Chapters 1-5
Chapters 6-8
Chapter 9, Appendixes, and Exhibits

Assessment and Treatment of Patients with Coexisting Mental Illness and Alcohol and Other Drug Abuse

[Title Page]

Assessment and Treatment of Patients with Coexisting Mental Illness and Alcohol and Other Drug AbuseTreatment Improvement Protocol (TIP) Series 9
 
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service
Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Treatment
Rockwall II, 5600 Fishers Lane
Rockville, MD 20857DHHS Publication No. (SMA) 95-3061
Printed 1994. Reprinted 1995.

[Disclaimer]

This publication is part of the Substance Abuse Prevention and Treatment Block Grant technical assistance program. All material appearing in this volume except quoted passages from copyrighted sources is in the public domain and may be reproduced or copied without permission from the Center for Substance Abuse Treatment (CSAT) or the authors. Citation of the source is appreciated.

This publication was written under contract number ADM 270-91-0007 from the Center for Substance Abuse Treatment of the Substance Abuse and Mental Health Services Administration (SAMHSA). Anna Marsh, Ph.D., and Sandra Clunies, M.S., served as the Government project officers. Elayne Clift, M.A., Carolyn Davis, Joni Eisenberg, Mim Landry, and Janice Lynch served as writers.

The opinions expressed herein are those of the consensus panel participants and do not reflect the official position of CSAT or any other part of the U.S. Department of Health and Human Services (DHHS). No official support or endorsement of CSAT or DHHS is intended or should be inferred. The guidelines proffered in this document should not be considered as substitutes for individualized patient care and treatment decisions.

DHHS Publication No. (SMA) 95-3061. Printed 1994. Reprinted 1995.

What Is a TIP?

CSAT Treatment Improvement Protocols (TIPs) are prepared by the Quality Assurance and Evaluation Branch to facilitate the transfer of state-of-the-art protocols and guidelines for the treatment of alcohol and other drug (AOD) abuse from acknowledged clinical, research, and administrative experts to the Nation's AOD abuse treatment resources.

The dissemination of a TIP is the last step in a process that begins with the recommendation of an AOD abuse problem area for consideration by a panel of experts. These include clinicians, researchers, and program managers, as well as professionals in such related fields as social services or criminal justice.

Once a topic has been selected, CSAT creates a Federal Resource Panel, with members from pertinent Federal agencies and national organizations, to review the state of the art in treatment and program management in the area selected. Recommendations from this Federal panel are then transmitted to the members of a second group, which consists of non-Federal experts who are intimately familiar with the topic.This group, known as a non-Federal Consensus Panel, meets in Washington for 3 days, makes recommendations, defines protocols, and arrives at agreement on protocols. Its members represent AOD abuse treatment programs, hospitals, community health centers, counseling programs, criminal justice and child welfare agencies, and private practitioners. A Chair for the panel is charged with responsibility for ensuring that the resulting protocol reflects true group consensus.

The next step is a review of the proposed guidelines and protocol by a third group whose members serve as expert field reviewers. Once their recommendations and responses have been reviewed, the Chair approves the document for publication.The result is a TIP reflecting the actual state of the art of AOD abuse treatment in public and private programs recognized for their provision of high-quality and innovative AOD abuse treatment.

This TIP, titled Assessment and Treatment of Patients With Coexisting Mental Illness and Alcohol and Other Drug (AOD) Abuse, provides practical information about the treatment of patients with dual disorders, including the treatment of AOD patients with mood and anxiety disorders, personality disorders, and psychotic disorders. This TIP also provides pragmatic information about systems and linkage issues relative to the AOD and mental health treatment systems. There is also a discussion about pharmacologic management of patients with dual disorders.

This TIP represents another step by CSAT toward its goal of bringing national leadership to bear in the effort to improve AOD abuse treatment.

Consensus Panel

Richard K. Ries, M.D., Chair
Director
Inpatient Psychiatry and Dual Disorder Programs
Harborview Medical Center
Seattle, Washington

Facilitators:

Marcelino Cruces, L.C.S.W.
Administrative Coordinator
Andromeda Transcultural Mental Health Center
Substance Abuse Treatment Division
Washington, D.C.
Mary Katherine Evans, C.A.D.C., N.C.A.C. II
Program Director
Evans and Sullivan
Beaverton, Oregon
James Fine, M.D.
Director
Addictive Disease Hospital at Kings County Hospital Center
Clinical Associate Professor
Department of Psychiatry
State University of New York
Health Service Center at Brooklyn
Brooklyn, New York
Bonnie Schorske, M.A.
Coordinator
Special Populations
New Jersey Division of Mental Health and Hospitals
Trenton, New Jersey

Workgroup Members:

Stephen J. Bartels, M.D.
Medical Director
West Central Services, Inc.
Research Associate
New Hampshire-Dartmouth Psychiatric Research Center
Lebanon, New Hampshire
Dolores Burant, M.D.
Program and Medical Director
University Outpatient Recovery Service
Madison, Wisconsin
Agnes Furey, L.P.N., C.A.P.
Primary Care Coordinator
Florida Alcohol and Drug Abuse Program
Department of Health and Rehabilitation Services
Tallahassee, Florida
Malcolm Heard, M.S.
Director
Division on Alcoholism and Drug Abuse
Nebraska Department of Public Institutions
Lincoln, Nebraska
Norman Miller, M.D.
Associate Professor of Psychiatry
Chief, Addiction Programs
Department of Psychiatry
University of Illinois at Chicago
Chicago, Illinois
Ernest Quimby, Ph.D.
Assistant Graduate Professor
Howard University
Department of Sociology and Anthropology
Washington, D.C.
Henry Jay Richards, Ph.D.
Associate Director for Behavioral Sciences
Patuxent Institution
Jessup, Maryland
Candace Shelton, M.S., C.A.C.
Clinical Director
Pascua Yaqui Adult Treatment Home
Tucson, Arizona
Virginia Stiepock, A.C.S.W, R.N., C.S.
Assistant Center Director
Clinical Director
Northern Rhode Island Community Mental Health Center
Woonsocket, Rhode Island
Mathias Stricherz, Ed.D., C.D.C. III
Director
Student Counseling Center
University of South Dakota
Vermillion, South Dakota
Patricia M. Weisser
National Association of Psychiatric Survivors
Sioux Falls, South Dakota
Joan Ellen Zweben, Ph.D.
Executive Director
The East Bay Community Recovery Project
The 14th Street Clinic and Medical Group
Berkeley, California

Foreword

The Treatment Improvement Protocol Series (TIPs) fulfills CSAT'smission to improve alcohol and other drug (AOD) abuse and dependencytreatment by providing best practices guidance to clinicians, programadministrators, and payers. This guidance, in the form of a protocol,results from a careful consideration of all relevant clinical and healthservices research findings, demonstration experience, and implementationrequirements. A panel of non-Federal clinical researchers, clinicians,program administrators, and patient advocates employs a consensusprocess to produce the product. This panel's work is reviewed andcritiqued by field reviewers as it evolves.

The talent, dedication, and hard work that TIPs panelists and reviewersbring to this highly participatory process have bridged the gap betweenthe promise of research and the needs of practicing clinicians andadministrators. I am grateful to all who have joined with us tocontribute to advance our substance abuse treatment field.

Susan L. Becker
Associate Director for State Programs
Center for Substance Abuse Treatment

Chapter 1 --Introduction

Overview

The treatment needs of patients who have a psychiatric disorder in combination with an alcohol and other drug (AOD) use disorder differ significantly from the treatment needs of patients with either an AOD use disorder or a psychiatric disorder by itself. This Treatment Improvement Protocol (TIP) consists of recommendations for the treatment of patients with dual disorders.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

  • AOD use can cause psychiatric symptoms and mimic psychiatric disorders. Acute and chronic AOD use can cause symptoms associated with almost any psychiatric disorder. The type, duration, and severity of these symptoms are usually related to the type, dose, and chronicity of the AOD use.

  • Acute and chronic AOD use can prompt the development, provoke the reemergence, or worsen the severity of psychiatric disorders.

