Dual-Diagnosis Clinical Standard of Care

1. Scope and Purpose

This dual-diagnosis standard applies to all adult clients admitted to Siam Rehab who present with, or are suspected to have, a co-occurring mental health disorder alongside a substance use disorder. It covers assessment, diagnosis, treatment planning, risk management, medication management, escalation, and transition to aftercare.

The objectives are to:

• Ensure that co-occurring mental health conditions are systematically identified and documented.
• Integrate psychiatric care with detox governance and psychosocial treatment.
• Provide clear risk stratification and escalation pathways for mental health–related safety concerns.
• Align dual-diagnosis care with existing governance frameworks for detox safety, risk management, emergency response, and aftercare.

2. Clinical Population and Eligibility

Typical dual-diagnosis presentations at Siam Rehab include, but are not limited to:

• Depressive disorders with alcohol, benzodiazepine, or polysubstance use.
• Anxiety and panic disorders with alcohol, cannabis, or stimulant use.
• Post-traumatic stress disorder (PTSD) with alcohol or drug dependence.
• Bipolar spectrum disorders with alcohol or stimulant misuse.
• Attention-deficit/hyperactivity disorder (ADHD) with alcohol, cannabis, or non-prescribed stimulants.
• Other personality and trauma-related conditions co-occurring with substance use.

Inclusion requires that the client can safely participate in a residential rehabilitation program, with medical and psychiatric stability confirmed during admission triage and detox risk screening.

Exclusion criteria include acute psychosis, uncontrolled mania, high-intent suicidality requiring continuous observation, or medical conditions requiring inpatient hospital care. These are managed under the existing emergency response and hospital transfer framework.

3. Assessment and Diagnostic Workflow

All clients undergo structured screening for co-occurring mental health disorders as part of the intake and early-program assessment process. This includes:

• Standardized mental health screening tools (for example, depression and anxiety scales) during admission and early days in treatment.
• Comprehensive clinical interview by senior counseling staff, including history of psychiatric diagnoses, previous treatments, and medications.
• Screening for trauma exposure, PTSD symptoms, self-harm history, and current risk factors.
• Identification of cognitive or attention-related difficulties suggestive of ADHD or neurodevelopmental conditions.

Where initial screening indicates a probable co-occurring condition, the case is reviewed with the program’s psychiatrist, who may provide a diagnostic opinion, confirm prior diagnoses, or recommend further evaluation. Diagnostic conclusions and provisional hypotheses are documented in the clinical record and incorporated into the integrated care plan.

4. Integrated Treatment Model

Dual-diagnosis care at Siam Rehab is delivered through an integrated model that combines medical oversight, psychiatric input, and structured psychosocial treatment. Core components include:

• Detox and medical safety: Clients with dual diagnoses follow the established medication safety and detox governance framework, with additional monitoring for mental-status changes.
• Psychiatric oversight: The visiting psychiatrist provides assessment, diagnostic clarification, and medication recommendations for clients with co-occurring disorders.
• Individual therapy: One-to-one sessions address both substance use and mental health symptoms, using evidence-based modalities such as CBT, trauma-informed therapy, and skills training.
• Group program: Group content is adapted to accommodate clients with anxiety, depression, trauma histories, and attention or learning difficulties.
• Family and systems involvement: Where appropriate, family communication addresses both addiction and co-occurring mental health conditions.

5. Risk Stratification for Dual-Diagnosis Clients

Risk stratification integrates mental health and substance-related risk into a single safety profile. Clients with co-occurring disorders are assigned to low, moderate, or high mental-health risk tiers based on:

• History of suicide attempts, self-harm, or severe impulsivity.
• Current suicidal ideation, intent, or plan.
• Presence of psychotic symptoms, mania, or severe dissociation.
• Recent severe trauma, loss, or destabilizing events.
• Severity of substance withdrawal and intoxication-related risks.

Risk tiering informs observation frequency, staff contact expectations, and escalation thresholds. It operates in parallel with the existing clinical risk management and early warning system for medical and behavioral risks.

6. Co-Occurring Disorders Risk Stratification Matrix

The dual-diagnosis risk matrix is used as a reference to align typical co-occurring profiles with baseline risk tiers, key risk domains, and observation patterns in the first week of treatment.

