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 exacerbated by primary substance use
disorders. In many individuals with
co-morbidity, both psychiatric and substance disorders are simultaneously and
interactively contributing to symptoms at the point of assessment, particularly
if assessment occurs when the patient is acutely decompensated. Consequently, differential diagnostic
assessment requires a careful, structured approach to assessment, often over a
period of time, in order to best elucidate diagnosis accurately.
3.
3. Accessibility
and Flexibility: Assessment begins at the point of clinical
contact, regardless of the client’s clinical presentation. Initiation of assessment should not be made
conditional on arbitrary criteria such as length of abstinence, non-intoxicated
alcohol level, negative drug screen, absence of psychiatric medication, and so
on. Although in some individuals with co-occurring disorder, establishing an
accurate diagnosis of one disorder requires the other disorder to be at
baseline, in most cases diagnosis can be reasonably established by history (see
below). Moreover, treatment must usually
be initiated when neither disorder is at baseline; consequently, initial
diagnoses are often presumptive, and the initial goal of assessment is to
engage the individual in an ongoing process of continual reassessment as
treatment progresses, during which diagnoses may be continually revised as new
data emerge.
.4. Screening and Detection:
.a. Screening tools in the mental health setting for
substance disorders may include the following:
Checklists of substances, including amounts and patterns of use for each
(include inquiry regarding over the counter preparations, caffeine, nicotine,
and gambling); screening tools validated for use in people with mental illness
(e.g., CAGE, MAST/DAST, MIDAS, DALI, RAFFT for adolescents – see Appendix
A.); and selective use of urine screens, particularly for adolescents and for
unreliable historians with puzzling presentations.
.b. For mental health screening in substance treatment
settings, the use of symptom checklists (e.g.,
Brief Psychiatric Symptom Inventory, MINI, Project Return Mental Health
Screening Form III, SCL-90 – See Appendix A.) can be helpful to facilitate
referral for a more comprehensive mental health diagnostic evaluation.
.5. Collateral Contact: screening AND assessment should routinely incorporate
obtaining permission to contact – and contacting- all available
collaterals, including family,
.friends, case manager, probation officer, protective
service worker, and other treaters, as well as obtaining records of previous
treatment episodes.
.6. Diagnostic Determination:
.a. Diagnosis of either mental illness or substance use
disorder can rarely be established only by assessment of current substance use,
mental health symptoms, or mental status exam.
In most cases, diagnosis is more reliably established by obtaining a
good history that is integrated, longitudinal, and strength-based.
.b. Diagnosis of substance use disorders involves
review of past and current patterns of substance use, and observing whether
those patterns meet criteria for substance dependence or substance abuse.
.c. Diagnosis of substance dependence is frequently
based on evidence of lack of control of substance use in the face of clear
harmful consequences, whether or not tolerance and withdrawal symptoms are
present. Once substance dependence has
been identified in the past, that diagnosis persists, even if the person
currently exhibits reduced use or abstinence.
.d. Diagnosis of substance abuse requires exclusion of
substance dependence, and identifying a pattern of harmful use in relation to
the individual’s own context. For
a person with a mental illness, any controlled use of substances that
interferes with treatment or outcome can be defined as abuse, and the extent of
use that would be considered problematic is inversely related to the severity
of the psychiatric disorder or disability.
For individuals with severe mental illness who are disabled at baseline,
any persistent use of substances is likely to be considered abuse, even though
harmful effects may not be apparent on each occasion.
.e. Diagnosis of non- substance related psychiatric
disorders similarly requires careful review of past and current patterns of
mental health symptoms, in relation to presence or absence of appropriate
medication and periods of substance abstinence or reduced use. Presence of symptoms meeting criteria for DSM
IV psychiatric disorder during periods of abstinence or reduced use that exceed
the resolution period for those symptoms based on the type and extent of
substance use (see SUPS Table in Appendix B) meet presumptive criteria for
mental illness.
.f. All diagnoses should be initially considered to be
presumptive, and subject to continual reevaluation and revision during the
course of continuing treatment.
.g. Whenever a psychiatric disorder and a substance
disorder co-exist, even if the psychiatric disorder is substance-induced, both
disorders should be considered primary, in the sense that each disorder
requires appropriately intensive primary diagnosis-specific treatment
simultaneously.
7. SMI Determination: SMI determination requires establishing (using the assessment methodology in the previous paragraph) a presumptive (NOT necessarily definitive) diagnosis of an SMI eligible psychiatric disorder, persistence of that disorder, and functional incapacity in accordance with state guidelines for SMI determination. If necessary, the SUPS Table (Appendix B) may be utilized to assess the resolution period after which substance-related contribution to symptomatology and functional incapacity are likely to be significantly reduced or eliminated.
B. Differential Diagnoses
1.
1. Substance
Disorder: Distinguish substance use,
substance abuse, and substance
dependence. Distinguish types and
categories of substances.
2.
2. Psychiatric
Disorder: Distinguish substance induced psychiatric disorder,
non-SMI psychiatric disorder, SMI psychiatric disorder.
3.
3. Co-occurring
Disorder Subtype: SMI + substance dependence (high-high); SMI + substance abuse
(high-low); non-SMI/ substance-induced disorder + substance dependence/severe
abuse (low-high); non-SMI/psychiatric symptoms + substance abuse (low-low).
C. Assessment of Common Comorbid Conditions
1.
1. Trauma related
disorders: Individuals with co-occurring psychiatric disorders (SMI) and
substance disorders have a high prevalence of trauma histories and trauma
related symptoms, women (85%) more so than men (50%). Use of a trauma screening tool for both
men and women, and ensuring that the engagement and assessment procedures are
trauma-informed and trauma-sensitive are highly recommended.
2.
2. Cognitive
disorders: Individuals with co-occurring disorders have a high risk
of comorbid cognitive impairment, with causes ranging from congenital
conditions (ADD, learning disabilities) to sequela of substance use, medical
conditions, and/or head injuries. Assessment
of cognitive impairment (e.g., with the Mini Mental Status Exam and with
specific assessment of reading skills and auditory/ visual learning capacity)
is important in modifying treatment in accordance with the individual’s
ability to learn most effectively.
3.
3. Personality
traits and disorders: Individuals with co-occurring axis I
disorders will frequently exhibit symptoms and behavior characteristic of axis
II disorders. At times, these
dysfunctional personality traits will resolve as recovery progresses; at times
they represent enduring personality disorders. Diagnosis of personality disorder is based on
patterns of dysfunctional behavior that are present either prior to onset of
substance disorder, or during periods of abstinence, and are not simply the
result of the axis I mental illness or substance disorder.
4.
4. Medical
conditions: Individuals with
co-occurring disorders are a high risk population for multiple medical
conditions, most notably sexually transmitted diseases.
Obtaining medical history and medical records is an
important component of diagnostic assessment.
D. Additional Assessment to Determine Treatment Needs
1.
1. Phase of
Recovery/Stage of Change/Stage of Treatment:
The literature on co-occurring
disorders has identified four phases of recovery (Minkoff, 1989): acute
stabilization; motivational enhancement/engagement; prolonged stabilization
(active treatment/relapse prevention); rehabilitation and recovery; five stages
of change (Prochaska & DiClemente, 1992): pre-contemplation,
contemplation, preparation, action, maintenance; four stages of treatment
for seriously mentally ill individuals with substance disorders (Osher &
Kofoed, 1989): engagement, persuasion,
active treatment, and relapse prevention. Research of the latter two groups clearly
states that effective interventions must be stage specific. Consequently, stage specific assessment is
required. The Substance Abuse Treatment Scale (McHugo,et al, 1995) is validated
for SMI populations; the URICA (DiClemente) and Readiness to Change Scale
(Rollnick et al) with less seriously mentally ill populations. (Appendix A.)
