Co-occurring Disorders: A Brief Introduction

1. Co-occurring Disorders:A Brief Introduction For San Luis Obispo County Behavioral Health Services December 8, 2006 John Lovern, Ph.D.

2. What We Will Cover Today (1 of 2) • What co-occurring disorders are, how prevalent they are, and how serious they are • How co-occurring disorders have been approached in the past and how beneficial the different approaches have been. • Common problems faced by clients with co-occurring disorders—case examples illustrating assessment, treatment, and other problems.

3. What We Will Cover Today (2 of 2) • A description of integrated care. • Categories of treatment programs. • Principles and practice standards • Medication issues. • Some evidence-based practices. • Psychological trauma and co-occurring disorders. • Comments, questions and answers.

4. What are Co-occurring Disorders? • The term “Co-occurring Disorders” refers to substance use (abuse or dependence) and mental disorders occurring together in one person. • Clients said to have co-occurring disorders have • one or more disorders relating to the use of alcohol and/or drugs of abuse and • one or more mental disorders. • At least one disorder of each type must be established independently of the other and is not simply a cluster of symptoms resulting from one disorder (or one type of disorder).

5. How Prevalent are Co-occurring Disorders? • Studies in substance abuse settings have found that from 50 to 75percent of clients had some type of mental disorder. • Studies in mental health settings have found that between 20 and 50percent of their clients had a co-occurring substance use disorder. • Experts in this field assert that co-occurring disorders should be the expectation, not the exception in any behavioral health setting. (Source: SAMHSA’s TIP 42)

6. How Serious are Co-occurring Disorders? • Clients with co-occurring disorders require more complex and expensive care. • Clients with co-occurring disorders tend to have more problems of all kinds (medical, legal, social, interpersonal, homelessness, etc.), and more (and more expensive) contacts with agencies and providers (mental health, drug & alcohol, law enforcement, courts, emergency rooms, social welfare, shelters, etc.). • Clients with co-occurring disorders tend to “fall through the cracks” of the traditional treatment system and develop even worse and more expensive problems.

7. A clients falling between the cracks.

8. What Approaches to Treating Co-occurring Disorders Have Been Tried? Four general approaches have been tried: • Not at all—referred out to treatment for the other problem or refused care entirely. • Serial Treatment—one type of disorder treated at a time, in separate settings. • Concurrent or Parallel Treatment—treatment for both types of disorder offered at the same time but in separate settings and by separate providers. • Integrated Treatment—both types of disorder assessed and treated together in specialized settings by providers possessing competency in the treatment of both types of disorder and integrated treatment.

9. How Beneficial Are These Approaches? (1 of 5) • No Treatment At All: • Denial of treatment is ineffective by definition. It is also unethical and could result in legal liability. (Yet I have heard reports that it is still taking place in this county in 2006.) • Serial Treatment: • This approach can be helpful for • those who are not so impaired by their “secondary” disorder that they can wait for it to be treated after their “primary” disorder is treated, or • those whose co-occurring disorders do not interact with one another.

10. How Beneficial Are These Approaches? (2 of 5) • Serial Treatment, continued: • Serial Treatment can worsen problems or create new ones: • Confusion due to conflicting treatment philosophies held by different providers. • Confusion due to conflicting treatment recommendations or priorities. • Treatment gaps arising due to communication problems between/among providers. • Practical considerations such as scheduling, transportation, etc.

11. How Beneficial Are These Approaches? (3 of 5) • Concurrent or Parallel Treatment: • This approach can be helpful for those who: • are not seriously impaired by either disorder, • do not require inpatient or residential care, and • are cognitively equipped to handle and integrate the two treatment experiences.

12. How Beneficial Are These Approaches? (4 of 5) • Concurrent/Parallel Treatment, continued: • As with serial treatment, this approach can worsen problems or create new ones: • Confusion due to conflicting treatment philosophies held by different providers. • Confusion due to conflicting treatment recommendations or priorities. • Treatment gaps arising due to communication problems between/among providers. • Practical considerations such as scheduling, transportation, etc.

13. How Beneficial Are These Approaches? (5 of 5) • Integrated Treatment: • A very recent development and not standard or typical—yet. • Essential for clients who are significantly impaired by both kinds of disorder. • Essential for clients whose mental disorder interferes with treatment of their substance use disorder. • Essential for clients whose substance use disorder interferes with treatment of their mental disorder. • Beneficial for all clients with co-occurring disorders due to its ability to avoid problems seen with other models (provider conflicts, poor provider communication, client confusion, scheduling or transportation problems, etc.).

