Chapters 1-5Chapters 6-8Chapter 9, Appendixes, and ExhibitsAssessment and Treatment of Patients with Coexisting Mental Illness
and Alcohol and Other Drug Abuse
[Title Page][Disclaimer]This publication is part of the Substance Abuse Prevention and Treatment Block Grant technical assistance program. All material appearing in this volume except quoted passages from copyrighted sources is in the public domain and may be reproduced or copied without permission from the Center for Substance Abuse Treatment (CSAT) or the authors. Citation of the source is appreciated. This publication was written under contract number ADM 270-91-0007 from the Center for Substance Abuse Treatment of the Substance Abuse and Mental Health Services Administration (SAMHSA). Anna Marsh, Ph.D., and Sandra Clunies, M.S., served as the Government project officers. Elayne Clift, M.A., Carolyn Davis, Joni Eisenberg, Mim Landry, and Janice Lynch served as writers. The opinions expressed herein are those of the consensus panel participants and do not reflect the official position of CSAT or any other part of the U.S. Department of Health and Human Services (DHHS). No official support or endorsement of CSAT or DHHS is intended or should be inferred. The guidelines proffered in this document should not be considered as substitutes for individualized patient care and treatment decisions. DHHS Publication No. (SMA) 95-3061. Printed 1994. Reprinted 1995. What Is a TIP?CSAT Treatment Improvement Protocols (TIPs) are prepared by the Quality Assurance and Evaluation Branch to facilitate the transfer of state-of-the-art protocols and guidelines for the treatment of alcohol and other drug (AOD) abuse from acknowledged clinical, research, and administrative experts to the Nation's AOD abuse treatment resources. The dissemination of a TIP is the last step in a process that begins with the recommendation of an AOD abuse problem area for consideration by a panel of experts. These include clinicians, researchers, and program managers, as well as professionals in such related fields as social services or criminal justice. Once a topic has been selected, CSAT creates a Federal Resource Panel, with members from pertinent Federal agencies and national organizations, to review the state of the art in treatment and program management in the area selected. Recommendations from this Federal panel are then transmitted to the members of a second group, which consists of non-Federal experts who are intimately familiar with the topic.This group, known as a non-Federal Consensus Panel, meets in Washington for 3 days, makes recommendations, defines protocols, and arrives at agreement on protocols. Its members represent AOD abuse treatment programs, hospitals, community health centers, counseling programs, criminal justice and child welfare agencies, and private practitioners. A Chair for the panel is charged with responsibility for ensuring that the resulting protocol reflects true group consensus. The next step is a review of the proposed guidelines and protocol by a third group whose members serve as expert field reviewers. Once their recommendations and responses have been reviewed, the Chair approves the document for publication.The result is a TIP reflecting the actual state of the art of AOD abuse treatment in public and private programs recognized for their provision of high-quality and innovative AOD abuse treatment. This TIP, titled Assessment and Treatment of Patients With Coexisting Mental Illness and Alcohol and Other Drug (AOD) Abuse, provides practical information about the treatment of patients with dual disorders, including the treatment of AOD patients with mood and anxiety disorders, personality disorders, and psychotic disorders. This TIP also provides pragmatic information about systems and linkage issues relative to the AOD and mental health treatment systems. There is also a discussion about pharmacologic management of patients with dual disorders. This TIP represents another step by CSAT toward its goal of bringing national leadership to bear in the effort to improve AOD abuse treatment. Consensus Panel
Facilitators:
Workgroup Members:
ForewordThe Treatment Improvement Protocol Series (TIPs) fulfills CSAT'smission to improve alcohol and other drug (AOD) abuse and dependencytreatment by providing best practices guidance to clinicians, programadministrators, and payers. This guidance, in the form of a protocol,results from a careful consideration of all relevant clinical and healthservices research findings, demonstration experience, and implementationrequirements. A panel of non-Federal clinical researchers, clinicians,program administrators, and patient advocates employs a consensusprocess to produce the product. This panel's work is reviewed andcritiqued by field reviewers as it evolves. The talent, dedication, and hard work that TIPs panelists and reviewersbring to this highly participatory process have bridged the gap betweenthe promise of research and the needs of practicing clinicians andadministrators. I am grateful to all who have joined with us tocontribute to advance our substance abuse treatment field.