2.
2.
Multidimensional Assessment: Significant research (McLellan et al)
has identified the value of problem-service matching for individuals with
substance disorders, including co-occurring psychiatric disorders. Use of multidimensional assessment tools like
the Addiction Severity Index or the GAIN offer the opportunity to assess
problems in multiple dimensions for the purpose of service matching. The ASI is not as well-validated in dual
diagnosis populations, however, and does not permit integration of dimensions,
or connection of dimensional problems to a particular disorder.
3.
3. Continuous
Integrated Treatment Relationship: One of the priorities of treatment is
to establish a primary treatment relationship.
Assessment for the presence and quality of such a relationship is a
necessary prerequisite for treatment planning.
4.
4. Family or
Caregiver Support: Available supports supply both
assistance and
contingencies for mobilizing treatment progress.
5.
5. Extent of
Impairment: Assess strengths and disabilities to determine extent to which
individuals require care and support unconditionally, and in what areas (housing,
money management, ADLs). Also, assess
capacity to learn recovery skills and to participate in substance disorder
treatment, with regard to need for DDC or DDE addiction programming. (See
below)
6.
6. External
Contingencies: Evaluate for presence of legal involvement, child protective
service involvement, or other external contingency. Also evaluate for possible contingencies
within existing mental health or substance program settings, including
payeeships.(Ries & Comtois, 1997).
7.
7. Level of Care: Assessment
of level of care requires use of multidimensional
assessment instruments, such as the ASAM PPC 2R (2001) for addiction related
presentations, and LOCUS (2.001) for mental health related presentations. Both
instruments have capacity to address comorbidity in level of care assessment.
IV. Treatment Interventions There is no one single correct intervention for individuals with co-occurring disorders. Intervention strategies must be appropriately matched to individualized clinical assessment based on the parameters listed below. Diagnosis specific interventions for psychiatric and substance disorder are addressed in the practice guidelines for each separate disorder; this section will cover only those issues that relate to individuals with co-occurring disorders specifically. One of the most important overarching principles is the value of continuous, integrated, unconditional treatment relationships that provide ongoing dual recovery management and support over time, regardless of treatment adherence or level of substance use. Within the context of these ongoing relationships, individuals can receive a variety of episodic clinical interventions matched to particular needs and stages of change. The nature of these interventions is described below. See Appendix C for a template for matching interventions according to subtype of dual disorder and stage of change/phase of recovery.
A. Continuity of Dual Recovery Management and Care: Research-based principles (Drake et al, 1993, 2001; Minkoff et al, 1998) emphasize the importance of empathic, hopeful, continuing treatment relationships, provided by an individual clinician, team of clinicians (Continuous Treatment Team – CTT; Integrated ACT), or community of recovering peers and clinicians (Modified Therapeutic Community [Sacks et al, 1999]; Dual Recovery Clubhouse), in which integrated treatment and coordination of care take place across multiple treatment episodes. Integrated treatment implies that the primary treatment relationship integrates mental health and substance interventions at any point in time and over time into a person-centered whole. For individuals with complex problems and/or severe impairment, establishment of a relationship to provide continuous integrated dual recovery management is the first priority of treatment planning.
B. Episodic Interventions: Both psychiatric and substance disorders are chronic relapsing conditions, and individuals may be appropriately served by a variety of episodic interventions at different points in time. Within the context of a continuous dual recovery disease management approach, episodic interventions may occur in acute, subacute, or long-term settings, in either mental health or substance treatment settings. (See Programs in Section V (C).) Ideally, there is a continuous interaction between “continuity interventions”, which are unconditional and flexible, with various treatment interventions which have time-limits and expectations which affect entry and discharge.
C. Subtype of Co-occurring Disorder: Subtype of co-occurring disorder affects locus of responsibility for client. Individuals who are seriously mentally ill (SMI) are commonly eligible for types of services provided in the mental health system (including continuing case management) that individuals with non-SMI symptoms or disorders may not be able to get. Non-SMI individuals require specific mechanisms for providing such continuity of care or case management through other means. Similarly, individuals with substance dependence are more likely to be appropriate for involvement in addiction episodes of care in the addiction system than are individuals with only substance abuse.
D. Diagnosis-Specific Treatment:
1.
1. Integrated
Dual Primary Treatment: When mental illness and substance disorder
coexist, both disorders are considered primary, and appropriately intensive
simultaneous diagnosis- specific treatment for each disorder is required. Integrated dual primary treatment is NOT a
new intervention. Rather, it involves a
variety of methods by which diagnosis-specific, evidence-based strategies for
each type of disorder are appropriately combined and coordinated in a single
setting and in an integrated treatment relationship, and in which the
interventions for each disorder are appropriately modified (if necessary) to
address treatment impediments resulting from the other disorder.
2.
2. Psychiatric
Disorder: Treatment for known diagnosed mental illness must be
initiated and maintained, including maintaining non-addictive medication, even
for individuals who may be continuing to use substances. In addition, the best available psychiatric
medication regime for each disorder may promote better outcomes for both
disorders. Non-psychopharmacologic treatment regimes (e.g., dialectic
behavioral therapy for borderline personality disorder) may be appropriately
utilized to develop cognitive-behavioral skills to manage the mental illness,
while applying similar skills to managing substance use, and integrating direct
substance disorder treatment interventions as well. Diagnosis-specific
integrated interventions have been developed and researched for trauma-related
disorders (Najavits et al, 1998; Harris, 1998, Evans and Sullivan, 1995), and
bipolar disorder (Weiss et al).
.3. Substance Disorder:
.a. Substance abuse treatment: individual
and group interventions to help individuals make, and implement, better choices
regarding substance use in relation to their mental illnesses. Outcomes focus on limitation of use to
achieve reduction in harmful outcome.
For individuals with severe mental illness and baseline disability,
abstinence outcomes are recommended, even though use can be controlled.
.b. Substance dependence treatment (addiction
treatment) for individuals with cooccurring disorders is fundamentally similar
to addiction treatment for anyone, with abstinence as a goal, and with the need
to develop specific skills for attaining and maintaining abstinence, including
use of generic recovery meetings (AA) and dual recovery programs (DRA,
DTR). Individuals with serious
psychiatric impairment often require more addiction treatment in smaller
increments with more support over a longer period to attain recovery skills. Treatment interventions must be simpler, more
concrete, with more role rehearsal, to meet the needs of seriously
psychiatrically impaired individuals, and require maintaining continuing mental
health supports and integrated treatment relationships while the learning
process takes place.
E. Phase of Recovery/Stage of Change/Stage of Treatment: As noted above, interventions need to be phase or stage-specific. This implies that the strategy for individuals who are pre-contemplative is to apply motivational enhancement interventions (individual and/or group) to help those individuals to be contemplators, and so on. Existing motivational enhancement strategies (cf. Miller and Rollnick, 1991; CSAT TIP #35, 1999) have been successfully adapted to individuals with serious mental illness (Carey, 1996; Ziedonis and Trudeau, 1997). Stage-specific group interventions have demonstrated effectiveness with dually diagnosed populations. (Mueser & Noordsy, 1996).
F. Extent of Impairment:
1.
1. Case
management support needs to be provided, usually unconditionally, to assist
individuals in basic needs that they cannot provide for themselves.
2.
