integrating treatment for co-occurring disorders

Integrating Treatment for Co-Occurring DisordersJay Piland MDPalmetto Addiction Recovery Center:86 Palmetto RoadRayville, LA [email protected]

Medical Director—Addiction Medicine Specialist

Jay L. Piland, MDDiplomate American Board of Addiction MedicineDiplomate American Board of Internal MedicineCMRO

Addiction Medicine Specialist

OBJECTIVES—TIP

Discuss the prevalence of co-occurring disorders in substance abuse treatment programs

Increase familiarity with mental disorders terminology and criteria—provide advice on how to proceed with COD

Contrast co-occurring treatment with traditional addiction treatment

Give a rationale for integrated treatment List instruments helpful for screening Describe evidence-based therapies helpful in treating

co-occurring disorders

Part One:Introduction to Co-occurring Disorders

SCOPE OF PRACTICE

An Addiction Professional’s scope of practice varies with education, training and state requirements.

With many people present today, each practitioner should keep his or her scope of practice in mind as we conduct this presentation.

Mental health disorder (MHD): significant and chronic disturbances with “feelings, thinking, functioning and/or relationships that are not due to drug or alcohol use and are not the result of a medical illness”22

Bipolar disorder Major depressive disorder Schizophrenia Obsessive-compulsive disorder

Social phobia Borderline personality disorder Posttraumatic stress disorder

DEFINING CO-OCCURRING DISORDERS

Substance use disorder (SUD): a behavioral pattern of continual psychoactive substance use that can be diagnosed as either substance abuse or substance dependence


DSM 5—SUD

DSM 5—SUD—Maladaptive pattern of substance use leading to significant impairment/distress

1. Recurrent Use leading to failure to fulfill major obligations2. Recurrent use in hazardous situations3. Continued use despite persistent or recurrent social problems caused or exacerbated by

effects of substance4. Tolerance5. Withdrawal6. Taken in larger amounts or for longer periods than intended7. Persistent desire or unsuccessful efforts to control, reduce, or stop8. Great deal of time spent obtaining, using, or recovering9. Important activities given up or reduced because of substance use10. Continued use despite knowledge of physical and psychological problems likely caused

or exacerbated by substance11. Craving or urge to use substance Mild 2-3 Moderate 4-5 Severe 6 or more

Co-occurring disorders (COD): the simultaneous existence of “one or more disorders relating to the use of alcohol and/or other drugs of abuse as well as one or more mental [health] disorders.”18


-Individual Level COD

-Service Definition of COD -Prediagnosis -Postdiagnosis -Unitary Disorder and acute signs and/or symptoms of co-occurring condition e.g., Suicidal Ideation in context of SUD Mental Health symptom that creates a severity problem


EXAMPLES OF CO-CCURRING CONDITIONS (COC):

MENTAL DISORDERS

Schizophrenia/PsychosesMood DisordersAnxiety DisordersSomatoform DisordersFactitious DisordersDissociative DisordersSexual DisordersEating DisordersSleep DisordersImpulse-control DisordersAdjustment DisordersPersonality DisordersDisorders-usually first diagnosed

in infancy, childhood, or adolescence

ADDICTION DISORDERS

Alcohol Abuse/Depen.Cocaine/

Amphet./StimulantsOpiates/OpioidsMarijuanaPolysubstance

combinationsPrescription drugsSyntheticsHallucinogensDissociatives

SUBSTANCE-INDUCED DISORDERS

-Are Distinct from independent co-occurring mental disorders in that all or most of the psychiatric symptoms are the direct result of substance use.

-Substance-Induced Disorders do not preclude co-occurring mental disorders, only that the specific symptom cluster at a specific point in time is more likely the result of substance use, abuse, intoxication, or withdrawal than of underlying mental illness

-Clients could even have both independent and substance-induced mental disorders

SUBSTANCE-INDUCED DISORDERS

Substance-Induced Mood DisorderSubstance-Induced Anxiety DisorderSubstance-Induced Psychotic DisorderSubstance-Induced Sexual DysfunctionSubstance-Induced Sleep DisorderSubstance-Induced DeliriumSubstance-Induced Persisting DementiaSubstance-Induced Amnestic DisorderHallucinogen Persisting Perceptual Disorder


50 to 75% of all clients who are receiving treatment for a substance use disorder also have another diagnosable mental health disorder.

Further, of all psychiatric clients with a mental health disorder, 25 to 50% of them also currently have or had a substance use disorder at some point in their lives.

KEY EPIDEMIOLOGIC FINDINGS SINCE 2002

Current national COD epidemiologic data are derived from 3 major studies: The National Comorbidity Survey and the NCS-Replication (NIMH); The National Survey on Drug Use and Health (SAMHSA); The National Epidemiologic Study on Alcohol and Related Conditions (NIAAA+NIDA)

• Substance use disorders are present in more than 9% of the large numbers of individuals sampled.

• More than 9% of adults have diagnosable mood disorders, primarily Maj. Dep.

• More than 7.7 million adult U.S. citizens have a serious mental illness—SMI (2.3 million with SUD & SMI)

SMI = Persons age 18 +, who currently or at any time during the past year, have had a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet DSM-IV diagnostic criteria , resulting in functional impairment which substantially interferes with or limits one or more major life activities.)

PAST YEAR SUD & AMI AMONG ADULTS—2013 NSDUH

PAST YEAR SUD & SMI AMONG ADULTS—2013 NSDUH

SUD IN THE PAST YEAR AMONG INDIVIDUALS AGE 12 OR OLDER--2013

COD SUD AND AMI/SMI AMONG ADOLESCENTS AND ADULTS—2013 NSDUH

COD MI & SUD AMONG ADULTS BY AGE AND GENDER—2013 NSDUH

MENTAL HEALTH & SUBSTANCE USE TREATMENT FOR ADULTS WITH AMI & SUD—2013

MENTAL HEALTH AND SUBSTANCE USE TREATMENTS FOR ADULTS WHO HAD SMI AND SUD—2013

MOST COMMON REASONS FOR NOT RECEIVING TREATMENT AMONG INDIVIDUALS 12 OR OLDER WHO NEEDED OR MADE AN EFFORT TO RECEIVE TREATMENT—2010-2013


Mood Disorders Anxiety Disorders Post-Traumatic Stress Disorders

Antisocial Personality Disorders

Borderline Personal-ity Disorders

Severe Mental Illness0%5%

10%15%20%25%30%35%40%45%

Addiction Treatment Provider Estimates by Psychiatric Disorder

WELL, HOW COMMON IS THE PROBLEM?

Estimates of psychiatric co-morbidity among clinical populations in substance abuse treatment settings range from 20-80%

Estimates of substance use co-morbidity among clinical populations in mental health treatment settings range from 10-45%, with the highest for those with Schizophrenia and Bipolar Disorder

* Differences in incidence due to: nature of population served (e.g.: homeless vs. middle class), sophistication of psychiatric diagnostic methods used (psychiatrist or DSM checklist) and severity of diagnoses included (major depression vs. dysthymia).

