Table of Contents
Chapter 1 --Introduction
Chapter 2 -- Dual Disorders: Concepts
and Definitions
Chapter 3 -- Mental Health And
Addiction Treatment Systems: Phil...
Chapter 4 -- Linkages For Mental
Health and AOD Treatment
Chapter 5 -- Mood Disorders
Chapter 6 -- Anxiety Disorders
Chapter 7 -- Personality Disorders
Chapter 8 -- Psychotic Disorders
Chapter 9 -- Pharmacologic Management
Appendix A -- Bibliography
Appendix B -- Treatment of Patients
With Dual Disorders: Sample ...
Appendix C -- Federal Resource
Panel
Appendix D -- Field Reviewers
Exhibits
This TIP was developed by a multidisciplinary consensus panel that included addiction counselors, social workers, psychologists, psychiatrists, other physicians, nurses, and program administrators with active clinical involvement in the treatment of patients with dual disorders. Consumers also participated on the panel.
This TIP was written principally for addiction treatment staff. However, it contains information and treatment recommendations that can be used by healthcare providers in a variety of treatment settings. For example, it will be useful to people who work in primary care clinics, hospitals, and various mental health settings. In addition, there are recommendations that are targeted to administrators and planners of healthcare services.
A thoughtful attempt has been made to include information that the consensus panel felt was clinically relevant. While many clinical topics are explored in depth, some are only briefly mentioned, and a few are avoided altogether.
It is not the goal of this TIP to provide an exhaustive description of all of the possible issues that relate to the treatment of patients with dual disorders. Rather, the primary goal is to provide treatment recommendations that are practical and useful.
Indeed, the usefulness of this TIP can be enhanced by blending these
recommendations with those of another TIP such as Intensive Outpatient
Treatment for Alcohol and Other Drug (AOD) Abuse.
By doing so, treatment
protocols can be developed which will meet very specific treatment needs.
Chapter 3
-- Mental Health and Addiction Treatment Systems: Philosophical and
Treatment Approach Issue -- describes the similarities, differences,
strengths, and weaknesses of the treatment systems used by patients with
dual disorders: the mental health system, the addiction treatment system,
and the medical system. Similarly, there is a description of treatment
models most frequently used: sequential treatment of each disorder, parallel
treatment of each disorder, and integrated treatment of both disorders.
The chapter includes a discussion of critical treatment issues and general
assessment issues in providing care to patients with dual disorders.
This chapter should be particularly useful for administrators and political
planners who address the potential administrative overlaps and gaps that
exist between the mental health and addiction treatment systems. The semi-outline
format of the chapter will allow planners of services a rapid checkup of
specific areas such as funding and reimbursement, program development,
and case management.
By combining chapters, strategies for treating patients with complex
disorders may be developed. For example, by combining techniques recommended
for the treatment of personality and mood disorders, borderline syndrome
treatment strategies can be developed.
Both content and stylistic approaches vary markedly among these chapters,
reflecting the differences of consensus panel members who composed them.
Since these differences in stylistic approaches may be useful to the reader,
they have been retained.
Addiction treatment program staff are increasingly encountering patients
who require prescribed medications in order to participate in recovery.
For this reason, it is important for clinical staff to have an understanding
of the principle medications used in psychiatry and how they are used.
In addition, agencies that hire a consulting psychiatrist may want to review
with the psychiatrist the prescribing issues raised in this chapter.
A bibliography is provided for further study in Appendix
A. A brief overview of sample cost data for the treatment of dual disorders
is in Appendix
B. It compares three treatment programs on features such as salary
ranges and administrative costs.
There are several possible relationships between AOD use and psychiatric
symptoms and disorders. AODs may induce, worsen, or diminish psychiatric
symptoms, complicating the diagnostic process.
The primary relationships between AOD use and psychiatric symptoms or
disorders are described in the following classification model (Landry
et al., 1991a; Lehman
et al., 1989; Meyer,
1986). All of these possible relationships must be considered during
the screening and assessment process.
For example, patients with anxiety and phobias may fear and resist attending
Alcoholics Anonymous or group meetings. Depressed people may be too unmotivated
and lethargic to participate in treatment. Patients with psychotic or manic
symptoms may exhibit bizarre behavior and poor interpersonal relations
during treatment, especially during group-oriented activities. Such behaviors
may be misinterpreted as signs of treatment resistance or symptoms of addiction
relapse.
The acronym MICA, which represents the phrase mentally ill
chemical abusers, is occasionally used to designate people who have
an AOD disorder and a markedly severe and persistent mental disorder such
as schizophrenia or bipolar disorder. A preferred definition is mentally
ill chemically affected people, since the word affected better
describes their condition and is not pejorative. Other acronyms are also
used: MISA (mentally ill substance abusers), CAMI (chemical
abuse and mental illness), and SAMI (substance abuse and mental
illness).
Common examples of dual disorders include the combinations of major
depression with cocaine addiction, alcohol addiction with panic disorder,
alcoholism and polydrug addiction with schizophrenia, and borderline personality
disorder with episodic polydrug abuse. Although the focus of this volume
is on dual disorders, some patients have more than two disorders, such
as cocaine addiction, personality disorder, and AIDS. The principles that
apply to dual disorders generally apply also to multiple disorders.
The combinations of AOD problems and psychiatric disorders vary along
important dimensions, such as severity, chronicity, disability, and degree
of impairment in functioning. For example, the two disorders may each be
severe or mild, or one may be more severe than the other. Indeed, the severity
of both disorders may change over time. Levels of disability and impairment
in functioning may also vary.
Thus, there is no single combination of dual disorders; in fact, there
is great variability among them. However, patients with similar combinations
of dual disorders are often encountered in certain treatment settings.
For instance, some methadone treatment programs treat a high percentage
of opiate-addicted patients with personality disorders. Patients with schizophrenia
and alcohol addiction are frequently encountered in psychiatric units,
mental health centers, and programs that provide treatment to homeless
patients.
Patients with mental disorders have an increased risk for AOD disorders,
and patients with AOD disorders have an increased risk for mental disorders.
For example, about one-third of patients who have a psychiatric disorder
also experience AOD abuse at some point (Regier
et al., 1990), which is about twice the rate among people without psychiatric
disorders. Also, more than half of the people who use or abuse AODs have
experienced psychiatric symptoms significant enough to fulfill diagnostic
criteria for a psychiatric disorder (Regier
et al., 1990; Ross
et al., 1988), although many of these symptoms may be AOD related and
might not represent an independent condition.
Compared with patients who have a mental health disorder or an AOD use
problem alone, patients with dual disorders often experience more severe
and chronic medical, social, and emotional problems. Because they have
two disorders, they are vulnerable to both AOD relapse and a worsening
of the psychiatric disorder. Further, addiction relapse often leads to
psychiatric decompensation, and worsening of psychiatric problems often
leads to addiction relapse. Thus, relapse prevention must be specially
designed for patients with dual disorders. Compared with patients who have
a single disorder, patients with dual disorders often require longer treatment,
have more crises, and progress more gradually in treatment.
Psychiatric disorders most prevalent among dually diagnosed patients
include mood disorders, anxiety disorders, personality disorders, and psychotic
disorders. Each of these clusters of disorders and symptoms is dealt with
in more detail in separate chapters.
Criteria for AOD abuse hinge on the individual's continued use of a
drug despite his or her knowledge of "persistent or recurrent social, occupational,
psychologic, or physical problems caused or exacerbated by the use of the
[drug]" (American
Psychiatric Association, 1987). Alternately, there can be "recurrent
use in situations in which use is physically hazardous." The DSM-IV draft
continues this emphasis (American
Psychiatric Association, 1993).
Thus, AOD abuse is defined as the use of a psychoactive drug to such
an extent that its effects seriously interfere with health or occupational
and social functioning. AOD abuse may or may not involve physiologic dependence
or tolerance. Importantly, evidence of physiologic dependence and tolerance
is not sufficient for diagnosis of AOD abuse. For example, use of AODs
in weekend binge patterns may not involve physiologic dependence, although
it has adverse effects on a person's life.
The phrase AOD addiction (called "psychoactive substance dependence"
in the DSM-III-R and "substance dependence" in the DSM-IV draft) is an
often progressive process that typically includes the following aspects:
1) compulsion to acquire and use AODs and preoccupation with their acquisition
and use, 2) loss of control over AOD use or AOD-induced behavior, 3) continued
AOD use despite adverse consequences, 4) a tendency toward relapse following
periods of abstinence, and 5) tolerance and/or withdrawal symptoms.
