Research & Treatment of Persons with SUDS & Psychotic Disorders

1. Research & Treatment of Persons with SUDS & Psychotic Disorders Kim T. Mueser, Ph.D.Professor of Psychiatry Dartmouth Medical School Kim.t.mueser@dartmouth.edu NIDA Blending Conference April 22, 2010

2. Overview • Comorbidity of substance use & severe psychiatric disorders • Distinguishing features of psychotic disorders with comorbid addiction • Understanding comorbidity: models of etiology & treatment implications • Special treatment needs of psychotic & other severe psychiatric disorders with comorbid addiction • Research reviews of integrated treatment for co-occurring disorders • New research on treatment of co-occurring disorders • Resources

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

5. Prevalence of Mental Illness in Alcohol Disorder Samples • In community, 24.4% have mental illness • In institutions, 55% have mental illness • In substance abuse treatment, 65% have mental illness Regier et al, JAMA 1990

6. Severe Mental Illnesses (SMI) • Psychiatric disorder that has profound effect on: • Work or school • Parenting • Self-care • Social relationships • People often on disability due to mental illness (e.g., SSI, SSDI) • Common SMIs: • Schizophrenia & schizoaffective disorder • Bipolar disorder • Major depression • PTSD • Borderline personality disorder • Often present for treatment in psychiatric settings, but also common in addiction treatment settings

7. Psychotic Disorders • Psychosis = “Lack of contact with reality” • Common psychotic symptoms: • Hallucinations • Delusions • Grandiosity • Suspiciousness • Bizarre behavior • Formal thought disorder (disordered or disorganized speech) • Conceptual disorganization • Psychotic symptoms common in schizophrenia, schizoaffective & bipolar • Psychotic symptoms relatively common in major depression & PTSD • Presence of psychotic symptoms associated with more severe mental illness & greater co-occurring addiction

8. Understanding Comorbidity: Why are the Rates of SMI/Psychotic Disorder so High? • Self-medication • Other common motives for using • Super-sensitivity • Common factors for mental illness & substance misuse

9. Self-Medication • Many clients report using substance for at least some reasons related to symptoms, BUT: • More symptomatic clients don’t use more than less symptomatic ones • No relationship between symptoms & types of substances used • No relationship between psychiatric diagnosis and types of substances used • Many clients report using DESPITE awareness it worsens symptoms or triggers relapses • Strongest case for self-medication: alcohol use disorder in PTSD frequently related to sleep problems • Self-medication/use for coping purposes is one of host of motivations related to SMI for using substances, but doesn’t explain all comorbidity

10. Other Common Motives for Using • Socialization • Leisure & recreation • Dealing with stress • Escaping the stigma of mental illness • Lack of structured time • Lack of engagement in personally meaningful roles (e.g., worker, student, parent)

11. Supersensitivity to Alcohol & Drugs • 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

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

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

14. Common Factors for SMI & Addiction: Conduct Disorder (CD) & Antisocial Personality Disorder (ASPD) • ASPD has highest addiction comorbidity of all psychiatric disorders (60-70% in most estimates) • CD is powerful predictor of later onset of SUD • ASPD associated with earlier onset of addiction • CD & ASPD more common in SMI than general population • CD/ASPD increase risk of addiction in SMI • CD/ASPD related to more severe addiction in co-occurring disorders • Estimated prevalence in co-occurring population: 20-25%

15. CD, ASPD, and Recent SUD in Clients with SMI (N = 293) Source: Mueser et. al. (1999)

16. Other Potential Common Factors Leading to Increased Comorbidity • Poverty/deprivation • Neurocognitive impairment • Trauma

17. Special Treatment Needs of Co-Occurring SMI/Psychotic Disorder • Integration of mental illness & substance use disorder treatment • Concurrent treatment • Same treatment providers • Integrated treatment of both disorders • Minimization of treatment-related stress • Outreach & engagement • Close monitoring, especially for co-occurring disorder clients with ASPD

18. Special Treatment Needs: Motivational Enhancement • Stages of change • Stages of treatment • Engagement • Persuasion • Active treatment • Relapse prevention • Adapted motivational interviewing • Articulation of personal goals • Active work towards goals • Supportive self-efficacy for goal attainment & substance reduction/abstinence

19. Motivational Enhancement (Con’d) • Concept of recovery from mental illness • Recovery defined by client, not in traditional medical terms • Recovery possible despite continued symptoms • Instills hope • Common themes: social relationships, role functioning, community membership, respect for self & from other

