Dual Diagnosis: Substance Abuse and Mental Health

Video
The parents of Danny Watt, who died in April 2008, describe their son's struggles with mental illness and the treatment they believe failed him. Note: This video is from 2008. Video by Whitney Shefte/The Washington Post
Tom Jackman
Washington Post Staff Writer
Tuesday, July 28, 2009; 3:00 PM

It was an end that Danny's parents, Bobby and Mary Watt of Reston, had struggled to stave off for many years. But after refinancing their house three times to put their son in every substance abuse and mental health program imaginable, after going to countless meetings and hearings and hospitals and jails, after badgering every possible person in Fairfax County who might help them, they could not save Danny.

Dual Disorders Rarely Treated Properly (Post, July 28)

Washington Post staff writer Tom Jackman was online Tuesday, July 28, at 3 p.m. ET to discuss his story about a family that was faced with a son who suffered from a phenomenon called co-occurring disorders, or dual diagnosis.

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Tom Jackman: Hello Everyone -- Tom Jackman here. Thanks for taking the time to read today's piece on Danny Watt and dual diagnosis. I think it's a very important issue that the mainstream media have largely ignored, and I can tell by your questions that it concerns many of you. Feel free to send along your query over the next hour. I will try to forward some of them to Mary Watt, who is on the road at this hour, and she'll give us her views. Let's go.

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McLean, Va.: Thank you for sheding light on this subject. This story hits very close to home for me. My mother is schizophrenic and my brother has struggled with a life of addiction and criminal behavior. While I believe he exhibits many of the traits consistent with mental illness and I know there is a somewhat strong genetic link, he has never been diagnosed with any serious disorder. He was diagnosed as "hyperactive" as a child, but nothing more. I believe it is possible that his other behaviors mask the real demons within him. It is an extremely difficult situation for families to deal with. On one hand, there is a substance abuse problem and other addictive behaviors (in my brother's case gambling, compulsive lying and stealing). These are the easy issues to diagnose and the most commonly accepted way prescribed by addiction specialists is to provide a bottom line, not enable, and let the addict hit bottom....A conclusion which we recently came to after thousands of dollars, years of disappointment. But what if it's not that simple? Are we doing the worst possible thing if, in fact, a mental illness exists? What can the Watt's story and others like it teach us?

Tom Jackman: I think what we, or I, learned from the Watts is you have to find people who are experienced in dealing with co-occurring disorders, and who have the time and patience to determine if that is the proper diagnosis. Virtually everyone in the mental health and substance abuse fields received training specific to those fields, and less specialization in the other. They are now cross-training, but that's only just getting started. So finding someone who is very well-versed in dual diagnosis is the key, and getting them to connect with the patient is, obviously, the other. Thanks for wriring.

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Washington, D.C.: As a professional who works with many dually diagnosed patients, I really appreciate your article and the resulting attention to this issue. One quibble: Schizoaffective Disorder is 'not' "a combination of schizophrenia and bipolar disorder," as you write in the article. The disorder, as defined by the DSM, includes elements of both (thought disorder and mood disturbance, respectively), but is considered unique. Differential diagnosis is extraordinarily complex, particularly in cases further complicated by substance abuse, but I do feel it's important to accurately define the terms used, even if they may not be the accurate diagnosis for an individual.

Your article also speaks to issues related to poor health care and insurance for mental health problems, as well as inadequately trained professionals or paraprofessionals. It's a sad story, but all too common, as your article amply illustrates.

Thank you again.

Tom Jackman: Thanks for pointing this out. When you let lowly laymen like newspaper reporters try to delve into technical stuff like this, their tendency to compress and summarize sometimes squeezes out the nuances. Your correction is appreciated.

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Vienna, Va.: My sympathies to Danny's parents. I am a psychology professor at a local community college. I have several students with the combination of psychological disorder plus substance abuse. They struggle terribly. Are there many cases in the psychiatric literature of people successfully coping with this pairing of problems? Is there a typical pathway to managing the illnesses?

Tom Jackman: There can be a good success rate, when treated properly, intensively and long-term. Dr. Robert Drake at the Dartmouth Psychiatric Research Center has written about the success rates they have had treating co-occurring disorders, how they approach it and why it needs to be done. He has published extensively on the subject. Here is one such article that he wrote in 2006, entitled Current Research on Co-occurring Substance-Use Disorder in Schizophrenia

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2632281

I doubt there is a typical pathway to managing the illnesses, as is true of many people dealing with mental illness. The therapist has to find the right mix of approaches, and everyone has different needs.