  • AOD use can mask psychiatric symptoms and disorders. Individuals may use AODs to purposely dampen unwanted psychiatric symptoms and to ameliorate the unwanted side effects of medications. AOD use may inadvertently hide or change the character of psychiatric symptoms and disorders.

  • AOD withdrawal can cause psychiatric symptoms and mimic psychiatric syndromes. Cessation of AOD use following the development of tolerance and physical dependence causes an abstinence phenomenon with clusters of psychiatric symptoms that can also resemble psychiatric disorders.

  • Psychiatric and AOD disorders can coexist. One disorder may prompt the emergence of the other, or the two disorders may exist independently. Determining whether the disorders are related may be difficult, and may not be of great significance, when a patient has long-standing, combined disorders. Consider a 32-year-old patient with bipolar disorder whose first symptoms of alcohol abuse and mania started at age 18, who continues to experience alcoholism in addition to manic and depressive episodes. At this point, the patient has two well-developed independent disorders that both require treatment.

  • Psychiatric behaviors can mimic behaviors associated with AOD problems. Dysfunctional and maladaptive behaviors that are consistent with AOD abuse and addiction may have other causes, such as psychiatric, emotional, or social problems. Multidisciplinary assessment tools, drug testing, and information from family members are critical to confirm AOD 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.

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.


AOD Use and Psychiatric Symptoms
  • AOD use can cause psychiatric symptoms and mimic psychiatric syndromes.
  • AOD use can initiate or exacerbate a psychiatric disorder.
  • AOD use can mask psychiatric symptoms and syndromes.
  • AOD withdrawal can cause psychiatric symptoms and mimic psychiatric syndromes.
  • Psychiatric and AOD use disorders can independently coexist.
  • Psychiatric behaviors can mimic AOD use problems.

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).

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.

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.

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.


AOD Abuse
  • Significant impairment or distress resulting from use
  • Failure to fulfill roles at work, home, or school
  • Persistent use in physically hazardous situations
  • Recurrent legal problems related to use
  • Continued use despite interpersonal problems

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.

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.


AOD Addiction or Dependence
  • Pathologic, often progressive and chronic process
  • Compulsion and preoccupation with obtaining a drug or drugs
  • Loss of control over use or AOD-induced behavior
  • Continued use despite adverse consequences
  • Tendency for relapse after period of abstinence
  • Increased tolerance and characteristic withdrawal (but not necessary or sufficient for diagnosis).

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.

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.

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.

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.

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.

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.

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.

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.


Similarities of Mental Health and Addiction Treatment Systems
  • Variety of treatment settings and program types
  • Public and private settings
  • Multiple levels of care
  • Biopsychosocial models
  • Increasing use of case and care management
  • Value of self-help adjuncts.

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.

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."

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.

However, physicians -- especially primary care physicians -- are able to devote very little time to eachpatient. 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.

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 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. Thisactivity 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.

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 illpatients 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).

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.

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.

The term sequential treatment describes the serial or nonsimultaneous participation in both mental healthand 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.

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.

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.

Treatment Models
  • Sequential: The patient participates in one system, then the other.
  • Parallel: The patient participates in two systems simultaneously.
  • Integrated: The patient participates in a single unified and comprehensive treatment program for dual disorders.

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.

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. Withrespect 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.

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.

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:

  • Identify medical, psychiatric, and AOD use disorders
  • Treat a range of illness severity
  • Provide drug detoxification, psychiatric medications, and other biopsychosocial levels of treatment
  • Provide a range of intensities of service.

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.

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.

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 cognition
Abnormal laboratory tests
Neurological exams
Using psychiatric medications
Other medications, conditions
Psychological: Intoxicated behavior
Withdrawal symptoms
Denial and manipulation
Responses to AOD assessments
AOD use history
Mental 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 histories
Support systems: Family, friends, others
Current psychiatric therapy
Hospitalization

ABC Model for Psychiatric Screening

  • Appearance, alertness, affect, and anxiety:
    Appearance:
    General appearance, hygiene, and dress.
    Alertness:
    What is the level of consciousness?
    Affect:
    Elation or depression: gestures, facial expression, and speech.
    Anxiety:
    Is the individual nervous, phobic, or panicky?
  • Behavior:
    Movements:
    Rate (Hyperactive, hypoactive, abrupt, or constant?).
    Organization:
    Coherent and goal-oriented?
    Purpose:
    Bizarre, stereotypical, dangerous, or impulsive?
    Speech:
    Rate, organization, coherence, and content.
  • Cognition:
    Orientation:
    Person, place, time, and condition.
    Calculation:
    Memory and simple tasks.
    Reasoning:
    Insight, judgment, problem solving.
    Coherence:
    Incoherent ideas, delusions, and hallucinations?

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).

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).

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.

Psychiatric and AOD abuse treatment issues are woven into the groups in such a way that concreteissues (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.

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.

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.

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).

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:

  • Alcohol prevention and treatment services
  • Drug prevention and treatment services
  • Mental health treatment services
  • Criminal justice systems
  • Legal services
  • Social and welfare services
  • General health care services
  • Child and adult protective services
  • Vocational rehabilitation programs
  • Housing agencies
  • Agencies for homeless people
  • Educational systems
  • HIV/AIDS prevention and treatment services.

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 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.

  • Providers should acknowledge that no single field has all the answers and that a need exists to integrate treatment by building upon and adapting from experience.Clinicians who work with dual disorder patients must add to their existing clinical skills. The development of a dual disorders program is an evolutionary process that requires agreed-upon outcome measures and program evaluation.

  • Providers should review admission criteria. These criteria should be inclusive, not exclusionary. Admission and placement criteria should be based on behaviors and skills required to participate in and benefit from a program rather than based solely on diagnosis.

  • Providers should find creative ways to bridge the differing funding streams, target populations, legal and regulatory mandates, and professional backgrounds and expertise.

  • Providers should accept the responsibility to provide integrated treatment -- not parallel or concurrent treatment efforts that require the patient to integrate and adapt to different and sometimes conflicting treatment models.

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.

  • Treatment should be provided in the least restrictive and most clinically appropriate setting within a continuum of care.
  • Treatment should be individualized for each patient.
  • The patient should be seen from a holistic, biopsychosocial perspective.
  • Self-help and peer support are valuable in the recovery process.
  • Families need education and support.
  • Case management plays a key role in effective treatment.
  • Multidisciplinary teams and approaches are necessary.
  • Group education and group process are valuable elements of the treatment process.
  • Ongoing support, relapse management, and prevention are necessary strategies.
  • Understanding that relapse and recovery are processes, not single events, and that relapse is not synonymous with failure is essential.
  • Cultural competence in programs and staff is required.
  • Gender-specific approaches to treatment are necessary.

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.

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:

  • Policy and planning structures
  • Funding and reimbursement
  • Data collection and needs assessment
  • Program development
  • Screening, assessment, and referral
  • Case management
  • Staffing issues
  • Training and staffing
  • Linkages with social services agencies
  • Linkages with the medical health care system
  • Linkages with the criminal justice system.

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.

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.

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.

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 andintegration 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.

1. The planning organization should have diverse composition.

  • There should be dedicated policy-level staff from different agencies to work on the joint planning body.
  • The planning group should be culturally competent and include a culturally diverse cross-section of the population.
  • The planning group should include a significant percentage of direct recipients of the services.
  • The planning group should include family members of patients.
  • The planning group should include providers.
  • The planning group should include academic representation from schools of medicine, nursing, psychology, social work, and public health.

2. The planning group should accomplish the following tasks:

  • The group should set yearly objectives that are practical and outcome oriented, and that can be tied to observable results on the service level.
  • The group should examine existing licensing requirements and regulations that affect programs that treat patients who have dual disorders. The goal should be to make the programs compatible and to reduce duplication of licensing reviews where possible.
  • The group should alert AOD and mental health programs that provide treatment for patients with dual disorders to existing Federal and State patient protection and confidentiality laws that may be applicable for both fields.
  • The results, findings, and recommendations of the joint planning body should be formally structured to feed back into the system and ensure that the initiatives are implemented and maintained.
  • The group should recommend model policies regarding dual disorders, and stimulate initiatives in program development and training.
  • There should be collaboration with universities and colleges to develop and integrate coursework, field placements, and treatment research specific to patients with dual disorders.
  • There should be a linkage with vocational rehabilitation and employment services.