2. At each point
in time during the course of treatment, however, whether in the context of a
continuing treatment relationship, or during an episode of care, case management
and care must be balanced with empathic detachment, empowerment, expectation,
and empathic confrontation for each individual, in order to promote learning
and growth.
3.
3. More seriously
impaired individuals at baseline (e.g., individuals with serious mental
illnesses) are likely to require more extensive case management, support, and
structure (unconditionally) to accommodate their psychiatric disabilities.
4.
4. Methods for
providing contingent learning opportunities within such structure include
tightly managed payeeships, residential and day programs with a variety of
contingent learning opportunities, etc.
Contingencies and expectations must be matched to the individual’s
stage of change and capacity for learning, and are ideally developed maximizing
consumer choice and participation.
5.
5. For
individuals requiring episodes of addiction treatment, requirement for
psychiatric enhancement or modification of addiction treatment settings is
proportional to the extent of psychiatric symptomatology or disability. Thus, different categories of addiction
program (Dual Diagnosis Enhanced – DDE; Dual Diagnosis Capable –
DDC) are required for different populations. (See Section V(B) for more
description of program categories.)
G. External Contingencies:
1.
1. Involvement of
the criminal justice system or the protective service system may create
treatment leverage that enhances motivation and treatment participation. Such interventions often require close
collaboration between primary mental health and addiction clinicians with
protective service workers and probation officers.
2.
2. External
contingencies may also be present through the involvement of natural
caregivers (e.g., families) to develop collaborative strategies of contingency
management and intervention.
3.
3. Contingencies
may emerge through participation in programmatic interventions within the
treatment system: payeeships,
abstinence-expected housing, etc. Careful integration of contingency management
strategies into ongoing treatment planning can substantially enhance outcome,
provided the contingencies are tightly managed, non
punitive, and organized to promote continuous learning rather than treatment discontinuation.
H. Level of Care: Diagnosis specific and stage specific interventions can often occur at almost any level of care, depending on formal service intensity assessment as described above. Specific program examples at various levels of care are described below.
V. Program Types
A. Program Categories (ASAM 2001; Minkoff, 2000): Within any system of care, available programmatic interventions can be categorized according to dual diagnosis capability. The expectation is that all programs in either system evolve to become at least dual diagnosis capable (DDC-CD; DDC-MH), and a subgroup of services is designed to be dual diagnosis enhanced (DDE-CD; DDE-MH).
1.
1. DDC-CD: Welcomes individuals with co-occurring
disorders whose conditions are sufficiently stable so that neither symptoms nor
disability significantly interfere with standard treatment. Makes provision for comorbidity in program
mission, screening, assessment, treatment planning, psychopharmacology
policies, program content, discharge planning, and staff competency and
training.
2.
2. DDC-MH: Welcomes individuals with active substance use
disorders for MH treatment. Makes provisions for comorbidity as above. Incorporates integrated continuity of case
management and/or stage-specific programming, depending on type of program.
3.
3. DDE-CD: DDC program enhanced to accommodate
individuals with subacute symptomatology or moderate disability. Enhanced mental health staffing and
programming, increased levels of staffing, staff competency, and supervision. Increased
coordination with continuing mental health or integrated treatment settings.
4.
4. DDE-MH: MH
program with increased substance related staffing skill or programmatic
design: e.g., dual diagnosis inpatient
unit, providing addiction programming in a psychiatrically managed setting;
intensive dual diagnosis case management teams (CTT), providing
pre-motivational engagement and stage-specific treatment for the most impaired
and disengaged individuals with active substance disorders; comprehensive
housing or day programs, providing multiple types of stage-specific treatment
interventions and substance-related expectations.
B. Program Models
1.
1. Continuous
Integrated Case Management: Range from high intensity to low intensity, and DDC or DDE. High
intensity DDE programs include Continuous Treatment Teams (CTT) (Drake et al,
2001), or integrated ACT teams. Moderate
intensity programs include DDC or DDE case management teams (ICM, SCM). Low intensity intervention may be provided by
individual outpatient clinicians (plus psychopharmacologists) in outpatient
clinic settings.
2.
2. Continuous
Recovery Support: Dual Recovery Clubhouse programs (DDE)
or Clubhouse programs with dual recovery supports or tracks (DDC); Dual
Recovery self-help programs.
3.
3. Emergency
Triage/ Crisis Intervention (DDC): Welcomes any type of mental health
and/or substance presentation, provides initial triage, level of care
assessment, and crisis intervention and/or referral
4.
4. Crisis
Stabilization Beds (DDC): Hospital diversion in staffed setting for
individuals with psychiatric presentations who may be actively using
substances, but do not require medically monitored detox.
5.
5. Psychiatric
Inpatient Unit or Partial Hospital (DDC or DDE): The
former does routine assessment, engagement, motivational enhancement, and
stage-specific groups; the latter provides more sophisticated assessment plus
addiction treatment in a psychiatrically managed setting. DDE programs have
also been designed and implemented in state hospitals for individuals in
long-term care.
6.
6. Detoxification
programs (DDC or DDE). Specialized psychiatrically enhanced detox
(Wilens) can provide supervised detoxification for individuals who may have
psychiatric exacerbations during episodes of acute substance intoxication
(e.g., suicidality, aggressive impulsivity, psychosis) but who can be safe in
an unlocked staffed setting.
7.
7. Psychiatric
Day Treatment (DDC or DDE): Intermediate to long-term programs for
psychiatric support that provide varying degrees of stage-specific programming
and integrated case management. DDE
programs have more sophisticated staff, more linkages with substance
programming, and a full range of stage-specific groups.
8.
8. Addiction IOP,
Partial, Residential (DDC or DDE): Episodes of abstinence-oriented active
addiction treatment in settings with varying degrees of psychiatric capability.
Programs can be very long term (years), such as Modified Therapeutic Community,
or short term (one to two weeks, up to 90 days)
.9. Psychiatric Housing Programs: Provide
housing supports for individuals with psychiatric disabilities. Programs need to be matched according to
stage of change;
.a. Abstinence-expected (“dry”) housing: This
model is most appropriate for individuals with comorbid substance disorders who
choose abstinence, and who want to live in a sober group setting to support
their achievement of abstinence. Such models may range from typical staffed
group homes to supported independent group sober living. In all these settings,
any substance use is a program violation, but consequences are usually focused
and temporary, rather than “one strike and you’re out”.
.b. Abstinence-encouraged (“damp”) housing.
This model is most appropriate for individuals who recognize their need
to limit use and are willing to live in supported setting where uncontrolled
use by themselves and others is actively discouraged.
However, they are not ready or willing to be abstinent. Interventions focus on dangerous behavior, rather than substance use per se. Motivational enhancement interventions are usually built in to program design.
c. Consumer-choice (“wet”) housing. This model has had demonstrated effectiveness in preventing homelessness among individuals with persistent homeless status and serious psychiatric disability (Tsemberis & Eisenberg, 2000: “Pathways to Housing Program”). The usual approach is to provide independent supported housing with case management (or ACT) wrap-around, focused on housing retention. The consumer can use substances as he chooses (though recommended otherwise) except to the extent that use related behavior specifically interferes with housing retention. Pre-motivational and motivational interventions are incorporated into the overall treatment approach.
VI. Psychopharmacology Practice Guidelines (Minkoff, 1998; Sowers & Golden, 1999)
A. Assessment
1.
1. Initial
psychopharmacologic assessment in mental health settings should not require
consumers to be abstinent.
2.
2. Initial
psychopharmacologic evaluation in substance disorder treatment should occur as
early in treatment as possible, and incorporate capacity to maintain existing
nonaddictive psychotropic medications during detoxification and early recovery.