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Columbus, Ohio: Thank you for the story. What about those without health insurance who suffer from dual diagnosis? Mental health budgets in Ohio have been cut and cut and cut -- is treatment even an option, even if someone wanted it?

Tom Jackman: You make an important point, and certainly those with insurance often have access to much better resources. But public health authorities across the country claim they are trying to convert themselves into dual diagnosis-ready places, and if they aren't, they oughta be. That's what they're there for. But it's also incumbent on the caregiver/parent to push and prod for the properly trained therapists and the proper treatment. And then hope for the best. Treatment is an option even in the public health setting. Or so your tax dollars say.

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washingtonpost.com: Introduction: Current Research on Co-occurring Substance-Use Disorder in Schizophrenia

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Raleigh, N.C.: Tom -- Isn't it unrealistic to think these types of people will reach out and call the "hotlines"? It's simplistic and often staffed by good listeners and not someone capable of actually helping.

Tom Jackman: Yes, it's unrealistic, for the person. But the person's parents or caregivers or friends can call, and what they should get is names and phone numbers of therapists and centers in their area who can do more than nod and listen. That is realistic. The hotlines should at least serve as a resource, but real help has to be done locally, in person and with full fervor, by both the therapists and the family/friends. Anything less is futile.

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Raleigh, N.C.: This story broke my heart. My adult daughter, an Iraq war veteran, is suffering from PTDS as well as other diagnosed mental illness. Our family has tried everything to help her. Private care isn't possible; county services have been slashed or eliminated, and veterans' services no longer coordinate with state and county mental-health services because of budget cutbacks.

She's attempted suicide several times. Despite this clear trend toward self-harm and harm to others (she's also been arrested several times for assault), she keeps slipping through the cracks. We cannot have her at home anymore because of the violence and threats. Her children are with me now. But she has been homeless now for two months, and I keep waiting for The Call that's bound to come.

Without reasonable treatment options, I don't see a chance for peace for her, or for us. The pain and overwhelming worry for all of us never ends, not for a single hour.

Tom Jackman: I regret to say that I have received quite a number of emails like this today. As Bobby Watt says in the accompanying video -- and if you haven't watched that, you should, if you can stand having your heart broken and stomped on -- the funding for public mental health services continues to suffer, and it keeps getting cut "because they can," in Mr. Watt's words.

But it's people like you, and the Watts, who made me write this article. There is so much suffering out there. The word needs to be spread far and wide.

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Great Falls, Va.: It was a quite a moving story. My heart goes out to his family.

Q: Was Danny not living with his family at the time of his death?

Q: When Danny showed up, right before his death, and handed a book of poems that he wrote to his mom, did Danny's mom know he was going to kill himself? I think Danny was saying good-bye to his mom. That's why he was crying.

I want to share a story about my cousin. He has mental problems such as seeing and hearing things. Somewhat similar to Danny's. It's been almost 30 years since we found out about his mental problem. I always thought that he was suicidal. But thanks to his devoted sister, he is still alive (his mother passed away years ago). I just want to say this to all families whose loved ones go through drugs, alcohol and mental issues.

DO NOT GIVE UP, EVER!

Don't ever make them feel that they are burden to you.

Tom Jackman: The following answer comes from Mary Watt, who is on a Blackberry somewhere on I-95:

At the time of his death Danny was not living at home. He was under the jurisdiction of Fairfax County living in "A New Beginning" a county run substance abuse residential program.

We (the parents) have seen Danny come and go so many times. The tears were real but we did not think he was going to kill himself. He was depressed thinking he was going back to jail but we did not want to be the ones calling the police on him. We thought we would hear from him within a few days.

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Alexandria, Va.: Your article mentions that the police were helpful when dealing with Danny's issues, but you also wrote that people were preying on Danny by providing alcohol/drugs in exchange for sex. It also seems like there were a lot of criminal factors enabling Danny's behavior -- from drug dealers to his circle of drug-abusing friends. What did the police do to go after them?

washingtonpost.com: Dual Disorders Rarely Treated Properly (Post, July 28)

Tom Jackman: Danny often traveled from Reston up to Montgomery County, for this circle of people who enabled his addictions in many sordid ways. The Montgomery County police conducted interviews and surveillance after hearing about all this from the Watts. But it was easy for Danny, and his enablers, to simply lay low when the police were around, the police don't have all the time in the world to investigate drug users who aren't openly defying the law, and in the end they had nothing to prosecute. At one point, the Montgomery police actually arrested Danny after he'd had a seizure, which they wouldn't typically do, because his father pleaded with them to search him and hold him if they could. They found a tiny rock of crack in his pocket, and it led to some long term incarceration. And suicide attempts. And his introduction to "Roy," the dominant voice in his head. But the Watts believe the police tried.