3. The planning group should maintain the following foci:

  • Define a needed array of services to address theneeds of the full spectrum of patients with dual disorders.
  • Encourage county and other joint or collaborative planning with similar objectives for treating patients with dual disorders.
  • Encourage the use of funding and contracting mechanisms as incentives to ensure that services for patients with dual disorders are included.
  • Ensure that competitive contract bids to operate treatment services specify services for patients with dual disorders.
  • Award additional points to proposals for programs that address the needs of patients with dual disorders.
  • Require that local and county program plans submitted for State funds address services for dually diagnosed patients as a special population.
  • Promote training and staff development strategies to encourage acquisition of and recognition for skills in treating patients with dual disorders.The planning group should identify and disseminate information regarding the availability of Federal grants.

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.

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 theCenter 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 separate monies for AOD abuse and mental health treatment.
  • The span of coverage limits the types of services that can be provided in each setting.
  • Few standards exist that define minimum benefits for either AOD abuse or mental health services.
  • Depending on the type of treatment program in which patients participate, the separation of AOD abuse services and mental health services often drives the: 1) primary diagnosis, 2) type of treatment, 3) level of treatment, and 4) level of reimbursement.This causes competition for benefits rather than cooperation.
  • Benefit funding levels vary dramatically.

Solutions

1. Facilitate the aggressive pursuit of Federal funds by the following actions:

  • Assign an individual to search for Federal grant programs serving patients with dual disorders. This can be done at the State, local, and agency levels.
  • A lead Federal agency should be identified to screen grants applicable to patients with dual disorders, and to encourage States to take advantage of potential Federal funding. (CSAT might be the lead agency.)
  • At the State level, technical assistance should be provided to screen for and assist local agencies to pursue Federal mental health and AOD funding.

2. Facilitate the use of block grant funds for treating patients with dual disorders.

  • Work to create joint funding of programs. For example, New Jersey's Division on Alcoholism and Drug Abuse and Mental Health cofunded a number of model programs for patients with dual disorders.
  • Strive to share staff resources in programs, thus spreading out monies. For example, mental health staff can cofacilitate a dual disorders group in an AOD treatment program, and vice versa. Similarly, a mental health program can provide staff to monitor medications to avoid duplication of effort by the AOD treatment program.
  • Coordinate the provision of services and the expenditure of funds within each block grant area.
  • Encourage the allocation of more Federal dollarsfor block grants and set-asides that include treatment for dual disorders.
  • There may be some innovative mechanisms other than set-asides to encourage use of block grant funds for patients with dual disorders.

3. Promote Requests for Proposals (RFPs) for treating patients with dual disorders.

  • States should promote the development of RFPs specifying programs and services for patients with dual disorders.
  • State grants might give extra points for demonstrating linkages among the systems.

4. Encourage initiatives within third-party reimbursement mechanisms to cover treatment for patients with dual disorders.

  • Play an active role in keeping dual disorders a priority in health care reform efforts.
  • Encourage providers and payers to more effectively communicate with each other.
  • Encourage State-mandated benefit minimums that recognize that a more intense level of case management than usual is needed for treating patients with dual disorders.
  • Educate third-party providers that treatment for patients with dual disorders may be not only more intense but also more lengthy.
  • Consolidate and coordinate reimbursement rules for AOD abuse and mental health treatment.
  • Negotiate with local health maintenance organizations and other providers of health and mental health services to contract services for patients with dual disorders.
  • Encourage managed care companies to cover and facilitate treatment for dual disorders.
  • Encourage States to establish standards for different levels of care and requirements for staffing. Encourage the development or adoption of criteria such as those developed by the American Society of Addiction Medicine with regard to dual disorder typologies, levels of care, and reimbursement. Reimbursement should be linked to the use of criteria.

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.

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.

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.

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.

Program Development

Problems

Linkages in the development of programs for treating patients with dual disorders are impeded by several factors:

  • Rigid models, resistance to changing programs, and turf battles
  • Regulations and reimbursement rules
  • Clinical assumptions about dual disorders
  • Program development driven byreimbursement rules rather than by patients' needs
  • Limited knowledge about what is effective; absence of outcome research for program models
  • Absence of good processes for disseminating information about existing programs throughout the country
  • Lack of standards for comprehensive dual disorders programs
  • Lack of incentives for good program development on the State and local levels
  • Absence of State licensing criteria specific to dual disorders
  • Lack of appropriately trained staff and other resources
  • Lack of ownership. Dual disorder treatment systems are not "owned" by the AOD abuse or mental health treatment systems.Therefore, development of dual disorder treatment programs is not a priority in either system.

Solutions

  • Provide financial incentives for integrated dual disorder treatment programs.
  • Provide grants for model program development.
  • Identify State and county dual disorder experts.
  • Publish a State bulletin to facilitate information exchange.
  • Encourage research on existing programs from both AOD abuse and mental health fields by collaborative grants between States and universities.
  • Determine how existing services can be adapted (such as with special tracks or staff training to serve the dually diagnosed population) and help define which services need to be developed and which are special and unique to groups (for example, detoxification, longer-term residential programs, halfway houses). For example, the State of New Jersey issued guidelines for a continuum of care that describe how to adapt existing AOD abuse and mental health services and what services need to be specialized to care for dual disorder patients. The guidelines serve as a blueprint for systems integration.
  • Publish a State glossary of terms to encourage communication across systems.
  • Make sure programs have integrated expertise from both AOD abuse and mental health treatment fields through a joint review process for RFPs as well as joint ongoing monitoring processes.
  • Review programs for gender and cultural competency.
  • Establish a consumer feedback process to modify programs.
  • Encourage the involvement of providers, patients, and their families in educating the public on the needs of dual disorder patients and advocating for resources.

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.

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.

Solutions

  • State policies should lengthen the time frames in which screening and assessments are done for patients thought to have dual disorders. State policies should recognize that screening and assessment are ongoing processes.
  • The Federal Government should encourage research to develop standardized screening and assessment tools for dual disorders.These tools should be appropriate for people with severe and moderate AOD and psychiatric problems.
  • There should be systems-wide training of gatekeepers on the proper way to screen for dual disorders and on effective ways to make referrals.
  • There should be widespread encouragement of the multidisciplinary approach through joint staffing of screening centers or on-call backup support.

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.

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.

Solutions

  • States and agencies need to define criteria for patients who need and do not need case management. Case management should be targeted to those who need it, while less severely ill persons should receive other services.
  • Develop multidisciplinary teams with expertise in dual disorders within AOD and mental health treatment settings. Also, encourage the use of peer counselors to help engage patients with dual disorders into appropriate treatment.
  • Encourage a continuum of case management, defining who should get what level of case management. Levels may range from treatment plan coordination while the patient is in treatment to coordinating services within the community (such as Social Security Income [SSI] and housing). Assertive mobile outreach teams can encourage out-of-treatment individuals to become engaged in treatment. These efforts can help potential patients who are reluctant to participate in treatment or who are unable to get to treatment.
  • States should help increase the case management function within the AOD abuse treatment field. Ways to develop collaboration by including AOD treatment experts in a mental health facility and in outreach operations should be found.

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.

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.

Solutions

  • Standards for staffing dual disorders programs should be developed. These standards should include expertise in meeting the emotional, social, psychological, biological, vocational, and recreational needs of the patient.
  • A certification process should be established for certifying clinicians who have expertise in treating dual disorders. Third-party payers should be encouraged to reimburse based on clinicians' knowledge, competence, and expertise rather than on academic degree.

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.

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.

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:

  • Hire administrators with clinical backgrounds in dual disorders.
  • Expose administrators to what is currently being done in the field of dual disorders through conferences, literature, visits to facilities, and visits to other States.
  • Develop clear education and experience guidelines for different levels of staff members who treat dual disorder patients. These guidelines should be used to establish training goals with staff and to establish opportunities for advancement.
  • Develop standards for State, local, and facility training for various levels of staff.
  • Ensure that continuing education credits are available for both AOD abuse and mental health staff.
  • Provide certification or credentialing for training in the other discipline to promote sensitivity in AOD and mental health treatment.
  • Discuss with State certification board members their willingness to develop associate credentialing on AOD treatment targeted to social welfare, mental health, and criminal justice personnel.
  • Increase awareness of dual disorders for State legislative and networking systems through appropriately detailed curricula on patients with dual disorders.
  • Prepare a training plan for new staff and plan ongoing training for existing staff.
  • Provide ample time to have staff fully trained (2 to 3 years).
  • Coordinate with local universities and colleges to create a dual disorders training track.