3.
3. Diagnostic
assessment of individuals with co-occurring disorders is based ideally on
obtaining an integrated, longitudinal, strength-based history, which
incorporates a careful chronological description of the individual’s
functioning, including emphasis on onset, interactions, effects of treatment,
and contributions to stability and relapse of both disorders at each point in
time. Particular focus is on assessing
either disorder during periods of time when the other type of disorder is
relatively stable. Obtaining information
from family members, previous treaters, and collateral caregivers is extremely
important.
4.
4. Diagnostic and
treatment decisions regarding psychiatric illness are best made when the
comorbid substance disorder is stabilized.
Nonetheless, thorough assessment (as described above) usually provides
reliable indications for initial diagnosis and psychopharmacologic treatment,
even for individuals who are actively using. This is particularly true for
individuals with SMI.
5.
5. Diagnostic and
treatment decisions regarding substance disorder (including psychopharmacologic
decisions) are best made when the comorbid psychiatric disorder is at baseline.
Nonetheless, thorough assessment usually provides reliable information about
the course and severity of the substance disorder, even for individuals whose
mental illness is destabilized.
B. General Principles of Psychopharmacologic Treatment
1.
1.
Psychopharmacology for people with co-occurring disorders is not an absolute
science. It is best performed in the context of an ongoing, empathic, clinical
relationship that emphasizes continuous re-evaluation of both diagnosis and
medication, and artful utilization of medication strategies to promote better
outcome of both disorders.
2.
2.
Psychopharmacologic providers need to have ready access to peer review or
consultation regarding difficult patients.
3.
3. Some initial
evidence of improvements in addictive disorders has been associated with
several classes of psychiatric medications (e.g., SSRIs, bupropion, atypical
antipsychotics – especially, clozapine – and others). The prescriber may want to consider the
potential impact on the substance use disorder when choosing a medication for
the psychiatric disorder.
.4. In general, psychopharmacologic interventions are
designed to maximize outcome of two primary disorders, as follows:
.a. For diagnosed psychiatric illness, the individual
receives the most clinically effective psychopharmacologic strategy available,
regardless of the status of the comorbid substance disorder.
.b. For diagnosed substance disorder, appropriate
psychopharmacologic strategies (e.g., disulfiram, naltrexone,
methadone/buprenorphine/LAAM) may be used as ancillary treatments to support a
comprehensive program of recovery, regardless of the presence of a comorbid
psychiatric disorder (although taking into account the individual’s
cognitive capacity and disability).
5. In general, psychopharmacologic providers will prioritize the following tasks, in order:
a. Establish medical and psychiatric safety in acute situations
1) In acutely dangerous behavioral situations, utilize
antipsychotics, benzodiazepines, and other sedatives, as necessary, in order to
establish rapid behavioral control.
2) In acute withdrawal situations requiring medical detoxification, use detoxification medications for addicted psychiatric patients according to the same protocols as used for patients with addiction only.
b. Maintain stabilization of severe and/or established psychiatric illness.
1) Provision of necessary non-addictive medication for
treatment of psychotic illness and other known serious mental illness must be
initiated or maintained regardless of continuing substance use. Administration of depot neuroleptics should
not be withheld because of concurrent substance use. Further,
ongoing substance use is not a contraindication to use of clozapine,
olanzapine, risperidone, quetiapine, or other atypical neuroleptics. Improving psychotic or
negative symptoms may promote substance recovery.
2) In patients with active substance dependence, non-addictive medication for established less serious disorders (e.g., panic disorder) may be maintained, provided reasonable historical evidence for the value of the medicine is present.
c. Use medication strategies to promote or establish sobriety.
1) Utilizing medication (e.g., disulfiram, naltrexone) to help treat addiction should always be presented as an ancillary tool to complement a full recovery program. Communicate clearly that medication will not eliminate the need for the patient to actively work on developing recovery skills.
2) Psychotropic medications for comorbid psychiatric disorders should be clearly directed to the treatment of known or probable psychiatric disorders – not to medicate normally occurring and expectable painful feelings.
3) Addicts in early recovery have a great deal of difficulty regulating medication; fixed dose regimes, not prn’s, are recommended, except for regulation of psychotic symptoms.
4) In clinical situations where the psychiatric diagnosis and/or the severity of the substance disorder may be unclear, psychotropic medication may be used to treat presumptive diagnoses as part of a strategy to facilitate engagement in treatment and the creation of contingency contracts to promote abstinence.
d. Diagnose and treat less serious psychiatric disorders (e.g., affective, anxiety, trauma-related, attentional, and/or personality disorders that are not serious or disabling) that may emerge once sobriety is established.
1) Once a disorder and an efficacious treatment regime for that disorder have been established, it is recommended to maintain that treatment regime even if substance use recurs.
2) In patients with active substance dependence, it is not recommended to initiate medication for newly diagnosed non-serious disorders while patients are actively using; it is usually impossible to make an accurate diagnosis and effectively monitor treatment.
3) In patients with substance dependence in very early recovery, however, nonaddictive medication for treatment of presumptive primary non-serious psychiatric disorders may be initiated, if there is reasonable indication that such a disorder might be present.
4) It is not recommended to establish arbitrary sobriety time periods for initiation of medication. At times, it may be appropriate to initiate psychotropic medication for non-psychotic disorders in the latter stages of detoxification; at other times, it may be appropriate to wait a few weeks, or even longer. With the emergence of newer medications (e.g., SSRI’s) with more benign side effect profiles, there is little evidence that prescription of these medications inhibits recovery from substance dependence, and some evidence that such medication may in fact promote successful abstinence.
5) Prescribers need to carefully consider the risks of prescribing potentially addictive medications (Schedule II-IV substances; non-specific sedatives, such as antihistamines, etc.) beyond the detoxification period. Continuing prescription of these medications should generally be avoided for patients with known substance dependence (active or remitted). On the other hand, they should not be withheld for selected patients with well-established abstinence who demonstrate specific beneficial responses to them without signs of misuse, merely because of a history of addiction. However, consideration of continuing prescription of potentially addictive medications for individuals with diagnosed substance dependence is an indication for both (a) careful discussion of risks and benefits with the patient (and, where indicated, the family) and (b) documentation of expert consultation or peer review with more experienced addiction prescribers if possible.
6) For patients with histories of addiction who present for treatment on already established regimes of addictive medication (e.g., benzodiazepines), prescribers should establish an initial treatment contract that connects continued prescription with continued abstinence. In the event of relapse, the prescriber can work with the patient over time to titrate gradual reduction of the benzodiazepine with continued opportunities to establish and maintain abstinence. If it becomes clear that abstinence cannot be maintained, then taper and discontinuation of the benzodiazepines is indicated. A recommended tapering strategy is to switch the patient to equivalent dosing of Phenobarbital, add carbamazepine at a therapeutic dose (valproate or gabapentin may also be used), and then taper the Phenobarbital over 7-10 days.
C. Diagnosis-Specific Recommendations
1.
1. Schizophrenic
Disorders: Individuals with active
comorbid substance disorder may benefit from addition of atypical
neuroleptics. Initial studies indicate
that clozapine, in particular, may have direct effect on reduction of substance
abuse, in addition to improvement of substance reduction skills through
reduction in positive and negative symptoms.(Albanese et al, 1994; Zimmet et
al, 2000)
2.