The Fairfax County police also helped bring the situation to the Watts' attention by interviewing and recording Danny's teenage revelations. They took him in for treatment, they took him home. The Watts were highly appreciative of the understanding nature of the Fairfax police. I know first hand that department has been very aggressive at training for mental health issues.

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Potomac, Md.: That was one of the best articles I've read about dual disorders not being treated properly. Thank you for making people aware of this horrible disease. We lost our son, Danny to suicide 9 months ago. He was twenty years old, in and out of treatment centers, never being kept long enough to help him. Our Danny was diagnosed with bipolar, manic depression and schizoaffective disorder. He felt like he was suppose to suffer and die. (He stabbed himself 22 times.)

Tom Jackman: Thank you for writing. All condolences to you.

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Rockville, Md.: I loved your article today. I have a child with bipolar disorder and since she was diagnosed at 15, I was able to make sure she got on meds before she was legally an adult and could "decide" not to. It was a tough time, but if she had been older, all of these really stupid laws would have come into play. One thing I did not hear discussed specifically in your article was the influence of marijuana and other street drugs on the mentally ill. There have been at least 6 studies done that have indicated that marijuana especially can lead to psychosis in individuals that may have a tendency towards mental illness, but would not have developed it without the weed. Did Danny's parents mention anything about that?

Tom Jackman: Mary Watt checks in again via Blackberry to answer this question:

I had a conversation with one of Danny's psychiatrists many years ago. The way he explained was "Danny was carrying this mental illness gene all his life just like you and I can be carrying it. But something triggered it off in Danny, be it drugs or a traumatic event. You never know what will trigger this gene or who is susceptible"

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Maryland: My father ended his life in January of this year after struggling with bipolar disorder for nearly two decades. In addition to the bipolar, he exhibited addictive behaviors, primarily sexual addiction. I know that that isn't technically substance abuse, but I do feel that he was failed by the mental health community. He was originally misdiagnosed for several years, and only by the perseverence of my mother was he able to get to a doctor who gave a proper diagnosis. Sadly, that doctor was not competent enough to medicate him properly, and he was left on strong anti-depressants for nearly a decade, which pushed him ever more manic. He had multiple psychotic episodes and suicide attempts during this time. All the while, he exhibited highly inappropriate sexual behaviors (no molestation, but constant infidelity and viewing of pornography on the family computer, that sort of thing). This addiction isolated him even more than the bipolar disorder did. He was treated by the VA in West Virginia, and frankly, the 10-minute appointments he had with a psychiatrist once every few months were nowhere near enough. Two weeks before Christmas, he asked me to check him into the VA hospital for in-patient treatment. They kept him a week, adjusted some meds, then sent him home with a three month supply of drugs, including powerful sleeping pills. On January 8th, he washed down those pills with half a bottle of vodka. If this is not evidence that the system is broken, I don't know what is.

Tom Jackman: Indeed.

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Falls Church, Va.: The article talks about the need for locked facilities. I thought community centers had to be unlocked by law. Isn't that accurate?

Tom Jackman: You are correct, community centers do have to be unlocked, and only certain state-run facilities may be locked. Those are the places the Watts wanted their son sent -- Western State Hospital, Central State Hospital, even Northern Virginia Mental Health Institute here in the Falls Church area, though they were not greatly impressed with the treatment there. (And Danny was, inexplicably, given a pass while he was there involuntarily, leading to his crashing a car and being thrown through the windshield, the event which led to his final downward spiral.)

The Watts knew, from one of Danny's therapists, that Western State or Central State would have better security and more intensive treatment, in part because they handle criminal defendants who must be locked up. And I know, from seeing it first hand, that criminal defendants who enter the Fairfax jail with severe mental problems, and are sent to Western or Central State, receive intensive treatment and return some months later in a clearly improved state. But the Watts were unable to convince anyone that that's what Danny needed, and Danny himself was not going to consent to that. And after 18, it was largely his choice.