Solutions for staff:

  • Create an individualized plan for each staff person, defining strengths as well as deficits and areas of needed growth; identify areas of greatest needs; define a training plan with a timetable and components.
  • Receive training at an established dual disorders treatment program.
  • Attend workshops on treating patients with dual disorders.
  • Include on-the-job training:
    • AOD abuse and mental health jointly facilitated groups
    • Mental health workers on an AOD abuse service
    • AOD abuse workers on a mental health service
    • Staff sharing.
  • Provide didactic inservice training:
    • Train mental health workers in AOD abuse treatment
    • Train AOD treatment staff about mental health treatment
    • Train staff in dual disorders.
  • Provide staff with important articles from the field by providing subscriptions to appropriate peer-reviewed journals.Purchase textbooks on dual disorders.
  • Work with local universities, colleges, and community college programs to create a dual disorders training track.

Solutions for the community:

  • Disseminate information to the general population through newspapers, television, and radio shows. Recovering people with dual disorders are good models.
  • Make presentations to community interest groups through speakers and speakers' bureaus.

Solutions for consumers and their families:

  • Consumers of treatment services should be offered a role in the training process for staff in the AOD abuse and mental health fields.
  • Consumers should be included on advisory boards for nonprofit and government treatment programs.
  • Consumers should be offered the opportunity to receive training in both fields to enhance their skills as peer counselors and group cofacilitators, and to help start AA and NA meetings that are sensitive to people with dual disorders, sometimes called "Double Trouble" meetings. Organizations that can help provide education to the public and patients include the National Alliance for the Mentally Ill, the National Association of Psychiatric Survivors, the National Association of Right Protection and Advocacy, and groups such as the Manic Depressive Association.
  • Families of patients should participate in Al-Anon and other support groups.

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.

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.

Solutions

  • Train SSI maintenance staff about patients with dual disorders.
  • Train AOD abuse and mental health staff in a range of social service areas, including income support, child welfare, and special populations.
  • Encourage an on-site application process for income support programs at AOD abuse and mental health treatment facilities. Mental healthand AOD abuse treatment programs can request training and support from Federal, State, or local administrators of various income support programs.
  • Develop mobile outreach approaches to assist patients with dual disorders in gaining access to income support programs and other needed social service programs.
  • Encourage an ongoing exchange among policy-level staff of AOD abuse, mental health, and Social Security agencies on Federal, State, and local levels.
  • Encourage a designated policy-level social services staff to create and maintain links with AOD abuse and mental health treatment systems.
  • Allocate sufficient social service staff time to assist patients who need a range of supports and services.

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.

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 tomedical systems and therefore are ineffective in providing information and ongoing education.

Solutions

  • AOD abuse and mental health staff should take the initiative to conduct training sessions through established medical organizations such as medical societies, hospital associations, nurses' associations, and other professional organizations.
  • AOD and mental health planning groups should publish materials that provide tips on linkage techniques for patients with dual disorders, and target such materials to the medical community.
  • Many public health clinics operated by the local health department are under the same administrative umbrella as the AOD programs. The local public health director can encourage the development of interagency training sessions, protocols, and policies and procedures to facilitate linkages between the clinics and AOD abuse treatment services and network with the mental health treatment services.Also, the local health director can help to establish stronger linkages between AOD and mental health providers with HIV/AIDS prevention and treatment systems.

Linkages With the Criminal Justice System

Problems

The criminal justice is a top-down system. There is often no mandated joint planning.

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 maycompete for the same AOD abuse and mental health treatment dollars.

Solutions

1. State

  • Establish joint top-level planning by the AOD abuse, mental health, and criminal justice fields.
  • Encourage funding that supports linkage at the service delivery level.
  • Work with AOD abuse and mental health treatment monitoring and licensing regulations to require and encourage cooperation with the criminal justice system.
  • Encourage funding for research and gathering data on persons with dual disorders in the criminal justice system.
  • Formally identify the responsibility of each system for providing specific services within the criminal justice system.

2. County and locality

  • Include representatives from the criminal justice system in local AOD abuse and mental health treatment planning groups.
  • Identify patients in each system who have an interest in cooperation.

3. Consumers

  • Educate consumer groups and the general public about the need for treatment of persons with dual disorders in the criminal justice system.
  • Encourage consumer groups to influence policy makers regarding linkages.

4. Pretrial process

  • Monitor and assess cases that involve AOD treatment and mental health treatment issues.
  • Advise and train judges regarding AOD treatment and mental health treatment options.

5. During incarceration

  • Conduct assessment for dual disorders at admission.
  • Provide treatment early in the incarceration.
  • Consider AOD abuse and mental health treatment issues during the parole hearing.

6. During the probation-parole period

  • Conduct joint assessment by AOD, mental health, and criminal justice staff prior to release.
  • Develop a release plan that addresses AOD and mental health issues.
  • Develop a clear contingency plan to address noncompliance.
  • Establish prompt and consistent graduated sanctions of custody status.
  • Establish joint supervision of problem cases.

7. Criminal justice staff

  • Provide EAP services that assess, identify, and treat AOD and mental health problems of staff.
  • Cooperate with unions.
  • Provide training on screening and assessment.
  • Provide training to address negative attitudes of criminal justice personnel regarding AOD abuse and mental health treatment and patients with dual disorders.

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.

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:

A. A prominent and persistent disturbance in mood characterized by either (or both) of the following:
1) depressed mood or markedly diminished interest or pleasure in all, or almost all, activities,
2) elevated, expansive, or irritable mood.
B. There is evidence from the history, physical examination, or laboratory findings of substance intoxication or withdrawal, and the symptoms in criterion A developed during, or within a month of, significant substance intoxication or withdrawal.
C. The disturbance is not better accounted for by a mood disorder that is not substance induced. Evidence that the symptoms are better accounted for by a mood disorder that is not substance induced might include: the symptoms precede the onset of the substance abuse or dependence; they persist for a substantial period of time (e.g., about a month) after the cessation of acute withdrawal or severe intoxication; they are substantially in excess of what would be expected given the character, duration, or amount of the substance used; or there is other evidence suggesting the existence of an independent non-substance-induced mood disorder (e.g., a history of recurrent non-substance-related major depressive episodes) .
D. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
E. The disturbance does not occur exclusively during the course of delirium.

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).

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:

  • The lifetime prevalence rates for any mood disorder ranged from 6.1 to 9.5 percent in the ECA study of New Haven, Baltimore, and St. Louis.
  • The lifetime prevalence rates for major depressive episode ranged from 3.7 to 6.7 percent.
  • The lifetime prevalence rates for dysthymia ranged from 2.1 to 3.8 percent.
  • The lifetime prevalence rates for manic episode ranged from 0.6 to 1.1 percent.

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.

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.

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.")

Acute manic symptoms may be induced or mimicked by intoxication with stimulants, steroids, hallucinogens, or polydrug combinations. They mayalso 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.

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.

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.

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 symptomscontinuing throughout the course, despite aggressive use of psychiatric treatment and medication.

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.

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.

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 depressiveepisode. 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.

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.

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 eitherworsened or lessened by the quality of the patient's recovery program.

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.

Alcohol, barbiturates, and the benzodiazepines can cause sedative-hypnotic intoxication, especially when taken in high doses. Psychomotor symptoms include mood lability, mental impairment, impaired memory and attention, loss of coordination, unsteady gait, slurred speech, and confusion.

Hallucinogens, Marijuana, and PCP

The hallucinogens can cause a state of intoxication called hallucinosis, which has several features in common with psychotic disorders and a few in common with mood disorders.Hallucinogens such as LSD and drugs such as MDMA (methylenedioxy-methamphetamine, or Ecstasy) and MDA (methylenedioxyamphetamine) may precipitate intense emotional experiences that may be perceived as positive or negative mood states by the drug user.

