Integrated Treatment for Dual Disorders

1. Integrated Treatment for Dual Disorders Kim Mueser, Ph.D. Dartmouth Medical School NH-Dartmouth Psychiatric Research Center Kim.t.mueser@dartmouth.edu

3. Overview Epidemiology Why focus on dual disorders? Models of etiology Assessment Treatment principles Research Avoiding the blame/demoralization trap How do illness management and recovery fit together?How do illness management and recovery fit together?

5. Rates of Lifetime Substance Use Disorder (SUD) among Recently Admitted Psychiatric Inpatients (N=325) (Mueser et al., 2000)

6. Factors Influencing Prevalence of Substance Use Disorders (SUD): Client Characteristics Higher Rates Males Younger Lower education Single or never married Good premorbid functioning History of childhood conduct disorder Antisocial personality disorder Higher affective symptoms Family history SUD

7. Factors Influencing Prevalence of Substance Use Disorders: Sampling Location Higher Rates Emergency rooms Acute psychiatric hospitals Jails Homeless Urban setting (drugs) Rural setting (alcohol)

8. Major Subgroups of Comorbid Clients Severely mentally ill - psychotic Frequently abuse moderate amounts of substances Small amounts of substance use trigger negative consequences Anxiety and/or depression Substance use can cause or worsen symptoms

9. Frequently abuse moderate to high amounts of substances Personality Disorders Antisocial & borderline most common Frequently abuse high amounts of substances

10. Clinical Epidemiology 1. Rates higher for people in treatment 2. Approximately 50% lifetime, 25% 35% current substance abuse 3. Rates are higher in acute care, institutional, shelter, and emergency settings 4. Substance abuse is often missed in mental health settings

11. Why Focus on Dual Disorders? 1. Substance abuse is the most common co- occurring disorder in persons with severe mental disorders 2. Significant negative outcomes related to substance abuse: 1) Clinical relapse & rehospitalization 2) Demoralization 3) Family stress 4) Violent behavior

12. 1) Incarceration 2) Homelessness 3) Suicide 4) Medical illness 5) Infections diseases 6) Early mortality 3. Outcomes improve when substance abuse remits 4. Poor treatment is expensive for families and society

13. Reasons for High Comorbidity Rates of Severe Mental Illness and Substance Abuse Berkson�s Fallacy Self-medication* Super-sensitivity to effects of substances* Socialization motives Precipitation of psychosis from substance use

14. Common factors Poverty/deprivation Neurocognitive impairment Conduct disorder/antisocial personality disorder

15. Self-Medication: More symptomatic clients don�t abuse more substances Substance selection unrelated to type of symptoms experienced Types of substances abused unrelated to psychiatric diagnosis Self-medication may contribute to some comorbidity but doesn�t explain all More evidence supporting self-medication in anxiety disorders (PTSD)

16. Super-sensitivity Model: Biological sensitivity increases vulnerability to effects of substances Smaller amounts of substances result in problems �Normal� substance use is problematic for clients with severe mental illness but not in general population Sensitivity to substances, rather than high amounts of use, makes many clients with mental illness different from general population

18. Status of Moderate Drinkers with Schizophrenia 4 - 7 Years Later (N=45)

19. Support for Super-sensitivity Model: Dual disorder clients less likely to develop physical dependence on substances Standard measures of substance abuse are less sensitive in clients with severe mental illness Clients are more sensitive to effects of small amounts of substances Few clients are able to sustain �moderate� use without impairment Super-sensitivity accounts for some increased comorbidity

20. Overview of Assessment of Substance Abuse in Clients with Severe Mental Illness

21. Psychological Dependence - Use of more substance than intended, unsuccessful attempts to cut down, giving up important activities to use substances, or spending lots of time obtaining substances. Physical Dependence - Development of tolerance to effects of substance, withdrawal symptoms following cessation of substance use, use of substance to decrease withdrawal symptoms.

22. Functional Assessment Goals: To understand client�s functioning across different domains and to gather information about substance use behavior Domains of Functioning 1. Psychiatric disorder 2. Physical health 3. Psychosocial adjustment (family & social relationships, leisure, work, education, finances, legal problems, spirituality)

24. Evaluating Social FactorsAssociated with Substance Abuse Does person have non-substance abusing peers? Can person resist offers to use substances? Is the person lonely? Can the person initiate and maintain conversations? Is person able to get others to respond positively to him/her? Can the person express feelings? Resolve conflicts?

25. Common Symptoms Associatedwith Self-Medication Depression, suicidal thoughts Anxiety, nervousness, tension Hallucinations Delusions of reference & paranoia Sleep disturbance Mania/hypomania

26. Recreational Skills and Substance Abuse What does the person do for fun? Hobbies? Sports? What is person�s involvement with others in recreational activities? Does the person not participate in activities which he/she previously did?

