‘Wrong door syndrome’ complicates treatment of dual disorder patients

Eduardo Matute was 16 years old when he started using hashish and marijuana. Later on, he became addicted to alcohol, cocaine and tobacco. At 23, he had his first psychotic break. It took almost 10 years for him to be properly diagnosed with bipolar schizoaffective disorder. People with this condition experience the psychotic symptoms of schizophrenia, as well as episodes of mania and depression typical of bipolar mood disorders. Now 47, Matute told EL PAÍS that it has been 14 years since he last consumed hashish and marijuana, and about eight years since he last consumed alcohol and cocaine. “I’m stable now. I still have occasional crises, but thanks to my medications, I no longer have psychotic or manic episodes. These crises happen when I’m stressed or tired, or when my schedule has been disrupted. But fortunately, they are no longer caused by substance abuse,” he said.

Matute is currently under the care of Madrid’s adult social services agency (AMTA) and lives in the heart of Madrid in a studio apartment owned by the Society of St Vincent de Paul, an international voluntary organization in the Catholic Church. He has lived in various types of supportive housing and recovery communities, and experienced several relapses along the way. “Sometimes people point to me as an example to follow, but young people shouldn’t have to go through as many relapses and hospital admissions as I’ve had. With an accurate dual disorder diagnosis, you can get proper, professional treatment. This way, the problem can be tackled earlier, and a lot of suffering can be avoided by patients and their families. My mother has suffered a lot because of me,” said Matute.

Dr. Néstor Szerman, a psychiatrist with Madrid’s Psychiatry and Mental Health Institute (Gregorio Marañón Hospital) and the president of the World Association for Dual Disorders (WADD), says many people have had the same experience as Matute. “Eduardo was told that his psychosis was the result of cannabis use. This is what we call ‘wrong door syndrome,’ which is a term to describe the difficulty of diagnosing and treating people that have addictions as well as other mental disorders. He had been going through the wrong treatment doors for 10 years when I first started seeing him. I told him that his addictions and psychosis are different symptoms of a single disorder.”

It’s known as dual diagnosis or dual disorder, which is the condition of having a mental illness and a comorbid substance use disorder. It’s based on a principle supported by scientific evidence: addiction is a mental disorder. “One chooses to consume alcohol, cannabis, cocaine or tobacco, but no one chooses to have an addictive disorder. Only 10% of people exposed to addictive substances end up developing an addiction because addictions depend on a preexisting individual, genetic or neurobiological vulnerability,” said Szerman. He also believes that dual disorders might not be the exception, but the norm. A study from the US National Institute on Drug Abuse, led by renowned psychiatrist Dr. Nora Volkow, estimated that more than 75% of serious mental illnesses involve substance addiction, and that 100% of people with addictions also have other mental disorders.

Wrong door syndrome

Lola Callealta, president of a Spanish support organization for families of dual disorder patients (AFEDU), has an ironic term for wrong door syndrome – ping-pong therapy – because dual disorder patients bounce back and forth between mental health and addiction therapies without receiving the type of comprehensive treatment that addresses all their disorders. “Mental health treatment is fragmented. Mental disorders are treated in clinical settings, while addictions are often treated in centers that do a lot of good but don’t provide essential psychiatric care,” said Callealta.

Callealta knows the problem very well. From her own experience and as president of AFEDU, she has seen many patients and their relatives go through the wrong doors time and time again. “I have supported many mothers who come to AFEDU for help, and I have personally seen how psychiatrists kept referring their children with substance abuse problems to outpatient treatment centers. They sometimes got better when they stopped using drugs for a while. But without psychiatric treatment, these boys and girls often relapse. These families have suffered real tragedies. And the prisons are full of people with dual disorders who receive no treatment or psychiatric care at all.”

Dr. Carlos Roncero, head of psychiatry at Salamanca Hospital (western Spain) and president of the Spanish Society for Dual Disorders (SEPD), recommends a comprehensive plan to treat all of a patient’s mental disorders. “Parallel treatment [when two different people or teams treat the same patient] is a complex model and often leads to failure due to coordination problems. Even worse outcomes result from sequential treatments – addiction first, followed by mental disorder treatment, or vice versa.”

The hole in national mental health strategies – addictions

Psychiatric care was not covered by Spain’s National Health System until 1986 when the General Health Law was enacted. “Before then, psychiatry was marginalized and in the hands of provincial governments and local entities,” said Szerman. However, the 1986 law failed to cover people with addiction as their primary diagnosis.

“Addiction has always been most underfunded and least valued branch of psychiatry,” said Roncero, who traces this back to a time when the psychiatry officialdom rejected the subject of addiction, especially when it pertained to illegal substances like heroin or cocaine. “The causes of addiction were considered to be bad social environments, bad company and the availability of illegal drugs on the streets. Fortunately, times are changing and efforts by scientific societies like ours, as well as greater sensitivity on the part of professionals and families, are producing new perspectives on addictions accompanied by other mental disorders, and on the need for solid psychiatric treatment approaches.”

Despite all the international recognition of the addiction as a mental disorder, Spain’s national mental strategy still does not incorporate the dual disorder concept. “No one would question the need to coordinate all the components of anorexia treatment,” said Szerman. “But mental disorders and addictions are still maintained in separate compartments and patients always find themselves having to choose between two doors, often with disastrous results.”

In the meantime, Eduardo Matute is doing his best to avoid the temptations that surround his apartment near the Gran Vía, a bustling part of Madrid’s city center. “There’s a lot of temptation on the Gran Vía. I’ve often gone out to buy a Coca-Cola and found myself staring at the beer for sale. But I’ve been trying hard for years now. The treatment helps keep the cravings away, and I don’t associate with people who drink and drug, which is the most important thing,” he said.

Matute goes to the gym on Mondays and Wednesdays, and to a crafts workshop on Thursdays. On Fridays, he attends a psychiatric education meeting, where he also receives regular psychiatric treatment for his mental disorder. The rest of the time he goes to exhibitions, hangs out with friends from his apartment building, takes walks, watches the news, and listens to a lot of music. To maintain his mental health, he tries to follow regular, balanced routines. As our interview ends, Matute repeats his message one more time: “Addictions are a mental disorder, not a vice.”

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