Chapter 3 -- Mental Health And Addiction Treatment Systems: Philosophical and Treatment Approach IssuesIntroductionFor people with dual disorders, the attempt to obtain professional help can be bewildering and confusing. They may have problems arising within themselves as a result of their psychiatric and AOD use disorders as well as problems of external origin that derive from the conflicts, limitations, and clashing philosophies of the mental health and addiction treatment systems. For example, internal problems such as frustration, denial, or depression may hinder their ability to recognize the need for help and diminish their ability to ask for help. A typical external problem might be the confusion experienced when individuals need services but lack knowledge about the different goals and processes of various types of available services. Other problems of external origin may be very fundamental, such as the inability to pay for child care services or the lack of transportation to the only available outpatient program. Historically, when patients in AOD treatment exhibited vivid and acute psychiatric symptoms, the symptoms were either: 1) unrecognized, 2) observed but misdescribed as toxicity or "acting-out behavior," or 3) accurately identified, prompting the patients to be discharged or referred to a mental health program. Virtually the same process occurred for patients in mental health treatment who exhibited vivid and acute symptoms of AOD use disorders. Mislabeling, rejecting, failing to recognize, or automatically transferring patients with dual disorders can result in inadequate treatment, with patients falling between the cracks of treatment systems. The symptoms of psychiatric and AOD use disorders often fluctuate in intensity and frequency. Current symptom presentation may reflect a short-term change in the course of long-term dual disorders. Thus, even when patients receive traditional professional help, treatment may address only selected aspects of their overall problem unless treatment is coordinated among services including AOD, mental health, social, and medical programs. As a result, the treatment system itself may be a stumbling block for some people attempting to receive ongoing, appropriate, and comprehensive treatment for combined psychiatric and AOD use disorders.Thus, treatment services for patients with dual disorders must be sensitive to both the individual's and the treatment system's impediments to the initiation and continuation of treatment. Treatment Systems:Mental Health, Addiction, And MedicalPeople with dual disorders who want to engage in the treatment process (or who need to do so) frequently encounter not one but several treatment systems, each having its own strengths and weaknesses.These treatment systems have different clinical approaches. The Mental Health SystemActually, there is no single mental health system, although most States have a set of public mental health centers. Rather, mental health services are provided by a variety of mental health professionals including psychiatrists; psychologists; clinical social workers; clinical nurse specialists;other therapists and counselors including marriage, family, and child counselors (MFCCs); and paraprofessionals. These mental health personnel work in a variety of settings, using a variety of theories about the treatment of specific psychiatric disorders. Different types of mental health professionals (for example, social workers and MFCCs) have differing perspectives; moreover, practitioners within a given group often use different approaches. A major strength of the mental health system is the comprehensive array of services offered, including counseling, case management, partial hospitalization, inpatient treatment, vocational rehabilitation, and a variety of residential programs. The mental health system has a relatively large variety of treatment settings. These settings are designed to provide treatment services for patients with acute, subacute, and long-term symptoms. Acute services are provided by personnel in emergency rooms and hospital units of several types and by crisis-line personnel, outreach teams, and mental health law commitment specialists. Subacute services are provided by hospitals, day treatment programs, mental health center programs, and several types of individual practitioners. Long-term settings include mental health centers, residential units, and practitioners' offices. Clinicians vary with regard to academic degrees, styles, expertise, and training. Another strength of the mental health system is the growing recognition at all system levels of the role of case management as a means to individualize and coordinate services and secure entitlements. Medication is more often used in psychiatric treatment than in addiction treatment, especially for severe disorders. Medications used to treat psychiatric symptoms include psychoactive and nonpsychoactive medications. Psychoactive medications cause an acute change in mood, thinking, or behavior, such as sedation, stimulation, or euphoria. Psychoactive medications (such as benzodiazepines) prescribed to the average patient with psychiatric problems are generally taken in an appropriate fashion