Dual diagnosis: 15 years of progress.

alization, psychiatry focused on helping patients with long-term institutional histories leave psychiatric hospitals and adjust to living in the community. Awareness of the problems of patients with severe mental illness who had never experienced prolonged hospitalization was slow to emerge. A spate of articles in the early 1980s identified, described, and labeled the “young adult chronic patient” (1–3). Encounters with the drug culture were described in these and similar articles as the young person’s attempt to cope with mental illness and life in the community. The medical designations of co-occurring disorders and dual diagnosis had not yet been used. In the late 1980s, as federal health agencies and providers of all kinds began to attend to this new, younger population of individuals with severe mental illness, the concept of co-occurring disorders emerged (4). Affected individuals were often discussed under the rubric of dual diagnosis but were also called mentally ill chemical abusers, substance-abusing mentally ill persons, and a host of other names that emphasized the concept of two co-occurring disorders. Researchers such as Lehman and colleagues (5) began to address the assessment and treatment of persons with dual diagnoses. At the same time, observers noted the administrative, organizational, financial, and clinical barriers these persons encountered in trying to obtain both mental health and substance abuse services (6). Simultaneously, clinicians, policy makers, and researchers began to tackle the conundrum of how to link mental health and substance abuse services, both conceptually (7) and practically (8). In many ways dual diagnosis is an unfortunate misnomer. There are other dual diagnosis populations, such as those with mental illness and developmental disabilities. Persons with severe mental illness and substance use disorders can be described in other ways and at other levels: they have multiple interacting disabilities, psychosocial problems, and disadvantages. The population of persons with co-occurring mental illness and substance use disorders is itself quite heterogeneous. It includes individuals with less disabling mental illnesses such as anxiety disorders, those with different severe illnesses such as schizophrenia and bipolar disorder, and those with either substance abuse or substance dependence. Nevertheless, the term dual diagnosis became standard usage. It began to be included in the subject index of Hospital and Community Psychiatry in 1989, and it has survived over the years to refer to adults with severe mental illness and co-occurring substance use disorders. On the positive side, when the complexities were reduced to a simple medical term, attention was drawn to problems related to substance use, which created a mandate for recognition