2. Bipolar
Disorders: Many individuals with co-occurring substance use disorder appear
to respond preferentially to second and third generation mood stabilizers, such
as valproate and lamotrigine. This is likely to be more due to better efficacy
with rapid cycling and atypical mood disorders, as well as broader efficacy
with regard to impulsivity, anger, PTSD, and anxiety symptoms, rather than due
to a direct effect on substance disorder. (Brady, 1995) Addition of second line
mood stabilizers such as gabapentin and topiramate may also be useful. A significant population of individuals,
however, will still respond best to lithium.
3.
3. Depressive
Disorders: No particular category of antidepressant is specifically
recommended or contraindicated, although tricyclics are more difficult to use
and more sedating. There is data that
serotoninergic medication may be helpful in certain addicted individuals,
particularly those with early-onset alcoholism. Venlafaxine and nefazodone may
have more anti-anxiety benefit than conventional SSRIs.
4.
4. Anxiety
Disorders: Recommendations on how to use benzodiazepines for individuals
with addiction have been discussed in the previous section. Medication strategies for panic disorder are
otherwise no different than for individuals without substance use disorders.
For generalized anxiety, recommendations may include clonidine or guanfacine;
venlafaxine, nefazodone, SSRIs, etc.; gabapentin, valproate, topiramate (PTSD
symptoms especially); atypical neuroleptics.
Buspirone can be effective, but it takes longer to work (months) in
higher doses (over 60 mg usually) in individuals with histories of addiction
and/or benzodiazepine use. (Tolefson et al)
5.
5. Attentional
Disorders: Bupropion is often
recommended as the first medication in early sobriety (Wilens et al, 2001),
proceeding to SSRIs and/or tricyclics.
Ordinarily, sobriety should be well-established before initiation of
stimulants. Data in both adolescents and
adults clearly support, however, the effectiveness of stimulants, when taken
properly in individuals with clearly diagnosed ADHD, in improving outcome for
both ADHD and substance disorder.
6.
6. Addictive
Disorders: Although medication
strategies for treatment of addiction, including opiate maintenance therapy,
have not been extensively studied in mentally ill populations, there is no
evidence to indicate they are differentially effective in those populations
compared to non-mentally ill populations.
A few studies have demonstrated effectiveness of tightly monitored
disulfiram in severely mentally ill alcoholics, when combined with other
substance treatments. (Mueser et al, in press.) Naltrexone, acamprosate, etc.
are all apparently effective in mentally ill populations when otherwise
indicated. Use of these interventions
should be restricted to motivated individuals participating in
abstinence-oriented treatment, as an ancillary tool to support recovery. Within such populations, there is not yet
clear data to determine who should be treated with psychopharmacologic
interventions, and at what point in the treatment process.
VII. Outcome Measures
A. Overview Outcome for individuals with co-occurring disorders needs to be individualized, in accordance with a range of variables that specify treatment interventions and programs for particular subpopulations (see below). These variables include:
1. Subtype of co-occurring disorder
.a. Serious mental illness (SMI) + substance dependence
.b. SMI + substance abuse
.c. Substance dependence + non-SMI psychiatric disorder
.d. Substance abuse + non-SMI psychiatric symptoms
1.
2. Seriousness of
baseline psychiatric disability
2.
3. Extent of
substance use, and associated problems
3.
4. Specific
psychiatric and substance diagnoses
.5. Behavioral or medical risk/ involvement in other
systems
.a. Homelessness
.b. Criminal behavior/violence
.c. Medical involvement (e.g., STD)
.d. Familial disruption/ child neglect or abuse
1.
6. Stage of
treatment/stage of change
2.
7. Intensity of
service utilization Outcome must also be categorized as long term,
defining the ultimate outcome of a continuing course of treatment with multiple
interventions, versus short term, defining the expected outcome of a
particular program or episode of care.
Finally, there are multiple dimensions of outcome, and the selection of which dimensions to measure depends on the variables listed above. These dimensions are enumerated in the following sections.
B. Improved Outcome of Psychiatric Illness Improved psychiatric outcome is measured by reduction in symptomatology, increased functionality and stability, identification and attainment of recovery goals, reduction in high end service utilization, and improved quality of life.
For individuals with co-occurring psychiatric and substance disorders (ICOPSD), psychiatric outcomes are defined by the desired outcomes specified in the service planning guidelines for each psychiatric diagnosis.
C. Improved Outcome of Substance Disorder
1. Long-term outcome:
a. For
individuals with substance dependence: sustained abstinence, increased
functional capacity, and increased subjective experience of recovery and
serenity.
(N.B. For ICOPSD
in methadone maintenance treatment, desired outcomes regarding substance use,
and continuation of methadone, are the same as for MMT in general.)
.b. For individuals with serious mental illness and
substance abuse: sustained non-harmful use (abstinence or occasional (less often
than weekly) use of mild substances not to intoxication) and elimination of
substance-related psychiatric symptom exacerbations.
.c. For individuals with substance abuse and
non-serious psychiatric symptoms: sustained non-harmful use defined by
elimination of substance-related psychiatric symptoms or symptom exacerbations.
2. Short-term outcomes: dependent on specific program and stage of treatment.
.a. Acute stabilization: safe
detoxification or sobering up, plus safe stabilization of substance-induced or
substance-exacerbated psychiatric symptoms or disorders, plus referral to
continuing interventions for motivational enhancement and/or prolonged
stabilization of each disorder.
.b. Motivational enhancement: treatment engagement and progress through stages of
change.
.c. Active treatment for substance abuse:
incremental small step changes in substance use patterns in order to
achieve reduction in harm with minimum change.
The pattern of use that is non-harmful is defined by successive trials
in relation to the severity of psychiatric disability and symptoms.
.d. Active treatment for substance dependence: commitment
to abstinence and acquisition of skills and supports to maintain abstinence at
the next level of care.
.e. Relapse prevention:
maintenance of abstinence
or non-harmful use patterns through appropriate use of recovery supports and
specific relapse prevention skills.
.f. Rehabilitation and recovery: development
of new skills and functional abilities to manage feelings and situations, to
improve self-concept, serenity, and self-esteem, as stability continues.
D. Stage of Change
1.
1. For
individuals who are engaged in treatment for psychiatric disorders, but are
pre-motivational regarding substance use: initial treatment outcome is defined
by progress through stages of change or stages of treatment, as measured by
Stages of Treatment Scale (McHugo et al, 1995) for SMI, Readiness to Change
Scale, etc. Expected outcomes for
individuals with SMI who are pre-motivational (in the “engagement”
phase), based on the work of Drake et al, are that approximately 80% will move
through one stage of treatment in six months.
2.
2. For
individuals who are not engaged in treatment for psychiatric disorders, and
have co-occurring substance disorder: outcome can be defined by progress
through stages of change regarding psychiatric treatment.
E. Reduction in Service Utilization
Interventions targeted to high service utilizers (e.g. intensive case management), often in managed care systems, will have the expected short-term outcome of reducing more intensive service utilization (e.g., hospitalization, detoxification) and increasing ambulatory contact. Evidence-based best practices targeting very high utilizers have achieved dramatic reductions within one year.
F. Harm Reduction and/or Improved Functioning and Stability
1.
1. In the context
of motivational enhancement interventions: individualized harm
reduction goals can be identified as short-term outcome targets.
2.
2. In the context
of general functioning and involvement in other systems, harm reduction
outcomes can include increased housing stability and reduced homelessness;
reduction in arrest, incarceration, and/or criminal activity; reduction in
abuse, neglect, and family disruption; increased medical stability and
treatment adherence (e.g. for HIV regime); reduction in sexual risk behaviors;
increased job stability and/or financial stability (e.g., reduction in level of
payeeship supervision); increased socialization with healthy peers; and
increased mental health treatment adherence and reduction of prescription drug
misuse.