and pose little or no risk of abuse or addiction. In contrast, the use of psychoactive medications by patients with a personal or family history of an AOD use disorder is associated with a high risk of abuse or addiction. Some medications used in psychiatry that have mild psychoactive effects (such as some tricyclic antidepressants with mild sedative effects) appear to be misused more by patients with an AOD disorder than by others. Thus, a potential pitfall is prescribing psychoactive medications to a patient with psychiatric problems without first determining whether the individual also has an AOD use disorder. While most clinicians in the mental health system generally have expertise in a biopsychosocial approach to the identification, diagnosis, and treatment of psychiatric disorders, some lack similar skills and knowledge about the specific drugs of abuse, the biopsychosocial processes of abuse and addiction, and AOD treatment, recovery, and relapse.Similarly, AOD treatment professionals may have a thorough understanding of AOD abuse treatment but not psychiatric treatment. The Addiction Treatment SystemAs with mental health treatment, no single addiction treatment system exists. Rather, there is a collection of different types of services such as social and medical model detoxification programs, short- and long-term treatment programs, methadone detoxification and maintenance programs, long-term therapeutic communities, and self-help adjuncts such as the 12-step programs. These programs can vary greatly with respect to treatment goals and philosophies.For example, abstinence is a prerequisite for entry into some programs, while it is a long-term goal in other programs. Some AOD treatment programs are not abstinence oriented. For example, some methadone maintenance programs have the overt goal of eventual abstinence for all patients, while others promote continued methadone use to encourage psychosocial stabilization. As with mental health treatment, addiction treatment is provided by a diverse group of practitioners, including physicians, psychiatrists, psychologists, certified addiction counselors, MFCCs, and other therapists, counselors, and recovering paraprofessionals. There can be a wide difference in experience, expertise, and knowledge among these diverse providers. As with mental health treatment, most States have public and private AOD treatment systems. The strengths of addiction treatment services include the multidisciplinary team approach with a biopsychosocial emphasis, and an understanding of the addictive process combined with knowledge of the drugs of abuse and the 12-step programs. In typical addiction treatment, medications are used to treat the complications of addiction, such as overdose and withdrawal.However, few medications that directly treat or interrupt the addictive process, such as disulfiram and naltrexone, have been identified or regularly used.Maintenance medications such as methadone are crucial for certain patients.However, most addiction treatment professionals attempt to eliminate patients' use of all drugs.
Many who work in the addiction treatment field have only a limited understanding of medications used for psychiatric disorders. Historically, some people have mistakenly assumed that all or most psychiatric medications are psychoactive or potentially addictive. Many addiction treatment staff tend to avoid the use of any medication with their patients, probably in reaction to those whose addiction included prescription medications such as diazepam (Valium). Many staff have a lack of training and experience in the use of such medications. In the treatment of dual disorders, a balance must be made between behavioral interventions and the appropriate use of nonaddicting psychiatric medications for those who need them to participate in the recovery process. Withholding medications from such individuals increases their chances of AOD relapse. An important adjunct to addiction treatment services is the massive system of consumer-developed groups, such as the 12-step program of Alcoholics Anonymous (AA). Participants in AA and other self-help groups (Narcotics Anonymous [NA], Cocaine Anonymous [CA], etc.) can provide needed support and encouragement for patients in treatment.Importantly, these services are widespread nationally and internationally.While self-help programs are not considered treatment per se, they are integral adjuncts to professional treatment services. However, patients in self-help groups may give others inappropriate advice regarding medication compliance, based on personal experience, fears of medication, or incomplete knowledge about the role of medication in dual disorders. In many urban areas, there are specialized 12-step groups for people with dual disorders. In these so-called "Double Trouble" meetings, medication compliance is a part of "working the program." The Medical SystemPrimary health care providers (physicians and nurses) have historically been the largest single point of contact for patients seeking help with psychiatric and AOD use disorders. Physicians and nurses are uniquely qualified to manage life-threatening crises and to treat medical problems related and unrelated to psychiatric