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