Patients who have both a psychiatric disorder and a substance abuse problem cause most clinicians to throw up their hands in despair. The clinical problems that these "dual diagnosis" patients present are enor mously complex. Diagnostically, how is one to tell if disorders of mood and thinking, for instance, are signs of a mental illness or consequences of substance abuse? How is one to obtain important historic information when the patient may be unable or unwilling to provide it and there are no readily available collateral sources of information? In any case, why bother? Treatments for dually diagnosed patients are ineffective; patients won't stay in treatment; recidivism occurs at a very high rate. To make matters even more difficult, traditional health care reim bursement mechanisms do not provide for the multimodality clinical programs and special services needed by the patient who is both mentally ill and a substance abuser. So the clinician needs an effective bureaucratic strategy as well as a treatment strategy. For the most part, clinicians have handled the problem by ignoring it."

It is well known that alcoholism continues to be one of this country's major public health problems. This issue is carefully documented by Dr. Gerald Klerman, Chief of ADAMHA, in the second chapter ofthis volume. In spite of the major role that alcohol plays in the health care issues of internal medicine, neurology, and psychiatry, the subject continues to fall between the cracks of the various disciplines. For this reason, it has become almost a discipline of its own; yet there are no academic departments of alcoholism because academic departments are unidisciplinary and alcoholism is clearly a multidisciplinary field within medicine. In spite of the many disciplines involved in the study and treatment of alcoholism, psychiatry continues to have a special, albeit often neglected, relationship to alcoholism, and it is the articulation ofthat relationship which prompted the Department of Psychiatry at the Downstate Medical Center to organize the conference upon which many chapters in this volume are based. Particular emphasis in selecting the topics to be covered was placed on the interface between alcoholism and clinical psychiatry, including affective disorders, schizophrenia, suicide, adolescence, the special problems of women, and psychotherapy, to mention only some of them.

Patients who have both a psychiatric disorder and a substance abuse problem cause most clinicians to throw up their hands in despair. The clinical problems that these "dual diagnosis" patients present are enor mously complex. Diagnostically, how is one to tell if disorders of mood and thinking, for instance, are signs of a mental illness or consequences of substance abuse? How is one to obtain important historic information when the patient may be unable or unwilling to provide it and there are no readily available collateral sources of information? In any case, why bother? Treatments for dually diagnosed patients are ineffective; patients won't stay in treatment; recidivism occurs at a very high rate. To make matters even more difficult, traditional health care reim bursement mechanisms do not provide for the multimodality clinical programs and special services needed by the patient who is both mentally ill and a substance abuser. So the clinician needs an effective bureaucratic strategy as well as a treatment strategy. For the most part, clinicians have handled the problem by ignoring it.

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