A very good question. Thanks.

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Washington, D.C.: NAMI (National Alliance of Mental Illness) is a wonderful way for family and friends to learn about mental illness. After the first class we stopped being mad at our son. National Alliance on Mental Illness

Tom Jackman: The Watts did this too, and it helped them greatly. Thanks for pointing this out. NAMI is a terrific resource and a very dedicated group of folks.

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Northern Virginia: As a Dual Diagnosis Specialist working in a local community mental health agency, I can assure you that your article has been passed around and read thoroughly. There are trained professionals doing all they can for people with dual diagnoses, but as long as the state laws only allow us to hospitalize people "at imminent" risk to self or others, we're limited. Budget cuts are continuing to impact our ability to coordinate and provide quality care. I encourage all of you to think about this family and 8-month waiting lists for care when you demand tax cuts.

Tom Jackman: Well said. Thanks for contributing this.

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Arlington, Va.: Wow, Mr. Jackman! An amazingly sensitive article. Thank you for the balanced and sensitive coverage. I've come to expect much less from the WP, and you've not disappointed me. Thank you!

Tom Jackman: Thanks Mom.

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West Des Moines, Iowa: As a reporter, you had a chance to talk to a lot of people for your story. I am struck by the heartwrenching story and the contrast between the family's grief and the workers' reponses. I always thought that people in the mental health world would be compassionate. Did you find this to be true?

Tom Jackman: The people in Fairfax County's Community Services Board are compassionate. They work hard and mean well, in my experience. But other people, such as the Watts, have had different experiences. It's hard to see behind such complex relationships, especially long-term ones such as the Watts had with the CSB. We certainly couldn't ignore the Watts' point of view, particularly when their son wound up dead.

In the end, I think the ultimate conclusion is that even when you have a well-equipped county such as Fairfax, dual diagnosis is such a difficult syndrome that even Fairfax couldn't save Danny Watt. The Watts would say Fairfax could have saved him. So we try to just lay that out there, and try to push the discussion forward.

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Arlington, Va.: Did you have a chance to review any of optomistic outcomes shown in the research on court-ordered mandatory outpatient treatement?

Tom Jackman: I have looked at the research on mandatory outpatient treatment, and folks like the Treatment Advocacy Center have been pushing for that to be used more in every state in the country. New York in particular has had outstanding success, from what I've read.

But for this article, and this case, Danny needed something more. At some point down the road, if he had been making progress, was no longer in residential care and started getting in trouble again, mandatory outpatient treatment probably would've been a good option. But he was several levels away from that being a viable option, since he was having trouble simply abiding by inpatient treatment rules.

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Gaithersburg, Md.: Our family found itself in a similar situation in Maryland. Even after our son had been hospitalized the first time, we were not told his diagnosis. A psychologist who saw him the first time while still a minor got the substance abuse part of his dual diagnosis because we told him about it. He funneled him into a drug program. This well respected treatment program promptly dumped him when his psychiatrist whom we had found for him put him on a mood stabilizer for bipolar disorder. When he was released from the hospital the second time he was still psychotic. The release specialist sent him by taxi to the Crisis Center in Montgomery County where he was told he should apply for benefits. We are sure he was discharged according to what our insurance (a very good federal employee plan) would pay for. Her advice to a psychotic individual to sit down and fill out paperwork, all of which takes great patience and collectedness of mind, still seemed inappropriate to us -- one of those gaps that no one thinks about when taking care of a person whose brain is not working. Instead he split with another patient and ended up in Ohio somewhere at another hospital, and this went on for months. After this junket and calamitous credit card expenditures later, he finally came down and was ready to go into treatment. Not being trained in any part of the mental health field, we never understood any of what passed for care of his condition until much too late. We did our best to get him care, but the problems associated with dual diagnosis, as the article describes, are not achievable under current law and benefits distribution. He was seen by a psychiatrist to treat his brain disorder, but substance abuse treatment remained elusive, even evasive. His application for Medicaid was denied pending resolution of his Social Security Disability determination, which has still not been resolved after three years. He died last year in August from an overdose. Our family could never have survived this or even begin to heal without joining a Family Support group run by NAMI in Montgomery County. Thanks to them we were able to continue to reach out to him in the very great pain he was in.

Tom Jackman: More proof of how widespread this is, and how helpful NAMI is. Thanks for this.

