Integrated Treatment for Dual Disorders

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

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

4. 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 Factors Influencing Prevalence of Substance Use Disorders: Client Characteristics

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

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

7. Why Focus on Dual Disorders? 1. Substance misuse is the most common concurrent disorder in persons with SMI 2. Significant negative outcomes related to substance abuse: a) Clinical relapse & rehospitalization b) Demoralization c) Family stress d) Violent behavior

8. e) Incarceration f) Homelessness g) Suicide h) Medical illness i) Infections diseases j) Early mortality 3. Outcomes improve when substance misuse remits 4. Poor treatment is expensive for families & society

9. Poor Outcomes of People with Mental Illness in Addiction Treatment Settings • Higher rates of drop out from treatment • Addiction to more substances • More problems in legal, social, functional, medical outcomes • Higher relapse rates into addiction • Lower utilization of self-help groups

10. 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

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

12. Reasons for High Comorbidity Rates of Severe Mental Illness and Substance Misuse • Berkson’s Fallacy • Self-medication • Super-sensitivity to effects of alcohol & drugs • Socialization motives • Acceptance • Peer pressure • Facilitates interactions/intimacy

13. Common factors for mental illness and substance misuse • Poverty/deprivation • Neurocognitive impairment • Conduct disorder/antisocial personality disorder

14. Self-Medication: • More symptomatic clients don’t misuse more substances • Substance selection unrelated to type of symptoms experienced • Types of substances misused unrelated to psychiatric diagnosis • Self-medication may contribute to maintaining substance misuse, but probably doesn’t explain high rates

15. 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 SMI but not in general population • Sensitivity to substances, rather than high amounts of use, makes many clients with mental illness different from general population

16. Medication Stress Coping Substance Abuse Severity of SMI Stress-Vulnerability Model Biological Vulnerability

17. Status of Moderate Drinkers with Schizophrenia 4 - 7 Years Later (N=45) Source: Drake & Wallach (1993)

18. CD, ASPD, and Recurrent Substance Use Disorders N=293 Source: Mueser et. al. (1999)

19. Support for Super-sensitivity Model: • Clients with concurrent disorders are less likely to develop physical dependence on substances • Standard measures of substance misuse are less sensitive in clients with SMI • 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. Treatment Barriers • Historical division of services 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 • Primary/secondary distinction

21. Primary/Secondary Distinction • Often difficult or impossible to make, even with extensive observation • Delays treatment of one disorder • Is used to shift responsibility from one service to another • Best to assume that both disorders are primary until proven otherwise

22. 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

23. Other Features of Dual Disorder Programs • No “wrong door” • Comprehensive services • Minimization of treatment-related stress • Harm reduction philosophy • Motivational enhancement (e.g., stages of change, stages of treatment)

24. No “Wrong Door” • Multiple doors to services exist in systems • Substance abuse or mental health services accessed through entry to system via multiple doors • Referrals to different services stigmatize “other” disorder & decrease chances of engagement • No referrals to other service providers: consultation/collaboration needed

25. Services Provided • Comprehensive assessment and monitoring of mental health & substance abuse • Concurrent treatment of dual disorders • Coordination & collaboration among treatment staff • Teamwork among treatment providers & recognition of staff expertise

26. Promises of a “No Wrong Door” Policy • Successful engagement of most clients in treatment • Systematic assessment of mental health & substance abuse disorders • Uniform record keeping • No need to follow up on referrals • More effective treatment of concurrent disorders, leading to fewer relapses, hospitalizations, detoxifications, etc. • Cost savings

27. Challenges of a “No Wrong Door” Policy • Need for comprehensive & undifferentiated training of all clinicians • How to integrate care while maintaining specialty foci? • Formation of integrated treatment teams: clinicians from same service or different services? • Fear of loss of professional identity • Turf issues & concern over funding streams that target specific disorders • Need for treatment guidelines to address specific dual disorders

28. What are the Stages of Treatment? • Based on the stages of change: Pre-contemplation, contemplation, preparation, action, maintenance • Stages of treatment: Engagement, persuasion, active treatment, & relapse prevention • Not linear; progress forward, relapses back • Stage of treatment determines primary goal • Goals determine interventions • Multiple options at each stage

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

30. Detection Goal:To identify clients who may be experiencing problems related to substance use Strategies 1. Maintain a high “index of suspicion” 2. Explore past history of substance abuse first 3. Be aware of clients characteristics related tosubstance abuse (age, sex, antisocial personality, etc.)