These experiences are affected greatly by personality, preexisting mood state, personal expectations, drug dosage, and environmental surroundings. While many users will experience sensory and perceptual distortions, some will experience euphoric religious or spiritual experiences that may resemble aspects of a manic or psychotic episode. Others may have a deeply troubling introspective experience, causing symptoms of depression.

Marijuana, which has sedative and psychedelic properties, can cause a variety of mood-related effects. In the individual who has not developed tolerance for the drug's effects, high doses of marijuana can cause acute marijuana intoxication with euphoria or agitation, grandiosity, and "profound thoughts." Together, these symptoms can mimic mania. Because marijuana is only slowly eliminated from the body, chronic use results in relatively constant marijuana levels. Thus, daily marijuana use can be, in effect, a chronic marijuana intoxication. This state may include symptoms of chronic, low-grade lethargy and depression, perhaps accompanied by anxiety and memory loss. Phencyclidine (PCP) intoxication can include symptoms of euphoria, mania, or depression, in addition to sensory dissociation, hallucinations, delusions, psychotic thinking, altered body image, and disorientation.

Mood Disorders Due to A Medical Condition

The DSM-IV draft describes diagnostic criteria for mood disorder due to a general medical condition. The five criteria are:

A. A prominent and persistent mood disturbance is characterized by either (or both) of the following:
1) depressed mood or markedly diminished interest or pleasure in all, or almost all, activities,
2) elevated, expansive, or irritable mood.
B. There is evidence from the history, physical examination, or laboratory findings of a general medical condition judged to be etiologically related to the disturbance.
C. The disturbance is not better accounted for by another mental disorder (e.g., adjustment disorder with depressed mood, in response to the stress of having a general medical condition).
D. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
E. The disturbance does not occur exclusively during the course of delirium or dementia.

Mood disorder due to a general medical condition can be described as having 1) manic features, 2) depressive features, or 3) mixed features in which symptoms of both mania and depression are present and neither predominates.

Medical conditions that can either precipitate or mimic mood disorders include the following:

  • Malnutrition
  • Anemia
  • Hyper- and hypothyroidism
  • Dementia
  • Brain disease
  • Lupus
  • HIV/AIDS
  • Postcardiac condition
  • Stroke, especially among elderly people.

Medications, including reserpine and other medications that treat hypertension and hypotension, can cause conditions that may be confused with psychiatric or AOD disorders.Both prescribed and over-the-counter (OTC) medications can precipitate depression. Diet pills and other OTC medications can lead to mania. Patients treated with neuroleptic (antipsychotic) drugs may have a marked constriction of affect that can be misinterpreted as a symptom of depression.

Stages of Assessment

The patient with coexisting AOD and mood disorders requires a thorough assessment and treatment for both disorders. The assessment process can be divided into three clinical phases: acute, subacute, and long term.

Acute and subacute assessment may not be applicable to certain patients seen in some clinical settings. For instance, AOD treatment program staff in outpatient settings may see fewer patients with acute psychiatric symptoms than are seen in detoxification settings.

Acute Evaluation

Assessing Danger to Self or Others

It is critical to assess whether patients are threats to themselves or others. This evaluation helps to determine if there is a duty to protect patients from self-harm, interrupt intentions of violence toward others, and/or warn intended victims of patients' announced violent intent.

The responsibility to protect some patients from suicide or violence due to mental illness is not mitigated by confidentiality laws with respect to AOD addiction.Imminent risk, according to the laws of most States, justifies and requires commitment of patients or the warning of potential victims.

Generally, AOD confidentiality laws are very stringent. While some States protect against involuntary commitment for AOD abuse, they do not protect against commitment for AOD-induced psychiatric states which involve danger to oneself or others.

Screening personnel should assess whether suicidal feelings are transitory or reflect a chronic condition.Consider: Do patients have a suicide plan or serious intentions? Have they made past attempts? Whether the patients have had prior psychiatric hospitalizationor are in current treatment should be determined. If patients are acutely dangerous to themselves or others, either voluntary or involuntary methods such as commitment should be pursued through local resources. AOD staff should have a thorough knowledge of local resources prior to and in anticipation of crises.

Placement in a safe holding environment can have a positive effect on patients with AOD problems and apparent suicidal intentions. If an intake facility cannot hold such patients, referral to an appropriate facility is recommended. For example, if someone walks into a program at 8:00 a.m. on Monday saying he wants to hurt himself, there should be time to talk the person down, assess treatment needs, and begin treatment or make assessment referrals. When necessary, an assessment should include a rapid triage. See the sections on the assessment of high-risk conditions in Chapter 7 (Personality Disorders) and Chapter 8 (Psychotic Disorders).

In virtually every recent study of successful or attempted suicide, AOD use and major depression are among the top associated conditions. Having both conditions simultaneously leads to even greater risk of suicide.

Patients with manic symptoms that approach psychotic proportions require thorough evaluation and require urgent care.Evaluation of mania should be done on a priority basis and should be monitored during subacute assessments.

Patients who have manic and hypomanic symptoms often minimize AOD and psychiatric disorders. Because of the symptom of grandiosity, manic patients may have poor insight into their AOD disorder, their mania, and their social situation. Manic patients may not see themselves as ill. They are usually hyperactive and irritable, and often become a danger to themselves or others through impulsivity, irritability, and poor judgment. When such people are also intoxicated, most will require involuntary commitment. See Chapter 8 for a discussion of assessment of patients with psychosis.

Medical Assessment

Patients, particularly the elderly, with mood disorders may have life-threatening medical conditions, including hypoglycemia (insulin overdose), stroke, or infections. These conditions, as well as withdrawal and toxic drug reactions, must always be considered and require a thorough physical examination and laboratory assessment. Assessment personnel should make appropriate referrals for medical assessment and treatment. Facilities that have no medical component should train assessment staff in triage and referral.

A plan should be developed to assess and treat medical conditions that precipitate or complicate mood disturbances. Endocrine disorders (such as thyroid problems), neurological disorders (such as multiple sclerosis), and HIV infection should be considered.In addition to obvious medical problems, it can be assumed that basic medical needs of patients with dual disorders are not being met, and a plan should be developed to address these deficits.

Initial Addiction Assessment Using the CAGE Questions

Clinicians can easily use the CAGE questions for screening (see Chapter 3) as well as adapt them for use with patients who may have mood disorders. For example, consider the following questions adapted from the CAGE questionnaire. "Have you ever cut down or increased your AOD use related to being severely depressed (or manic, etc.)?" "Do you ever get more irritable, angry, depressed, or annoyed when using AODs?" "Do you drink or use other drugs to deal with guilt feelings?" "Do you feel more moody in the morning or evening?" "Have you ever been suicidal when intoxicated?"

Initial AOD assessment should focus on recent use of alcohol and other drugs and a behavioral history. The assessor needs to know what drug has been used, in what quantity, with what frequency, and how recently. Past treatments, past episodes of delirium tremens, hallucinosis, blackouts, and destructive behavior should be recorded.

Social Assessment

The social assessment should evaluate the patient's social environment, especially in relation to AOD and psychiatric disorders. It is important to assess whether the patient experiences housing instability or homelessness. Where does the patient live? Does the patient live in a home? With whom does the patient live? With whom does the patient have regular social contact? Are the social and home environments stable?

In the patient's social life, is there a precipitating crisis occurring? What is the patient's existing support structure in the home and community? What role do others have?Is the home free of AODs? Are the home and social environments safe and free from violence? Do the home and social environments support an abstinent lifestyle? If not, it should be assessed whether the patient has the support necessary to overcome the adverse effect of home and social environments that do not support abstinence and recovery.

Violence by Others

During the screening interview, it is important to determine whether the patient's family members are physically abusive. It should be determined whether the patient is in danger. Physical and behavioral observation can be an important aspect of evaluation. The best predictor of future violence is previous violence.