14. An Important Point About Integrated Care: It is a Separate Specialty Area • Integrated treatment providers should be knowledgeable about mental illness and skilled in assessing mental problems and providing mental health treatment. • They should also be knowledgeable about addictions and skilled in assessing substance use problems and providing addiction treatment. • But these separate knowledge and skill sets are not enough. Providers should also be knowledgeable about and skilled in integrated assessment and treatment of co-occurring disorders.

15. Common Problems that Integrated Care is Designed to Address We will address this topic by using fictional case examples that illustrate each of the following three types of problems: • Assessment Problems. • Treatment Problems. • Other Problems.

16. Assessment Problems (1 of 4) • Case Example 1: José presents with restless-ness, agitation, anxiety, and tremulousness. • Mental health providers may tend to suspect an anxiety disorder or a manic episode. • Substance abuse providers may tend to suspect amphetamine intoxication or sedative withdrawal. • Integrated care providers suspect and investigate all of these possibilities and are sensitive to the additional issues that clients with co-occurring disorders may face.

17. Assessment Problems (2 of 4) • Case Example 2: Ellen presents with depressed mood, tearfulness, and psychomotor retardation. • Mental health providers may tend to suspect a mood disorder—major depressive episode or dysthymic disorder. • Substance abuse providers may tend to suspect amphetamine withdrawal or alcohol or sedative intoxication. • Integrated care providers suspect and investigate all of these possibilities and are sensitive to the additional issues that clients with co-occurring disorders may face.

18. Assessment Problems (3 of 4) • Case Example 3: George presents with hallucinations and paranoid ideation. • Mental health providers may tend to suspect a psychotic disorder—i.e., paranoid schizophrenia. • Substance abuse providers may tend to suspect amphetamine psychosis or hallucinogen intoxication. • Integrated care providers suspect and investigate all of these possibilities and are sensitive to the additional issues that clients with co-occurring disorders may face.

19. Assessment Problems (4 of 4) • Case Example 4: Bob presents with grandiosity, excess energy, and serious legal and debt problems. • Mental health providers may tend to suspect bipolar disorder (manic phase). • Substance abuse providers may tend to suspect amphetamine intoxication and dependence. • Integrated care providers suspect and investigate all of these possibilities and are sensitive to the additional issues that clients with co-occurring disorders may face.

20. Treatment Problems (1 of 4) • Case Example 5: María, in treatment for addiction but also with unrecognized co-occurring major depressive disorder, is labeled “resistant” and “unmotivated” by staff. • Case Example 6: Sam, in treatment for addiction but also with co-occurring paranoid schizophrenia, has difficulty tolerating group sessions, bonding with other members of his group, and fitting in at AA meetings.

21. Treatment Problems (2 of 4) • Case Example 7: Heather, in treatment for bulimia nervosa, is not doing well because of her amphetamine use which providers erroneously view as part of her eating disorder instead of as independently co-occurring amphetamine dependence. • Case Example 8: Michael, in treatment for bipolar disorder, is unable to control his mood swings because of his drinking, which providers erroneously view as “self-medicating behavior” instead of as independently co-occurring alcohol dependence.

22. Treatment Problems (3 of 4) • Case Example 9: Mario, who has co-occurring bipolar disorder and alcohol dependence, is discouraged from taking his medications by addiction treatment staff, and is told by mental health staff that his “real” problem is his mood disorder, and that the drinking is secondary. • Case Example 10: Edmund, who has co-occurring major depressive disorder and polysubstance dependence, is denied medication by his psychiatrist until he returns to the mental health clinic having been clean and sober for 30 days.

23. Treatment Problems (4 of 4) • Case Example 11: Susan—who is alcohol- and drug- dependent, has PTSD (and possibly a dissociative disorder) secondary to extreme child sexual abuse, and is HIV and HCV positive—cannot participate in PTSD treatment because she is rarely sober; cannot participate in addiction treatment because of crises precipitated by extremely dysphoric intrusive flashbacks that she tries to cope with by drinking alcohol, taking drugs, self-mutilating, binge-eating, and acting out sexually; does not keep appointments for HIV or HCV treatment; is a public health risk due to her high-risk behaviors of needle-sharing and multiple sexual partners; and is not quite suicidal enough or incapable enough of caring for herself to be involuntarily hospitalized.

