Assessment and Treatment of Patients with Coexisting Mental Illness
and Alcohol and Other Drug Abuse
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)
Printed 1994. Reprinted 1995.
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
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
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.
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.
- Richard K. Ries, M.D., Chair
- Inpatient Psychiatry and Dual Disorder Programs
- Harborview Medical Center
- Seattle, Washington
- 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.
- 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.
- Special Populations
- New Jersey Division of Mental Health and Hospitals
- Trenton, New Jersey
- 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.
- 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
- 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
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
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
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.
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.
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.
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
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.
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
- 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
- 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
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
- Psychiatric and AOD use disorders can independently coexist.
- Psychiatric behaviors can mimic AOD use problems.
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.
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.
- 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
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.
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.
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.
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
Some medications used in psychiatry that have mild psychoactive effects
(such as some tricyclic antidepressants with mild sedative effects) appear
to be misused more by patients with an AOD disorder than by others. Thus,
a potential pitfall is prescribing psychoactive medications to a patient
with psychiatric problems without first determining whether the individual
also has an AOD use disorder.
While most clinicians in the mental health system generally have expertise
in a biopsychosocial approach to the identification, diagnosis, and treatment
of psychiatric disorders, some lack similar skills and knowledge about
the specific drugs of abuse, the biopsychosocial processes of abuse and
addiction, and AOD treatment, recovery, and relapse.Similarly, AOD treatment
professionals may have a thorough understanding of AOD abuse treatment
but not psychiatric treatment.
As with mental health treatment, 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
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
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."
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
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
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
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
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
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.
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
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.
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
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.
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
| Treatment Models
- Sequential: The patient participates in one system, then the
- 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.
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.
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
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.
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.
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
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.
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
||Alcohol on breath
Positive drug tests
Abnormal laboratory tests
Injuries and trauma
Toxicity and withdrawal
|Abnormal laboratory tests
Using psychiatric medications
Other medications, conditions
Denial and manipulation
Responses to AOD assessments
AOD use history
|Mental status exam: Affect mood, psychosis,
Stress, situational factors
Self-image, defenses, etc.
||Collateral information from others
Social interactions and lifestyle
Involvement with other AOD groups
Family history of AOD use disorders
Housing and employment histories
|Support systems: Family, friends, others
Current psychiatric therapy
ABC Model for Psychiatric Screening
- Appearance, alertness, affect, and anxiety:
- General appearance, hygiene, and dress.
- What is the level of consciousness?
- Elation or depression: gestures, facial expression, and speech.
- Is the individual nervous, phobic, or panicky?
- Rate (Hyperactive, hypoactive, abrupt, or constant?).
- Coherent and goal-oriented?
- Bizarre, stereotypical, dangerous, or impulsive?
- Rate, organization, coherence, and content.
- Person, place, time, and condition.
- Memory and simple tasks.
- Insight, judgment, problem solving.
- Incoherent ideas, delusions, and hallucinations?
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.
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
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
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.
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
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,
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
- 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
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
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
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
- Ongoing support, relapse management, and prevention are necessary
- 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.
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
- 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.
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.
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
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
- 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
- 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
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.
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
- 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.
1. Facilitate the aggressive pursuit of Federal funds by the following
- 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
2. Facilitate the use of block grant funds for treating patients with
- 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
- 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
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
- 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
- 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.
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.
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.
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'
- 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
- 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.
- Provide financial incentives for integrated dual disorder treatment
- 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
- 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
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.
- 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
- 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
- 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
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
- 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
- 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
- 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
- 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.
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.
- 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
- 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.
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
Consumers are not adequately involved in the training process.
Relatively few academic programs involve training or research in this
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.
- 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
- Prepare a training plan for new staff and plan ongoing training for
- Provide ample time to have staff fully trained (2 to 3 years).
- Coordinate with local universities and colleges to create a dual disorders
- 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.
- Disseminate information to the general population through newspapers,
television, and radio shows. Recovering people with dual disorders are
- Make presentations to community interest groups through speakers and
- 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
A large proportion of patients with dual disorders require social services.The
scope of social services is extremely broad, encompassing public and private
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 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
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.
- 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
- Encourage an ongoing exchange among policy-level staff of AOD abuse,
mental health, and Social Security agencies on Federal, State, and local
- 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.
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.
- 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.
The criminal justice is a top-down system. There is often no mandated
The mental health system has no formal responsibility for inmates with
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
The criminal justice system and community AOD abuse and mental health
treatment agencies maycompete for the same AOD abuse and mental health
- 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
- 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.
- 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
- Advise and train judges regarding AOD treatment and mental health
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
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.
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
- 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
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.
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
- 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.
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.
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.
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
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.
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
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
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 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,
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.
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,
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,
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:
- Hyper- and hypothyroidism
- Brain disease
- 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.
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
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.
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
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
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.
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.
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.
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
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.
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.
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
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
- "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
- "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
- "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"
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.
Settings for subacute assessment include the following:
- Medical clinics
- Mental health clinics
- Sexually transmitted disease (STD) clinics
- 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.
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.
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.
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
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.
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.
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
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.
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
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
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
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.
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
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
Meetings (12-step or other recovery-oriented self-help)
Abstinence from all psychoactive drugs
Sponsor and other helping people
Social support systems
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
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.
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:
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
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
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.
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.
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
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
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
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.
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.
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.
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
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
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
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 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.
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.
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.
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.