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  • DD between dual pathology VS. Substance induced mental illness?

     Ahmed updated 1 month ago 2 Members · 3 Posts
  • Ahmed

    May 16, 2021 at 10:04 am

    Hello everyone,

    Congratulations on the new forum.

    What are your clinical approaches to DD in between dual pathology (diagnosis) VS. Substance induced mental illness? Whatever you encounter; psychotic, mood or anxiety disorder. This is a practical problem that always has an administrative value in some hospitals. Where would you place a patient? In an acute substance recovery ward (detox) or in an acute psychiatric ward? What is your cut-off duration? Two weeks or more? Thank you.

  • Dr. Harvinder Singh

    May 16, 2021 at 11:54 am

    Hi Ahmed. I did the inpatient + consultation-liaison psychiatry work for 5 years before moving to outpatient psychiatry work now. It can be difficult to differentiate these two conditions initially and it can vary from 24 hr (in mild intoxication cases) to even 5 (or more) days for either high dose substance abuse or combined substance use. I never placed a timing on medical clearance for this reason and will always work with our medical unit colleagues to decide.

    Our goal was to admit patients to the medical unit if:

    • Unstable vitals, or
    • need for multiple PRN medications to control the aggression, or
    • abnormal labs (electrolytes, ammonia, or CPK levels)

    I think building a good relationship with your medical unit physician is most important, as you can transfer them quickly in case patient is admitted first to psychiatry unit & they destabilized medically.

    The question regarding the decision between admission to detoxification unit versus the acute psychiatric unit is similarly not the same for every patient. In these cases: admit to acute psychiatric unit only if patient is actively suicidal or at risk of self-harm or to others. Otherwise I don’t see any reasons to not do the detoxification first and then transfer to acute psychiatric unit if a patient is still having at-risk symptoms.

    What criteria or guidelines you follow in your hospital.

  • Ahmed

    May 17, 2021 at 12:23 pm

    Thank you Dr. Singh for your insight. In our hospital, they are strict about admitting pts to a detox unit. As this unit has collaborative meetings and activities with psychologists, social workers and ex-substance users. Any pt with active psychosis would be disruptive to the unit activities and meetings. It is like a boot camp for the half-way house and aftercare services that is attached to our facility. But many times, acute psychosis comes out, then we transfer pts to an acute psychiatric unit. Another problem comes at discharge time when medical reports are requested and long-term management plans are needed to be documented. Whether those pt would be deemed as substance induced psychosis? Or schizophrenia-spectrum ds “dual pathology”? Previous ASAM Essentials put 2-week as cutoff period. Recent ones, DSM5 and ICD11 use a vague description “for a substantial period of time after cessation of the substance use or withdrawal”! In the DSM5 text they give one month as an example. Some authors erroneously consider it as the DSM5 cutoff time between dual pathology and substance induced mental illness. I do not know a scientific answer to this question. But my observation is that the longer and heavier use behavior is, the longer a mental illness is lagging behind cessation of the substance. Sometimes it takes weeks or months, before final recovery. I do not talk about acutely destabilized pts, like in acute alcohol or stimulant intoxicated pts. My point is about how long and how much would you consider a pt as suffering from a dual pathology and two independent illness, whatever they recover from substance use or not? This problem has an administrative and legal values, even on medical reporting or documentation. I hope colleagues put their input and insight. Best regards to all

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