In the DSM-III-R, criteria 1 and 2 deal with loss of control; criterion
3 addresses time involvement; criteria 4 and 5 relate to social dysfunction;
criterion 6 relates to continued use despite adverse consequences;and criteria
7, 8, and 9 relate to the development of tolerance and withdrawal. It is
important to note that tolerance, physiologic dependence, and withdrawal
are neither necessary nor sufficient for the establishment of a diagnosis
of AOD addiction.
The term AOD dependence can be confusing because it has multiple
meanings. The DSM-III-R uses the phrase "psychoactive substance dependence"
to describe the process of addiction, while many pharmacologists use the
term "dependence" exclusively for describing the biologic aspects of physical
tolerance and/or withdrawal. The American Society of Addiction Medicine
describes drug dependence as having two possible components: 1) psychologic
dependence and 2) physical dependence.
Psychologic dependence centers on the user's need of a drug to
reach a level of functioning or feeling of well-being. Because this term
is particularly subjective and almost impossible to quantify, it is of
limited usefulness in making a diagnosis.
Physical dependence refers to the issues of physiologic dependence,
establishment of tolerance, and evidence of an abstinence syndrome or withdrawal
upon cessation of AOD use. In this case, AOD type, volume, and chronicity
are the important variables: Given a certain substance, the higher the
dose and longer the period of consumption, the more likely is the development
of tolerance, dependence, and subsequent withdrawal symptoms. Physical
dependence and tolerance are best understood as two of many possible consequences
(which may or may not include addiction and abuse) of chronic exposure
to psychoactive substances.
Among patients with a psychiatric problem, any AOD use -- whether abuse
or not -- can have adverse consequences. This is especially true for patients
with severe psychiatric disorders and patients who are taking prescribed
medications for psychiatric disorders. For patients with psychiatric disorders,
the infrequent consumption of alcohol can lead to serious problems such
as adverse medication interactions, decreased medication compliance, and
AOD abuse. Screening questions can relate to evidence of any use of alcohol
and other drugs, as well as frequency, dose, and duration.
Medication misuse describes the use of prescription medications
outside of medical supervision or in a manner inconsistent with medical
advice. While medication misuse is not an abuse problem per se, it is a
high-risk behavior that: 1) may or may not involve AOD abuse, 2) may or
may not lead to AOD abuse, 3) may represent medication noncompliance and
promote the reemergence of psychiatric symptoms, and 4) may cause toxic
effects and psychiatric symptoms if it involves overdose.
Thus, some patients may consume medications at higher or lower doses
than recommended or in combination with AODs. Also, certain patients may
respond to prescribed psychoactive medications by developing compulsive
use and loss of control over their use.
Historically, when patients in AOD treatment exhibited vivid and acute
psychiatric symptoms, the symptoms were either: 1) unrecognized, 2) observed
but misdescribed as toxicity or "acting-out behavior," or 3) accurately
identified, prompting the patients to be discharged or referred to a mental
health program. Virtually the same process occurred for patients in mental
health treatment who exhibited vivid and acute symptoms of AOD use disorders.
Mislabeling, rejecting, failing to recognize, or automatically transferring
patients with dual disorders can result in inadequate treatment, with patients
falling between the cracks of treatment systems. The symptoms of psychiatric
and AOD use disorders often fluctuate in intensity and frequency. Current
symptom presentation may reflect a short-term change in the course of long-term
dual disorders. Thus, even when patients receive traditional professional
help, treatment may address only selected aspects of their overall problem
unless treatment is coordinated among services including AOD, mental health,
social, and medical programs.
As a result, the treatment system itself may be a stumbling block for
some people attempting to receive ongoing, appropriate, and comprehensive
treatment for combined psychiatric and AOD use disorders. Thus, treatment
services for patients with dual disorders must be sensitive to both the
individual's and the treatment system's impediments to the initiation and
continuation of treatment.
These mental health personnel work in a variety of settings, using a
variety of theories about the treatment of specific psychiatric disorders.
Different types of mental health professionals (for example, social workers
and MFCCs) have differing perspectives; moreover, practitioners within
a given group often use different approaches.
A major strength of the mental health system is the comprehensive array
of services offered, including counseling, case management, partial hospitalization,
inpatient treatment, vocational rehabilitation, and a variety of residential
programs. The mental health system has a relatively large variety of treatment
settings. These settings are designed to provide treatment services for
patients with acute, subacute, and long-term symptoms. Acute services are
provided by personnel in emergency rooms and hospital units of several
types and by crisis-line personnel, outreach teams, and mental health law
commitment specialists. Subacute services are provided by hospitals, day
treatment programs, mental health center programs, and several types of
individual practitioners. Long-term settings include mental health centers,
residential units, and practitioners' offices. Clinicians vary with regard
to academic degrees, styles, expertise, and training. Another strength
of the mental health system is the growing recognition at all system levels
of the role of case management as a means to individualize and coordinate
services and secure entitlements.
Medication is more often used in psychiatric treatment than in addiction
treatment, especially for severe disorders. Medications used to treat psychiatric
symptoms include psychoactive and nonpsychoactive medications. Psychoactive
medications cause an acute change in mood, thinking, or behavior, such
as sedation, stimulation, or euphoria.
Psychoactive medications (such as benzodiazepines) prescribed to the
average patient with psychiatric problems are generally taken in an appropriate
fashion and pose little or no risk of abuse or addiction. In contrast,
the use of psychoactive medications by patients with a personal or family
history of an AOD use disorder is associated with a high risk of abuse
or addiction.
Some medications used in psychiatry that have mild psychoactive effects
(such as some tricyclic antidepressants with mild sedative effects) appear
to be misused more by patients with an AOD disorder than by others. Thus,
a potential pitfall is prescribing psychoactive medications to a patient
with psychiatric problems without first determining whether the individual
also has an AOD use disorder.
While most clinicians in the mental health system generally have expertise
in a biopsychosocial approach to the identification, diagnosis, and treatment
of psychiatric disorders, some lack similar skills and knowledge about
the specific drugs of abuse, the biopsychosocial processes of abuse and
addiction, and AOD treatment, recovery, and relapse. Similarly, AOD treatment
professionals may have a thorough understanding of AOD abuse treatment
but not psychiatric treatment.
As with mental health treatment, addiction treatment is provided by
a diverse group of practitioners, including physicians, psychiatrists,
psychologists, certified addiction counselors, MFCCs, and other therapists,
counselors, and recovering paraprofessionals. There can be a wide difference
in experience, expertise, and knowledge among these diverse providers.
As with mental health treatment, most States have public and private AOD
treatment systems.
The strengths of addiction treatment services include the multidisciplinary
team approach with a biopsychosocial emphasis, and an understanding of
the addictive process combined with knowledge of the drugs of abuse and
the 12-step programs. In typical addiction treatment, medications are used
to treat the complications of addiction, such as overdose and withdrawal.
However, few medications that directly treat or interrupt the addictive
process, such as disulfiram and naltrexone, have been identified or regularly
used. Maintenance medications such as methadone are crucial for certain
patients. However, most addiction treatment professionals attempt to eliminate
patients' use of all drugs.
An important adjunct to addiction treatment services is the massive
system of consumer-developed groups, such as the 12-step program of Alcoholics
Anonymous (AA). Participants in AA and other self-help groups (Narcotics
Anonymous [NA], Cocaine Anonymous [CA], etc.) can provide needed support
and encouragement for patients in treatment. Importantly, these services
are widespread nationally and internationally. While self-help programs
are not considered treatment per se, they are integral adjuncts to professional
treatment services.
However, patients in self-help groups may give others inappropriate
advice regarding medication compliance, based on personal experience, fears
of medication, or incomplete knowledge about the role of medication in
dual disorders. In many urban areas, there are specialized 12-step groups
for people with dual disorders. In these so-called "Double Trouble" meetings,
medication compliance is a part of "working the program."
However, physicians -- especially primary care physicians -- are able
to devote very little time to each patient. Pressured for time, these physicians
may prescribe such psychiatric medications as antidepressants or anxiolytics
or medication such as disulfiram or naltrexone as a primary approach, rather
than as an adjunctive approach. Indeed, primary care physicians are the
largest single prescriber of antianxiety medications. Some of these medications,
such as the benzodiazepines, are psychoactive and can be abused.
