Mr. Fodero is the Advocacy Chair of the Alliance for the Mentally Ill in Otsego County.

Dual diagnosis proclaimed by the mental health sector is unfortunately considered in a narrow, exclusive or restrictive oriented framework. Whatever the antecedents are for perceiving dual diagnosis solely as mental illnesses cooccurring with substance abuse disorders, it is by no means the only form of a dual diagnosis.

The mental health sector must be willing to recognize, understand, and include in its advocacy agenda the common comorbidity of mental retardation and mental illness. With the prevalence rates showing from 20 to 35 percent of persons with mental retardation have a mental illness compared to 16 to 20 percent among the general population (Stark 1989), this long neglected issue needs to be seriously addressed.

Many of the research findings pertaining to the MICA (mentally ill chemical abuser) population plus other factors such as exclusionary policies of bureaucracies also apply to the MRDD/MI (mentally retarded, developmentally delayed/mentally ill) population. Notable are the principle of primary diagnosis and the I.Q. score of 70 as the cutoff point used to determine mental retardation. Sadly, the majority of persons with I.Q. scores over 70 but under 100 are pushed and pulled between the two service spheres of mental health and mental retardation/developmental disabilities (MH/MRDD). The end result of this tug of war is that many consumers are under served or inappropriately served. Another factor contributing to consumers being caught in this bureaucratic crossfire is the belief that dually diagnosed consumers are immune to psychological or psychiatric disorders (Fletcher 1988). This myth has been scientifically refuted.

People are not easily classified, either quantitatively or qualitatively by so-called statistically significant test and measurement data and tautological concepts, nor should they be. People are too varied and complex (including those with disabilities) to be classified exclusively by statistically derived instruments. This is particularly the case for the mentally retarded population because their communication difficulty emanating from their cognitive impairment can result in diagnostic overshadowing resulting in inappropriate treatment (Reiss et al 1982; Sovner, 1986). Moreover, the most vigorously psychometrically developed instruments to assess mental retardation are not compatible with diagnoses generated by the use of the DSM criteria (Matson et al, 1984). Further, clinical guidelines of the DSM for determining psychiatric diagnoses were found not to be applied uniformly to the MRDD population (Sovner, 1986). For these reasons, extended clinical observations should be an integral part of the criteria to determine qualification of services.

Attempts to pigeonhole people into one system or the other based on criteria, some of which are draconian, are not only impractical, they are inhumane. Systems need to fit persons not the other way around. The mental health and the mental retardation/developmental disabilities systems must be compelled to coordinate their efforts in a collaborative approach to provide effective, comprehensive community-based services for this priority population.

Related to the assessment protocols is the matter of training for professionals. The limited knowledge and skill that currently exist among providers in each other’s domain are a deterrent to serving the dually diagnosed (Sovner& Hurley 1983, 1990). This condition can be corrected by cross training implemented at the curricular level in colleges and universities and through in-service institutes for current practitioners (Fletcher 1995). Cross training of professionals will enable them to effectively recognize, assess, and provide appropriate treatment plans for the respective disorders of this priority population. Further, blending funding into a seamless process coupled with unduplicated service data will ensure the health and protect the lives of persons dually diagnosed as mentally ill with mental retardation or other developmental disabilities.

In brief, an initiative needs to be taken for an integrated approach for services. This integrated approach requires a coherent policy that is person centered (Fletcher 1993). This is not a new approach. It is being done in some areas with remarkable results, i.e., Austin, Texas (Casner 1996); Rochester, New York (Cain & Davidson 1995) and the eastern rural region of North Carolina (Antonacci, et al, 1997). However, this occurs primarily at the local level where the professionals and their organizations can clearly see what needs to be done. It is the governing and regulatory agencies/departments/offices at state levels that transcend or otherwise eliminate the practice of using primary diagnosis, I.Q. level, age and so on as qualifications for appropriate services (Reiss, 1993). These barriers must be dismantled and the gates and doors opened to an integrated system of services.