3.
3. Achievement of
harm reduction outcomes may often occur long before abstinence (or even full
non-harmful use) is achieved.
Treatment Matching Paradigm:
Subtype of Dual Disorder by Phase of Treatment
Quadrant
I: Low Severity MI/ Low Severity SA
Examples
45-year-old married man presents with complaints of
depression, anxiety, increased alcohol use, and insomnia, in association with
marital stress, and increased job pressure.
23-year-old single female graduate student reports
increasing anxiety and panic attacks.
She is a regular marijuana user, and is also under considerable stress
due to financial and academic pressures.
Continuity Interventions
1.
1. Integrated longitudinal assessment,
possibly extending over several sessions, to establish possible diagnosis and
formulation.
2.
2. Intervention in outpatient clinic
setting, type of clinic depending on type of initial presentation (MH vs. SA).
3.
3. Involvement of collaterals in
assessment process.
4.
4. Stage-specific interventions as
indicated for each disorder, while ongoing assessment and reformulation
continue.
Stage- and Phase-Specific Interventions
Acute Stabilization
1.
1. Outpatient setting only.
2.
2. Discontinuation of substance use via
outpatient contract.
3.
3. Initiation of medication as indicated
for possible psychiatric disorders.
4.
4. Counseling interventions for stress
management and problem-solving.
5.
5. Modification of interventions as
indicated for individuals with personality disorders.
Motivational Enhancement
1.
1. Application of motivational enhancement
strategies in outpatient counseling, as part of
assessment and intervention.
2.
2. Involvement of collaterals in the
motivational process.
3.
3. Group interventions not usually used.
Active Treatment/Relapse Prevention
1.
1. Identify cognitive and behavioral
strategies required to address substance use difficulties.
2.
2. Outpatient substance abuse group may be
indicated.
3.
3. If criteria met for MI independently of
substance use, initiate or continue appropriate medication.
4.
4. Individual, group, and/or family
counseling to address problematic issues or stresses.
Quadrant II: SPMI + Substance Abuse
Examples
39-year-old
man with schizophrenia, living in a community residential program, who drinks a
six-pack of beer on the weekend, when he has access to it. He also uses marijuana and cocaine
occasionally. When he uses substances,
he sometimes becomes more aggressive and loud, but he reports he enjoys using
and wishes he could do it more often.
25-year-old woman with bipolar disorder and PTSD,
living with her mother, and her two children, attending a mental health day
treatment program, and receiving case management services, who drinks alcohol
excessively during periods of hypomania, but not at other times, feeling that
she is entitled to “have a good time” when she feels a bit high,
since most of the time she feels depressed.
Continuity Interventions
1.
1. Continuing case management with an
individual clinician, case management team, or ACT team, depending on intensity
of need.
2.
2. Ongoing responsibility of mental health
agency/system.
3.
3. Unconditional support, access to crisis
intervention, social support, psychosocial rehabilitation/day treatment, and
housing support commensurate with disability.
4.
4. Continued medication, regardless of
continuing substance use.
5.
5. Development of ongoing treatment plan,
balancing care and support with structured expectation and contingencies, while
maintaining continuity.
6.
6. Stage-specific interventions as
indicated.
Stage- and Phase-Specific Interventions
Acute
Stabilization
1.
1. For severe MI decompensation, DDC
inpatient unit.
2.
2. For substance use stabilization, no
detox needed.
3.
3. For substance related symptomatic
exacerbation of MI, without severe decompensation, DDC psychiatric crisis
stabilization bed.
Motivational
Enhancement
1.
1. Individual motivational interviewing,
assuming role of dual recovery companion.
2.
2. Encourage participation in
pre-motivational and persuasion groups.
3.
3. Involve families and other collaterals
to support the motivational process and to promote
interventions.
4.
4. Promote harm reduction interventions
during the motivational process.
5.
5. Develop contracts and behavioral plans
to promote contingency based learning, using payeeships and other available
contingencies.
6.
6. Utilize negative consequences and
adverse outcomes in a supportive context to promote learning and encourage
change.
7.
7. Use best psychotropic medication
available, including clozapine. Certain
medication changes can be contingent upon reduced substance use.
8.
8. Wet housing and damp housing supports
9.
9. Individualized placement and support
for vocational rehabilitation.
Active Treatment
1.
1. Continuing medication for mental
illness, along with appropriate treatment supports: individual therapy, group therapy, day
treatment/psychosocial rehabilitation, housing support, case management, etc.
2.
2. Emphasize building strengths and skills
(including substance reduction skills) to promote recovery from mental illness.
3.
3. Cognitive-behavioral skills training
(appropriate for level of psychiatric disability) to promote substance
reduction and elimination, in individual and group settings integrated into
mental health treatment.
4.
4. Skills training may be integrated into
day treatment or psychosocial rehabilitation program.
5.
5. Abstinence is recommended goal, but
appropriate outcome can be non-harmful use (e.g., alcohol less than weekly, not
to intoxication; no use of hallucinogens or amphetamines)
6.
6. May benefit from dry or sober housing,
or damp housing with active treatment focus.
7.
7. AA/NA/DRA/DTR optional; addiction
treatment referrals NOT appropriate.
Recovery/Rehabilitation/Relapse
Prevention
1.
1. Continued recovery and rehabilitation
programming re: psychiatric disability.
2.
2. Ongoing relapse prevention groups, peer
supports, and other sobriety supports integrated into mental health settings.
3.
3. AA/NA/DRA/DTR optional, according to consumer preference.
Quadrant III: Low Severity Psychiatric Disorder, High
Severity Substance Disorder (Addiction)
Examples
32-year-old woman with severe crack cocaine
dependence, working as prostitute, children under custody of protective
services, with lifelong and ongoing trauma, HIV positive, suffering symptoms of
posttraumatic stress disorder and dysthymia, particularly when not using
crack. She is currently on probation,
and has been referred for mandatory addiction treatment.
48-year-old
man with alcohol dependence and opiate dependence who has been experiencing
progressive anxiety and panic attacks over the past three years. He reports these are relieved when he drinks,
yet keep getting worse.
Continuity Interventions
1.
1. Outpatient counseling, in addiction
treatment or mental health treatment setting, depending on level of dual
diagnosis capability and consumer preference.
Primary counselor coordinates and integrates interventions for each
problem.
2.
2. Intervention can be integrated with
systems in which external contingencies are present, such as corrections,
protective services.
3.
3. If patient has established psychiatric
disorder requiring medication, continuing psychopharmacology integrated as
well.
Stage- and Phase-Specific Interventions
Acute
Stabilization
1.
1. For substance exacerbations, may need
DDC detox.
2.
2. For substance exacerbations accompanied
by significant psychiatric impairment (suicidal impulses, overwhelming panic),
may need DDE detox or DDC psychiatric crisis bed, depending on need for medical
treatment for withdrawal, DDC/DDE inpatient psych if the appropriate lesser
level of care is not available.
Motivational
Enhancement
1.
1. Individual or group motivational
enhancement interventions, to promote either recognition of addiction or more
consistent adherence with treatment recommendations.
2.
2. Involvement of families,
collaterals (e.g., probation officer),
etc. in development of contingency strategies to promote motivation (e.g., drug
court).
3.
3. Harm reduction strategies can focus on
improvement of medical outcomes, avoidance of jail, etc.
4.
4. Initial medication evaluation may be made
contingent upon brief initiation of abstinence (one week); If medication is
already in use, medication reassessment can be made contingent.
Active
Treatment
1.