and substance use disorders. And because they are in contact with such large numbers of patients, they have an exceptional opportunity to screen and identify patients with psychiatric and AOD disorders. However, physicians -- especially primary care physicians -- are able to devote very little time to eachpatient. Pressured for time, these physicians may prescribe such psychiatric medications as antidepressants or anxiolytics or medication such as disulfiram or naltrexone as a primary approach, rather than as an adjunctive approach. Indeed, primary care physicians are the largest single prescriber of antianxiety medications.Some of these medications, such as the benzodiazepines, are psychoactive and can be abused. Also, physicians and nurses have historically been trained to focus on the medical consequences of addiction, such as withdrawal, overdose, or hepatitis, without assessing, treating, or actively referring the individual for treatment of the addiction itself. The role of physicians with regard to addiction is changing through the leadership of national organizations such as the American Society of Addiction Medicine, the American Academy of Psychiatrists on Alcohol and Addiction, and the Association of Medical Education and Research on Substance Abuse. Similar groups exist for nurses and allied health care professionals. Such groups can provide medical professionals with important information and education about the biopsychosocial nature of addiction and treatment, especially regarding patients with dual disorders. Differing Approaches: Individual Responsibility and Treatment FocusTraditionally, patients in mental health settings have had the responsibility of getting themselves to treatment services and appointments as a sign of treatment motivation. More recently, and in recognition that many severely mentally ill patients are unwilling or unable to use traditional community-based services, the mental health field has emphasized the role of case management. Case management (also called care management) can help to engage, link, and support patients in needed community services. Case management can help to reduce the negative consequences to the individual from lack of followup and participation in treatment. Without case management, many severely ill patients would decompensate, need to be hospitalized, or become homeless. The case management model identifies individual limitations, deficits, and strengths and aggressively attempts to provide patients with what they need. When a patient rejects professional assistance, the case manager assumes the responsibility for finding a different way to get the individual to accept assistance. The case manager may minimize the negative consequences to the individual in order to engage or maintain the patient in treatment. Thisactivity might be seen as "enabling" by traditional addiction treatment personnel. In contrast, the addiction treatment system focuses on individual responsibility, including the responsibility of accepting help. Motivation for recovery is enhanced through confrontation of the adverse consequences of addiction. Further, addiction intervention and treatment involve diminishing the individual's denial about the presence and severity of the addiction through direct but therapeutic confrontation of examples of addiction-related behaviors. Thus, traditionally, patients in the addiction treatment system who did not want help or could not tolerate confrontation might not get help. Mental health personnel might regard this situation as an abandonment of the most needy. More recently, the addiction treatment system has been developing case management models to better address treatment-resistant patients. Treatment of patients with dual disorders must blend both mental health and AOD treatment models, with each applied at appropriate times and in appropriate situations according to patients' needs. There should be a balance between clinician and patient acceptance of responsibility for treatment and recovery from dual disorders. For example, in AOD treatment, clinical staff and fellow patients often aggressively confront patients who deny that they have an AOD problem or who minimize the severity of their problem. However, treatment of individuals with dual disorders first requires innovative approaches to engage them in treatment as a prerequisite to confrontation. The role of confrontation may need to be substantially modified, particularly in the treatment of disorganized or psychotic patients, who may tolerate confrontation only in later stages of treatment (when their symptoms are stable and they are engaged in the treatment process). In addiction treatment, the focus is often on the "here and now," while in mental health treatment, the focus is often on past developmental issues. Mental health practitioners may identify AOD abuse as a symptom of a prior trauma rather than an illness in its own right.The focus of treatment may be on the developmental issues, with the assumption that the AOD use disorder will improve automatically once these issues are treated.Inadvertently, the mental health therapist can enable AOD use to continue. The Role of AbstinenceWithin parts of the addiction