CO-OCCURRING DISORDERS: PREVALENCE

National Co-Morbidity Survey52% of those with AUD at some point in their lifetime also

had a history of at least one mental disorder.59% of those with other DUD at some point in their

lifetime also had a history of at least one mental disorder.

84% of those that experienced a lifetime of co-occurrence report that their mental illness symptoms preceded their substance use disorder (Kessler et al, 1994).

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LIFETIME PREVALENCE OF SUD FOR EACH MHD

Bipolar Disorder 56%

Schizophrenia 47% Major Depression 27% Any Anxiety Disorder 24% PTSD 30-75%

Borderline Personality Disorder

23%

Eating Disorder 23-55%*

Co-morbidity of Substance Use and Psychiatric Disorders

Among a sample of about 10,000 adults:

13.5% had an alcohol use disorder. Of those, 36.6% also had a psychiatric disorder.

6.1% had a drug use disorder. Of those, 53.1% also had a psychiatric disorder.

22.5% had a psychiatric disorder. Of those, 28.9% also had an alcohol or drug use disorder.


Source: Regier et al. 1990

Psychiatric Disorders in Addiction TreatmentTwo studies of Prevalence rates in addiction treatment settings had similar findings. Persons

with substance use disorders are also likely to have mood and anxiety disorders.

Source: Cacciola et al, 2001; Ross, Glaser and Germanson 1988


CROSS-CUTTING ISSUES

SuicidalityWhile suicidality is not a DSM-5 mental disorder per se, it is a high-risk behavior associated with COD

Nicotine Use Disorder is recognized as a disorder in DSM-5, and as such a client with nicotine use disorder and a mental disorder could be considered to have a co-occurring disorder

Tobacco’s chief effects are medical rather than behavioral, and it is not conceptualized and presented

as a typical co-occurring addiction disorder

SUICIDALITY

Alcohol abuse is associated with 25-50% of suicidesBetween 5-27% of all deaths of people who abuse alcohol are

caused by suicideLifetime risk for suicide among alcohol abusers estimated to

be 15%Strong relationship between substance abuse and suicide in

young peopleCOD—Alcoholism and Depression increase risk

10 LEADING CAUSES OF DEATH, UNITED STATES2008, ALL RACES, BOTH SEXES

WISQARSTM Produced By: Office of Statistics and Programming, National Center for Injury Prevention and Control, CDC Data Source: National Center for Health Statistics (NCHS), National Vital Statistics System

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SUICIDE: TOUGH REALITIES

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TOUGH REALITIES

50 percent of those who die by suicide were afflicted with major depression…the suicide rate of people with major

depression is 8 times that of the general population

90 percent of individuals who die by suicide had a mental disorder

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*TOUGH REALITIES

~30 % of deaths by suicide involved alcohol intoxication – BAC at or above legal limit

4 other substances were identified in ~10% of tested victims – amphetamines, cocaine, opiates (prescription & heroin), marijuana

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*MISSED OPPORTUNITIES = LIVES LOST

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77 percent of individuals who die by suicide had visited their primary care doctor w/in the year

45 percent had visited their primary care

doctor w/in the month

18 percent of elderly patients visited their primary care doctor on same day as their suicide

THE QUESTION OF SUICIDE WAS SELDOM RAISED . . .

LIKELIHOOD OF A SUICIDE ATTEMPT

Risk Factor

Cocaine useMajor DepressionAlcohol useSeparation or Divorce

NIMH/NIDA

Increased Odds Of Attempting Suicide

62 times more likely41 times more likely8 times more likely11 times more likelyECA EVALUATION

SUICIDALITY

SUD alone increases suicidality, while the added presence of some mental disorder doubles an already heightened risk

Risk of suicide is greatest when relapse occurs after a substantial period of abstinence—especially if there is concurrent financial or psychosocial loss

SUICIDALITY

Advice to the Counselor:

Counseling a Client Who Is SuicidalScreen for suicidal thoughts or plans with anyone who makes suicidal references, appears seriously

depressed, or who has a history of suicide attempts. Treat all suicide threats with seriousness.Assess the client’s risk of self-harm by asking about what is wrong, why now, whether specific plans

have been made to commit suicide, past attempts, current feelings, and protective factorsDevelop a safety and risk management process with the client that involves a commitment on the

client’s part to follow advice, remove the means to commit suicide (e.g., a gun), and agree to seek help and treatment. Avoid sole reliance on “no suicide contracts.”

Assess the client’s risk of harm to others.Provide availability of contact 24 hours per day until psy chiatric referral can be realized. Refer

those clients with a serious plan, previous attempt, or serious mental illness for psychiatric intervention or obtain the assistance of a psychiatric consultant for the management of these clients.

Monitor and develop long-term recovery plans to treat substance abuse and strategies to ensure medication adherence.

Review all such situations with the supervisor and/or treatment team members.Document thoroughly all client reports and counselor suggestions.

COD—SUD & AFFECTIVE DISORDERS

Co-occurring Substance Use Disorder and Affective Disorders

DSM 5 MAJOR DEPRESSIVE EPISODE

A. Five (or more) present during the same 2-week period, represent a change, at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.(1) depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful).(2) markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)(3) significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains.(4) insomnia or hypersomnia nearly every day(5) psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)(6) fatigue or loss of energy nearly every day(7) feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)(8) diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)(9) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide B. Symptoms do not meet criteria for a Mixed Episode.C. Symptoms cause clinically significant distress or impairment in functioning.D. Symptoms are not due to the direct physiological effects of a substance or a medical condition.

BIPOLAR II DISORDER

A. Presence (or history) of one or more Major Depressive Episodes. B. Presence (or history) of at least one Hypomanic Episode. (Duration 4 days)C. There has never been a Manic or a Mixed Episode. D. The mood symptoms in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified. E. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.Bipolar I Disorder One or more Manic Episodes...or Mixed Episodes... Often individuals have also had one or more Major Depressive Episodes, but this is not required for diagnosis. Episodes of Substance-Induced Mood Disorder or of Mood Disorder Due to a General Medical Condition do not count toward a diagnosis of Bipolar I Disorder

A manic episode is defined in the DSM as a period of seven or more days (or any period if admission to hospital is required) of unusually and continuously effusive and open elated or irritable mood, where the mood is not caused by drugs/medication or a medical illness and (a) is causing obvious difficulties at work or in social relationships and activities, or (b) requires admission to hospital to protect the person or others, or (c) the person is suffering psychosis, changes in activity and energy as well as mood.

To be classed as a manic episode, while the disturbed mood is present at least three (or four if only irritability is present) of the following must have been consistently prominent: grand or extravagant style, or expanded self-esteem; pressured speech; reduced need of sleep (e.g. three hours may be sufficient); talks more often and feels the urge to talk longer; ideas flit through the mind in quick succession, or thoughts race and preoccupy the person; over indulgence in enjoyable behaviors with high risk of a negative outcome (e.g., extravagant shopping, sexual adventures or improbable commercial schemes). [

If the person is concurrently depressed, they are said to be having a mixed episode.