Also, physicians and nurses have historically been trained to focus
on the medical consequences of addiction, such as withdrawal, overdose,
or hepatitis, without assessing, treating, or actively referring the individual
for treatment of the addiction itself. The role of physicians with regard
to addiction is changing through the leadership of national organizations
such as the American Society of Addiction Medicine, the American Academy
of Psychiatrists on Alcohol and Addiction, and the Association of Medical
Education and Research on Substance Abuse. Similar groups exist for nurses
and allied health care professionals. Such groups can provide medical professionals
with important information and education about the biopsychosocial nature
of addiction and treatment, especially regarding patients with dual disorders.
The case management model identifies individual limitations, deficits,
and strengths and aggressively attempts to provide patients with what they
need. When a patient rejects professional assistance, the case manager
assumes the responsibility for finding a different way to get the individual
to accept assistance. The case manager may minimize the negative consequences
to the individual in order to engage or maintain the patient in treatment.
This activity might be seen as "enabling" by traditional addiction treatment
personnel.
In contrast, the addiction treatment system focuses on individual responsibility,
including the responsibility of accepting help. Motivation for recovery
is enhanced through confrontation of the adverse consequences of addiction.
Further, addiction intervention and treatment involve diminishing the individual's
denial about the presence and severity of the addiction through direct
but therapeutic confrontation of examples of addiction-related behaviors.
Thus, traditionally, patients in the addiction treatment system who did
not want help or could not tolerate confrontation might not get help. Mental
health personnel might regard this situation as an abandonment of the most
needy. More recently, the addiction treatment system has been developing
case management models to better address treatment-resistant patients.
Treatment of patients with dual disorders must blend both mental health
and AOD treatment models, with each applied at appropriate times and in
appropriate situations according to patients' needs. There should be a
balance between clinician and patient acceptance of responsibility for
treatment and recovery from dual disorders.
For example, in AOD treatment, clinical staff and fellow patients often
aggressively confront patients who deny that they have an AOD problem or
who minimize the severity of their problem. However, treatment of individuals
with dual disorders first requires innovative approaches to engage them
in treatment as a prerequisite to confrontation. The role of confrontation
may need to be substantially modified, particularly in the treatment of
disorganized or psychotic patients, who may tolerate confrontation only
in later stages of treatment (when their symptoms are stable and they are
engaged in the treatment process).
In addiction treatment, the focus is often on the "here and now," while
in mental health treatment, the focus is often on past developmental issues.
Mental health practitioners may identify AOD abuse as a symptom of a prior
trauma rather than an illness in its own right. The focus of treatment
may be on the developmental issues, with the assumption that the AOD use
disorder will improve automatically once these issues are treated. Inadvertently,
the mental health therapist can enable AOD use to continue.
For some patients with dual disorders, requiring abstinence as a condition
of entering treatment may hinder or discourage engagement in the treatment
process. For these patients, abstinence may be redefined as a goal, with
encouragement provided for incremental steps in the reduction of amount
and frequency of drug use. For example, patients who experience homelessness
and housing instability likely do not live in drug-free environments. For
such patients, it may be unrealistic to mandate abstinence as a requirement
for treatment. Exhibit
3-1 describes some of the treatment strategy differences for managing
patients in mental health, addiction, and dual disorder treatment approaches.
The term sequential treatment describes the serial or nonsimultaneous
participation in both mental health and addiction treatment settings. For
example, a person with dual disorders may receive treatment at a community
mental health center program during occasional periods of depression and
attend a local AOD treatment program following infrequent alcoholic binges.
Systems that have developed serial treatment approaches generally incorporate
one of the above orientations toward the treatment of patients with dual
disorders.
There are advantages and disadvantages in sequential, parallel, and
integrated treatment approaches. Differences in dual disorder combinations,
symptom severity, and degree of impairment greatly affect the appropriateness
of a treatment model for a specific individual. For example, sequential
and parallel treatment may be most appropriate for patients who have a
very severe problem with one disorder, but a mild problem with the other.
However, patients with dual disorders who obtain treatment from two separate
systems frequently receive conflicting therapeutic messages; in addition,
financial coverage and even confidentiality laws vary between the two systems.
Engagement begins with efforts that are designed to enlist people into
treatment, but it is a long-term process with the goals of keeping patients
in treatment and helping them manage ongoing problems and crises. Essential
to the engagement process is: 1) a personalized relationship with the individual,
2) over an extended period of time, with 3) a focus on the stated needs
of the individual.
For patients with dual disorders, engagement in the treatment process
is essential, although the techniques used will depend upon the nature,
severity, and disability caused by an individual's dual disorders. An employed
person with panic disorder and episodic alcohol abuse will require a different
type of engagement than a homeless person with schizophrenia and polysubstance
dependence. With respect to severe conditions such as psychosis and violent
behaviors, therapeutic coercive engagement techniques may include involuntary
detoxification, involuntary psychiatric treatment, or court-mandated acute
treatment.
The acute stabilization of AOD use disorders typically begins with detoxification,
such as inpatient detoxification for patients with significant withdrawal
or outpatient detoxification for mild to moderate withdrawal, as well as
nonmedical withdrawal, such as occurs in social-model detoxification programs.
Also, initiation of methadone maintenance can provide outpatient acute
stabilization for patients addicted to opioids.
Acute stabilization of psychiatric symptoms more frequently occurs within
a mental health or emergency medical setting, but involves a range of treatment
intensity. Patients with severe symptoms, especially psychotic, violent,
or impulsive behaviors, usually require acute psychiatric inpatient treatment
and psychiatric medications, while patients with less severe symptoms can
be treated in outpatient or day treatment settings.
Dual disorder programs that provide stabilization to patients with acute
needs should have the capability to:
For example, patients recently detoxified from AODs frequently experience
subacute symptoms such as insomnia and anxiety that may linger for a few
days or weeks. On the other hand, recently detoxified patients with dual
disorders may experience subacute symptoms of insomnia and anxiety either
as subacute withdrawal symptoms or as a prelude to relapse with depression.
Although the subacute phase is not generally regarded as a period of crisis,
ignoring these symptoms and failing to assess and treat them may lead to
symptom escalation, decompensation, and relapse.
As AOD-induced toxic or withdrawal symptoms resolve, constant reassessment
and rediagnosis is required. During this phase, a psychoeducational and
behavioral approach should be used to educate patients about their disorders
and symptomatology. During this phase, treatment providers should provide
assessment and planning for dealing with long-term issues such as housing,
long-term treatment, and financial stability.
With regard to the initiation and maintenance of sobriety in patients
with dual disorders, another way of looking at acute, subacute, and long-term
phases involves a four-step approach that leads to abstinence. This approach
is particularly important for patients with severe psychiatric problems
and an AOD use disorder (Minkoff
and Drake, 1991; Ries,
1993a).
Psychiatric and AOD abuse treatment issues are woven into the groups
in such a way that concrete issues (such as medication compliance) are
addressed in persuasion groups, while abstract concepts (such as self-image)
are addressed in active treatment or abstinence support groups. Some patients
-- such as severely psychotic patients -- may not be able to advance beyond
persuasion groups or active treatment groups.
Full assessments of patients with dual disorders should be performed
by clinicians who have certified training in the areas that they assess.
However, clinicians who are not certified can learn to perform screening
tests. Assessments of patients who may have dual disorders should include
at least a brief mental status exam to assess for the presence and severity
of psychiatric problems, as well as a screening for AOD use disorders.
The "ABC" model described on the previous page is a simple screening
technique for the presence of psychiatric disorders. The CAGE questionnaire
and the CAGE questionnaire modified for other drugs (CAGEAID) are rapid
and accurate screening tools for AOD use disorders (Exhibit
3-2). The substances used most often by patients with dual disorders
are the same as those used by society in general: alcohol, marijuana, cocaine,
and more rarely, opioids. It is recommended that all front-line AOD and
mental health staff receive detailed training in the use of a mental status
exam and AOD screening tests.
The treatment of patients with dual disorders is a clinical challenge,
as well as a systems challenge, requiring innovation and coordination.
The goal of this chapter is to help State and local administrators consider
strategies for linkages across systems in order to improve service delivery
and treatment outcomes.
Profiles of patients with dual disorders demonstrate that they are more
or differently disabled and require more services than patients with a
single disorder. They have higher rates of homelessness and legal and medical
problems. They have more frequent and longer hospitalizations and higher
acute care utilization rates. For example, among patients with schizophrenia,
episodes of violence and suicide are twice as likely to occur among those
who abuse street drugs as among those who do not.