31. 4. Use laboratory tests 5. Carefully monitor clients who “use” but do not “misuse” substances 6. Use self-report screens for substance abuse 7. Evaluate clients for common consequences of substance abuse in SMI

32. Relapse & re-hospitalization Financial problems Family burden Housing instability & homelessness Non-compliance with treatment Violence Suicide Legal problems Prostitution Health problems Infectious disease risky behaviors Common Consequences of Substance Abuse in SMI

33. Classification Goal:To determine whether client meets criteria for a substance use disorder Strategies 1. Use Clinician Rating Scales for Alcohol and Drug Use 2. Base ratings on multiple sources of information • Client self-reports

34. Clinician observations • Reports of other treatment providers • Reports of significant others • Records, laboratory tests 3. Make rating every 6 months 4. Rate based on the worst period over the past 6 months 5. Stick to the evidence -- don’t assume consequences of substance abuse 6. Gather additional information when necessary

35. Clinician Rating Scales 1. Abstinent 2. Use without impairment 3. Abuse 4. Dependence 5. Dependence with institutionalization

36. Substance Use Disorders(Based on DSM Series) Substance Abuse • A pattern of substance use resulting in significant problems in the areas of social or psychological functioning, work, health, or use in dangerous situations Substance Dependence • The use of substances that results in development of the dependence syndrome

37. 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

38. Functional Assessment • Goals:To understand client’s functioning across different domains & 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)

39. Dimensions of Substance Misuse • 1. 6-Month Time-Line Follow-Back Calendar • 2. Substances misused & route of use • 3. Patterns of use • 4. Situations in which use occurs • 5. Reported motives for use • Social • Coping • Recreational • Structure/sense of purpose • 6. Consequences of use

40. Social Factors for Substance Use • Does consumer have non-substance using peers? • Is substance use serving to maintain a pre-existing social network? • Is substance use facilitating social contacts with a new social network? • Can person resist offers to use substances? • Is the person lonely?

41. Common Symptoms &Self-Medication • Depression, suicidal thoughts • Anxiety, nervousness, tension • Hallucinations • Delusions of reference & paranoia • Sleep disturbance

42. Recreational/Leisure & Substance Use • Boredom/relaxation as motivation for using substances • What does the client 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?

43. Other Motivating Factors for Using Substances • Escape from unpleasant memories of psychosis (“sealing over”) • Increased unstructured time due to dropout from school or not working • Demoralization due to shattering of personal goals & assault on self-esteem • Ready access to money through family, disability income • Normal rebelliousness of delayed adolescence/early adulthood

44. Functional Analysis • Goal:To identify factors which influence or control substance use behavior • Constructing a Payoff Matrix 1. List advantages & disadvantages of using substances, & advantages & disadvantages of not using 2. Use all available information from functional assessment 3. Consider advantages & disadvantages from the client’s perspective 4. View different reasons listed as hypotheses about maintaining factors, not established facts; reasons may change as new information emerges 5. If client is using, the pros of using & cons of not using should outweigh the pros of not using & cons of using

45. Pay-Off Matrix Using Substances Not Using Substances Advantages Disadvan-tages

46. Common Advantages & Disadvantages of Using Substances & Not Using

47. Examples of Interventions Based on the Payoff Matrix

48. Treatment Planning • Goals: To determine which interventions are most likely to be effective & how to measure outcome • Steps: 1. Engage the client & significant others • Assess motivation to change • Select target behaviors, thoughts, emotions to change • Identify interventions to address targets • Choose measures to assess effects of intervention

49. 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

50. 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