treatment system, abstinence from psychoactive drugs is a precondition to participate in treatment. For the more severely illpatients with dual disorders (such as patients with schizophrenia), abstinence from AODs is often considered a goal, possibly a long-term goal, similar to the approach at some methadone maintenance programs. On the other hand, treatment of less severe dual psychiatric conditions, such as depression or panic disorder, should require AOD abstinence, since AOD use compromises both diagnosis and treatment (see individual chapters). For some patients with dual disorders, requiring abstinence as a condition of entering treatment may hinder or discourage engagement in the treatment process. For these patients, abstinence may be redefined as a goal, with encouragement provided for incremental steps in the reduction of amount and frequency of drug use. For example, patients who experience homelessness and housing instability likely do not live in drug-free environments. For such patients, it may be unrealistic to mandate abstinence as a requirement for treatment. Exhibit 3-1 describes some of the treatment strategy differences for managing patients in mental health, addiction, and dual disorder treatment approaches. Treatment Models: Sequential, Parallel, Or IntegratedAs the mental health and AOD abuse treatment fields have become increasingly aware of the existence of patients with dual disorders, various attempts have been made to adapt treatment to the special needs of these patients (Baker, 1991; Lehman et al., 1989; Minkoff, 1989; Minkoff and Drake, 1991; Ries, 1993a). These attempts have reflected philosophical differences about the nature of dual disorders, as well as differing opinions regarding the best way to treat them. These attempts also reflect the limitations of available resources, as well as differences in treatment responses for different types and severities of dual disorders. Three approaches have been taken to treatment. Sequential TreatmentThe first and historically most common model of dual disorder treatment is sequential treatment. In this model of treatment, the patient is treated by one system (addiction or mental health) and then by the other. Indeed, some clinicians believe that addiction treatment must always be initiated first, and that the individual must be in a stage of abstinent recovery from addiction before treatment for the psychiatric disorder can begin. On the other hand, other clinicians believe that treatment for the psychiatric disorder should begin prior to the initiation of abstinence and addiction treatment. Still other clinicians believe that symptom severity at the time of entry to treatment should dictate whether the individual is treated in a mental health setting or an addiction treatment setting or that the disorder that emerged first should be treated first. The term sequential treatment describes the serial or nonsimultaneous participation in both mental healthand addiction treatment settings. For example, a person with dual disorders may receive treatment at a community mental health center program during occasional periods of depression and attend a local AOD treatment program following infrequent alcoholic binges. Systems that have developed serial treatment approaches generally incorporate one of the above orientations toward the treatment of patients with dual disorders. Parallel TreatmentA related approach involves parallel treatment:the simultaneous involvement of the patient in both mental health and addiction treatment settings. For example, an individual may participate in AOD education and drug refusal classes at an addiction treatment program, participate in a 12-step group such as AA, and attend group therapy and medication education classes at a mental health center. Both parallel and sequential treatment involve the utilization of existing treatment programs and settings. Thus, mental health treatment is provided by mental health clinicians, and addiction treatment is provided by addiction treatment clinicians. Coordination between settings is quite variable. Integrated TreatmentA third model, called integrated treatment, is an approach that combines elements of both mental health and addiction treatment into a unified and comprehensive treatment program for patients with dual disorders. Ideally, integrated treatment involves clinicians cross-trained in both mental health and addiction, as well as a unified case management approach, making it possible to monitor and treat patients through various psychiatric and AOD crises. There are advantages and disadvantages in sequential, parallel, and integrated treatment approaches. Differences in dual disorder combinations, symptom severity, and degree of impairment greatly affect the appropriateness of a treatment model for a specific individual. For example, sequential and parallel treatment may be most appropriate for patients who have a very severe problem with one disorder, but a mild problem with the other. However, patients with dual disorders who obtain treatment from two separate systems frequently receive conflicting therapeutic messages; in addition, financial coverage and even confidentiality laws vary between the two systems.