20. Special Treatment Needs: Management of Cognitive Impairment • Smaller “chunks” of information • Asking questions so client actively processes information • Frequent review of material • Shaping approach to reinforcing successive steps towards desired goals • Patience & abundant reinforcement in light of small changes • Programming generalization of skills to natural environment by • Home practice assignments • Involvement of significant others in practicing skills • Involvement of paraprofessionals in helping clients practice skills

21. Special Treatment Needs: Training in Illness Self-Management • Information about mental illness & its treatment • Stress-vulnerability model • Involvement of family or significant other persons • Driven by personal goals • Principles of relapse prevention: • Medication adherence • Minimization of alcohol & drug use • Stress reduction • Meaningful but not over-demanding daily structure • Coping & competence skills • Social support • Relapse prevention plan

22. Special Treatment Needs: Psychiatric Rehabilitation • Address motives underlying substance use • Skills training to address social motives, independent living skills • Coping skills training/CBT for persistent symptoms • Targeted CBT to address primary or comorbid depression, anxiety, PTSD symptoms • Supported employment/education for competitive work or return to school • Family psychoeducation to reduce family stress & burden, & facilitate management of co-occurring disorders • Cognitive remediation for cognitive impairment • Supported housing for housing instability

23. Special Treatment Needs: Psychiatric Medications • Primary medications for schizophrenia-spectrum disorders & bipolar disorder effective despite active substance use • When in doubt, assume both disorders are primary & pharmacologically treat psychiatric disorder • Medication non-adherence high • Fear of interactions with substances despite rarity (main exception: MAOIs) • Denial/minimization of psychiatric disorder • Forgetting to take medication: behavioral tailoring to integrate into daily routine • Simplify medication regimen complexity • Promote dialogue between client & prescriber

24. Special Treatment Needs: Medications for Alcoholism • Naltrexone established efficacy for alcoholism in SMI • Disulfirim effective in SMI, but psychiatrists reluctant to prescribe it

25. Research Reviews of Treatment of Co-Occurring Disorders • Drake et al. (1998): 36 studies, including pre-post, quasi-experimental, and RCTs • Brunette et al. (2004): 10 quasi-exp or RCTs of residential programs for DD • Drake et al. (2004): 26 recent studies, quasi-exp or RCTs (1994-2004) • Donald et al. (2005): 10 RCTs • Mueser et al. (2005): 30 studies of specific interventions, including pre-post, quasi-exp, & RCTs • Kavanagh & Mueser (2007): 17 RCTs • Cleary et al. (2008): 25 RCTs • Drake et al. (2008): 22 RCTs, 23 quasi-exp

26. Summary of Research on Treating Co-Occurring Disorders in SMI • Limited impact of brief interventions • Primary purpose is to engage in treatment • Useful for enhancing follow through for mental illness & substance misuse treatment • Limited gain from providing more intensive case management, such as Assertive Community Treatment • But, effects of intensity of service may interact with client characteristics, such as ASPD

27. Study Design (Essock et al., 2006) • 198 clients with SMI • 2 sites in Connecticut: Hartford & Bridgeport • 3 year follow-up period with assessments every 6 months • Randomized to ACT (N = 99) or SCM (N = 99) • Everyone received integrated treatment for co-occurring disorders

28. SATS Predicted and Actual Means 8 Site 1 ACT Site 1 STD Site 2 ACT Site 2 STD 7 6 5 SATS Mean 4 3 2 1 0 6 12 18 24 30 36 Study Months Essock, Mueser, Drake et al. Psychiatr Serv. 2006

29. Total Psychiatric Hospital Days During Entire Study Period 50 45 ACT 41(60) 40 Standard 35 32(91) 30 26(48) 23(68) Mean Number of Days Spent in Hospital 25 20 15(27) 15 12(28) 10 5 0 MWU=3971, p=.12 MWU=1043, p=.35 MWU=713, p=.002* Total Site 1 Site 2 Essock, Mueser, Drake et al. Psychiatr Serv. 2006

30. Did Clients with ASPD Benefit from ACT Treatment More? • Secondary data analysis (Frisman et al., 2009) • Focused on most extreme subgroups: Full ASPD (N = 36) or No CD/ASPD (N = 88) • Outcomes = AUS, DUS, days alcohol use, days drug use, SATS, BPRS, hospital days, homeless days, jail days • Statistical analyses: mixed effects linear modeling with time, treatment group, and ASPD group, with test of primary interest being the 3-way interaction • Significant interactions 2 variables: AUS and days in jail

31. Figure 1. Mixed effect results: estimated and observed (obs) mean value for alcohol consensus rating over time by ASPD and treatment groups alcohol consensus rating

32. Figure 1. Mixed effect results: estimated and observed (obs) mean value for alcohol consensus rating over time by ASPD and treatment groups alcohol consensus rating