Treatment and social needs of patients with dual disorders differ depending
on the type and severity of the disorders. Patients with dual disorders
are generally less able to navigate between, engage in, and remain engaged
in treatment services. Focusing on linkages highlights the fact that treatment
providers, rather than patients and their families, have the responsibility
for coordinating diverse and often conflicting treatment services.
Treatment must be suited to patients' personal needs and characteristics,
linking services across several different systems of care. Instead of blaming
patients for poor treatment outcomes as they fall through the cracks of
separate service systems, patients can be empowered and better treated
when given effective options.
Collaboration across multiple systems and philosophies of care is needed
to treat patients with dual disorders effectively. The systems often affected
include:
In order to work effectively together, AOD treatment providers and mental
health professionals need to understand and respect the different historical
and philosophical underpinnings of both systems. As explained in the third
chapter, the systems developed separately. There are inherent stresses
and strengths among medical, psychoanalytic, psychosocial, and self-help
care orientations, as well as between AOD treatment and mental health treatment.
These differences have frequently been a source of conflict and have
caused problems for some patients. For example, if a patient with a dual
disorder is told by his psychiatrist that he needs psychotropic medication
to treat his psychiatric disorder, but members of his self-help AA group
tell him to give up all mood-altering drugs to recover from his AOD abuse,
to whom does he listen?
Patients with dual disorders challenge the treatment systems. Their
involvement in treatment can become an opportunity for providers to examine
the philosophical and practical aspects of treatment.
It is beyond the scope of this document to provide detailed discussion
of each area, but the following discussion of problems and solutions will
help readers in their problem solving. The areas to be discussed in this
chapter include:
The Federal Government requires two separate planning processes for
programs receiving Federal funds: A State mental health plan and a State
substance abuse plan. The federally mandated State planning processes required
under the Public Health Service Act for mental health treatment and AOD
abuse treatment are separate and have no requirements for coordination.
The development and use of long-term structural mechanisms (such as
coordinating bodies, task forces, memoranda of understanding, and letters
of agreement) can help improve planning for and integration of services
for patients who have dual disorders.
To accomplish this goal, States might create a joint planning mechanism
-- an officially organized planning group -- that would: 1) have diverse
composition, 2) carry out specific types of tasks, and 3) maintain specific
foci.
States often do not take advantage of Federal monies that can be used
for patients with dual disorders. It is difficult to identify Federal grants
that can be used for dual disorders, since grants and announcements are
scattered across many agencies such as the Substance Abuse and Mental Health
Services Administration (SAMHSA), CSAT, the Center for Substance Abuse
Prevention (CSAP), the National Institute on Drug Abuse (NIDA), the National
Institute on Alcohol Abuse and Alcoholism (NIAAA), the National Institute
of Mental Health (NIMH), and the Center for Mental Health Services (CMHS),
to name a few.
Current reimbursement practices inhibit integration of services and
effective treatment, and there are several problems related to reimbursement
from both public and private third-party payers. These problems include
the following:
There are systemic disincentives to gathering data on patients with
dual disorders. For example, Medicaid may cover a patient who makes a suicide
attempt as a result of major depression, but may not cover a patient who
makes a drug-induced suicide attempt.
State planning bodies should encourage or require local needs and resource
assessment and data collection. Local planners should collect data from
various systems, examining and comparing data from different groups, programs,
and locations. The State could gather all the data and compile them for
use in improved planning and in evaluating outcomes.
Confidentiality laws must protect the patient, but also must allow for
inclusion of anonymous case number data in pools to promote better assessment
and treatment outcome studies.
There should be aggressive efforts to examine cost-effectiveness and
outcomes of specific models of treatment services for patients with dual
disorders. These research efforts can be incorporated into State and local
initiatives, perhaps involving local colleges and universities.
There is no "gold standard" instrument to diagnose dual disorders. Some
of the instruments that are used often yield false positive results.
Screeners are not adequately trained to make effective referrals across
systems, which can result in denial of treatment services.
Screening for dual disorders may take longer than screening for a single
disorder. For example, psychiatric symptoms can appear or disappear as
the AOD-induced symptoms clear.
The Public Health Service Act requires that State mental health agencies
that receive Federal funds provide case management services to patients
with severe mental illness. However, a comparable requirement is not built
into the Federal mandate for AOD abuse treatment services. AOD abuse treatment
agencies usually do not have enough social service staff to handle the
case management functions of linkage or followup for many dual disorder
patients.
There is often insufficient staff time available for the level of case
management required for dual disorder patients.
Staff selection is often driven more by clinicians' academic degree
and their ability to provide reimbursable services than by clinicians'
expertise in dual disorders.
The diagnosis and treatment of dual disorders are not generally understood
by staff, administrators, and legislators, let alone the general public.
Agency directors and supervisors often assign whom they believe to be the
most appropriate staff member to work with dual disorder patients without
a clear idea of the knowledge and skills required.
Professionals in AOD abuse and mental health treatment have accumulated
biases against the other discipline, as well as negative stereotypes of
both patients and staff.
There are no structured incentives for individuals or programs to develop
or take part in training, such as pay differentials and career opportunities
specific to dual disorders. Opportunities and incentives for cross-training
are lacking.
Consumers are not adequately involved in the training process.
Relatively few academic programs involve training or research in this
field.
Federally mandated income support programs are notoriously complex,
each with its own set of regulations. Some, such as the Social Security
Income (SSI) maintenance program, are administered by the Federal Government,
while others are administered by the State and vary from State to State.
Income support programs include SSI, Medicaid, Medicare, welfare, Aid
to Families With Dependent Children (AFDC), and food stamps.
Regulations for each program are often not understood by professionals
and others who provide services to potential recipients. This makes it
even more difficult for the potential recipient to get and retain benefits.
Some programs, such as SSI, require proof of a permanent and total disability.
Mental health problems often do not neatly fit into categories, making
it difficult to obtain this support.
Income support programs for single individuals have been cut drastically
in recent years.
Applications for these income support programs are often taken at a
site other than where either mental health or AOD services are provided
for the patient.
The complexity of the application and appeal process adds to the stress
of a person with a dual disorder.
Overburdened staff who are processing income support applications often
do not understand dual disorders.
Federally mandated services for children, youth, and families include
services that fall under the child welfare system (for example, child protective
services and foster care placement).
Child welfare system staff are overburdened and understaffed. A large
percentage of caseloads involve family AOD use problems.
Most child welfare staff are not trained in recognizing or treating
dual disorder problems. Mental health and AOD abuse staff are not trained
in child welfare. There is a lack of knowledge of each other's systems
and resources.
Other social service programs serve a wide range of special needs populations,
including the homeless and victims of domestic violence or sexual abuse,
who require a broad array of support services. Although many users of these
services have mental health and AOD abuse problems, these services are
often not available on site. Social service staff often lack knowledge
of how to refer people with such problems into these systems.
Public primary care clinics are often overburdened, understaffed, and
underfinanced. They are often oriented to treating presenting physical
problems, and staff may not be trained in screening for either AOD abuse
or mental health problems. The same problems often exist in nonprofit primary
care facilities. Staff are often not knowledgeable about how and where
to refer patients.
Historically, physicians have not received any education about AOD treatment
and little education about mental health problems in medical school. Primary
care physicians are often unaware of the signs and symptoms of AOD use
disorders, and may have only a basic understanding of a few psychiatric
problems such as depression and anxiety. For example, persons who experience
physical trauma, such as burn injuries or falls, often have AOD use disorders.
Yet, when presented with injured patients, primary care physicians may
not screen for AOD use disorders.
At hospital discharge, personnel often have difficulty dealing with
AOD abuse and mental health concerns. Patients are sometimes discharged
inappropriately with inadequate discharge planning and linkage with aftercare
services.
Staff in mental health and AOD abuse treatment systems often do not
know how to gain access to medical systems and therefore are ineffective
in providing information and ongoing education.
The mental health system has no formal responsibility for inmates with
dual disorders.
Incarceration is often a substitute for AOD abuse and mental health
treatment. Treatment may not begin until shortly prior to release.
Medical services for the incarcerated are not reimbursable under Medicaid
or any third-party payer. There is often an interagency debate regarding
who should pay for care.
Offenders who should be committed are often released. Prerelease assessments
are often inadequate. There usually is no coordinated plan for release.