24. Other Problems (1 of 2) • Case Example 11: During residential polydrug detox, treatment staff notice that Jim has a serious mental disorder. They refer him for mental health treatment, but the earliest he can be seen by a psychiatrist is 60 days away—long after he will have completed detox. • Case Example 12: Jane is referred to addiction treatment by her mental health provider, but, because the receptionist at the addiction treatment program (who has not been trained in how to respond to mentally ill clients) reacts to her in an insensitive manner, Jane feels unwelcome and leaves without making an appointment.

25. Other Problems (2 of 2) • Case Example 13: Mike is referred to addiction treatment by mental health providers, but he is homeless and without transportation, so he never makes it to his appointment. • Case Example 14: Dan’s mental health provider, Ellen, has a strong countertransference reaction to Dan because Dan resembles Ellen’s alcoholic father.

26. What is Integrated Care? (1 of 3) • The client participates in one program that provides treatment for both disorders. • The client’s mental and substance use disorders are treated by the same clinicians. • The clinicians are trained in psychopathology, assessment, and treatment strategies for both mental and substance use disorders. • The clinicians offer substance abuse treatments tailored for clients who have severe mental disorders.

27. What is Integrated Care? (2 of 3) • The focus is on preventing anxiety rather than breaking through denial. • Emphasis is placed on trust, understanding, and learning. • Treatment is characterized by a slow pace and a long-term perspective. • Providers offer stagewise and motivational counseling.

28. What is Integrated Care? (3 of 3) • Supportive clinicians are readily available. • Twelve-Step groups are available to those who choose to participate and can benefit from participation. • Neuroleptics and other pharmacotherapies are indicated according to clients’ psychiatric and other medical needs. (TIP 42, p. 45)

29. Categories of COD Programs • Dual Diagnosis Capable (DDC-CD or DDC-MH). • DDC-CD Welcomes individuals with chemical dependency (CD) whose conditions are stable; makes provision for comorbidity in program mission, screening, assessment, treatment planning, staff training, etc. • DDC-MH is similar to the above in a mental health (MH) treatment setting. • DDE=Dual Diagnosis Enhanced (DDE-CD or DDE-MH). • DDE-CD is a CD program that is enhanced to accommodate individuals with subacute symptomatology or moderate disability; enhanced MH staffing and programming, etc. • DDE-MH is similar to the above in a MH setting.

30. COD Program Models • Continuous Integrated Case Management. • Continuous Recovery Support. • Emergency Triage/Crisis Intervention. • Crisis Stabilization Beds. • Psychiatric Inpatient Unit or Partial Hospital. • Detoxification Programs. • Psychiatric Day Treatment. • Addiction Intensive Outpatient (IOP), Partial, Residential. • Psychiatric Housing Programs: • Abstinence-expected (dry). • Abstinence-encouraged (damp). • Consumer-choice (wet).

31. Principles and Standards • Next, we will cover aspects of the Minkoff Model for assessment and treatment of co-occurring disorders: • The Nine Principles, and • The Eight Practice Standards

32. The Nine Principles (1 of 4) 1. Dual diagnosis is an expectation, not an exception. 2. The population of individuals with co-occurring disorders can be organized into four subgroups based on high and low severity of each type of disorder (see next slide). 3. Treatment success involves formation of empathic, hopeful, integrated treatment relationships.

33. The Nine Principles (2 of 4)The Four Quadrants

34. The Nine Principles (3 of 4) 4. Treatment success is enhanced by maintaining integrated treatment relationships providing disease management interventions for both disorders continuously across multiple treatment episodes, balancing case management support with detachment and expectation at each point in time. 5. Integrated dual primary diagnosis-specific treatment interventions are recommended. 6. Interventions need to be matched not only to diagnosis, but also to phase of recovery, stage of treatment, and stage of change.

35. The Nine Principles (4 of 4) 7. Interventions need to be matched according to level of care and/or service intensity requirements, utilizing well-established level of care assessment methodologies. 8. There is no single correct dual diagnosis intervention, nor single correct program. For each individual, at any point in time, the correct intervention must be individualized, according to subgroup, diagnosis, stage of treatment or stage of change, phase of recovery, need for continuity, extent of disability, availability of external contingencies, and level of care assessment. 9. Outcomes of treatment interventions are similarly individualized, based upon the above variables and the nature and purpose of the intervention. Outcome variables include not only abstinence, but also amount and frequency of use, reduction in psychiatric symptoms, stage of change, level of functioning, utilization of acute care services, and reduction of harm.