33. Figure 2. Estimated percentage of any jail time by ASPD group % jail

34. Figure 2. Estimated percentage of any jail time by ASPD group % jail

35. Summary of Research on Treating Co-Occurring Disorders in SMI • Co-occurring treatment associated with better substance abuse & psychiatric outcomes • Strongest effects for group counseling, contingency management, & residential treatment • Group counseling most studied treatment modality

36. Integrated Group Therapy (IGT) for BPD & SUD (Weiss et al., 2007) • Supported by NIDA Behavioral Therapies Development Program • Goal: to develop & test an integrated group therapy for clients with bipolar disorder & substance misuse • 20 sessions that have 12 repeating topics, “rolling admissions” • Identifies thoughts & behavior patterns common to recovery from & relapse/recurrence to substance use and psychiatric symptoms • Evaluated in RCT comparing IGT with Group Drug Counseling (GDC)

37. Days of Substance Use/Month by Treatment Over Time (p<.001) Days used Baseline Month

38. Time to First Abstinent Month by Treatment (p<.03) Abstinent (%) Baseline Month

39. Summary of Research on Integrated Treatment for SMI • Cognitive-behavioral therapy (CBT) approaches appear promising than supportive, educational, or 12-step approaches • Program fidelity to principles of integrated treatment contributes to better outcomes

40. Fidelity to IDDT Model Improves Outcome (McHugo et al., 1999)

41. Efforts to Provide Integrated Treatment of Anxiety Disorders & Substance Abuse • RCTs of integrated treatment for panic disorder & social phobia indicate improvement in anxiety & substance misuse for both integrated & substance treatment groups • No trials of integrated treatment for GAD or OCD • Limited success thus far with integrated PTSD treatment, but new developments under way

42. Integrated Treatments for PTSD & Addiction • Substance Dependence PTSD Therapy (Triffleman, 1999) • Exposure-based, 40 sessions, no RCTs • Concurrent Treatment of PTSD & Cocaine Dependence (Brady et al, 2001) • Exposure-based, high dropout rate (62%), no RCTs • Transcend (Donovan et al, 2001) • Broad-based, residential, 60 session, no RCTs • Seeking Safety (Najavits, 2003; Hien et al, 2004) • Ecclectic, moderate dropout rate (35-40%), RCTs don’t support treatment over standard substance abuse treatment

43. Cognitive Restructuring for PTSD in Vulnerable Populations • 12-16 week standardized treatment program for PTSD developed by Mueser et al. (2009) • Core components: breathing retraining, education about PTSD, cognitive restructuring • Feasibility established in SMI, addiction, adolescents, ethnic/cultural minorities, disaster/mass violence survivors • RCTs completed on SMI (Mueser et al., 2008) & addiction (McGovern et al., in pres) populations

44. STAGE I Phase II.a: Feasibility StudyMain Outcomes (McGovern et al.)

45. Clinical Resources • Bellack, A. S., Bennet, M. E., & Gearon, J. S. (2007). Behavioral Treatment for Substance Abuse in People with Serious and Persistent Mental Illness. New York: Taylor and Francis. • Center for Substance Abuse Treatment. (2005). Substance Abuse Treatment for Persons With Co-Occurring Disorders. (Vol. DHHS Publication No. (SMA) 05-3922). Rockville, MD: Substance Abuse and Mental Health Services Administration. • Centre for Addiction and Mental Health. (2001). Best Practices: Concurrent Mental Health and Substance Use Disorders. Ottowa: Health Canada. • IDDT Toolkit: http://www.mentalhealth.samhsa.gov/cmhs/communitysupport/toolkits/default.asp • Graham, H. L., Copello, A., Birchwood, M. J., & Mueser, K. T. (Eds.). (2003). Substance Misuse in Psychosis: Approaches to Treatment and Service Delivery. Chichester, England: Wiley. • Graham, H. L., Copello, A., Birchwood, M. J., Mueser, K. T., Orford, J., McGovern, D., Atkinson, E., Maslin, J., Preece, M. M., Tobin, D., & Georgion, G. (2004). Cognitive-Behavioural Integrated Treatment (C-BIT): A Treatment Manual for Substance Misuse in People with Severe Mental Health Problems. Chichester, England: John Wiley & Sons. • Mercer-McFadden, C., Drake, R. E., Clark, R. E., Verven, N., Noordsy, D. L., & Fox, T. S. (1998). Substance Abuse Treatment for People with Severe Mental Disorders: A Program Manager's Guide. Concord, NH: New Hampshire-Dartmouth Psychiatric Research Center. • Mueser, K. T., & Gingerich, S. (2006). The Complete Family Guide to Schizophrenia: Helping Your Loved One Get the Most Out of Life. New York: Guilford Press. • Mueser, K. T., Noordsy, D. L., Drake, R. E., & Fox, L. (2003). Integrated Treatment for Dual Disorders: A Guide to Effective Practice. New York: Guilford Press. • Mueser, K. T., Rosenberg, S. D., & Rosenberg, H. J. (2009). Treatment of Posttraumatic Stress Disorder in Special Populations: A Cognitive Restructuring Program. Washington, DC: American Psychological Association. • Roberts, L. J., Shaner, A., & Eckman, T. A. (1999). Overcoming Addictions: Skills Training for People with Schizophrenia. New York: W.W. Norton. • Weiss, R. D., Griffin, M. L., Jaffee, W. B., Bender, R. E., Graff, F. S., Gallop, R. J., & Fitzmaurice, G. M. (2009). A community-friendly version of Integrated Group Therapy for patients with bipolar disorder and substance dependence: A randomized controlled trial. Drug and Alcohol Dependence, 104, 212-219.