COD—AUD/DUD AND AFFECTIVE DISORDERS

https://www.inkling.com/read/ries-asam-principles-addiction-medicine-5th/chapter-86/table-86-4

50% of individuals with SUD have an affective or anxiety disorder at some time in their lives

Among women with SUD—Mood Disorders may be prevalent with women more likely than men to be clinically depressed and/or to have PTSD

CO-OCCURRING MOOD DISORDERS & ANXIETY DISORDERS

Older adults may be the group at highest risk for combined mood disorder and substance problems

Episodes of mood disturbance generally increase in frequency with age

COD (mood d/o & SUD)—tend to have more episodes as they get older, even when their substance use is controlled


Medical problems and medications can produce symptoms of anxiety and mood disorders.

25% of individuals with chronic or serious general medical conditions, such as diabetes or stroke, develop major depressive disorder


Both substance use and discontinuance may be associated with depressive symptoms

Acute manic symptoms may be induced or mimicked by intoxication with stimulants, anabolic steroids, hallucinogens, or poly-drug combinations

Substance use is more often a cause of anxiety symptoms rather than an effort to cure these symptoms

Since mood and anxiety symptoms may result from SUD, not an underlying mental disorder—careful and continuous assessment is essential


Mood Disorder Intoxication Withdrawal

Depression/ Alcohol, BZD, Alcohol, BZD, Dysthymia Opioid, Barb., Barb., Opioid,(Persistent Depressive Disorder) THC, Steroids Steroids,

Stimulants StimulantsMania and Cyclothymia Stimulants, Alcohol, Alcohol,BZD

Hallucinogens, Inh. Barb.,Opioid Steroid(chronic/acute) Steroid(chronic)

DRUGS THAT PRECIPITATE OR MIMIC MOOD DISORDERS

ADVICE TO THE COUNSELOR: COUNSELING A CLIENT WITH A MOOD OR ANXIETY DISORDER

Differentiate among the following: mood and anxiety disorders; commonplace expressions of anxiety and depression; and anxiety and depression associated with more serious mental illness, medical conditions and med ication side effects, and substance-induced changes.

Although true for most counseling situations, it is espe cially important to maintain a calm demeanor and a reassuring presence with these clients.

Start low, go slow (that is, start “low” with general and non-provocative topics and proceed gradually as clients become more comfortable talking about issues).

Monitor symptoms and respond immediately to any intensification of symptoms.

Understand the special sensitivities of phobic clients to social situations.

Gradually introduce and teach skills for participation in mutual self-help groups.

Combine addiction counseling with medication and men tal health treatment.


CO-OCCURRING ANXIETY DISORDERS

Prevalence (NESARC)17.7% with SUD in past 12 months met criteria for

Independent Anxiety Disorder15% with Anxiety Disorder in past 12 months had at least one

co-occurring SUDRelationship between Anxiety Disorders and Drug Use

Disorders (OR 2.8) was stronger than the relationship between anxiety and alcohol use disorder (AUDS) (OR 1.7)

AUD—12 month prevalence 8.5% & Lifetime prevalence 30.3%

AUD with AD—OR 1.9/12months & OR 10.4/lifetime



OR were more positive for abuse compared with dependence and for women compared to men

Most Common Drugs:Marijuana use disorder—15.1 % in ADsCocaine use disorder—5.4% in ADsAmphetamine use disorder—4.8% in ADsHallucinogen use disorder—3.7% in ADsSedative use disorder—2.6% in ADs



TREATMENT:-Maximize use of non-pharmacologic treatments

(AA/NA, IOP, attendance at 12-step recovery programs, finding a sponsor, and speaking up in groups???)-CBTs-Pharmaco-therapeutics

SRI’s first line, SNRI’s alternate first lineVenlafaxine (GAD, PD, and SAD)Mirtazapine (PD and SAD)Buspirone (useful for GAD, generally not for

PD/SAD)Anticonvulsants (Pregabalin—GAD, SAD)Agents Targeting SUD—Naltrexone, Disulfiram


PSYCHOTIC DISORDERS—WITH COD

There is no clear pattern of drug choice among clients with schizophrenia. Instead, it is likely that whatever substances happen to be available or in vogue will be the sub stances used most typically.

• What looks like resistance or denial may in reality be a manifestation of negative symp toms of schizophrenia.

• An accurate understanding of the role of substance use disorders in the client’s psy chosis requires a multiple-contact, longitu dinal assessment.

• Clients with a co-occurring mental disorder involving psychosis have a higher risk for self-destructive and violent behaviors.

• Clients with a co-occurring mental disorder involving psychosis are particularly vulner able to homelessness, housing instability, victimization, poor nutrition, and inade quate financial resources.

• Both psychotic and substance use disorders tend to be chronic disorders with multiple relapses and remissions, supporting the need for long-term treatment. For clients with co-occurring disorders involving psy chosis, a long-term approach is imperative.


NEGATIVE SYMPTOMS OF SCHIZOPHRENIA

Positive symptoms make treatment seem more urgent, and they can often be effectively treated with antipsychotic drugs. But negative symptoms are the main reason patients with schizophrenia cannot live independently, hold jobs, establish personal relationships, and manage everyday social situations.

Blunted affectAlogia (poverty of speech)Anhedonia Associality (lack of desire to form relationships)Avolition (lack of motivation)


PREVALENCE SCHIZOPHRENIA

The lifetime prevalence rate for adults with schizophrenia is between 0.5 and 1.5 percent (APA 2000). The Epidemiologic Catchment Area (ECA) studies reported that among clients with schizophrenia, 47 percent met criteria for some form of a substance use disorder (Regier et al. 1990). Fifteen years earlier, McLellan and Druley (1977) also found that about half of male inpatients with schizophrenia could be expected to have a co occurring addiction to amphetamines, alcohol, or hallucinogens.


PSYCHOTIC DISORDERS

Descriptive FeaturesThe term “psychotic” historically has received a number of different definitions, none of which has achieved universal

acceptance. The narrowest definition of psychotic is restricted to delusions or prominent halluci nations, with the hallucinations occurring in the absence of insight into their pathological nature. A slightly less restrictive definition also would include prominent hallucinations that the individual realizes are hallu cinatory experiences. Broader still is a definition that also includes other positive symptoms of schizophre nia (i.e., disorganized speech, or grossly disorganized or catatonic behavior). Unlike these definitions based on symptoms, the definition used in earlier classifications (e.g., DSM-II and ICD-9) probably was far too inclusive and focused on the severity of functional impairment. In that context, a mental disorder was termed “psychotic” if it resulted in “impairment that grossly interferes with the capacity to meet ordinary demands of life.” The term also has previously been defined as a “loss of ego boundaries” or a “gross impairment in reality testing.”

Schizophrenia is a disorder that lasts for at least 6 months and includes at least 1 month of active-phase symptoms (i.e., two or more) of the following: delusions, hallucinations, disorganized speech, grossly disor ganized or catatonic behavior, negative symptoms.

5 subtypes: (1) paranoid type, in which delusions or hallucina tions predominate; (2) disorganized type, in which speech

and behavior peculiarities pre dominate; (3) catatonic type, in which catalep sy or stupor, extreme agitation, extreme negativism or mutism, peculiarities of voluntary movement or stereotyped movements predomi nate; (4) undifferentiated type, in which no sin gle clinical presentation predominates; and (5) residual type, in which prominent psychotic symptoms no longer predominate.