1. Addiction treatment in DDC setting
(occasionally symptomatic acuity will require DDE setting), with level of care
determined by ASAM PPC 2R.
2.
2.
Specific mental health counseling to address psychiatric
issues and disorders.
3.
3. Maintain non-addictive psychotropic
medication as indicated.
4.
4. Modify addiction treatment
interventions to accommodate mental health issues (e.g., trauma issues,
learning impairments).
5.
5. Integrate attention to other primary
problems: medical care, vocational
rehab, parenting skills, and coordinate with other treaters (e.g., PCP) if
present.
Relapse Prevention/Recovery
1.
1. Continued addiction recovery program,
utilizing any available addiction treatment tools, including AA/NA, and, if
available, DTR/DRA.
2.
2. Continued integrated outpatient
counseling addressing both disorders.
3.
3. DDC sober living setting if indicated.
4.
4. Continued psychopharmacology, with
regular review to determine if medication needs change, and/or any symptoms
improve or worsen as sobriety proceeds.
5.
5. Ongoing attention to medical care,
vocational rehab, parenting skills, etc.
Quadrant 4A: High Severity Psych (SPMI) + High Severity
Substance (Addiction)
Examples
27-year-old woman with paranoid schizophrenia and
crack cocaine dependence, homeless, living on the streets, prostituting and
panhandling to support herself.
35-year-old
man with schizoaffective disorder and alcohol dependence, living in a group
home, attending day treatment, with frequent episodes of intoxication and
symptom exacerbation, which are not dangerous, but are disruptive to the group
home. He has had multiple detoxes and
alcohol treatment episodes, but has maintained sobriety only for brief periods.
Continuity Interventions
1.
1. Continuing case management with an
individual clinician, case management team, or ACT/CTT team, depending on the
intensity of need. DDE level of
competency may be indicated.
2.
2. Ongoing, responsibility of mental
health agency/system
3.
3. Unconditional support, access to crisis
intervention, social support, psychosocial rehabilitation/day treatment, and
housing support commensurate with disability.
4.
4. Continued non-addictive medication,
regardless of continuing substance use.
5.
5. Development of ongoing treatment plan,
balancing care and support with structured expectation and contingencies, while
maintaining continuity.
6.
6. Stage-specific interventions for
addiction, as indicated.
7.
7. Continued encouragement of
participation in abstinence oriented addiction recovery program, but not
mandating abstinence as a condition of treatment until client is in appropriate
stage of change.
Stage- and Phase-Specific Interventions
Acute
Stabilization
1.
1. For severe MI decompensation, DDC or
DDE inpatient unit, depending on willingness to address addiction
2.
2. For substance stabilization only, while
MI at baseline, DDC or DDE detox depending on level of MI disability at
baseline. In some systems, DDE psych
inpatient will be the only level of care that can provide this service for
SPMI.
3.
3. For substance related symptomatic
exacerbation of MI, without severe decompensation or need for medical detox
(e.g., binge drinking), DDC or DDE psychiatric crisis bed.
Motivational
Enhancement
1.
1. Individual motivational interviewing,
assuming role of dual recovery companion.
2.
2. Encourage participation in
pre-motivational and persuasion groups.
3.
3. Involve families and other collaterals
to support the motivational process and to promote
interventions.
4.
4. Promote harm reduction interventions
during the motivational process.
5.
5. Develop contracts and behavioral plans
to promote contingency based learning, using payeeships and other available
contingencies, positive and negative.
6.
6. Utilize negative consequences and
adverse outcomes in a supportive context to promote learning and change.
7.
7. Use best psychotropic medication
available, including clozapine. Certain
medication changes can be contingent on reduced substance use.
8.
8. Wet housing and damp housing supports
9.
9. Individualized placement and support
for vocational rehabilitation.
10.
10.
Unsuccessful efforts to engage in active treatment for substance abuse may be
part of the motivational process.
11.
11.
Utilize indications of lack of control of substance use to demonstrate presence
of addiction (vs. abuse) and encourage recognition of need for abstinence
rather than controlled use.
Active
Treatment
1.
1. Continuing medication for mental
illness, along with appropriate treatment supports: individual therapy, group therapy, day
treatment/psychosocial rehabilitation, housing support, case management, etc.
2.
2. Emphasize building strengths and skills
(including relapse prevention and abstinence maintenance skills) to promote recovery from mental
illness and addiction.
3.
3. Skills training appropriate for level
of psychiatric disability integrated into day treatment, psychosocial
rehabilitation, and/or residential programming.
4.
4. Continued contingent reinforcement
strategies to promote treatment adherence and abstinence.
5.
5. Referral to DDE addiction treatment, at
intensive outpatient or residential level of care, may be appropriate, with
continuing integrated mental health case management maintained.
6.
6. Addiction treatment interventions in
all settings focus on specific skills training for developing recovery support,
including attendance at 12 Step Meetings, as well as cognitive-behavioral
relapse prevention skills.
7.
7. Abstinence is consistently recommended
goal, but slips are not regarded as failures, so much as learning
opportunities. Positive outcome can also
be measured as days sober, reduction in total use, etc.
8.
8. Medication for treatment of addiction,
including methadone maintenance, may be appropriate as indicated.
9.
9. May benefit from dry or sober housing,
either group home or supported housing model.
10.
10.
AA /NA/DRA/DTR strongly recommended on a daily basis.
11.
11.
Integrated attention to other primary problems (e.g., medical care, vocational
rehabilitation.)
Recovery/Rehabilitation/Relapse
Prevention
1.
1. Continued dual recovery and
rehabilitation programming
2.
2. Ongoing relapse prevention groups, peer
supports, and other sobriety supports integrated into mental health settings.
3.
3. Continued involvement in addiction
recovery programming, at consumer’s level of capacity, including AA, NA,
DRA, DTR.
4.
4. Utilization of recovery concepts from
each disorder to promote recovery and growth from the other disorder (e.g.
“One day at a time.”)
Quadrant IVB: High Severity Psychiatric Disturbance
(non-SPMI) and High Severity Substance Disorder (Addiction)
Examples
43-year-old woman with severe alcohol dependence,
borderline personality disorder, and post traumatic stress disorder, with a
history of multiple detox admissions for alcohol, as well as multiple
psychiatric hospitalizations and emergency room visits for suicidal behavior.
29-year-old
man with polysubstance dependence, attention deficit disorder, atypical mood
disorder, explosive disorder, personality disorder, who is on probation for
recurrent violent behavior and criminal assault, and who has a history of
psychiatric admissions for explosive behavior, homicidal impulses, and paranoid
thinking, particularly when intoxicated.
He lives with his girl friend, and works intermittently as a painter.
Continuity Interventions
1.
1. Continuing case management with an
individual clinician, case management team, or ACT team (or equivalent),
depending on intensity of need.
2.
2. Ongoing responsibility may be assigned
to mental health agency, substance agency, or specialized program related to
specific issues like court involvement, parenting issues, HIV status, etc.
3.
3. May not be appropriate for programs
designed for individuals with psychotic disorders.
4.
4. Unconditional support, access to crisis
intervention, social support, rehabilitative interventions, and housing support
commensurate with disability.
5.
5. Continued non-addictive medication for
any known mental illness, regardless of continuing substance use.
6.
6. Development of ongoing treatment plan,
balancing care and support with structured expectation and contingencies, while
maintaining continuity.
7.
7. Stage-specific interventions as
indicated, integrating contingencies from other systems (e.g., legal,
protective services) where appropriate.
Stage- and Phase-Specific Interventions
Acute
Stabilization
1.
