BEHAVIORAL HEALTH RECOVERY MANAGEMENT
SERVICE PLANNING GUIDELINES
CO-OCCURRING PSYCHIATRIC AND SUBSTANCE DISORDERS
KENNETH MINKOFF, M.D.
These guidelines were developed for the Behavioral Health
Recovery Management project by Kenneth Minkoff, M.D.
The Behavioral Health Recovery Management project is an initiative of Fayette Companies, Peoria, IL; Chestnut Health Systems, Bloomington, IL; and the University of Chicago Center for Psychiatric Rehabilitation
The project is funded by the Illinois Department of Human Services' Office of Alcoholism and Substance Abuse.
Dr. Minkoff is Medical Director of Choate Health Management in Woburn, MA, Assistant Clinical Professor of Psychiatry at Harvard Medical School, and a nationally known consultant and trainer on co-occurring disorders. April, 2001
SERVICE PLANNING GUIDELINES CO-OCCURRING PSYCHIATRIC AND SUBSTANCE DISORDERS
Introduction
During the past two decades, as awareness of individuals with co-occurring psychiatric and substance disorders has increased, there has been a steady accumulation of data to permit the development of both evidence- based and consensus-based best practice models for the treatment of these individuals. These ‘best practices” need much more study, but they are sufficiently well developed at present that it is possible to use them to formulate coherent practice guidelines for assessment, treatment, and psychopharmacology of individuals with co-occurring disorders. These practice guidelines are outlined in this document. Before delineating the practice guidelines themselves, however, it is important to describe the data-based and consensus-based foundation in the literature that supports them. This evidence base incorporates the following principles: (Minkoff, 2000):
1.
1. Dual diagnosis is an expectation,
not an exception. Both the
Epidemiologic Catchment Area survey (Regier et al, 1990) and the National
Comorbidity Survey (Kessler et al, 1996) support the high prevalence of
comorbidity in both mentally ill populations and substance disordered
populations. 55% of individuals in treatment for schizophrenia report lifetime
substance use disorder (Regier et al, 1990), and 59.9% of individuals with
substance disorder have an identifiable psychiatric diagnosis (Kessler et al,
1996).
2.
2. The population of individuals with
co-occurring disorders can be organized into four subgroups for service
planning purposes, based on high and low severity of each type of disorder. (NASMHPD/NASADAD,
1998; Ries & Miller, 1993). In 1998,
the National Association of State Mental Health Program directors and the
National Association of State Alcohol and Drug Abuse Directors arrived at an
unprecedented consensus to use this “four quadrant” model for
service planning purposes.
3.
3. Treatment success involves formation
of empathic, hopeful, integrated treatment relationships. (Drake et al,
1993, 2001 Minkoff, 1998) This principle derives from analysis of multiple
program models. Integrated treatment
does not imply a single type of intervention, so much as the capacity, in the
primary treatment relationship, to integrate appropriate diagnosis-specific
interventions for each disorder into a client-centered coherent whole, with the
ability to modify interventions for each disorder to take into account the
other.
4.
4. Treatment success is enhanced by
maintaining integrated treatment relationships providing disease management
interventions for both disorders continuously across multiple treatment
episodes, balancing case management support with detachment and expectation at
each point in time. (Drake, et al 1993; 2001 Minkoff, 1998) Progress is usually incremental, and no data
supports a single brief intervention as providing definitive treatment for
persistent comorbid conditions. The
extent of case management support and
structure required are proportional to the individual’s level of disability and impairment in functioning.
1.