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Denver, Colo.: Thanks for writing this, Tom. The public and policy makers need to be educated about dual diagnosis, as the combination of mental illness and addiction is more the norm rather then the exception with young people that have a substance abuse problem. The addiction rarely occurs in isolation. And many many thanks to the Watts for telling their story. An unbelievably heart-wrenching act of bravery... We as a family have been living this nightmare with our now 20-year- old son for almost five years. Things seem to improve for a while, only to slide further downhill when he moves on to a less structured environment. And I, having worked in the medical and behavioral health field for over 20 years, feel completely lost and overwhelmed when trying to coordinate any kind of long term services for him. Is there any hope that there are models of effective long-term dual diagnosis treatment being developed? Seems like everyone is playing catch-up.

Tom Jackman: There is some hope. Dr. Robert Drake at Dartmouth and Dr. Kenneth Minkoff at Harvard have written extensively about techniques that work, and Dr. Minkoff in particular travels continuously to train mental health providers about how to deal with it. Google them to get more information on the hopeful approaches they've developed.

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Alexandria, Va.: I know why the person who wrote in said that families should never give up, but in some cases that is not realistic. If the person in question is violent, refuses treatment, refuses to stay treatment compliant and causes too much upheaval in the home, some people are forced to not have the person in their homes.

My husband's brother is schizophrenic and he is not welcome in our home. This is not because we do not love or care about him, but because he is not treatment compliant, has been off his meds for 2 years, and we have a 2-year-old daughter. We understand his situation and are very sympathetic, but we must think of the welfare of our own child first.

People must have healthy balances in order to maintain some semblance of a normal life when dealing with sick relatives. Schizophrenia is not a sprint that is over quickly... it is a life-long illness that can really wear out everyone around the patient if they do not set healthy boundaries.

Tom Jackman: Well said. Thank you.

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El Paso, Tex.: My "knowledge" may well be out of date. But about 10 years ago a very good psychiatrist told me, as I recall, that a psychiatrist cannot make a DSM-type diagnosis of a mental illness until the subject has been drug-free for a year. Do you know if psychiatrists -- rightly or wrongly -- as physicians -- hold this view?

Tom Jackman: From Mary Watt and her trusty Blackberry:

When Danny was diagnosed by NoVa Mental Health Institute he had 8 months sober. Plenty of time to withdraw and clean out his system. No, no one has ever delineated an exact time period to us.

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D.C.: As someone who actively manages his bioplar disorder, and knows several people who actively manage their dual diagnosis, I suggest you be careful not to paint us with too broad a brush.

Many of us our responsible citizens, who recognize the need to care for our medical condition, and work with professionals as necessary to find long-term solutions that allow us to serve society as lawyers, doctors, professors, and others.

I understand that not everyone's situation is the same, and grieve with you for the loss of your son, but we must all be careful not to further stigmatize people -- those of us with these conditions already face intense stigmas, hence the reason so few are "out" in our personal or professional lives.

Tom Jackman: An excellent point. And a hopeful one, too. People survive and thrive. Thank you very much for reminding of this.

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Out West: My brother is an alcoholic and has been diagnosed with depression. He is an adult. How do you go about finding someone who can treat dual disorders? Finding one seems to be so difficult.

Tom Jackman: This is the federal government's website, for an agency it de-funded in March, but it still has numerous resources and listings for places to find in your area. Good luck.

http://coce.samhsa.gov/

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washingtonpost.com: The Co-Occurring Center for Excellence (COCE)

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Warrenton, Va.: My heart goes out to the family and to all the people who tried to help Danny Watt. I wanted to ask about the services you describe in the article. I've always believed that Fairfax County has some of the finest substance addiction and mental illness services in the country. I've heard that their available services are amazing and advanced. In your research, how do these services look in the rest of Virginia or the rest of the country? Would Danny have received better services somewhere else? What options are out there for people? It seems like there is such a very, very dire need for people who have these problems and that there are limited services. What about all the other Dannys out there?

Tom Jackman: And finally, Mary Watt weighs in on this one:

It is my belief that YES Fairfax County does have one of the best mental health systems. Since it is only available to FxCo residents, people have been known to stay in homeless shelters just to be "classified" as a FxCo resident. Fairfax County is very unique for even having a dual diagnosis program. It is the "decision makers" that can make or break you.

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Tom Jackman: That's all the time we have. Your questions and comments were terrific, and greatly appreciated. Thanks.

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