1. For severe decompensation of SA with
active MI symptoms, DDE inpatient psych unit or DDE detox, depending on
severity of mental health symptoms.
2.
2. For less severe exacerbations of
substance use and psychiatric symptoms, DDC/DDE crisis stabilization bed.
Motivational
Enhancement
1.
1. Individual or group motivational
enhancement interventions, to promote recognition of addiction and psychiatric disturbance,
and more consistent adherence with treatment recommendations for either
disorder.
2.
2. Involvement of families, collaterals
(probation officer), etc. in development of contingency strategies to promote
motivation.
3.
3. Harm reduction strategies to focus on
improvement of mental health outcomes, medical status, avoidance of jail, etc.
4.
4. Provision of mental health intervention
in the context of empathic, hopeful, integrated relationships can promote
willingness to address substance related issues.
5.
5. Medication reassessment may be made
contingent upon initiation of abstinence oriented treatment efforts.
Active
Treatment
1.
1. Maintain integrated unconditional case
management
2.
2. to coordinate care.
3.
3. Addiction treatment in a DDE setting,
with level of care determined by ASAM PPC 2R.
For individuals with very severe behavioral disturbances at baseline,
treatment may occur in DDE mental health settings (day treatment/psychosocial
rehabilitation).
4.
4. Integrated primary treatment
relationship to apply simultaneous interventions to both disorders, in the
context of addiction recovery efforts.
5.
5. Mental health counseling, medication,
and cognitive-behavioral skills training to address issues like trauma, self-harm,
and anger.
6.
6. Modified addiction treatment
interventions to teach specific recovery skills within the context of
limitations imposed by mental health issues (trauma history, impulsivity,
learning disability).
7.
7. Continued contingency reinforcement
strategies to promote treatment adherence and abstinence, as indicated.
8.
8. Medication for treatment of addiction,
including methadone maintenance, may be indicated.
9.
9. DDE residential treatment, halfway
house, or sober housing may be indicated.
10.
10.
Integrate attention to other primary problems:
medical care, vocational
rehab, parenting skills, legal issues, and coordinate care with other primary
treaters if present.
Relapse
Prevention/Rehabilitation/Recovery
1.
1. Continued involvement in dual recovery
and rehabilitative programming.
2.
2. Addiction recovery supports utilizing
all available tools, including medication, sober housing, and DRA/DTR.
3.
3. Continued mental health support and
rehabilitation, including individual, group, and family counseling, as well as
medication.
4.
4. Continued integrated outpatient
counseling and case management regarding both disorders.
5.
5. Regular psychopharmacologic review to
determine if medication needs change, and/or any symptoms improve or worsen as
sobriety proceeds.
6.
6. Ongoing attention to medical care,
vocational rehab, parenting skills, housing needs, etc.
Kenneth Minkoff, MD
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DUAL DIAGNOSIS VIDEO MATERIALS
Promise of Recovery. Gerald T. Rogers Productions.
800-227-9100.
Double Trouble. Gerald T. Rogers Productions.
Out of the Tunnel; Into the Light.
Hazelden. 800-328-9000.
12 Steps & Dual Disorders. Hazelden.
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Substance Use/Psychiatric Symptomatology Table
The psychiatric symptomology table is a guideline
only and is not to be used as a substitute for professional clinical judgment.
|
Category
of Substance |
Type of
symptoms seen with use pattern |
|
Resolution Period Persistence of symptoms/impairment
past this period is sufficient for psychiatric diagnosis. |
|
||||
|
|
Mild Use
Uses no more
than 1-2 times/wk; does not use to severe intoxication; no observable
impairment. |
Moderate
Use Uses
regularly, but not usually to severe intoxication; and/or episodes of severe
intoxication occur, but once/wk or less; and/or presence of negative
out-comes (hangover, money loss), but not severe. |
Heavy
Use Uses
regularly (more than 2x/wk) to point of severe intoxication; significant
impairment, negative outcomes noted, such as ER visits, fights, can’t
pay rent, medical complications of substance dependence (liver disease,
hemorrhage, etc.) |
|||||
|
Alcohol
Benzodiazepines Sedatives |
None |
Anxiety,
depression, not dysfunctional |
Hallucinosis,
not psychosis Patient
usually reports hearing “voices”, content non-bizarre, good
reality testing, no thought disorder or bizarre behavior. |
30 days |
|
|||
|
|
|
|
Anxiety
Mood instability Patients
occasionally can develop a first true manic episode during withdrawal Personality disorder |
30-90 days Most severe symptoms will resolve
(if they do) within 30 days - disability/fragility may persist longer. |
|
|||
|
Stimulants
(cocaine,
methamphetamine) |
Mild
anxiety, depression |
Anxiety/panic,
depression, mood instability |
More severe
anxiety & depression Personality disorder symptoms |
30 days
(mild/moderate) 30-90 days (heavy) |
|
|||
|
Paranoid
psychosis |
30 days |
|
||||||
|
Hallucinogens
(Mescaline, LSD,
peyote) |
Anxiety
& depression |
Anxiety
& depression |
Psychosis |
Usually 30
days For heavy
marijuana users, persistent anxiety, panic attacks, and mood/thought
alteration may last up to 90 days. |
|
|||
|
Occasional
psychosis or severe panic A single episode of hallucinogen use can occasionally precipitate
psychosis or severe panic. This may
also happen with methamphetamine. |
Flashbacks/
hallucinotic experiences Sometimes, psychosis, panic, mood instability |
Severe
panic, mood instability |
Up to 90
days |
|
||||
Substance Use/Psychiatric Symptomatology Table (continued)
The psychiatric symptomology table is a guideline only and is not to be
used as a substitute for professional clinical judgment.
|
Category
of Substance |
Type of
symptoms seen with use pattern |
|
Resolution Period |
|
||||
|
|
|
|
Persistence
of |
|
||||
|
|
|
|
|
|||||
|
|
Mild Use
Uses no more
than 1-2 times/wk; does not use to severe intoxication; no observable
impairment. |
Moderate
Use Uses
regularly, but not usually to severe intoxication; and/or episodes of severe
intoxication occur, but once/wk or less; and/or presence of negative
out-comes (hangover, money loss), but not severe. |
Heavy
Use Uses
regularly (more than 2x/wk) to point of severe intoxication; significant
impairment, negative outcomes noted, such as ER visits, fights, can’t
pay rent, medical complications of substance dependence (liver disease,
hemorrhage, etc.) |
symptoms/impairment
past this period is sufficient for psychiatric diagnosis. |
|
|||
|
Opiates |
None |
Mild-moderate anxiety & depression |
More severe
anxiety & depression, personality disorder symptoms |
60-90 days |
|
|||
|
Occasional
psychotic symptoms, during withdrawal only |
7-10 days |
|
||||||
|
Category
of Substance |
Type of
symptoms seen with use pattern |
|
Resolution Period |
|
||||
|
|
|
|
Persistence
of symptoms/impairment past this period is sufficient for psychiatric
diagnosis. |
|
||||
|
|
Mild Use
Smoking a
single marijuana cigarette 1 - 2 times/wk |
Moderate
Use One or two
marijuana cigarettes 3 -5 times/wk |
Heavy
Use Two or
more marijuana cigarettes daily |
|||||
|
Marijuana
(cannabis sativa) |
None |
Mental
confusion, agitation, feelings of panic |
Acute toxic
psychosis, paranoia, disorientation, severe agitation, |
Moderate -
24 - 72 hours Heavy - 30 to 60 days |
|
|||
|
|
|
|
depersonalization
|
|
|
|||