Assessing Mood Symptomatology

During AOD use history taking and psychiatric screening and assessment sessions, patients with AOD disorders may overemphasize or underemphasize their psychiatric symptoms. For instance, patients who feel depressed during the assessment may distort their past psychiatric experiences and unwittingly exaggerate the intensity or frequency of past depressive episodes.

In contrast, patients who are profoundly depressed during the assessment may minimize their depressive illness because they think it represents a normal state. Indeed, some patients may believe that they "deserve" to be depressed, rather than recognizing that depression is a deviation from normal mood states.

Some patients experience feelings of guilt that are excessive and inappropriate.Other patients do not accurately label their depression and fail to remember that they have experienced depression before. Since patients frequently confuse depression with sadness and other emotions, it is important during the assessment to ask such questions as: "Have you ever seen a psychiatrist or therapist?" (If yes: "Why?") "Are you able to get out of bed in the morning or do you feel chronically tired?" "Have there been any recent changes in your sleeping patterns or in your appetite?"

Patients may select details from their psychiatric history consistent with their current mood. Those who are depressed may give a generally negative self-report. Addicted patients tend to emphasize psychiatric symptoms; psychiatric patients often underemphasize them. Unhappy addicted patients in a transient disturbance of mood will often rationalize their histories as lifelong depression. Thus, it is important to obtain collateral information from other people and from documents such as medical and psychiatric records.It is critical to continue the process of evaluation past the period of drug withdrawal.


Tips for Assessment

The following are sample questions to ask during the assessment process.
For depression:
  • "During the past month, has there been a period of time during which you felt depressed most of the day nearly every day?"
  • "During this period of time, did you gain or lose any weight?"
  • "Did you have trouble concentrating?"
  • "Did you have problems sleeping or did you sleep too much?"
  • "Did you try to hurt yourself?"
For mania:
  • "During the past month, have you experienced times during which you felt so hyperactive that you got into trouble or were told by others that your behavior was not normal for you?"
  • "Have you recently experienced bouts of irritability during which you would yell or fight with others?"
  • "During this period, did you feel more self-confident than usual?"
  • "Did you feel pressured to talk a great deal or feel that your thoughts were racing?"
  • "Did you feel restless and irritable?"
  • "How much sleep do you need?"

Patients' responses to questions are often influenced by the way questions are asked.Most patients being interviewed tend to say what they believe the interviewer wants to hear. Therefore, the manner in which the interview is conducted is important. The interviewer should not lead the patient or make suggestions regarding the "correct" answer.

Because of the subjective nature of mood disturbances, the way in which questions are asked is important. Subjective and quantifiable questions should be asked in an objective way. Neutral, open-ended questions can be effective. Questions should be asked about impairment and disturbance of sleep, appetite, and sexual function, as well as other disturbances in functional impairment. Interviewers must be alert to contradictory responses and recognize that AOD-dependent patients have a tendency to distort information.

Subacute and Longer-Term Assessment

Settings for subacute assessment include the following:

  • Medical clinics
  • Mental health clinics
  • Sexually transmitted disease (STD) clinics
  • Hospitals
  • Emergency rooms
  • Welfare and social services offices
  • Other nontreatment settings
  • Doctors' offices
  • Psychotherapists' offices.

This section will focus on patients who likely have coexisting AOD use and mood disorders, are not imminently dangerous, and are candidates for treatment. Their functional levels, liabilities, and strengths should be assessed. The goal of subacute assessment is to develop treatment plans with less need for the focus on acute protection (as in the case of acute assessment). Treatment planning is based on a full assessment of treatment needs.

Assessments can be considered part of the treatment process since the assessment process often facilitates breaking through the addicted person's denial mechanisms. By asking specific questions (about work, relationships, health, or legal problems), the clinician calls attention to the consequences of AOD use. Toxicology screens and/or abnormal liver function tests such as the GGT should be obtained when symptoms and AOD use reports don't match. Such results can be identified as "consequences" of AOD use. Diagnostic and assessment sessions can be the first intervention. The boundary between assessment and treatment is fluid.

Medical Assessment

A plan should be developed to assess and treat medical conditions that can precipitate or complicate mood disturbances. Such conditions include endocrine disorders (such as thyroid problems), neurological disorders (such as multiple sclerosis), and HIV infection.

Some medical problems may have a heightened visibility because of their more obvious need for ongoing treatment. However, frequently the primary health care needs of patients with combined AOD and mood disorders are not pursued. For this reason, a plan to assess and meet these treatment needs should be developed.

Psychiatric and Addiction Screening

A subacute nonemergency setting is appropriate for screening and in depth diagnostic interviews for AOD and psychiatric disorders.The following sources can provide valuable information for screening and assessment: psychiatric history, previous medical and psychiatric records, and information from collateral sources such as employers, family members, and laboratory data.

A diagnostic interview, unlike a screening interview, can be done over the course of several sessions. Collateral sources, especially family members, can help clarify diagnostic issues and to help patients recognize the denial that may accompany their disorders.

A thorough history of AOD use, problems, patterns, and treatments should be obtained at this stage. Such information should be collected in a supportive nonjudgmental manner and over multiple interviews when possible. As with the psychiatric assessment, interviews with family and collateral sources are important.

Assessment Instruments

The diagnostic evaluation can include the clinical application of the DSM-III-R (or DSM-IV), perhaps in the form of the Structured Clinical Interview from DSM-III-R (SCID). The Brief Psychiatric Rating Scale, the Hamilton Scale, the Addiction Severity Index (ASI), and the Beck Scale can also be used to assess patients with dual disorders.

The SCID and the ASI are research instruments, but their demonstrated reliability and the advantages of consistent, standardized tools make it reasonable to administer them. Facilities that use these instruments should provide training in their use.

Psychosocial Assessment

A comprehensive psychosocial and vocational assessment can be an important aspect of the overall assessment. Evaluation of the patient's ongoing support system is important: What is the patient's support network, including friends and family? What patterns of interpersonal and family relationships exist within the nuclear family, the extended family, and the family of choice? What means of financial support does the patient have? What job skills does the patient have? Also, both ethnic and cultural backgrounds may alter a person's experience of both AOD and psychiatric conditions.

Treatment Strategies, Issues, and Goals

Acute Treatment Strategies

Management of Intoxication And Withdrawal

Management of withdrawal is often crucial to patients' safety and comfort. Withdrawal management can foster patient engagement in an ongoing treatment and recovery process.Although withdrawal management does not in itself produce enduring abstinence, it can help to increase retention in the treatment process, which improves long-term outcome.

Treatment strategies for intoxication range from letting patients "sleep it off" to confinement in a medical or psychiatric unit. Treatment for acute sedative-hypnotic withdrawal should include medically managed detoxification.Hospital settings are preferable, especially for depressed patients. Opiate withdrawal, while not life threatening, should also be treated medically and on an inpatient basis when possible. When such hospital-based settings are unavailable, residential or outpatient support with or without medication should be attempted.

Since unassisted withdrawal can cause seizure, psychosis, depression, and suicidal thoughts, it can be dangerous. Thus, successful detoxification is often a lifesaving process. Also, the medical management of withdrawal alleviates patients' suffering. It can provide a safe, supportive, and nonthreatening environment for depressed patients.

Medical Treatment

Acute treatment may be required for medical conditions identified in the medical assessment. For example, thyrotoxicosis (thyroid storm) is a life-threatening imitator of mania. Also, low blood sugarresulting from insulin overdose can resemble intoxication and depression.

Psychiatric Treatment

Patients who are imminently dangerous to themselves or others due to a psychiatric disturbance require emergency psychiatric treatment. Such treatment may involve voluntary or involuntary confinement.

The presence of a coexisting AOD use disorder or the suspicion that the psychiatric disturbance is AOD induced does not mitigate requirements for confinement. Rather, it may necessitate addiction-specific emergency treatment such as detoxification.

Patients not requiring confinement after evaluation may benefit from the support of existing family networks, existing programs, or when available, a rapid referral to a dual disorders treatment program.

Medical management of acute psychiatric symptoms is a treatment strategy during the acute phase regardless of long-term diagnostic results. Patients who experience hallucinations, delusions, mania, or significant disorganization of thought can benefit from medical treatment with antipsychotic medication (such as haloperidol or thioridazine) whether or not their symptoms are AOD induced. If potentially abusable medications are required (such as benzodiazepines for acute mania), a period of tapering or reduction of the medication within 1 or 2 weeks should be built into the original treatment plan.