46. Research • Brunette, M. F., Mueser, K. T., & Drake, R. E. (2004). A review of research on residential programs for people with severe mental illness and co-occurring substance use disorders. Drug and Alcohol Review, 23, 471-481. • Cleary, M., Hunt, G., Matheson, S., Siegfried, N., & Walter, G. (2008). Psychosocial interventions for people with both severe mental illness and substance misuse (Review). Cochrane Database of Systematic Reviews, Issue 1. Art. No.: CD001088. DOI: 10.1002/14651858.CD001088.pub2. • Donald, M., Dower, J., & Kavanagh, D. J. (2005). Integrated versus non-integrated management and care for clients with co-occurring mental health and substance use disorders: A qualitative systematic review of randomised controlled trials. Social Science & Medicine, 60, 1371-1383. • Drake, R. E., Mercer-McFadden, C., Mueser, K. T., McHugo, G. J., & Bond, G. R. (1998). Review of integrated mental health and substance abuse treatment for patients with dual disorders. Schizophrenia Bulletin, 24, 589-608. • Drake, R. E., Mueser, K. T., Brunette, M. F., & McHugo, G. J. (2004). A review of treatments for clients with severe mental illness and co-occurring substance use disorder. Psychiatric Rehabilitation Journal, 27, 360-374. • Drake, R. E., O'Neal, E., & Wallach, M. A. (2008). A systematic review of psychosocial interventions for people with co-occurring severe mental and substance use disorders. Journal of Substance Abuse Treatment, 34, 123-138. • Frisman, L. K., Mueser, K. T., Covell, N. H., Lin, H.-J., Crocker, A., Drake, R. E., & Essock, S. M. (2009). Use of integrated dual disorder treatment via assertive comunity treatment versus clinical case management for persons with co-occurring disorders and antisocial personality disorder. Journal of Nervous and Mental Disease, 197, 822-828. • Green, A. I., Noordsy, D. L., Brunette, M. F., & O'Keefe, C. D. (2008). Substance abuse and schizophrenia: Pharmacotherapeutic intervention. Journal of Substance Abuse Treatment, 34, 61-71. • Kavanagh, D. J., & Mueser, K. T. (2007). Current evidence on integrated treatment for serious mental disorder and substance misuse. Journal of the Norwegian Psychological Association, 5, 618-637. • McGovern, M. P., Lambert-Harris, C., Acquilano, S., Weiss, R. D., & Xie, H. (2009). A cognitive behavioral therapy for co-occurring substance use and posttraumaticstress disorders. Addictive Behaviors, 34, 892-897. • Mueser, K. T., Drake, R. E., Sigmon, S. C., & Brunette, M. F. (2005). Psychosocial interventions for adults with severe mental illnesses and co-occurring substance use disorders: A review of specific interventions. Journal of Dual Diagnosis, 1, 57-82. • Mueser, K. T., Kavanagh, D. J., & Brunette, M. F. (2007). Implications of research on comorbidity for the nature and management of substance misuse. In P. M. Miller & D. J. Kavanagh (Eds.), Translation of Addictions Science into Practice (pp. 277-320). Amsterdam: Elsevier. • Mueser, K. T., Noordsy, D. L., Fox, L., & Wolfe, R. (2003). Disulfiram treatment for alcoholism in severe mental illness. American Journal on Addictions, 12, 242-252. • Weiss, R. D., Griffin, M. L., Kolodziej, M. E., Greenfield, S. F., Najavits, L. M., Daley, D. C., Doreau, H. R., & Hennnen, J. A. (2007). A randomized trial of integrated group therapy versus group drug counseling for patients with bipolar disorder and substance dependence. American Journal of Psychiatry, 164, 100-107.

47. Slides: www.ebcrp.org