5. Integrated dual primary
diagnosis-specific treatment interventions are recommended. (Minkoff, 1998)
The quality of any integrated intervention depends on the accuracy of diagnosis
and quality of intervention for each disorder being treated. In this context, integrated treatment
interventions should apply evidence-based best practices (for psychopharmacology
as well as for other interventions) for each separate primary disorder being
addressed. In addition, a growing data
set supports the high prevalence of trauma histories and trauma-related
disorders in these individuals, women (85%) (Alexander, 1996; Harris, 1998)
more so than men (50%) (Pepper, 1999), and there is increasing evidence of the
value of trauma-specific interventions being combined with interventions for
other psychiatric disorders as well as for substance disorders. (Harris, 1998;
Evans and Sullivan, 1995, Najavits et al, 1998)
2.
6. Interventions need to be matched not
only to diagnosis, but also to phase of recovery, stage of treatment, and stage
of change. The value of stagewise
(engagement, persuasion, active treatment, relapse prevention) treatment
(Mueser et al, 1996;Drake et al, 1993, 2001) has been well-documented, as well
as stage specific treatment within the context of the transtheoretical model of
change (Prochaska & DiClemente, 1992).
Minkoff (1989, 1998) has articulated parallel phases of recovery (acute
stabilization, motivational enhancement, prolonged stabilization,
rehabilitation and recovery) that have been incorporated into national
consensus guidelines.
3.
7. Interventions need to be matched
according to level of care and/or service intensity requirements, utilizing
well-established level of care assessment methodologies. Both ASAM PPC2 (ASAM, 1995) and LOCUS
(AACP, 1998) have been demonstrated in preliminary studies to be valid tools
for assessment of level of care requirements for individuals with addictive disorders
and psychiatric disorders, respectively. Both instruments use a
multidimensional assessment format to determine multiple dimensions of service
intensity that comprise appropriate placement.
ASAM PPC2R (2001) incorporates additional capacity for level of care
assessment and placement for individuals with co-occurring disorders, though it
has not yet been field tested.
4.
8. Based upon all of the above
together, there is no single correct dual diagnosis intervention, nor single
correct program. For each individual, at
any point in time, the correct intervention must be individualized, according
to subgroup, diagnosis, stage of treatment or stage of change, phase of
recovery, need for continuity, extent of disability, availability of external
contingencies (e.g., legal), and level of care assessment. This paradigm
for treatment matching forms the basis for the design of the practice
guidelines.
5.
9. Outcomes of treatment interventions
are similarly individualized, based upon the above variables and the nature and
purpose of the intervention. Outcome
variables include not only abstinence, but also amount and frequency of use,
reduction in psychiatric symptoms, stage of change, level of functioning,
utilization of acute care services, and reduction of harm. (Drake et al, 2001; Minkoff, 1998)
I. Target Group: Any psychiatric
disorder (including both Axis I and Axis II disorders, as
well as substance-induced psychiatric disorders), combined with substance
dependence
and/or abuse.
N.B. For individuals with SMI associated with persistent disability, any persistent pattern of substance use may be defined as abuse.
II. Recommended Practice Standards (derived from the above principles.)
A. Practice Standards
1.
1. Welcoming
expectation: Individuals with comorbidity are an expectation in every
treatment setting, and should be engaged in an empathic, hopeful, welcoming
manner in any treatment contact.
2.
2. Access to
assessment: Access to assessment or to any service should not require
consumers to self-define as mental health OR substance disordered before
arrival. Assessment should routinely expect that all consumers may have
comorbid disorders, and that the assessment process may need to be ongoing in
order to accurately determine what disorders are present, and what
interventions are required. Arbitrary
barriers to mental health assessment based on alcohol level or length of
sobriety should be eliminated. Similarly, no one should be denied access to
substance disorder assessment or treatment due to the presence of a comorbid
psychiatric disorder and/or the presence of a regime of non-addictive
psychotropic medication.
3.
3. Access to
continuing relationships: For individuals with more severe comorbid
conditions, empathic, hopeful, continuous treatment relationships must be
initiated and maintained even when the individual does not follow treatment
recommendations.
4.