Subacute Treatment Issues

Matching Patients and Treatment

During subacute treatment, the first decision to be made is whether patients should receive treatment in a psychiatric or addiction setting. In some locations, a third alternative is available: the dual disorders treatment setting. When realistic, both types of treatment should be provided simultaneously; integrated treatment generally is preferable.

Criteria for determining placement include the patient's treatment needs and potential for loss of control, as well as program features such as intensity, structure, and limitations. There are also considerations specific to mood disorders.

For example, if patients are experiencing mania or psychotic depression with disordered thinking, it must be determined whether the program is capable of handling and treating patients with these problems.While psychotic depression or mania is being managed, patients may then be shifted to an addiction or dual disorder setting. Appropriate matching of patients to facilities is important.

Some patients with dual disorders require rare orminimal psychiatric intervention, such as AOD patients whose bipolar disorder is successfully managed with lithium and regular blood level monitoring. Patients who require a strong recovery-oriented AOD abuse treatment program should also receive treatment for their psychiatric disorder (parallel treatment), with an emphasis on AOD treatment.

In contrast, patients who experience chronic and severe psychiatric disturbances and who episodically use AODs in a markedly destructive fashion will be better treated in a psychiatric program that has staff with expertise in addiction treatment. The optimal match for the patient with two active disorders that require treatment is the integrated facility. The intensity of each disorder dictates the relative intensity of each treatment component required.

Referral to an appropriate facility should be based on practical clinical criteria rather than on diagnosis alone. For example, patients' ability to understand, interpret, and tolerate the level of care being provided is most important. Some patients can participate in standard 12-step groups. Others will require 12-step groups that are intended for people with dual disorders (Double Trouble groups).Still others will require professionally run therapy groups that include patients with similar problems.

Effective treatment is based on what patients can understand and tolerate, which is not always predicted by diagnosis. Some psychotic patients function well in traditional programs, while others require special settings. An individual plan and a flexible ongoing reassessment of effectiveness are the best ways to ensure fit.

Psychiatric Medications

The judicious use of antidepressant and mood-regulating medication is appropriate for AOD patients with mood disorders. For example, patients who experience debilitating, misery-provoking, and incapacitating depressive symptoms may require antidepressant medication to participate in addiction recovery.(See Chapter 9 for further discussions of psychiatric medications.)

When depressive symptoms interfere with functioning, antidepressant medication can provide symptom relief and allow participation in recovery activities and activities of daily living. Relief from depression and anxiety can be significant motivating factors in recovery. Left untreated, symptoms can keep patients from taking part in recovery activities.

Patients who have difficulty engaging in Alcoholics Anonymous and other support groups and who do not exhibit evidence of a personality disordermay be depressed. Depression may manifest as social withdrawal, reclusiveness, or inability to complete activities of daily living such as going to work.Regularly spending many hours a day in bed or having serious insomnia may be cardinal signs of depression but are often seen among patients with AOD disorders during the first weeks and months of abstinence.

When prescribing antidepressants for people participating in addiction treatment, the acronym MASST is a reminder for clinicians of the areas of AOD recovery that need to be continually assessed. MASST is an acronym that reminds clinicians to assess patients' treatment needs regarding: 1) Meetings, 2) Abstinence from all psychoactive drugs, 3) Sponsor (or other helping people), 4) Social support systems, and 5) overall Treatment efforts. (See the discussion on the use of 12-step programs in Chapter 6.)


MASST Areas of Recovery
M:
Meetings (12-step or other recovery-oriented self-help)
A:
Abstinence from all psychoactive drugs
S:
Sponsor and other helping people
S:
Social support systems
T:
Treatment efforts.

Case Management

Case management is crucial when patients are receiving simultaneous AOD and psychiatric care at separate settings (parallel treatment). There must be good linkages between the two treatment programs or providers.For example, patients might see their mental health counselor three times a week, go to both AOD self-help group meetings and mental health support group meetings, and receive AOD counseling. This level and mix of treatment can be overwhelming and confusing for the patient. An effective case manager can help with planning sensible treatment. Case managers can also facilitate the use of self-help groups. (See the discussion on the use of 12-step programs and other self-help groups in Chapter 6).

The separate disorders, their distinct treatment needs, and the divergent treatment approaches can cause staff splitting and turf problems that exacerbate the patient's denial and can cause other treatment problems. These problems can be avoided in almost all cases by effective communication and coordinated treatment planning. Good psychiatric and addiction treatment efforts are rarely truly conflicting.

Counseling and Psychotherapy For Depression

It is beyond the scope of this TIP to provide comprehensive details on the use of psychotherapeutic treatment.However, there are numerous resources regarding counseling and psychotherapy and depression. Recent publications written for both counselors and patients include The Good News About Depression by M.S. Gold and When Self-Help Fails by P. Quinnet.

Levels of Care

Once psychiatric and addiction severity has been determined, the treatment intensity, structure, and level of care required must be decided. From the least to the greatest intensity, the levels of care are:

  1. Individual treatment with a psychotherapist or counselor. This is the least intensive level of care and includes few, if any, additional treatment services such as education.
  2. Outpatient treatment. Within this level of care are services that vary greatly in structure and intensity. They include weekly to daily individual or group counseling, often in combination with additional treatment services such as detoxification, education, medical services, and specially focused groups. A multidisciplinary treatment team that includes assertive and intensive case management services may be needed for patients with severe and persistent mood disorders coexisting with AOD disorders.
  3. Intensive outpatient treatment. This level of care includes treatment models such as partial hospitalization (which includes day treatment, evening, and weekend programs). For example, patients in day treatment generally participate in a full day of treatment for 5 or more days per week. Intensive outpatient treatment represents a range of treatment intensities. The level of intensity of a given program is based primarily on the number of treatment services offered. Generally, intensive outpatient treatment programs offer several treatment components such as group therapy, educational sessions, and social support services.
  4. Halfway houses. These are settings that serve as safe AOD-free homes for people who can manage independent daily activities and can benefit from a structured and recovery-oriented group living arrangement. They vary widely in style and purpose.
  5. Residential rehabilitation setting. Participation can vary from 30 days to 3 months or more, with patients removed from familiar surroundings andseparated from AODs. In residential settings, patients receive education about dual disorders and learn important recovery skills such as utilizing groups, building trust, and talking about feelings. Therapy and support groups provide socialization and support and are the core of treatment. They prepare the patient for increased reliance on group support systems after discharge.
  6. Therapeutic communities.Long-term therapeutic communities often require patient participation lasting from 6 months to 2 years. They are generally considered to be appropriate for patients with severe AOD disorders who have significant social and vocational deficits and who require long-term and intensive support, skill building, interpersonal abilities refinement, and trauma resolution.
  7. Hospitals. Psychiatric or AOD hospitalization may be required for acute and subacute stabilization. In this age of managed care, hospitalization episodes have become much shorter and more acute than a few years ago. This puts more responsibility and risk on outpatient treatment providers.

Patients with severe and persistent mood and AOD disorders frequently require intensive and assertive treatment approaches as outlined in Chapter 8 on psychotic disorders.These patients will benefit from programs that can provide concurrent, integrated dually focused treatment. Also, these patients may require assertive case management to encourage medication compliance and to help them secure all psychiatric, addiction, and social services that they may need.

While some programs for dual disorders exist at all levels of care and in several program models, few AOD or mental health residential programs are dually focused, and many AOD programs refuse to accept patients who have histories of psychiatric disorders or who currently are prescribed medication for psychiatric disorders.

Traditional biases in the addiction field against psychiatric medication should be shed in light of the evidence that medicating existing disorders is humane, can be provided safely, and is necessary for some patients to engage in treatment. It is helpful to use psychiatrists who are skilled and are perhaps specialists in the treatment of coexisting psychiatric and AOD disorders.

Similarly, traditional psychiatric biases regarding rapid medication intervention and some clinicians' emphases on "getting in touch with feelings" can impede or reverse the AOD recovery process. Encouraging emotional expression without regard for the patient's stage of AOD recovery and stability canaggravate AOD disorders. Many residential facilities in the mental health system are inadequately controlled for the presence of AODs, are not abstinence based, and are not safe environments for AOD users.