In contrast, integrated treatment places the burden of treatment continuity on a case manager who is expert in both psychiatric and AOD use disorders.Further, integrated treatment involves simultaneous treatment of both disorders in a setting designed to accommodate both problems. Critical Treatment Issues For Dual DisordersMental health and addiction treatment programs that are being designed to accommodate patients with dual disorders should be modified to address the specific needs of these patients. Although there are different dual disorder treatment models, all such programs must address several key issues that are critical for successful treatment. These issues include: 1) treatment engagement, 2) treatment continuity and comprehensiveness, 3) treatment phases, and 4) continual reassessment and rediagnosis. Treatment EngagementIn general, treatment engagement refers to the process of initiating and sustaining the patient's participation in the ongoing treatment process. Engagement can involve such enticements as providing help with the procurement of social services, such as food, shelter, and medical services. Engagement can also involve removing barriers to treatment and making treatment more accessible and acceptable, for example, by providing day and evening treatment services. Engagement can be enhanced by providing adjunctive services that may appear to be indirectly related to the disorders, such as child care services, job skills counseling, and recreational activities.It may also be coercive, such as through involuntary commitment or a designated payee. Engagement begins with efforts that are designed to enlist people into treatment, but it is a long-term process with the goals of keeping patients in treatment and helping them manage ongoing problems and crises. Essential to the engagement process is: 1) a personalized relationship with the individual, 2) over an extended period of time, with 3) a focus on the stated needs of the individual. For patients with dual disorders, engagement in the treatment process is essential, although the techniques used will depend upon the nature, severity, and disability caused by an individual's dual disorders. An employed person with panic disorder and episodic alcohol abuse will require a different type of engagement than a homeless person with schizophrenia and polysubstance dependence. Withrespect to severe conditions such as psychosis and violent behaviors, therapeutic coercive engagement techniques may include involuntary detoxification, involuntary psychiatric treatment, or court-mandated acute treatment. Treatment ContinuityTo treat patients with dual disorders, it is critical to develop continuity between treatment programs and treatment components, as well as treatment continuity over time. In practice, many patients participate in treatment at different sites. Even in integrated treatment programs, many patients require different treatment services during different phases of treatment.For this reason, treatment should include an integrated dual disorder case management program, which can be located within a mental health setting, an addiction treatment setting, or a collaborative program. Treatment ComprehensivenessAn overall system for treating dual disorders includes mental health and addiction treatment programs, as well as collaborative integrated programs. Programs should be designed to: 1) engage clients, 2) accommodate various levels of severity and disability, 3) accommodate various levels of motivation and compliance, and 4) accommodate patients in different phases of treatment. There should be access to abstinence-mandated programs and abstinence-oriented programs, as well as to drug maintenance programs.Different levels of care, ranging from more to less intense treatment, should be available. Phases of TreatmentIn general, the medical term acute describes phenomena that begin quickly and require rapid response. Acute problems are contrasted with chronic problems. Most commonly, acute stabilization of patients with dual disorders refers to the management of physical, psychiatric, or drug toxicity crises. These include injury, illness, AOD-induced toxic or withdrawal states, and behavior that is suicidal, violent, impulsive, or psychotic. The acute stabilization of AOD use disorders typically begins with detoxification, such as inpatient detoxification for patients with significant withdrawal or outpatient detoxification for mild to moderate withdrawal, as well as nonmedical withdrawal, such as occurs in social-model detoxification programs. Also, initiation of methadone maintenance can provide outpatient acute stabilization for patients addicted to opioids. Acute stabilization of psychiatric symptoms more frequently occurs within a mental health or emergency medical setting, but involves a range of treatment intensity.Patients with severe symptoms, especially psychotic, violent, or impulsive behaviors, usually require acute psychiatric inpatient treatment and psychiatric medications, while patients with less severe symptoms can be treated in outpatient or day treatment settings. Dual disorder programs that provide stabilization to patients with acute needs should have the capability to:
These programs should be capable of promoting the patient's engagement with the treatment system. They should be able to aggressively provide linkages to other programs that will provide ongoing treatment and engagement. Subacute StabilizationThe medical term subacute describes the status of a medical disorder at points between the acute condition and either resolution or chronic state. The subacute phase of a medical problem occurs as the acute course of the problem begins to diminish, or when symptoms emerge or reemerge but are not yet severe enough to be described as acute. For example, patients recently detoxified from AODs frequently experience subacute symptoms such as insomnia and anxiety that may linger for a few days or weeks. On the other hand, recently detoxified patients with dual disorders may experience subacute symptoms of insomnia and anxiety either as subacute withdrawal symptoms or as a prelude to relapse with depression. Although the subacute phase is not generally regarded as a period of crisis, ignoring these symptoms and failing to assess and treat them may lead to symptom escalation, decompensation, and relapse. As AOD-induced toxic or withdrawal symptoms resolve, constant reassessment and rediagnosis is required. During this phase, a psychoeducational and behavioral approach should be used to educate patients about their disorders and symptomatology.During this phase, treatment providers should provide assessment and planning for dealing with long-term issues such as housing, long-term treatment, and financial stability. Biopsychosocial Assessment Issues From the AOD and Psychiatric Perspectives
ABC Model for Psychiatric Screening
Long-Term StabilizationThe treatment settings for long-term treatment, rehabilitation, and recovery from dual disorders include outpatient, day treatment, and residential settings. Ideally, treatment intensity is dictated by disorder severity and motivation for treatment, as well as by personal and local treatment resources. In more severe conditions, ongoing dual disorder case management is essential. The management of long-term severe conditions is described in more detail in the chapter on psychotic disorders (Chapter 8). With regard to the initiation and maintenance of sobriety in patients with dual disorders, another way of looking at acute, subacute, and long-term phases involves a four-step approach that leads to abstinence. This approach is particularly important for patients with severe psychiatric problems and an AOD use disorder (Minkoff and Drake, 1991; Ries, 1993a). Individual case management.Individual case management provides an initial introduction to treatment goals and concepts and may provide assistance with regard to crises, housing, and entitlements. An individual treatment plan is developed. Persuasion groups.Patients who display strong denial about their AOD use disorder and lack motivation can attend persuasion groups, which provide basic AOD education and treatment engagement. Premature, potent, and direct confrontation and an insistence on abstinence should be avoided since these approaches may prompt more fragile patients to leave treatment. Active treatment groups.Active treatment groups consist of patients who have accepted the goal of abstinence and are relatively mentally stable.These groups use supervised peer confrontation and a psychoeducational-behavioral approach to AOD abuse. Abstinence support groups.Finally, abstinence support groups consist of patients who are essentially committed to abstinence and are relatively stable mentally, who require ongoing education and support for sobriety and the development of relapse prevention skills. Psychiatric and AOD abuse treatment issues are woven into the groups in such a way that concreteissues (such as medication compliance) are addressed in persuasion groups, while abstract concepts (such as self-image) are addressed in active treatment or abstinence support groups. Some patients -- such as severely psychotic patients -- may not be able to advance beyond persuasion groups or active treatment groups. General Assessment IssuesEach of the following chapters will address assessment and evaluation issues relative to specific psychiatric disorders. Specific assessment tools may be recommended for certain interventions and certain settings. Irrespective of the treatment or intervention setting, and notwithstanding the crisis that may have initiated the treatment contact, all treatment contacts with patients who may have dual disorders should include a basic screening for psychiatric and AOD use disorders. These issues are addressed in detail in the chapters on mood, personality, and psychotic disorders.With respect to both psychiatric and AOD use disorders, the assessment process should be sensitive to biological, psychological, and social issues. Full assessments of patients with dual disorders should be performed by clinicians who have certified training in the areas that they assess. However, clinicians who are not certified can learn to perform screening tests. Assessments of patients who may have dual disorders should include at least a brief mental status exam to assess for the presence and severity of psychiatric problems, as well as a screening for AOD use disorders. The "ABC" model described on the previous page is a simple screening technique for the presence of psychiatric disorders. The CAGE questionnaire and the CAGE questionnaire modified for other drugs (CAGEAID) are rapid and accurate screening tools for AOD use disorders (Exhibit 3-2).The substances used most often by patients with dual disorders are the same as those used by society in general: alcohol, marijuana, cocaine, and more rarely, opioids. It is recommended that all front-line AOD and mental health staff receive detailed training in the use of a mental status exam and AOD screening tests. Chapter 4 -- Linkages For Mental Health and AOD TreatmentOverviewConventional boundaries between single-focus agencies have impeded the clinical progress of patients who have psychiatric disorders and alcohol