36. The Eight Practice Standards(1 of 3) 1. Welcoming Expectation. • Expect comorbidity and engage clients in an empathic, hopeful, welcoming manner. 2. Access to Assessment. • Access to services should not require clients to self-define as MH or SUD before arrival; eliminate barriers; deny no client treatment based on disorders. 3. Access to Continuing Relationships. • Initiate and maintain empathic, hopeful, continuous treatment relationships—even if treatment recommendations are not followed. 4. Balance Case Management and Care with Expectation, Empowerment, and Empathic Confrontation.

37. The Eight Practice Standards(2 of 3) 5. Integrated Dual Primary Treatment. • Each disorder receives appropriate diagnosis-specific and stage-specific treatment, regardless of the status of the comorbid condition. 6. Stage-Wise Treatment: • Acute Stabilization. • Motivational Enhancement. • Active Treatment. • Relapse Prevention. • Rehabilitation and Recovery.

38. The Eight Practice Standards(3 of 3) 7. Early Access to Rehabilitation. • Clients who request assistance with housing, jobs, socialization, and meaningful activity are provided access even if they are not initially adherent to MH or SUD treatment recommendations. 8. Coordination and Collaboration. • Consistent collaboration between all treaters, family caregivers, and external systems is required. • Collaboration with families should be considered an expectation for all individuals at all stages of change.

39. Medication Guidelines for CODsfrom Minkoff, et al (1998) “Psychopharmacology for people with co-occurring disorders is best performed in the context of an ongoing, empathic, clinical relationship that emphasizes continuous reevaluation of both diagnosis and medication, and artful utilization of medication strategies to promote better outcome of both disorders.”

40. Medication Guidelines (2 of 3) Maximize outcome of two primary disorders: • For diagnosed psychiatric illness, the most clinically effective psychopharmacologic strategy available, regardless of the status of the comorbid substance disorder. • For diagnosed substance disorder, appropriate psychopharmacologic strategies may be used as ancillary treatments to support a comprehensive program of recovery, regardless of the presence of a comorbid psychiatric disorder (although taking into account the individual’s cognitive capacity and disability).

41. Medication Guidelines (3 of 3) Priorities: • Establish medical and psychiatric safety in acute situations. • Maintain stabilization of severe and/or established psychiatric illness. • Use medication strategies to promote or establish sobriety. • Diagnose and treat less serious psychiatric disorders that may emerge once sobriety is established.

42. Diagnosis-Specific Recommendations (1 of 2) • Schizophrenic Disorders: • Atypical neuroleptics; clozapine may reduce substance abuse. • Bipolar Disorders: • Second and third generation mood stabilizers (valproate, lamotrigine). • Gabapentin and topiramate may also be useful. • A significant population will still respond to lithium. • Depressive Disorders: • No particular category of antidepressant is specifically recommended or contraindicated.

43. Diagnosis-Specific Recommendations (2 of 2) • Anxiety Disorders: • Benzodiazepines for acute situations and detox only. • For anxiety: clonidine, venlafaxine, SSRIs, gabapentin, valproate, topiramate, atypical neuroleptics, buspirone. • Attentional Disorders: • Bupriprion, SSRIs, Strattera (atomoxatine). • Addictive Disorders: • Disulfiram, naltrexone, acamprosate, methadone, LAAM, buprenorphine.

44. Some Evidence-Based Practices • Stages of Change/Motivational Interviewing. • Harm Reduction. • Mutual Self-Help Programs. • Consumer-Delivered Services. • Specialty Courts (Drug Court, Mental Health Court, Co-occurring Disorders Court). • Specialized Services for Homeless Populations. • Group Treatment. • Family Treatment.

45. Psychological Trauma and Co-occurring Disorders • Many studies link childhood trauma to both mental illness and addiction. • One particularly striking study is called the ACE Study (http://www.acestudy.org), in which 17,000 patients of Kaiser-Permanente were assessed for number of different types of Adverse Childhood Experiences and subsequent medical, mental health, and addiction problems. • Some results of this study appear on the next slides.

46. Definition of Adverse Childhood Experiences Growing up (prior to age 18) in a household with: (score 1 point for 1 or more incidents in each category) • Recurrent physical abuse. • Recurrent emotional abuse. • Sexual abuse. • An alcohol or drug abuser. • An incarcerated household member. • Someone who is chronically depressed, suicidal, institutionalized or mentally ill. • Mother being treated violently. • One or no parents. • Emotional or physical neglect.

47. Adverse Childhood Experiences and Smoking (Tobacco)

48. Adverse Childhood Experiences and COPD

49. Adverse Childhood Experiences and Addiction

50. Adverse Childhood Experiences and Attempted Suicide