27. Functional Analysis Goal: To identify factors which influence or control substance use behavior Characteristics of Useful Functional Analyses 1. Focus on behaviors, NOT stable traits 2. Constructive, NOT eliminative 3. Contextual, NOT mechanistic 4. Examines maintaining factors, NOT etiological factors 5. Leads to hypotheses that can be tested by treatment & modified, NOT theories that remain unchanged regardless of outcome 6. Change usually doesn�t happen magically on its own

30. Pay-Off Matrix

31. Common Advantages and Disadvantages of Using Substances and Not Using Substances

32. Examples of Interventions Based on the Payoff Matrix

33. Treatment Planning Goals: To determine which interventions are most likely to be effective and how to measure outcome Steps 1. Engage the client and significant others 2. Assess motivation to change

34. 3. Select target behaviors, thoughts, emotions to change 4. Identify interventions to address targets: select at least 1 strategy to enhance motivation & 1 strategy to address needs currently met by substance use 5. Choose measures to assess effects of intervention

36. Treatment Barriers Historical division of service and training Sequential and parallel treatments Organizational and categorical funding barriers in the public sector Eligibility limits, benefit limits, and payment limits in the private sector

37. Integrated Treatment Mental health and substance abuse treatment Delivered concurrently By the same team or group of clinicians Within the same program The burden of integration is on the clinicians

38. Other Features of Dual Disorder Programs Assertive outreach Stage-wise treatment: engagement, persuasion, active treatment, and relapse prevention Long-term commitment Comprehensive treatment Reduction of negative consequences

39. What are the Stages of Treatment? 1. Engagement, persuasion, active treatment, and relapse prevention 2. Not linear 3. Stage determines goals 4. Goals determine interventions 5. Multiple options at each stage

40. What Do We Do During Engagement? Goal: To establish a working alliance with the client Clinical Strategies 1. Outreach 2. Practical assistance 3. Crisis intervention 4. Social network support 5. Legal constraints

41. What Do We Do During Persuasion? Goal: To motivate the client to address substance abuse as a problem Clinical Strategies 1. Psychiatric stabilization 2. �Persuasion� groups 3. Family psychoeducation 4. Rehabilitation 5. Structured activity 6. Education 7. Motivational interviewing

42. What Do We Do During Active Treatment? Goal: To reduce client�s use/abuse of substance Clinical Strategies 1. Self-monitoring 2. Social skills training 3. Social network interventions 4. Self-help groups

43. 5. Substitute activities 6. Close monitoring 7. Cognitive-behavioral techniques to address: High risk situations Craving Motives for substance use Socialization Persistent symptoms Pleasure enhancement

44. What Do We Do During Relapse Prevention? Goals: To maintain awareness of vulnerability and expand recovery to other areas Clinical Strategies 1. Self-help groups 2. Cognitive-behavioral and supportive interventions to enhance functioning in: Work, relationships, leisure activities, health, and quality of life

45. Relapse Prevention Strategies Construction a relapse prevention plan: Risky situations Early warning signs Immediate response Social supports Abstinence violation effect

46. Recovery Mountain Combat demoralization related to relapses Reframe relapses as part of road to recovery Don�t loose sight of gains made between relapses Learning experience, modify relapse prevention plan

48. Stages of Substance Abuse Treatment 1. Pre-engagement: No contact with a counselor. 2. Engagement: Irregular contact with a counselor. 3. Early Persuasion: Regular contact with a counselor, but no reduction in substance abuse. 4. Late Persuasion: Regular contact with a counselor and reduction in substance use (< 1 month).

49. 5. Early Active Treatment: Reduction in substance use (> 1 month). 6. Late Active Treatment: No abuse for 1-6 months. 7. Relapse Prevention: No abuse 6-12 months. 8. Remission: No abuse for over one year.

50. Research on Integrated Treatment (IT) 26+ RCT or quasi-experimental studies of IT (reviewed by Drake et al., 2004) 3/4 studies of brief motivational interviewing interventions showed positive effects 6/7 studies found group intervention better than 12-step or standard care

51. Research on IT (Cont.) Family intervention: no RCTs examining family treatment alone Comprehensive IT: 2 RCT & 1 quasi-exp. study favor comp. IT over treatment as usual Intensity: more intensive IT produces slightly better outcomes (e.g., Drake et al., 1998)

52. Drake et al. (1998) 203 clients (77% schizophrenia) ACT vs. standard case management (SCM) (both IT) 3 year follow-up ACT better than SCM in alcohol severity & stage of treatment No differences in hospitalization, symptoms, quality of life

53. NH Dual Diagnosis Study I�m going to show you some evidence from the New Hampshire Dual Diagnosis study. This slice shows that people in recovery get more stable community housing as they recover.I�m going to show you some evidence from the New Hampshire Dual Diagnosis study. This slice shows that people in recovery get more stable community housing as they recover.

54. NH Dual Diagnosis Study This slide shows that people stay out of the hospital more as they recover. Staying out of the hospital improves people�s quality of life and reduces cost.This slide shows that people stay out of the hospital more as they recover. Staying out of the hospital improves people�s quality of life and reduces cost.

55. Fidelity to IT Model Improves Outcome This slide shows that the treatment offered really needs to adhere to the principles of integrated treatment, or it will not be effective. The blue line shows how people recover when they receive IDDT that adheres to the treatment principles. The pink line on the bottom shows the lower rates of recovery of people in IDDT programs that did not adhere to the treatment principles, or had low fidelity to the model.This slide shows that the treatment offered really needs to adhere to the principles of integrated treatment, or it will not be effective. The blue line shows how people recover when they receive IDDT that adheres to the treatment principles. The pink line on the bottom shows the lower rates of recovery of people in IDDT programs that did not adhere to the treatment principles, or had low fidelity to the model.

56. Limitations of Research Lack of standardization of treatments No or limited fidelity assessment No replication of program effects Unclear or variable comparison conditions

57. Avoiding the Blame/Demoralization Trap Don�t blame the client for substance abuse or relapses because: Substance abuse is a disorder for which clients are no more responsible than their primary psychiatric symptoms Clients with most severe substance abuse need professional help the most; many others improve spontaneously Remember that the clients are doing the best they can

58. To avoid demoralization: Remember: integrated treatment works in the long run There is usually no obvious �best solution� Adopt a collaborative-empirical approach to treatment View relapses as an inevitable part of the recovery process Develop a case formulation based on a functional analysis to guide treatment