No systemic funding incentives to provide care exist. There is a range
of custody status.
Criminal justice staff often have AOD abuse or mental health problems.
There are many inadequate employee assistance programs within the criminal
justice system.
The criminal justice system and community AOD abuse and mental health
treatment agencies may compete for the same AOD abuse and mental health
treatment dollars.
A major depressive episode involves a depression in mood with
an accompanying loss of pleasure or indifference to most activities, most
of the time for at least 2 weeks. These deviations from normal mood may
include significant changes in energy, sleep patterns, concentration, and
weight. Symptoms may include psychomotor agitation or retardation, persistent
feelings of worthlessness or inappropriate guilt, or recurrent thoughts
of death or suicide. The diagnosis of major depression requires
evidence of one or more major depressive episodes occurring without clearly
being related to another psychiatric, AOD use, or medical disorder. Major
depression is subclassified as major depressive disorder, single episode
and
recurrent.
There are nine symptoms of a major depressive episode listed in the DSM-IV
draft, and diagnosis of this disorder requires at least five of them to
be present for 2 weeks.
Dysthymia is a chronic mood disturbance characterized by a loss
of interest or pleasure in most activities of daily life but not meeting
the full criteria for a major depressive episode. The diagnosis of dysthymia
requires mild to moderate mood depression most of the time for a duration
of at least 2 years.
A manic episode is a discrete period (at least 1 week) of persistently
elevated, euphoric, irritable, or expansive mood. Symptoms may include
hyperactivity, grandiosity, flight of ideas, talkativeness, a decreased
need for sleep, and distractibility. Manic episodes, often having a rapid
onset and symptom progression over a few days, generally impair occupational
or social functioning, and may require hospitalization to prevent harm
to self or others. In an extreme form, people with mania frequently have
psychotic hallucinations or delusions. This form of mania may be difficult
to differentiate from schizophrenia or stimulant intoxication.
A hypomanic episode is a period (weeks or months) of pathologically
elevated mood that resembles but is less severe than a manic episode. Hypomanic
episodes are not severe enough to cause marked impairment in social or
occupational functioning or to require hospitalization.
A bipolar disorder is diagnosed upon evidence of one or more
manic episodes, often in an individual with a history of one or more major
depressive episodes. Bipolar disorder is subclassified as manic, depressed,
or mixed, depending upon the clinical features of the current or most recent
episodes. Major depressive or manic episodes may be followed by a brief
episode of the other.
Cyclothymia can be described as a mild form of bipolar disorder,
but with more frequent and chronic mood variability. Cyclothymia includes
multiple hypomanic episodes and periods of depressed mood insufficient
to meet the criteria for either a manic or a major depressive episode.
The revised third edition of the Diagnostic and Statistical Manual of
Mental Disorders (DSM-III-R) states that for a diagnosis of cyclothymia
to be made, there must be a 2-year period during which the patient is never
without hypomanic or dysthymic symptoms for more than 2 months.
Substance-induced mood disorder is described in the DSM-IV draft
according to the following criteria:
The most common psychiatric diagnoses among patients with an AOD disorder
are anxiety and mood disorders. Among those with a mood disorder, a significant
proportion has major depression. Mood disorders may be more prevalent among
patients using methadone and heroin than among other drug users. In an
addiction treatment setting, the proportion of patients diagnosed with
major depression is lower than in a mental health setting.
The prevalence rates of mood disorders in the general population can
be estimated from the results of the ECA studies (Regier
et al., 1988; Robins
et al., 1988). These studies indicate that:
During the first months of sobriety, many AOD abusers may exhibit symptoms
of depression that fade over time and that are related to acute withdrawal.
Thus, depressive symptoms during withdrawal and early recovery may result
from AOD disorders, not an underlying depression. A period of time should
elapse before depression is diagnosed.
Among women with an AOD disorder, the prevalence of mood disorders may
be high. The prevalence rate for depression among alcoholic women is greater
than the rate among men. Counselors should be reminded that women in both
addiction and nonaddiction treatment settings are more likely than men
to be clinically depressed.
In addition to women, other populations require special consideration.
Native Americans, patients with HIV, patients maintained on methadone,
and elderly people may all have a higher risk for depression. The elderly
may be the group at highest risk for combined mood disorder and AOD problems.
Episodes of mood disturbance generally increase in frequency with age.
Elderly people with concurrent mood and AOD disorders tend to have more
mood episodes as they get older even when their AOD use is controlled.
Acute manic symptoms may be induced or mimicked by intoxication with
stimulants, steroids, hallucinogens, or polydrug combinations. They may
also be caused by withdrawal from depressants such as alcohol and by medical
disorders such as AIDS and thyroid problems. Acute mania with its hyperactivity,
psychosis, and often aggressive and impulsive behavior is an emergency
and should be referred to emergency mental health professionals. This is
true whatever the causes may appear to be.
Other psychiatric conditions can mimic mood disorders. The predominant
condition that mimics a mood disorder is addiction, which is frequently
undiagnosed or misdiagnosed. Disorders that can complicate diagnosis include
schizophrenia, brief reactive psychosis, and anxiety disorders.
Patients with personality disorders, especially of the borderline, narcissistic,
and antisocial types, frequently manifest symptoms of mood disorders. These
symptoms are often fluid and may not meet the diagnostic criterion of persistence
over time. In addition, all of the psychiatric disorders noted here can
coexist with AOD and mood disorders.
Mary is a 37-year-old divorced female who was brought into a detoxification
unit with a blood alcohol level of 150 and was noted to be depressed and
withdrawn. She has never used drugs (other than alcohol), and began drinking
alcohol only 3 years ago. However, she has had several alcohol-related
problems since then. She has a history of three psychiatric hospitalizations
for depression, at ages 19, 23, and 32. She reports a positive response
to antidepressants. She is currently not receiving AOD or psychiatric treatment.
Similarly, what if Mary had abstained from alcohol for 6 months "on
her own," but over the past 3 months, she had become increasingly depressed,
tired, and withdrawn, with disordered sleep and poor concentration, as
well as suicidal thoughts? In addition, last night, while planning to kill
herself, she relapsed. A different diagnostic picture would emerge in this
case if Mary had been using antidepressants for the past year and, during
the past month, she had experienced an increase in heavy drinking, losing
her job yesterday because of alcohol use.
All psychoactive drugs cause alterations in normal mood. The severity
and manner of these alterations are regulated by preexisting mood states,
type and amount of drug used, chronicity of drug use, route of drug administration,
current psychiatric status, and history of mood disorders.
AOD-induced mood alterations can result from acute and chronic drug
use as well as from drug withdrawal. AOD-induced mood disorders, most notably
acute depression lasting from hours to days, can result from sedative-hypnotic
intoxication. Similarly, prolonged or subacute withdrawal, lasting from
weeks to months, can cause episodes of depression, sometimes accompanied
by suicidal ideation or attempts.
Also, stimulant withdrawal may provoke episodes of depression lasting
from hours to days, especially following high-dose, chronic use. Stimulant-induced
episodes of mania may include symptoms of paranoia lasting from hours to
days. Overall, the process of addiction per se can result in biopsychosocial
disintegration, leading to chronic dysthymia or depression often lasting
from months to years.
Since symptoms of mood disorders that accompany acute withdrawal syndromes
are often the result of the withdrawal, adequate time should elapse before
a definitive diagnosis of an independent mood disorder is made.
Conditions that most frequently cause and mimic mood disorders and symptoms
must be differentiated from AOD-induced conditions. When symptoms persist
or intensify, they may represent AOD-induced mental disorders. Transient
dysphoria following the cessation of stimulants can mimic a depressive
episode. According to the DSM-IV draft, if symptoms are intense and persist
for more than a month after acute withdrawal, a depressive episode can
be diagnosed. Symptoms of shorter duration can be diagnosed as a substance-induced
mood disorder.
It is difficult to generalize about specific drugs causing specific
behavioral syndromes. There is tremendous variability, as demonstrated
in Exhibit 5-1.
Multiple drug use further complicates the differential diagnosis. Diagnostic
procedures such as urinalysis and toxicology screens should be used if
possible. It should also be emphasized that addicted patients may experience
withdrawal from one drug despite using another drug.