4. Balance case
management and care with expectation, empowerment, and empathic confrontation:
Within a continuing relationship or an episode of care, consumers are provided
assistance with those things that they cannot do for themselves by virtue of
acute impairment or persistent disability, while being empowered to take
responsibility for decisions and choices they need to make for themselves, and allowed
to be empathically confronted with the negative consequences of poor decisions.
5.
5. Integrated
dual primary treatment: Each disorder receives appropriate
diagnosis-specific and stage-specific treatment, regardless of the status of
the comorbid condition. Each disorder must not be undertreated because the
other disorder is present; in fact, individuals often require enhanced
treatment for either disorder because of the presence of comorbidity. For
individuals with serious mental illness, for example, active substance use
disorder may be an indication for using more effective psychotropic medication
for the primary mental illness.
Similarly, individuals with serious mental illness may require more
addiction treatment than individuals with addiction only, in the sense that
they need more practice, rehearsal, and repetition, in smaller increments, with
more structure and support, to learn recovery skills.
.6. Stage-wise treatment: Interventions
–and expected outcomes- need to be matched to stage of change.
.a. Acute stabilization: Detoxification
or safe sobering up; initial stabilization of acute psychiatric symptoms.
.b. Motivational Enhancement: Individual
motivational strategies (Miller & Rollnick, 1991; Carey, 1996; Ziedonis
& Trudeau, 1997) and pre-motivational or persuasion groups (Sciacca
1991, Mueser & Noordsy, 1996). In the latter, group process facilitates
discussion of substance use decisions for group members who are likely to be
actively using and have made no commitment to change.
.c. Active Treatment:
Individual and group
treatment interventions for substance use disorders in individuals with
psychiatric disorders and disabilities often require focus on specific
substance reduction or elimination skills, including participation in self-help
recovery programs (particularly for those with addiction), but with
modification of skills training to accommodate disability-impaired learning capacities. These interventions may require smaller
groups, with more specific role-playing and behavioral rehearsal of more basic
skills. (Mueser & Noordsy, 1996;, Bellack & DiClemente, 1999; Roberts
et al, 1999.)
.d. Relapse Prevention:
May require specific skills
training on participation in self-help recovery programs, as well as access to
specialized self-help programs like Dual Recovery Anonymous (Hamilton &
Samples,1995) and Double Trouble in Recovery (Vogel, 1999)
.e. Rehabilitation and Recovery: Focus
on developing new skills and capacities, based on strengths, and on developing
improved self-esteem, pride, dignity, and sense of purpose in the context of
the continued presence of both disorders.
1.
7. Early access
to rehabilitation: Disabled individuals who request
assistance with housing, jobs, socialization, and meaningful activity are
provided access to that assistance even if they are not initially adherent to
mental health or substance disorder treatment recommendations.
2.
8. Coordination and
collaboration: Both ongoing and
episodic interventions require consistent collaboration and coordination
between all treaters, family caregivers, and external systems. Collaboration
with families should be considered an expectation for all individuals at all
stages of change, as families may provide significant assistance in developing
strategies for motivational enhancement and contingent learning, in identifying
specific skills or techniques required for modification of substance using
behavior, and in actively supporting participation in recovery-based
programming to promote relapse prevention. With regard to external systems,
significant new research has identified valuable models for integrated
treatment of individuals involved in the correctional system (Peters &
Hills, 1997; Godley et al, 2000), the child protective service system, and the
primary health care system.
III. Assessment, Differential Diagnoses, and Comorbid Conditions
A. Principles of Diagnostic Assessment: Screening, Detection, and Diagnosis
1.
1. Welcoming
expectation: Because of the high prevalence of comorbidity, routine
assessment in all settings should be based on the assumption that any client is
likely to have a comorbid condition.
Direct communication to the client that such a presentation is both
welcome and expectable will facilitate honest disclosure.
2. 2. Structured Assessment Process: Accurate diagnostic assessment for individuals with co-occurring disorders is complicated by the difficulty of distinguishing symptom patterns that result from primary psychiatric illness from symptom patterns that are caused or