programs. Patients may have relapses without fear of termination, and it's expected that some may need medication to control their mental illnesses.
"We tell people [in traditional addiction programs] to deal with situations without medication," said Ms. Riley-Kauer of the Carroll County addictions bureau.
L "But you can't tell that to somebody with a mental illness."
On the other hand, any medication can be abused, and the dual diagnosis programs in Montgomery and Carroll counties address this issue with careful monitoring of medications by psychiatrists and urinalysis.
An evaluation of the Montgomery County program's first 157 patients, from January 1990 to December 1992, showed 50 percent abstained from drugs or alcohol for the duration of the treatment. Twenty percent were termed a "complete success," which means they achieved sobriety, obtained work or entered school, and regularly attend Alcoholics Anonymous or Narcotics Anonymous.
The Carroll County mental health bureau plans to measure the success of its dual diagnosis program by comparing specific patient behaviors, such as citations for driving while intoxicated, hospitalizations and suicide attempts, at the beginning and end of treatment.