Acute stimulant withdrawal generally lasts from several hours
to 1 week and is characterized by depressed mood, agitation, fatigue, voracious
appetite, and insomnia or hypersomnia. Depression resulting from stimulant
withdrawal may be severe and can be worsened by the individual's awareness
of addiction-related adverse consequences. Symptoms of craving for stimulants
are likely and suicide is possible.
Protracted stimulant withdrawal often includes sustained episodes
of anhedonia and lethargy with frequent ruminations and dreams about stimulant
use. There may be bursts of dysphoria, intense depression, insomnia, and
agitation for several months following stimulant cessation. These symptoms
may be either worsened or lessened by the quality of the patient's recovery
program.
Alcohol, barbiturates, and the benzodiazepines can cause sedative-hypnotic
intoxication, especially when t
Contents
Definitions and Models
Chapter 2 --
Dual
Disorders: Concepts and Definitions -- provides descriptions and diagnostic
criteria for AOD abuse and dependence. There is also a description of the
possible interactions between AOD use and psychiatric symptoms and disorders.
Linkages
Chapter 4 --
Linkages
for Mental Health and AOD Treatment -- describes several areas of critical
concern for programs that provide services to patients with dual disorders.
There are discussions regarding policy and planning; funding and reimbursement;
data collection and needs assessment; program development; screening, assessment,
and referral; case management; staffing and training; and linkages with
social service, health care, and the criminal justice systems.
Specific Psychiatric Disorders
While entire books can be written regarding specific psychiatric disorders,
this TIP describes the disorders that account for the majority of psychiatric
problems seen in patients with dual disorders. TIP chapters that address
specific psychiatric problems include Chapter
5, Mood Disorders; Chapter
6, Anxiety Disorders; Chapter
7, Personality Disorders; and Chapter
8, Psychotic Disorders.
Psychopharmacology
Chapter 9 --
Pharmacologic
Management -- is a brief overview of the types of medications used
in psychiatry and addiction medicine and for patients with dual disorders.
A stepwise treatment model that can minimize medication abuse risks is
discussed, and cautions about drug interactions are reviewed.
Chapter 2 -- Dual Disorders: Concepts and Definitions
The Relationships Between AOD Use and Psychiatric Symptoms
and Disorders
Establishing an accurate diagnosis for patients in addiction and mental
health settings is an important and multifaceted aspect of the treatment
process. Clinicians must discriminate between acute primary psychiatric
disorders and psychiatric symptoms caused by alcohol and other drugs (AODs).
To do so, clinicians must obtain a thorough history of AOD use and psychiatric
symptoms and disorders.
The symptoms of a coexisting psychiatric disorder may be misinterpreted
as poor or incomplete "recovery" from AOD addiction. Psychiatric disorders
may interfere with patients' ability and motivation to participate in addiction
treatment, as well as their compliance with treatment guidelines.
AOD Use and Psychiatric Symptoms
The Terminology of Dual Disorders
The term dual diagnosis is a common, broad term that indicates the
simultaneous presence of two independent medical disorders. Recently, within
the fields of mental health, psychiatry, and addiction medicine, the term
has been popularly used to describe the coexistence of a mental health
disorder and AOD problems. The equivalent phrase dual disorders also
denotes the coexistence of two independent (but invariably interactive)
disorders, and is the preferred term used in this Treatment Improvement
Protocol (TIP).
AOD Abuse, Addiction, Dependence, Misuse
The characteristic feature of AOD abuse is the presence of dysfunction
related to the person's AOD use. The Diagnostic and Statistical Manual
of Mental Disorders (DSM-III-R), produced by the American Psychiatric
Association and updated periodically, is used throughout the medical and
mental health fields for diagnosing psychiatric and AOD use disorders.
It provides clinicians with a common language for communicating about these
disorders and for making clinical decisions based on current knowledge.
For each diagnosis, the manual lists symptom criteria, a minimum number
of which must be met before a definitive diagnosis can be given to a patient.
AOD Abuse
Therefore, screening questions should relate to life problems that result
from AOD use, taking into consideration that patients may not have the
insight to perceive that their life problems are caused by AOD abuse.
AOD Addiction or Dependence
The DSM-III-R describes nine diagnostic criteria (shown
in Exhibit 2-1), of which three or more must be present for a month
or more to establish a diagnosis of dependence. Screening questions can
be based on these criteria. The DSM-IV draft committee deleted DSM-III-R
criterion 4 and the requirement of symptoms being present for at least
1 month. The DSM-IV draft emphasizes the symptoms of tolerance and withdrawal,
which the draft committee placed at the top of the list of criteria.
Chapter 3 -- Mental Health And Addiction Treatment Systems:
Philosophical and Treatment Approach Issues
Introduction
For people with dual disorders, the attempt to obtain professional help
can be bewildering and confusing. They may have problems arising within
themselves as a result of their psychiatric and AOD use disorders as well
as problems of external origin that derive from the conflicts, limitations,
and clashing philosophies of the mental health and addiction treatment
systems. For example, internal problems such as frustration, denial, or
depression may hinder their ability to recognize the need for help and
diminish their ability to ask for help. A typical external problem might
be the confusion experienced when individuals need services but lack knowledge
about the different goals and processes of various types of available services.
Other problems of external origin may be very fundamental, such as the
inability to pay for child care services or the lack of transportation
to the only available outpatient program.
Treatment Systems: Mental Health, Addiction, And Medical
People with dual disorders who want to engage in the treatment process
(or who need to do so) frequently encounter not one but several treatment
systems, each having its own strengths and weaknesses. These treatment
systems have different clinical approaches.
The Mental Health System
Actually, there is no single mental health system, although most States
have a set of public mental health centers. Rather, mental health services
are provided by a variety of mental health professionals including psychiatrists;
psychologists; clinical social workers; clinical nurse specialists; other
therapists and counselors including marriage, family, and child counselors
(MFCCs); and paraprofessionals.
The Addiction Treatment System
As with mental health treatment, no single addiction treatment system exists.
Rather, there is a collection of different types of services such as social
and medical model detoxification programs, short- and long-term treatment
programs, methadone detoxification and maintenance programs, long-term
therapeutic communities, and self-help adjuncts such as the 12-step programs.
These programs can vary greatly with respect to treatment goals and philosophies.
For example, abstinence is a prerequisite for entry into some programs,
while it is a long-term goal in other programs. Some AOD treatment programs
are not abstinence oriented. For example, some methadone maintenance programs
have the overt goal of eventual abstinence for all patients, while others
promote continued methadone use to encourage psychosocial stabilization.
Similarities of Mental Health and Addiction Treatment Systems
Many who work in the addiction treatment field have only a limited understanding
of medications used for psychiatric disorders. Historically, some people
have mistakenly assumed that all or most psychiatric medications are psychoactive
or potentially addictive. Many addiction treatment staff tend to avoid
the use of any medication with their patients, probably in reaction to
those whose addiction included prescription medications such as diazepam
(Valium). Many staff have a lack of training and experience in the use
of such medications. In the treatment of dual disorders, a balance must
be made between behavioral interventions and the appropriate use of nonaddicting
psychiatric medications for those who need them to participate in the recovery
process. Withholding medications from such individuals increases their
chances of AOD relapse.
The Medical System
Primary health care providers (physicians and nurses) have historically
been the largest single point of contact for patients seeking help with
psychiatric and AOD use disorders. Physicians and nurses are uniquely qualified
to manage life-threatening crises and to treat medical problems related
and unrelated to psychiatric and substance use disorders. And because they
are in contact with such large numbers of patients, they have an exceptional
opportunity to screen and identify patients with psychiatric and AOD disorders.
Differing Approaches: Individual Responsibility and
Treatment Focus
Traditionally, patients in mental health settings have had the responsibility
of getting themselves to treatment services and appointments as a sign
of treatment motivation. More recently, and in recognition that many severely
mentally ill patients are unwilling or unable to use traditional community-based
services, the mental health field has emphasized the role of case management.
Case management (also called care management) can help to engage, link,
and support patients in needed community services. Case management can
help to reduce the negative consequences to the individual from lack of
followup and participation in treatment. Without case management, many
severely ill patients would decompensate, need to be hospitalized, or become
homeless.
The Role of Abstinence
Within parts of the addiction treatment system, abstinence from psychoactive
drugs is a precondition to participate in treatment. For the more severely
ill patients with dual disorders (such as patients with schizophrenia),
abstinence from AODs is often considered a goal, possibly a long-term goal,
similar to the approach at some methadone maintenance programs. On the
other hand, treatment of less severe dual psychiatric conditions, such
as depression or panic disorder, should require AOD abstinence, since AOD
use compromises both diagnosis and treatment (see individual chapters).