Family Involvement In Treatment Settings

In all of the above settings, patients should receive family therapy and education, addiction and recovery counseling, and psychiatric counseling. Special attention must be focused on the chronic and cyclical nature of addiction and mood disorders and the likelihood of relapse.

Manic patients' uncontrolled grandiose behaviors have frequently caused their families great stress. Thus, family members need education about the nature of addiction, mania, and recovery. It is necessary for staff to ally with family members to ensure cooperation with treatment and reduce collusion between family members and the patient.

Similarly, the depressed patient is frequently seen as a family burden. Families need assistance to engage the depressed patient.The combination of depression and addiction can be very difficult for family members, and the challenges for the family must be considered.

Family and friends are often mistakenly afraid that they might exacerbate or aggravate depression or mania if they confront the dangerous and maladaptive behaviors and denial that result from addiction and mood disorders. Such fears are ungrounded. In fact, supportive intervention by the patient's social network is helpful with respect to both disorders.

The patient's family should be encouraged to confront the patient rather than remain reticent, and they should be coached to confront the patient in a supportive way. Support for and education of family members are necessary to encourage their constructive involvement and to help them avoid collusion in the patient's drug-using behavior or denial of psychiatric disturbance.

Professional and Vocational Planning

While some patients with dual disorders have severe and poorly remitting mood and AOD disorders, most patients improve, especially with careful psychiatric treatment. Since these disorders are generally well controlled, patients can experience very high levels of vocational, social, and creative functioning. As a result, vocational planning should be long term and accentuate patient strengths.

AIDS and HIV Risk Reduction

Studies demonstrate that HIV/AIDS risk reduction measures can make a difference in the rate of HIV infection. Potential and actual risk behaviors that are identified in evaluation should be addressed by referral to specific educational, training, and intervention programs.

Staff at these programs should be sensitive to patients' cultural and ethnic backgrounds, and understand how these can influence AOD use, sexual behaviors, and patients' receptivity to risk reduction measures. Programs should be proficient in communicating with patients using culturally sensitive language.However, the most culturally insensitive position is to avoid raising these issues out of fear or hesitancy.

With respect to risk reduction, special attention should be paid to the fact that, while depressed, many patients may be sexually abstinent, but this behavior may not reflect their typical behavior patterns. If patients are assessed while they are depressed, they should be asked to describe their sexual behavior during times when not depressed, or perhaps they should be assessed when they are not depressed. Mania and active AOD use markedly elevate the potential for high-risk behaviors and should be seen as extremely dangerous situations for the transmission of HIV and other sexually transmitted diseases.

HIV counseling and testing is appropriate and advisable for patients with coexisting AOD and mood disorders. There is no evidence that people with mood disorders become suicidal or experience thought disorganization in response to HIV testing.

Long-Term Treatment Goals

Treatment goals should include consolidating the AOD-free lifestyle, establishing psychiatric stability, achieving social independence and stability, and enhancing vocational choices and goals. Long-term treatment can be viewed as a maintenance period -- a time for personal growth and development and consolidation of long-term, satisfying patterns of social adaptation.

Addiction Treatment

The long-term management of addiction includes participation in 12-step programs and other support groups, individual and group counseling, and in some cases, continued participation in a treatment program. The severity of a patient's illness should be matched with the appropriate treatment intensity and level of care.

Patients with dual disorders who experience lowlevels of psychiatric impairment require a level of care that can be provided in traditional low-structure abstinence-oriented addiction treatment programs.Dual disorder patients who experience severe psychiatric symptoms or cognitive impairment require a more intense level of care such as that provided by a highly structured dual disorders treatment program. Matching patients to the appropriate treatment and level of care can help achieve desired outcomes.

Psychiatric Treatment

The majority of patients receiving treatment for combined mood disorders and addiction improve in response to treatment. When they don't improve, there should be a reevaluation of the treatment plan. For example, a patient receiving antidepressant medication who is abstinent from AODs but anhedonic (unable to feel pleasure or happiness) requires a careful evaluation and assessment to identify resistant psychiatric conditions that require treatment. In this example, based on assessment, an additional treatment service such as psychotherapy may be added. Indeed, psychotherapy has been shown to improve the efficacy of addiction treatment and of psychiatric treatment that involves antidepressant medication.

When patients do not improve as expected, it is not necessarily because of treatment failure or patient noncompliance. Patients may be compliant and plans may be adequate, but disease processes remain resistant. Persistent attention to the addictive process and its complications as well as meticulous attention to psychiatric therapy usually leads to improvement. However, patients with severe and persistent AOD and mood disorders should not be seen as resistant, manipulative, or unmotivated but as extremely ill and requiring intensive treatment.

Long-Term Treatment Needs

Patients who have experienced sexual, physical, or psychological abuse may have problems that surface during acute treatment or that are identified during long-term treatment evaluations. Treatment needs resulting from these types of abuse should be addressed in the long-term treatment plan.

The resolution of problems related to sexual, physical, and psychological abuse usually requires specialized, long-term treatment. However, these problems should be addressed whenever they surface in any phase of treatment for AOD and mood disorders.

For example, addressing these problems during early recovery should be viewed from the perspectiveof anxiety reduction and consolidation of abstinence. At that phase of recovery, the treatment goal is to have patients contain or express their potent and surfacing feelings without using alcohol and other drugs. Later in recovery, these problems can be dealt with in terms of long-term stabilization and psychological resolution.

Continuing addiction counseling and participation in group support activities are useful to help consolidate abstinence. These recovery maintenance activities include participation in social clubs, 12-step programs, religious organizations, and other cultural institutions. Community-based activities can provide long-term stability to these patients.

At this stage of treatment, special treatment needs can be identified through targeted testing in such areas as neurologic, cognitive, and personality disorders. Special treatment needs should be specifically addressed by the appropriate treatment strategy. STD and HIV risk reduction, evaluated throughout the progression of illness, should now address the importance of long-term stable changes in behavior.

Family Issues

Family members should be evaluated for AOD problems in acute and subacute stages when the family members begin to become involved in the patient's treatment.There is usually adequate time to deal with family issues in the subacute phase, when personnel and family members become acquainted. Family members include household members as well as members of the patient's support system.

The family often needs and should receive treatment. After careful evaluation of family dynamics, the presence of addictive disorders or codependent behavior in the family should be evaluated. The presence of AOD and mood disorders in the patient is the best predictor of AOD and mood disorders in the family. A family history of one disease increases the risk for the other; a family history of both disorders multiplies the risk factor.

Family therapy can be provided on site.Individual family members should be referred for the treatment of specific problems when required. It is often necessary to help families "mop up the rage" that has accumulated. It is important to determine when to deal with the family as a group to resolve conflicts and when members need to work with a therapist alone to develop independence from dysfunctional reliance. Participation in Al-Anon and related self-help groups for family members should be encouraged and incorporated in the treatment schedule for family members.

Eating Disorders and Gambling

Other conditions that coexist with dual disorders include eating disorders and pathologic gambling. It may be helpful to refer patients to support groups that deal with these conditions. Eating disorders are more commonly diagnosed in women, and pathologic gambling is more commonly diagnosed in men.

Reassessment and Reassessment...

The purposes of ongoing reassessments are: 1) to continue to refine prior diagnostic assessments, 2) to evaluate life adjustment in general, 3) to evaluate the effectiveness of treatment efforts for the dual disorders, and 4) to evaluate the discontinuation orcontinued use of medication and other treatments.

Persistently emerging and remitting problems should be addressed. For example, patients who chronically exhibit a negative disposition should be assessed for a personality disorder. Such patients may have a personality disorder with depressive features rather than a mood disorder.

Testing

Specific neuropsychological, psychological, educational, and vocational testing assessments should be performed when necessary and appropriate. These include testing for learning disorders, cognitive or literacy impairments, and personality disorders. These tests are more reliable and accurate when performed following several months of sobriety.


Chapters 1-5
Chapters 6-8
Chapter 9, Appendixes, and Exhibits