SCHIZOPHRENIA--FEATURES

Diagnostic criteria for schizophreniaCharacteristic symptoms: Two (or more) of the following, each present for a significant portion of time during a 1-month

period (or less if successfully treated):DelusionsHallucinationsDisorganized speech (e.g., frequent derailment or incoherence)Grossly disorganized or catatonic behaviorNegative symptoms, i.e., affective flattening, alogia, or avolition

Note: Only one Criterion A symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person’s behavior or thoughts, or two or more voices conversing with each other.

Social/occupational dysfunction: For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, failure to achieve expected level of interpersonal, academic, or occupational achievement).

Duration: Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active- phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).

Schizoaffective and Mood Disorder exclusion: Schizoaffective Disorder and Mood Disorder With Psychotic Features have been ruled out because either (1) no Major Depressive, Manic, or Mixed Episodes have occurred concurrently with the active-phase symptoms; or (2) if mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and residual periods.


SCHIZOPHRENIA-CONTINUED-FEATURES

Criteria:--Continued:Substance/general medical condition exclusion: The disturbance is not due to the direct physiological effects of a

substance (e.g., a drug of abuse, a medication) or a general medical condition.

Relationship to a Pervasive Developmental Disorder: If there is a history of Autistic Disorder or another Pervasive Developmental Disorder, the additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations also are present for at least a month (or less if successfully treated).

Classification of longitudinal course (can be applied only after at least 1 year has elapsed since the initial onset of active-phase symptoms):

•Episodic With Inter episode Residual Symptoms (episodes are defined by the reemergence of prominent psychotic symptoms); also specify if: With Prominent Negative Symptoms

•Episodic With No Inter episode Residual Symptoms•Continuous (prominent psychotic symptoms are present throughout the period of observation); also spec ify if: With

Prominent Negative Symptoms•Single Episode In Partial Remission; also specify if: With Prominent Negative Symptoms•Single Episode In Full Remission•Other or Unspecified PatternSource: Reprinted with permission from DSM-IV-TR (APA 2000, pp. 298–302, 312–313).


PSYCHOTIC DISORDERS

Although schizophrenia is the illness most strongly associated with psychotic disorders, people with bipolar disorder (or what used to be termed “manic depressive illness”) may experience psychotic states during periods of mania—the heightened state of excitement, lit tle or no sleep, and poor judgment described above. Other conditions also can be accompa nied by a psychotic state, including toxic poi soning, other metabolic difficulties (infections [e.g., late stage AIDS]), and other mental

dis orders (major depression, dementia, alcohol withdrawal states, brief reactive psychoses, and others).


PREVALENCE BIPOLAR DISORDER

The lifetime prevalence of bipolar disorder also is roughly 1 percent of the general U.S. popula tion (APA 2000), so both schizophrenia and bipolar disorder are relatively rare compared to major depressive illness, which has lifetime incidences in the general population of 10 to 25 percent for women and 5 to 12 percent for men (APA 2000).


PREVALENCE BIPOLAR DISORDER

The lifetime prevalence of bipolar disorder also is roughly 1 percent of the general U.S. popula tion (APA 2000), so both schizophrenia and bipolar disorder are relatively rare compared to major depressive illness, which has lifetime incidences in the general population of 10 to 25 percent for women and 5 to 12 percent for men (APA 2000).

People with bipolar disorder also are subject to high rates of co -occurring sub stance abuse and dependence, with even higher rates in specific populations. In the ECA study, nearly 90 percent of those with bipolar disor der in a prison population had a co -occurring substance use disorder (Regier et al. 1990).


CO-OCCURRING AD/HD

Defined as persistent pattern of inattention and/or hyperactivity-impulsivity that is displayed more frequently and more serious than is observed typically in individuals at a comparable level of development


CO-OCCURRING AD/HD PREVELANCE

Prevelance:Studies of the adult substance abuse treatment population have found AD/HD in 5 to 25 % of

persons(about 1 in 6 patients)

Approximately 33% of adults with AD/HD have histories of alcohol abuse or dependence

20% of adults have other drug abuse or dependence


CO-OCCURRING AD/HD

Adults with Persistent symptoms of AD/HD who have a history of conduct disorder or have co-occurring APD (antisocial personality disorder) are at the highest risk for SUD


CO-OCCURRING AD/HD

AD/HD adults found to primarily use alcohol, with marijuana being the second most common drug of abuse

History of a typical AD/HD substance abuse treatment client may show early school problems before substance abuse began

AD/HD substance abuse treatment client may use self-medication for AD/HD as an excuse for drug use


CO-OCCURRING AD/HD

Most common attention problems in Treatment populations are secondary to short-term toxic effects of substances, and these should be substantially better with each month of sobriety


CO-OCCURRING AD/HD

Most common attention problems in Treatment populations are secondary to short-term toxic effects of substances, and these should be substantially better with each month of sobriety

Presence of AD/HD complicates the treatment of substance abuse, since clients with these COD may have more difficulty engaging in Treatment and learning abstinence skills, be at greater risk for relapse, and have poorer substance use outcomes


CO-OCCURRING AD/HD

Clients may respond differently to various therapeutic approaches


CO-OCCURRING AD/HD

Advice to the Counselor Counseling a client who has AD/HD


CO-OCCURRING TREATMENT ADVICE

1) Clarify repeatedly what elements of a question he or she has responded to and what remains to be addressed

2) Eliminate distracting stimuli from the environment3) Use visual aides to convey information4) Reduce the time of meetings and length of verbal

exchanges5) Encourage the client to use tools (e.g., activity journals,

written schedules, and “to do” lists to organize important events and information

6) Refer for evaluation of the need for medication7) Focus on Enhancing client’s knowledge about AD/HD


CLINICAL CASE STUDY: SELF CANNOT SEE SELF—JERRY M.

Jerry M. is a 59y/o divorced male nurse who is a UR RN for a state psychiatric hospital who has been in “recovery” from opioid dependency (IV) since 1993. He had returned to use of alcohol about 5 years after going through Tx in 1993—then 3 years of aftercare with RNP. He went to AA for a few years but stopped when he resumed his drinking. Recently, Jerry (who always has been a little “odd”) turned 59 in June of 2014 and felt that he needed to enroll in a “anti-aging” program—which included regular testosterone injections weekly. He also felt that he was less attentive and a psychiatrist at his workplace recommended that he take Adderall to focus better and to treat his “undiagnosed” AHDH. He got a script for Adderall by his treating psychiatrist. Had to add Ambien at bedtime about 8 weeks later for his increasing problem with severe insomnia.

To be continued…..


SEVERITY OF CO-OCCURRING DISORDERS

Co-occurring mental health disorders are often placed on a continuum of severity.

Non-severe: early in the continuum and can include mood disorders, anxiety disorders, adjustment disorders and personality disorders.

Severe: include schizophrenia, bipolar disorder, schizoaffective disorder and major depressive disorder.

SEVERITY OF CO-OCCURRING DISORDERS

The classification of “severe and non-severe” is based on a specific diagnosis and by state criteria for Medicaid qualification but can vary significantly based on severity of the disability and the duration of the disorder.