Treatment Models: Sequential, Parallel, Or Integrated
As the mental health and AOD abuse treatment fields have become increasingly
aware of the existence of patients with dual disorders, various attempts
have been made to adapt treatment to the special needs of these patients
(Baker,
1991;
Lehman
et al., 1989; Minkoff,
1989; Minkoff
and Drake, 1991; Ries,
1993a). These attempts have reflected philosophical differences about
the nature of dual disorders, as well as differing opinions regarding the
best way to treat them. These attempts also reflect the limitations of
available resources, as well as differences in treatment responses for
different types and severities of dual disorders. Three approaches have
been taken to treatment.
Sequential Treatment
The first and historically most common model of dual disorder treatment
is sequential treatment. In this model of treatment, the patient is treated
by one system (addiction or mental health) and then by the other. Indeed,
some clinicians believe that addiction treatment must always be initiated
first, and that the individual must be in a stage of abstinent recovery
from addiction before treatment for the psychiatric disorder can begin.
On the other hand, other clinicians believe that treatment for the psychiatric
disorder should begin prior to the initiation of abstinence and addiction
treatment. Still other clinicians believe that symptom severity at the
time of entry to treatment should dictate whether the individual is treated
in a mental health setting or an addiction treatment setting or that the
disorder that emerged first should be treated first.
Parallel Treatment
A related approach involves parallel treatment: the simultaneous
involvement of the patient in both mental health and addiction treatment
settings. For example, an individual may participate in AOD education and
drug refusal classes at an addiction treatment program, participate in
a 12-step group such as AA, and attend group therapy and medication education
classes at a mental health center. Both parallel and sequential treatment
involve the utilization of existing treatment programs and settings. Thus,
mental health treatment is provided by mental health clinicians, and addiction
treatment is provided by addiction treatment clinicians. Coordination between
settings is quite variable.
Integrated Treatment
A third model, called integrated treatment, is an approach that
combines elements of both mental health and addiction treatment into a
unified and comprehensive treatment program for patients with dual disorders.
Ideally, integrated treatment involves clinicians cross-trained in both
mental health and addiction, as well as a unified case management approach,
making it possible to monitor and treat patients through various psychiatric
and AOD crises.
Treatment Models
In contrast, integrated treatment places the burden of treatment continuity
on a case manager who is expert in both psychiatric and AOD use disorders.
Further, integrated treatment involves simultaneous treatment of both disorders
in a setting designed to accommodate both problems.
Critical Treatment Issues For Dual Disorders
Mental health and addiction treatment programs that are being designed
to accommodate patients with dual disorders should be modified to address
the specific needs of these patients. Although there are different dual
disorder treatment models, all such programs must address several key issues
that are critical for successful treatment. These issues include: 1) treatment
engagement, 2) treatment continuity and comprehensiveness, 3) treatment
phases, and 4) continual reassessment and rediagnosis.
Treatment Engagement
In general, treatment engagement refers to the process of initiating and
sustaining the patient's participation in the ongoing treatment process.
Engagement can involve such enticements as providing help with the procurement
of social services, such as food, shelter, and medical services. Engagement
can also involve removing barriers to treatment and making treatment more
accessible and acceptable, for example, by providing day and evening treatment
services. Engagement can be enhanced by providing adjunctive services that
may appear to be indirectly related to the disorders, such as child care
services, job skills counseling, and recreational activities. It may also
be coercive, such as through involuntary commitment or a designated payee.
Treatment Continuity
To treat patients with dual disorders, it is critical to develop continuity
between treatment programs and treatment components, as well as treatment
continuity over time. In practice, many patients participate in treatment
at different sites. Even in integrated treatment programs, many patients
require different treatment services during different phases of treatment.
For this reason, treatment should include an integrated dual disorder case
management program, which can be located within a mental health setting,
an addiction treatment setting, or a collaborative program.
Treatment Comprehensiveness
An overall system for treating dual disorders includes mental health and
addiction treatment programs, as well as collaborative integrated programs.
Programs should be designed to: 1) engage clients, 2) accommodate various
levels of severity and disability, 3) accommodate various levels of motivation
and compliance, and 4) accommodate patients in different phases of treatment.
There should be access to abstinence-mandated programs and abstinence-oriented
programs, as well as to drug maintenance programs. Different levels of
care, ranging from more to less intense treatment, should be available.
Phases of Treatment
In general, the medical term acute describes phenomena that begin
quickly and require rapid response. Acute problems are contrasted with
chronic problems. Most commonly, acute stabilization of patients with dual
disorders refers to the management of physical, psychiatric, or drug toxicity
crises. These include injury, illness, AOD-induced toxic or withdrawal
states, and behavior that is suicidal, violent, impulsive, or psychotic.
These programs should be capable of promoting the patient's engagement
with the treatment system. They should be able to aggressively provide
linkages to other programs that will provide ongoing treatment and engagement.
Subacute Stabilization
The medical term subacute describes the status of a medical disorder
at points between the acute condition and either resolution or chronic
state. The subacute phase of a medical problem occurs as the acute course
of the problem begins to diminish, or when symptoms emerge or reemerge
but are not yet severe enough to be described as acute.
Biopsychosocial Assessment Issues From the AOD and Psychiatric Perspectives
AOD
Psychiatric
Biological:
Alcohol on breath
Positive drug tests
Abnormal laboratory tests
Injuries and trauma
Toxicity and withdrawal
Impaired cognitionAbnormal laboratory tests
Neurological exams
Using psychiatric medications
Other medications, conditions
Psychological:
Intoxicated behavior
Withdrawal symptoms
Denial and manipulation
Responses to AOD assessments
AOD use historyMental status exam: Affect mood, psychosis, etc.
Stress, situational factors
Self-image, defenses, etc.
Social:
Collateral information from others
Social interactions and lifestyle
Involvement with other AOD groups
Family history of AOD use disorders
Family history
Housing and employment historiesSupport systems: Family, friends, others
Current psychiatric therapy
Hospitalization
ABC Model for Psychiatric Screening
Long-Term Stabilization
The treatment settings for long-term treatment, rehabilitation, and recovery
from dual disorders include outpatient, day treatment, and residential
settings. Ideally, treatment intensity is dictated by disorder severity
and motivation for treatment, as well as by personal and local treatment
resources. In more severe conditions, ongoing dual disorder case management
is essential. The management of long-term severe conditions is described
in more detail in the chapter on psychotic disorders (Chapter
8).
Individual case management.
Individual case management provides an initial introduction to treatment
goals and concepts and may provide assistance with regard to crises, housing,
and entitlements. An individual treatment plan is developed.
Persuasion groups.
Patients who display strong denial about their AOD use disorder and lack
motivation can attend persuasion groups, which provide basic AOD education
and treatment engagement. Premature, potent, and direct confrontation and
an insistence on abstinence should be avoided since these approaches may
prompt more fragile patients to leave treatment.
Active treatment groups.
Active treatment groups consist of patients who have accepted the goal
of abstinence and are relatively mentally stable. These groups use supervised
peer confrontation and a psychoeducational-behavioral approach to AOD abuse.
Abstinence support groups.
Finally, abstinence support groups consist of patients who are essentially
committed to abstinence and are relatively stable mentally, who require
ongoing education and support for sobriety and the development of relapse
prevention skills.
General Assessment Issues
Each of the following chapters will address assessment and evaluation issues
relative to specific psychiatric disorders. Specific assessment tools may
be recommended for certain interventions and certain settings. Irrespective
of the treatment or intervention setting, and notwithstanding the crisis
that may have initiated the treatment contact, all treatment contacts with
patients who may have dual disorders should include a basic screening for
psychiatric and AOD use disorders. These issues are addressed in detail
in the chapters on mood, personality, and psychotic disorders. With respect
to both psychiatric and AOD use disorders, the assessment process should
be sensitive to biological, psychological, and social issues.
Chapter 4 -- Linkages For Mental Health and AOD Treatment
Overview
Conventional boundaries between single-focus agencies have impeded the
clinical progress of patients who have psychiatric disorders and alcohol
and other drug (AOD) use disorders (Baker,
1991;
Schorske
and Bedard, 1988).