This matrix does not replace individual clinical judgment; it supplements case formulation and supports consistent safety practices across the team.

7. Psychiatric Medication Management

Psychiatric medications are managed under the medication safety and detox governance framework, with additional safeguards for dual-diagnosis clients:

• Continuation of established psychiatric medications is considered when safe and clinically indicated, with attention to interactions with detox regimens.
• Initiation or adjustment of psychiatric medications is undertaken by the psychiatrist, with clear documentation of target symptoms, expected onset, and monitoring plan.
• Medications with abuse or dependence potential are avoided where possible; where necessary, usage is time-limited, supervised, and linked to a tapering plan.
• Changes in mental status, suicidality, agitation, or sleep are monitored closely in the first weeks following medication changes.

Nursing and counseling staff monitor adherence, side effects, and symptom response, and promptly escalate emerging concerns through the established risk and emergency pathways.

8. Monitoring, Escalation, and Emergency Management

Monitoring for dual-diagnosis clients combines routine observations with targeted checks for mental health risks:

• Observation frequency is set according to risk tier and adjusted as risk changes.
• Daily check-ins assess mood, anxiety, sleep, thought content, and substance cravings.
• Staff are trained to recognize warning signs of suicidality, escalating agitation, disorganized thinking, and destabilization.

Escalation follows the same principles as the emergency response and hospital transfer protocol, with specific triggers for psychiatric risk, including:

• Emergent suicidal ideation with intent or plan.
• New-onset psychosis or severe agitation.
• Acute deterioration in reality testing or self-care capacity.
• Severe dissociation, non-responsiveness, or significant behavioral disinhibition.

Where required, rapid hospital transfer and psychiatric stabilization are arranged prior to continuation or re-admission to the residential program.

9. Condition-Specific Considerations

Within the general framework, additional considerations apply to key co-occurring presentations:

• Depression and substance use: Increased monitoring for suicidality during early detox, sleep disruption, and early abstinence.
• Anxiety and panic disorders: Gradual exposure to group environments, structured skills training, and careful use of medications with dependence potential.
• PTSD and trauma-related conditions: Stabilization-first approach, pacing of trauma-related work, and clear boundaries around triggering material.
• Bipolar spectrum disorders: Monitoring for emerging hypomanic or mixed states, adherence to mood stabilizers, and sleep regulation.
• ADHD and neurodevelopmental conditions: Adaptations in group structure, pacing, and learning modalities; consideration of stimulant and non-stimulant options where appropriate.

10. Roles and Responsibilities

Key roles in dual-diagnosis care include:

• Psychiatrist: Diagnostic clarification, medication management, risk assessment, and liaison with external psychiatric services.
• Medical team: Detox oversight, physical health monitoring, and collaboration on medication safety.
• Counseling team: Integrated treatment planning, individual and group therapy, risk monitoring, and documentation of mental health progress.
• Support staff: Observation of day-to-day functioning, prompt reporting of changes, and adherence support.
• Clinical leadership: Oversight of dual-diagnosis practice standards, audit, and continuous quality improvement.

11. Documentation, Handover, and Aftercare

For dual-diagnosis clients, documentation includes:

• Initial and revised diagnostic impressions, including mental health and substance use diagnoses.
• Risk assessments and changes in risk tier over time.
• Medication decisions, monitoring plans, and responses.
• Summary of key therapeutic themes, coping strategies, and relapse-prevention plans.

At discharge, the aftercare plan includes clear recommendations for ongoing psychiatric and psychological care, as well as participation in remote follow-up and community resources. For governance details on follow-up and safety monitoring after discharge, see the aftercare monitoring and follow-up safety framework.

12. Quality Assurance and Governance

Dual-diagnosis care is monitored through the existing clinical governance system, including:

• Regular case reviews with psychiatric input for complex clients.
• Inclusion of dual-diagnosis cases in risk review and incident reflection processes.
• Use of outcome measures to track changes in mood, anxiety, functioning, and substance use.
• Periodic audit of documentation, risk management, and medication practices.

Findings from audits and reviews inform staff training, protocol updates, and service development for co-occurring disorders.