QUADRANTS OF CARE

The quadrants of care are a conceptual frame work that classifies clients in four basic groups based on relative symptom severity, not diagnosis.• Category I: Less severe mental disorder/

Less severe substance disorder• Category II: More severe mental disorder/

Less severe substance disorder• Category III: Less severe mental disorder/

More severe substance disorder• Category IV: More severe mental disorder/

More severe substance disor der

(National Association of State Mental Health Program Directors [NASMHPD] andNational Association of State Alcohol and Drug Abuse Directors [NASADAD] 1999)

QUADRANTS OF CARE

Figure 1: Special Settings as a Function of COD Severity

Source: Adapted from National Association of State Mental Health Program Directors (NASMHPD) & National Association of State Alcohol and Drug Abuse Directors (NASADAD), 1999.

QUADRANTS OF CARE

Model provides a framework for understanding the range of co-occurring conditions and the level of coordination that service systems need to address them.

Four Quadrants of Care provides a structure for moving beyond minimal coordination to fostering consultation, collaboration, and integration among systems and providers in order to deliver appropriate care


MODELS OF TREATMENT

Clients with co-occurring disorders have historically received substance abuse treatment services in isolation from mental health treatment services.

As more research on co-occurring disorders began to be conducted, the many limitations this approach places on the client and his or her success in treatment began to surface.

A twenty-eight year-old-woman named Anita entered an addiction treatment center where she was assessed as having alcohol dependence. Six months earlier, Anita had been diagnosed with major depressive disorder and was prescribed medication by her family doctor. At the treatment facility, it was recommended that Anita be re-assessed and treated, if necessary, at a mental health clinic, located nearby in town. What model of treatment does this scenario represent?

single model of treatment sequential model of treatment parallel model of treatment integrated model of treatment

MODELS OF TREATMENT

Single model of care - It was believed that once the “primary disorder" was treated effectively, the client’s substance use problem would resolve itself because drugs and/or alcohol were no longer needed to cope.

Sequential model of treatment - acknowledges the presence of co-occurring disorders but treats them one at a time.

Parallel model of treatment - mental health disorders are treated at the same time as co-occurring substance use disorders, only by separate treatment professionals and often at separate treatment facilities.

MODELS OF TREATMENT

INTEGRATED MODEL OF TREATMENT

Integrated model of treatmentan approach to treating co-occurring disorders that utilizes one competent treatment team at the same facility to recognize and address all mental health and substance use disorders at the same time.

WHY IS THIS SO DIFFICULT?

Fear in the SUD treatment community of putting addiction on the back burner.

High utilization of time and resources.Primary approach for MI is medications.Primary approach for SUD after detox is other therapeutic

interventions (pre-Suboxone).“Denial” by the individual and their family members regarding both. Fear of placing more and more people in the bind of creating more

stigma, more disability.(According to the 2004 World Health Report, Maj. Dep. Is the leading

cause of disability in the US and Canada for ages 15-44.)


WHY IS THIS SO DIFFICULT?

Addiction Disorders• Health problems• Family/intimacy problems• Isolation• Financial problems• Employment problems• School problems• High risk driving/other accidents• Multiple admissions• Chronic/relapsing• Increased suicide• Has many patterns• Lack of progress=failure• Changing diagnostic criteria

Psychiatric Disorders• Health problems• Family/intimacy problems• Isolation• Financial problems• Employment problems• School problems• High risk driving/other accidents• Multiple admissions• Chronic/relapsing• Increased suicide• Has many patterns• Lack of progress=failure• Changing diagnostic criteria

INTEGRATED MODEL OF TREATMENT

The integrated model of treatment can best be defined by following seven components:

1) Integration2) Comprehensiveness3) Assertiveness4) Reduction of negative consequences 5) Long-term perspective 6) Motivation-based treatment 7) Multiple psychotherapeutic modalities

BENEFITS OF AN INTEGRATED MODEL OF CARE

Benefits of an Integrated Model of Care

Reduced need for coordination Reduced frustration for clients Shared decision-making responsibilities Families and significant others are included Transparent practices help everyone involved share responsibility Clients are empowered to treat their own illness and manage their

own recovery The client and his/her family has more choice in treatment, more

ability for self-management, and a higher satisfaction with care

One disorder does not necessarily present as “primary.”

There isn’t necessarily a causal relationship between co-occurring disorders.

These are co-occurring brain diseases that need to be treated simultaneously.

An integrated model of care assumes that:

CO-OCCURRING DISORDERS INTERACTIONS

SCREENING AND ASSESSMENT

Screening: The first phase of evaluation where the potential client is interviewed to determine if he or she is appropriate for that specific treatment facility and to determine the possible presence or absence of a substance use or mental health problem.

Assessment: The second phase of evaluation where a systematic interview is necessary to verify the potential presence of a mental health or substance use disorder detected during the screening process.



IntoxicationWithdrawalSubstance-induced disordersMotivational factorsFeelings, symptoms, and disorders

Complexities of Screening and Assessment

CO-OCCURRING DISORDERS INTERACTIONS

Substances and Negative Emotions

The choice of screening measures depends on:1) The skill of the screening professional

2) The cost of the screening materials 3) How simple the scale is to interpret and use across

disciplines

4) Psychometric qualities

5) The relevance of screening to prevalent disorders

6) Movement from very sensitive (generic) measures to more specific measures


MENTAL HEALTH SCREENING FORM III

Mental Health Screening Form-IIIThe Mental Health Screening Form III was ini tially designed as a rough screening

device for clients seeking admission to substance abuse treatment programs.

Each MHSF III question is answered either “yes” or “no.” All questions reflect the respon dent’s entire life history; therefore all questions begin with the phrase “Have you ever...”

The MHSF III features a “Total Score” line to reflect the total number of “yes” responses.

The maximum score on the MHSF III is 18 (question 6 has two parts). This feature will permit programs to do research and program evaluation on the mental health -chemical dependence interface for their clients.


MENTAL HEALTH SCREENING FORM III

Mental Health Screening Form-IIIThe first four questions on the MHSF III are not unique to any particular diagnosis;

howev er, questions 5 through 17 reflect symptoms associated with the following diagnoses/diagnos tic categories: Q5, Schizophrenia; Q6, Depressive Disorders; Q7, Posttraumatic Stress Disorder; Q8, Phobias; Q9, Intermittent Explosive Disorder; Q10, Delusional Disorder; Q11, Sexual and Gender Identity Disorders; Q12, Eating Disorders (Anorexia, Bulimia); Q13, Manic Episode; Q14, Panic Disorder; Q15, Obsessive- Compulsive Disorder; Q16, Pathological Gambling; and Q17, Learning Disorder and Mental Retardation

A “yes” response to any of questions 5 through 17 does not, by itself, ensure that a mental health problem exists at this time. A “yes” response raises only the possibility of a current problem, which is why a consult with a mental health specialist is strongly recommended.