For the treatment of patients with dual disorders, the primary systems
involved are AOD and mental health treatment. Programs that focus on dual
disorders operate in both the mental health and AOD systems. Staff and
administrative initiative is required to collaborate across systems. At
a minimum, both systems should be involved when developing initiatives
to improve linkages. This TIP is focused on the linkages between these
systems.
In spite of the historical and philosophical differences that have separated
the fields, the consensus panel identified several shared treatment concepts
that administrators can use to help move toward integration.
Areas of Primary Concern
To establish and maintain linkages among the various systems working with
patients who have dual disorders, several primary administrative areas
need to be examined.
Policy and Planning Structures
Problems
Often there is little or no communication or collaboration among various
departments and levels of government that have separate administrative
structures, constituencies, mandates, and target groups. There are also
different Federal, State, and local planning cycles within the AOD use
and mental health treatment systems.
Solutions
Amendments are needed to the Public Health Service Act to encourage coordinated
long-term planning between the State mental health and AOD abuse treatment
systems for patients with dual disorders.
1. The planning organization should have diverse composition.
2. The planning group should accomplish the following tasks:
3. The planning group should maintain the following foci:
Funding and Reimbursement
Problems
Because of diminishing fiscal resources and competition among many interest
groups for particular types of treatment, those who seek funds for the
treatment of patients with dual disorders have an increasingly difficult
task. In many areas, patients with dual disorders may not be recognized
as a priority group for funding. No specific monies are set aside for patients
with dual disorders under the block grants. The amount of funds that the
Federal Government allocates to States for the AOD and mental health block
grant programs changes from year to year and often includes mandated set-asides
for specific groups (for example, needle users, women, etc.). Set-asides
tend to be different for mental health and AOD abuse treatment and limit
the amount available for special groups not specifically targeted.
Solutions
1. Facilitate the aggressive pursuit of Federal funds by the following
actions:
2. Facilitate the use of block grant funds for treating patients with dual
disorders.
3. Promote Requests for Proposals (RFPs) for treating patients with dual
disorders.
4. Encourage initiatives within third-party reimbursement mechanisms to
cover treatment for patients with dual disorders.
Data Collection and Needs Assessment
Problems
Only limited treatment and research data are available, and those that
are available are not in a standardized format. Existing data also tend
to be general and not useful to local planners for developing a continuum
of care. Data collection systems are mandated to be separate from each
other. It is difficult to gather prevalence data on patients with dual
disorders because many of them interact with several treatment agencies
or systems, while others do not interact with any.
Solutions
At least on the State level, common identifiers in data collection should
exist for both AOD abuse and mental health treatment systems. Research
should be in a form that allows for evaluation of cost-effectiveness and
outcome. Outcomes should be measured across several categories encompassing
biopsychosocial issues. Examples might be 1) severity of AOD and psychiatric
symptomatology, 2) housing, 3) service involvement and utilization, and
4) vocational involvement. Collaboration with local colleges and universities
to conduct such research should be encouraged.
Program Development
Problems
Linkages in the development of programs for treating patients with dual
disorders are impeded by several factors:
Solutions
Screening, Assessment, And Referral
Problems
The screening process amplifies the tendency to look for a single diagnosis.
Staff in single-focus screening services are not trained to assess patients
for dual disorders.
Solutions
Case Management
Problems
There frequently is no single person or agency responsible for following
up on referrals and ensuring that patients are linked to treatment and
that services are coordinated. People with dual disorders need others to
help them obtain the services that they require, which are often fragmented.
Solutions
Staffing
Problems
All too often, treatment staff are knowledgeable about either mental health
or AOD treatment. They lack thorough training and education about dual
disorder patients.
Solutions
Training and Staffing
Problems
Clinicians in AOD abuse treatment and mental health treatment usually are
not trained in the other discipline. The availability of staff trained
in both fields is limited. Agencies frequently lack the resources to recruit
and retain staff who have sufficient education and experience. There is
both a shortage of qualified staff and an inability to financially compensate
qualified staff for their specialized abilities.
Solutions
Cross-training is one of the most effective tools administrators have for
bridging gaps between clinicians and services from different fields. Training
programs that provide knowledge about local networking can greatly improve
linkages for patients with dual disorders.
Solutions for administrators:
Solutions for staff:
Solutions for the community:
Solutions for consumers and their families:
Linkages With Social Service Systems
Problems
A large proportion of patients with dual disorders require social services.
The scope of social services is extremely broad, encompassing public and
private multisystems.
Solutions
Linkages With the Health Care System
Problems
The medical system is vast, covering a wide range of public and private
programs including primary, secondary, and tertiary care.
Solutions
Linkages With the Criminal Justice System
Problems
The criminal justice is a top-down system. There is often no mandated joint
planning.
Solutions
1. State
2. County and locality
3. Consumers
4. Pretrial process
5. During incarceration
6. During the probation-parole period
7. Criminal justice staff
Chapter 5 -- Mood Disorders
Definitions and Diagnoses
The term mood describes a pervasive and sustained emotional state
that may affect all aspects of an individual's life and perceptions.
Mood
disorders are pathologically elevated or depressed disturbances of
mood, and include full or partial episodes of depression or mania. A mood
episode (for example, major depression) is a cluster of symptoms that
occur together for a discrete period of time.
Substance-induced mood disorder can be specified as having 1) manic features,
2) depressive features, or 3) mixed features. Also, it can be described
as having an onset during intoxication or withdrawal. For most of the major
mental illnesses, the DSM-IV draft includes the alternative of a substance-induced
disorder within that diagnosis.
Prevalence
Using structured interviews, the Epidemiologic Catchment Area (ECA) studies
found that nearly 40 percent of people with an alcohol disorder also fulfilled
criteria for a psychiatric disorder. Among people with other drug disorders,
more than half reported symptoms of a psychiatric disorder (Regier
et al., 1990).
Some studies demonstrate that the prevalence of mood and anxiety disorders
is no greater among AOD abusers than in the general population. Other studies
show elevated rates of these disorders among people with AOD disorders.
Many patients receiving treatment for addiction appear depressed, but only
a small percent receive a formal diagnosis of major depression as a concurrent
illness.
Differential Diagnosis
Diagnostic Process
Diagnoses of psychiatric disorders should be provisional and constantly
reevaluated. In addiction treatment populations, many psychiatric disorders
are substance-induced disorders that are caused by AOD use. Treatment of
the AOD disorder and an abstinent period of weeks or months may be required
for a definitive diagnosis of an independent psychiatric disorder. Unfortunately,
the severely depressed person may drop out of treatment or even commit
suicide while the clinician is trying to sort things out (see section on
"Assessing Danger to Self or Others.")
Case Examples: George and Mary
George is a 37-year-old divorced male who was brought into the emergency
room intoxicated. His blood alcohol level was 152, and the toxicology screen
was positive for cocaine. He was also suicidal ("I'm going to do it right
this time! I've got a gun."). He has a history of three psychiatric hospitalizations
and two inpatient AOD treatments. Each psychiatric admission was preceded
by AOD use. George has never followed through with psychiatric treatment.
He has intermittently attended AA, but not recently.
Differential diagnostic issues for case examples.
Many factors must be examined when making initial diagnostic and treatment
decisions. For example, what if George's psychiatric admissions were 2
or 3 days long -- usually with discharges related to leaving against medical
advice? Decisions about diagnosis and treatment would be quite different
if two of his psychiatric admissions were 4 to 6 weeks long with clearly
defined manic and psychotic symptoms continuing throughout the course,
despite aggressive use of psychiatric treatment and medication.
AOD-Induced Mood Disorders
It is important to distinguish between mood disorders and AOD intoxication,
withdrawal, and/or chronic effects. These distinctions are especially important
following the chronic use of drugs that cause physiologic dependence.
Stimulants
Stimulants such as cocaine and the amphetamines cause potent psychomotor
stimulation. Stimulant intoxication generally includes increased
mental and physical energy, feelings of well-being and grandiosity, and
rapid pressured speech. Chronic, high-dose stimulant intoxication, especially
when combined with sleep deprivation, may prompt an episode of mania. Symptoms
may include euphoric, expansive, or irritable mood, often with flight of
ideas, severe impairment of social functioning, and insomnia.
Depressants
The general effect of the central nervous system depressants such as alcohol,
the benzodiazepines, and the opioids is a slowing down of an individual's
psychomotor processes. However, acute alcohol intoxication and opioid
intoxication often include two phases: an initial period of euphoria
followed by a longer period of relaxation, sedation, lethargy, apathy,
and drowsiness.