SIMPLE SCREENING INSTRUMENT FOR SUBSTANCE ABUSE (SSI-SA)

SSI-SA (1994) It is a 16 item scale, although only 14 items are scored so that scores can range

from 0 to 14. These 14 items were selected by the TIP 11 consensus panelists from existing alcohol and drug abuse screening tools. A score of 4 or greater has become the established cut off point for war ranting a referral for a full assessment.

Peters et al. (2000) found the SSI SA to be effective in identifying substance dependent inmates, and the SSI SA demonstrated high sensitivity (92.6 percent for alcohol or drug dependence disorder, 87.0 percent for alcohol or drug abuse or dependence disorder) and excellent test -retest reliability (.97)

Others: TCUDS (Texas Christian University Drug Dependence Screen)MAST (Michigan Alcohol Screening Test)



Sources for Items Included in the Simple Screening Instrument for

Substance Abuse

Question No. Source Instrument1 Revised Health Screening Survey (RHSS)2 Michigan Alcohol Screening Test (MAST)3 CAGE4 MAST, CAGE5 History of Trauma Scale, MAST, CAGE6 MAST, Drug Abuse Screening Test

(DAST)7 MAST, Problem- Oriented Screening

Instrument for Teenagers (POSIT)

8 MAST, DAST9 MAST, DSM II R

10 POSIT, DSM III R11 POSIT12 POSIT13 MAST, POSIT, CAGE, RHSS,

Alcohol Use Disorders Identification Test (AUDIT), Addiction Severity Index (ASI)

Note: References for these sources appear at the end of this section.



Domains Measured:Substance ConsumptionPreoccupation and loss of controlAdverse ConsequencesProblem recognitionTolerance and Withdrawal



Short-form of SSI-SA

The four boldfaced questions—1, 2, 3, and 16—constitute the short form of the screening instrument.

Introductory statement:“I’m going to ask you a few questions about your use of alcohol and other drugs during the past 6 months. Your

answers will be kept private. Based on your answers to these questions, we may advise you to get a more complete assessment. This would be voluntary—it would be your choice whether to have an addition al assessment or not.”

During the past 6 months...

1)Have you used alcohol or other drugs? (Such as wine, beer,

hard liquor, pot, coke, heroin or other opioids, uppers,

downers, hallucinogens, or inhalants.) (yes/no)

2)Have you felt that you use too much alcohol or other drugs? (yes/no)

3)Have you tried to cut down or quit drinking or using drugs? (yes/no)

16)Do you feel that you have a drinking or drug problem now? (yes/no)



SSI-SA Self-Administered FormFigure H 3 Simple Screening Instrument for Substance Abuse Self -Administered FormDirections: The questions that follow are about your use of alcohol and other drugs. Your answers will be kept private. Mark the response that best fits for you. Answer the questions in terms of your experiences in the past 6 months.During the last 6 months...1 Have you used alcohol or other drugs? (Such as wine, beer, hard liquor, pot, coke, heroin or other opi oids, uppers, downers, hallucinogens, or inhalants)

Yes No2 Have you felt that you use too much alcohol or other drugs?

Yes No3 Have you tried to cut down or quit drinking or using alcohol or other drugs?

Yes No4Have you gone to anyone for help because of your drinking or drug use? (Such as Alcoholics Anonymous, Narcotics Anonymous, Cocaine Anonymous, counselors, or a treatment program.)

Yes No5 Have you had any health problems? For example, have you:

Had blackouts or other periods of memory loss?

Injured your head after drinking or using drugs?

Had convulsions, delirium tremens (“DTs”)?

Had hepatitis or other liver problems?

Felt sick, shaky, or depressed when you stopped?

Felt “coke bugs” or a crawling feeling under the skin after you stopped using drugs?

Been injured after drinking or using?

Used needles to shoot drugs?6 Has drinking or other drug use caused problems between you and your family or friends? Yes No7 Has your drinking or other drug use caused problems at school or at work? Yes No



SSI-SA Self-Administered Form

Total Score:______________ (0-14)

Score Degree of Risk for Substance Abuse

0-1 None to Low

2-3 Minimal

>4 Moderate to HighPossible need for assessment

(Do not score 1 and 15)


Integrated Assessment Process – 12 Steps1. Engage the Client



2. Identify and Contact Collaterals




3. Screen for and Detect Co-occurring Disorders





4. Determine Quadrant and Locus of Responsibility






5. Determine Level of Care


American Society of Addiction Medicine Patient Placement Criteria – 2nd Edition Revised (ASAM PPC-2R) dimensions of care

Dimension 1: Acute Intoxication and/or Withdrawal Potential Dimension 2: Biomedical Conditions and Complications Dimension 3: Emotional, Behavioral or Cognitive Conditions

and Complications Dimension 4: Readiness to Change Dimension 5: Relapse, Continued Use or Continued Problem

Potential Dimension 6: Recovery/Living Environment

DETERMINING LEVEL OF CARE

Level I: Outpatient treatment.

Level II: Intensive outpatient treatment, including partial hospitalization.

Level III: Residential/medically monitored intensive inpatient treatment.

Level IV: Medically managed intensive inpatient treatment.






5. Determine Level of Care

6. Determine Diagnosis


DETERMINE DIAGNOSIS (DDX)

Case 1. Maria M., the 38-year-old Hispanic/Latina female with cocaine and opioid dependence, initially was receiving methadone maintenance treatment only. She also used antidepressants prescribed by her outside primary care physician. She presented to methadone maintenance program staff with complaints of depres sion. Maria M. reported that since treatment with methadone (1 year) she had not used illicit opioids.

However, she stated that when she does not use cocaine, she often feels depressed “for no reason.” Nevertheless, she has many stressors involving her children, who also have drug problems. She reports that depression is associated with impulses to use cocaine, and consequently she has recurrent cocaine binges.

These last a few days and are followed by persistent depression.What is the mental diagnosis?



To answer this question it is important to obtain a mental disorder history that relates mental symptoms to particular time periods and patterns of substance use and abuse.

The client’s history reveals that although she grew up with an abusive father with an alcohol problem, she herself was not abused physically or sexually. Although hampered by poor reading ability, she stayed in school with no substance abuse until she became pregnant at age 16 and dropped out of high school. Despite becoming a single mother at such a young age, she worked three jobs and functioned well, while her mother helped raise the baby. At age 23, she began a 9-year relationship with an abusive person with an alcohol and illicit drug problem, during which time she was exposed to a period of severe trauma and abuse. She is able to recall that during this relationship, she began to lose her self-esteem and experience persistent depression and anxiety.



She began using cocaine at age 27, initially to relieve those symptoms. Later, she lost control and became addicted. Four years ago, she was first diagnosed as having major depression, and was prescribed antide pressant medication, which she found helpful. Two years ago, she began using opioids, became addicted, and then entered methadone treatment. She receives no specific treatment for cocaine dependence. She has noticed that her depression persists during periods of cocaine and opioid abstinence lasting more than 30 days. On one occasion, during one of these periods, her medication ran out, and she noticed her depression became much worse. Even at her baseline, she remains troubled by lack of self-confidence and fearfulness, as well as depressed mood.



Her depression persists during periods of more than 30 days of abstinence and responds to some degree to antidepressants. The fact that her depression persists even when she is abstinent and responds to antide pressants suggests strongly a co-occurring affective disorder. There are also indications of the persistent effects of trauma, possibly posttraumatic stress disorder. Trauma issues have never been addressed. Her opioid dependence has been stabilized with methadone. She has resisted recommendations to obtain more specific treatment for cocaine dependence.


Integrated Assessment Process – 12 Steps

7. Determine Disability and Functional Impairment


DETERMINE DISABILITY AND FUNCTIONAL IMPAIRMENT

Assessment of Maria M.’s functional capacity at baseline indicated that she could read only at a second grade level. Consequently, educational materials presented in written form needed to be presented in alternative formats. These included audiotapes and videos to teach her about addiction, depression, trauma, and recovery from these conditions. In addition, Maria M.’s history of trauma (previously dis cussed) led her to experience anxiety in large group situations, particularly where men were present. This led her counselor to recommend attending 12-Step meetings that were smaller and/or women only. The counselor also suggested that she attend in the company of female peers. Further, the clinician referred her to trauma-specific counseling.




8. Identify Strengths and Supports





9. Identify Cultural and Linguistic Needs and Supports


IDENTIFY CULTURAL AND LINGUISTIC NEEDS AND SUPPORTS

Assessment Step 9—Application to Case Maria M.Maria M. initially had difficulty identifying herself as being a

victim of trauma both because she had normalized her perception of her early family experience with her abusive father and because she had received cultural reinforcement in the past that condoned the behavior of her abusive boyfriend as “nor mal machismo.” Referral to a group that included other Hispanic women who also had suffered abuse was very helpful to her. With the help of the group, she began to recognize the reality of the impact that trauma had had in her life.






10. Identify Problem Domains







11. Determine Stage of Change







11. Determine Stage of Change

12. Plan Treatment


ELEMENTS OF AN INTEGRATED MODEL

Diagnostic process that produces provisional diagnosis of psychiatric and substance use disorders using:

Substances used (Limitations of but necessity of valid toxicology results.) and when, how much, how often, last time.

Review of signs and symptoms (psychiatric and substance use). Rating scales may be helpful but not better than a really good history. Collateral information.

Personal history timeline of symptom emergence (what started when).

Family history of psychiatric/substance use disorders.Psychiatric/substance use treatment history.Look for things that cluster.



Initial treatment plan (Days 1-10) that includes:

Choice of a treatment setting appropriate to initially stabilize medical conditions, psychiatric symptoms and drug/alcohol withdrawal symptoms

Initiation of medications to control urgent psychiatric symptoms (psychotic, severe anxiety, etc.)

Implementation of medication protocol appropriate for treating withdrawal syndrome(s)

Ongoing assessment and monitoring for safety, stabilization and withdrawal



Early stage treatment plan (Days 2-14) that includes:Selection of treatment setting/housing with adequate

supervisionCompletion of withdrawal medicationReview of psychiatric medicationsCompletion of assessment in all domains (psychology,

family, educational, legal, vocational, recreational)Initiation of individual therapy and counseling (extensive use

of motivational strategies and other techniques to reduce attrition)

Introduction to behavioral skills group and educational groups, step groups

Introduction to self help programsUrine testing and breath alcohol testing



Intermediate treatment plan (up to 6 or 8 weeks) that includes:

Housing plan that addresses psychiatric and substance use needsPlan of ongoing medication for psychiatric and substance use

treatment with strategies to enhance compliancePlan of individual and group therapies and psychoeducation

with attention to both psychiatric and substance use needsSkills training for successful community participation and relapse

preventionFamily involvement in treatment processesSelf-help program participationProcess of monitoring treatment participation (attendance and

goal attainment)Urine and breath alcohol testing



Extended treatment plan that includes (up to 6 months):

Housing planOngoing medication for psych and substance use treatmentPlan of individual and group therapies and psychoeducation with

attention to both psychiatric and substance use needsOngoing participation in relapse prevention groups and

appropriate behavioral skills groups and family involvementInitiation of new skill groups (e.g.; education, vocational, recreational

skills) Self help involvement and ongoing testingMonitoring attendance and goal attainment



Ongoing plan (Continuing Care Plan) of visits for review of:

Medication needsIndividual therapiesSupport groups for psych and substance use conditionsSelf help involvementInstructions to family to recognize relapse to psych and

substance useIn short, a chronic care model is used to reduce

relapse and if/when relapse (psychiatric or substance use) occurs, treatment intensity can be intensified.


STRATEGIES FOR WORKING WITH CLIENTS WITH CO-OCCURRING DISORDERS

Key Techniques for Working With Clients Who Have COD

Provide motivational enhancement consistent with the client’s specific

stage of change.

Design contingency management techniques to address specific target

behaviors.

Use cognitive–behavioral therapeutic techniques.

Use relapse prevention techniques.

Use repetition and skills-building to address deficits in functioning.

Facilitate client participation in mutual self-help groups.


EVIDENCE-BASED PRACTICES

In most treatment addiction centers, the three primary evidence-based practices used are:

motivational enhancement therapy (MET) cognitive-behavioral therapy (CBT) twelve step facilitation (TSF)

All of these treatment models are widely used – often without formal training – by addiction professionals around the country and can be easily applied to clients suffering from co-occurring disorders.

EVIDENCE-BASED PRACTICES

The Integrated Combined Therapies model combines these three EBPs (Evidence-Based Practices) into a stage-wise treatment plan whereby:

motivational enhancement therapy is first utilized to initiate change and engage the client in the therapeutic process;

cognitive-behavioral therapy is then used to help make change within the client; and

twelve step facilitation is essential to helping maintain and sustain changes.

STAGES OF CHANGE/STAGES OF TREATMENT


Guidelines for Developing Successful Therapeutic Relationships With Clients With COD

•Develop and use a therapeutic alliance to engage the client in treatment•Maintain a recovery perspective•Manage countertransference•Monitor psychiatric symptoms•Use supportive and empathic counseling•Employ culturally appropriate methods•Increase structure and support



Advice to the Counselor:Forming a Therapeutic Alliance

-Demonstrate an understanding and acceptance of the client.-Help the client clarify the nature of his difficulty.-Indicate that you and the client will be working together.-Communicate to the client that you will be helping her to help herself.-Express empathy and a willingness to listen to the client’s formulation

of the problem.-Assist the client to solve some external problems directly and

immediately. Foster hope for positive change.



Advice to the Counselor:Maintaining a Recovery PerspectiveThe consensus panel recommends the following ap proaches for maintaining a

recovery perspective with clients who have COD:

Assess the client’s stage of change (Motivational Enhancement below).Ensure that the treatment stage (or treatment expecta tions) is (are) consistent with the

client’s stage of change.Use client empowerment as part of the motivation for change.Foster continuous support.Provide continuity of treatment.Recognize that recovery is a long-term process and that even small gains by the client

should be supported and applauded.


CASE STUDY: USING MET WITH A CLIENT WHO HAS COD

Gloria M. is a 34-year-old African-American female with a 10-year history of alcohol dependence and 12-year history of bipolar disorder. She has been hospitalized previously both for her mental disorder and for sub stance abuse treatment. She has been referred to the outpatient substance abuse treatment provider from inpatient substance abuse treatment services after a severe alcohol relapse.

Over the years, she sometimes has denied the seriousness of both her addiction and mental disorders. Currently, she is psychiatrically stable and is prescribed Valproic acid to control the bipolar disorder. She has been sober for 1 month.

At her first meeting with Gloria M., the substance abuse treatment counselor senses that she is not sure where to focus her recovery efforts—on her mental disorders or her addiction. Both have led to hospitaliza tion and to many life problems in the past. Using motivational strategies, the counselor first attempts to find out Gloria M.’s own evaluation of the severity of each disorder and its consequences to determine her stage of change in regard to each one.

Gloria M. reveals that while in complete acceptance and an active stage of change around alcohol depen dence, she is starting to believe that if she just goes to enough recovery meetings she will not need her bipolar medication. Noting her ambivalence, the counselor gently explores whether medications have been stopped in the past and, if so, what the consequences have been. Gloria M. recalls that she stopped taking medications on at least half a dozen occasions over the last 10 years; usually, this led her to jail, the emergency room, or a period of psychiatric hospitalization. The counselor explores these times, asking: Were you feeling then as you were now—that you could get along? How did that work out? Gloria M. remembers believing that if she attended 12-Step meetings and prayed she would not be sick. In response to the counselor’s questions, she observes , “I guess it hasn’t ever really worked in the past.”

The counselor then works with Gloria M. to identify the best strategies she has used for dual recovery in the past. “Has there been a time you really got stable with both disorders?” Gloria M. recalls a 3-year period between the ages of 25 and 28 when she was stable, even holding a job as a waitress for most of that period. During that time, she recalls, she saw a psychiatrist at a local mental health center, took medications regular ly, and attended AA meetings frequently. She recalls her sponsor as being supportive and helpful. The coun selor then affirms the importance of this period of success and helps Gloria M. plan ways to use the strategies that have already worked for her to maintain recovery in the present.


Double Trouble in Recovery Mental Illness Anonymous Dual Disorders Anonymous Dual Recovery Anonymous Dual Diagnosis Anonymous

DUAL-RECOVERY MUTUAL SELF-HELP

Specific dual-recovery groups can provide essential peer support:

GUIDING PRINCIPLES OF RECOVERY

There are many pathways to recovery.

Recovery is self-directed and empowering, involving personal recognition of the need for change and transformation.

Recovery exists on a continuum of improved health and wellness.

Recovery involves addressing discrimination and transcending shame and stigma.

Recovery is supported by peers and allies, and involves joining and rebuilding a life in the community.

Recovery is a reality.

(from CSAT’s Regional Recovery Meetings, May 2008)

12 STEP VERSUS COGNITIVE BEHAVIORAL TREATMENT (SELF-MANAGEMENT AND RECOVERY TRAINING) IN DUAL DIAGNOSIS (BROOKS & PENN, AM J OF ALCOHOL AND DRUG ABUSE, 29 (2), 359-383, 2003.12 Step

More effective in decreasing alcohol use and increasing social interactions

Worsening of medical problems, health, employment, psychiatric hospitalizations

Cognitive Behavioral• More effective in improving overall health and work status

N=50½ went to 12 step treatment and ½ to SMART. One year observation. Findings drawn from those who finished 3 months of treatment.

(Brooks & Penn, 2003)

DOES PARTICIPATION IN SELF-HELP GROUPS REDUCE DEMAND FOR HEALTH CARE? N=1774, 1 YEAR FOLLOW-UP HUMPHREYS ET AL , 2001

Outpt Inpt days Abstinence Visits Rates

12 Step 13.1 10.5 45.7

Cog Beh 17 17 36.2

* all p< .001 ** 64% higher cost for CBT

.


One year ABSTINENCE was predicted by:• AA involvement ( n=377 men and 277 women)

• Not having pro-drinking influences in one's network

• Having support for reducing consumption from people met in AA

• In contrast, having support from non-AA members was

not a significant predictor of abstinence.

Kaskutas: Addiction 2002

DOUBLE TROUBLE RECOVERY (DTR) OUTCOMES

Members of 24 DTR groups (n=240) New York City, 1 year outcomes

Drug/alcohol abstinence = 54% at baseline, increased to 72% at follow-up.

More attendance = better medication adherence,

Better medication adherence = less hospitalization

Magura Add Beh 2003, Psych Serv 2002


EVIDENCE-BASED PRACTICES REGARDING SELF-HELP J OF SUB. ABUSE TREATMENT, VOL 26, ISSUE 3, PP. 151-158, APRIL, 2004.

Summary of status of U.S. self-help groupsA diverse set of self-help organizations has developed for all substances of significant public health concern (Most research done on AA/NA/DTR)

Collectively, these self-help organizations are both appealing and affordable to a broad spectrum of people.

Clinical, agency and governmental procedure and policy influence the prevalence, organizational stability, and availability of addiction-related self-help groups

Synthesis of effectiveness research resultsLongitudinal studies associate AA and NA participation with greater likelihood of abstinence, improved social functioning, and greater self-efficacy. Participation seems more helpful when members engage in other group activities in addition to attending meetings.

Twelve-step self-help groups significantly reduce health care utilization and costs, removing a significant burden from the health care system.

Self-help groups are best viewed as a form of continuing care rather than as a substitute for acute treatment services (e.g., detoxification, hospital-based treatment, etc.)

Randomized trials with coerced populations suggest that AA combined with professional treatment is superior to AA alone.



Jerry M. is a 59y/o divorced male nurse who is a UR RN for a state psychiatric hospital who has been in “recovery” from opioid dependency (IV) since 1993. He had returned to use of alcohol about 5 years after going through Tx in 1993—then 3 years of aftercare with RNP. He went to AA for a few years but stopped when he resumed his drinking. Recently, Jerry (who always has been a little “odd”) turned 59 in June of 2014 and felt that he needed to enroll in a “anti-aging” program—which included regular testosterone injections weekly. He also felt that he was less attentive and a psychiatrist at his workplace recommended that he take Adderall to focus better and to treat his “undiagnosed” AHDH. He got a script for Adderall by his treating psychiatrist. Had to add Ambien at bedtime about 8 weeks later for his increasing problem with severe insomnia.

Jerry M. was in an MVA (second time) in his rental car 2 days before Christmas and charged with DUI (second offense in 30 days) with his immediate transfer to Trauma center after being extracted from car.



Jerry M. is a 59y/o divorced male nurse who is a UR RN for a state psychiatric hospital was then admitted to the ICU after having a BAL of 0.125%. He was transferred the next day for 7 days of “detox” on the mental health ward—diagnosed with Bipolar Disorder (Mania) and placed on Lithium. His mental status improved after the intoxication from alcohol and Ambien resolved, but he still had flight of ideas, pressured speech, disheveled appearance, and a recollection of his prior “hallucinations” he had prior to his initial MVA/DUI. On the seventh day he was transferred to a long term inpatient residential treatment center—now off Adderal, Testosterone injections, Ambien, but now on Lithium. Diagnosis?? Assessments? Treatment Plan?


JAY PILAND MD

Thank You for your participation


integrating treatment for co-occurring disorders

Healthcare