and other drug (AOD) use disorders (Baker, 1991; Schorske and Bedard, 1988). The treatment of patients with dual disorders is a clinical challenge, as well as a systems challenge, requiring innovation and coordination. The goal of this chapter is to help State and local administrators consider strategies for linkages across systems in order to improve service delivery and treatment outcomes. Profiles of patients with dual disorders demonstrate that they are more or differently disabled and require more services than patients with a single disorder. They have higher rates of homelessness and legal and medical problems. They have more frequent and longer hospitalizations and higher acute care utilization rates. For example, among patients with schizophrenia, episodes of violence and suicide are twice as likely to occur among those who abuse street drugs as among those who do not. Treatment and social needs of patients with dual disorders differ depending on the type and severity of the disorders. Patients with dual disorders are generally less able to navigate between, engage in, and remain engaged in treatment services.Focusing on linkages highlights the fact that treatment providers, rather than patients and their families, have the responsibility for coordinating diverse and often conflicting treatment services. Treatment must be suited to patients' personal needs and characteristics, linking services across several different systems of care. Instead of blaming patients for poor treatment outcomes as they fall through the cracks of separate service systems, patients can be empowered and better treated when given effective options. Collaboration across multiple systems and philosophies of care is needed to treat patients with dual disorders effectively. The systems often affected include:
For the treatment of patients with dual disorders, the primary systems involved are AOD and mental health treatment. Programs that focus on dual disorders operate in both the mental health and AOD systems. Staff and administrative initiative is required to collaborate across systems. At a minimum, both systems should be involved when developing initiatives to improve linkages. This TIP is focused on the linkages between these systems. In order to work effectively together, AOD treatment providers and mental health professionals need to understand and respect the different historical and philosophical underpinnings of both systems. As explained in the third chapter, the systems developed separately. There are inherent stresses and strengths among medical, psychoanalytic, psychosocial, and self-help care orientations, as well as between AOD treatment and mental health treatment. These differences have frequently been a source of conflict and have caused problems for some patients. For example, if a patient with a dual disorder is told by his psychiatrist that he needs psychotropic medication to treat his psychiatric disorder, but members of his self-help AA group tell him to give up all mood-altering drugs to recover from his AOD abuse, to whom does he listen? Patients with dual disorders challenge the treatment systems. Their involvement in treatment can become an opportunity for providers to examine the philosophical and practical aspects of treatment.
In spite of the historical and philosophical differences that have separated the fields, the consensus panel identified several shared treatment concepts that administrators can use to help move toward integration.
Areas of Primary ConcernTo establish and maintain linkages among the various systems working with patients who have dual disorders, several primary administrative areas need to be examined. It is beyond the scope of this document to provide detailed discussion of each area, but the following discussion of problems and solutions will help readers in their problem solving. The areas to be discussed in this chapter include:
Policy and Planning StructuresProblemsOften there is little or no communication or collaboration among various departments and levels of government that have separate administrative structures, constituencies, mandates, and target groups.There are also different Federal, State, and local planning cycles within the AOD use and mental health treatment systems. The Federal Government requires two separate planning processes for programs receiving Federal funds: A State mental health plan and a State substance abuse plan. The federally mandated State planning processes required under the Public Health Service Act for mental health treatment and AOD abuse treatment are separate and have no requirements for coordination. SolutionsAmendments are needed to the Public Health Service Act to encourage coordinated long-term planning between the State mental health and AOD abuse treatment systems for patients with dual disorders. The development and use of long-term structural mechanisms (such as coordinating bodies, task forces, memoranda of understanding, and letters of agreement) can help improve planning for andintegration of services for patients who have dual disorders. To accomplish this goal, States might create a joint planning mechanism -- an officially organized planning group -- that would: 1) have diverse composition, 2) carry out specific types of tasks, and 3) maintain specific foci. 1. The planning organization should have diverse composition.
2. The planning group should accomplish the following tasks:
3. The planning group should maintain the following foci:
Funding and ReimbursementProblemsBecause of diminishing fiscal resources and competition among many interest groups for particular types of treatment, those who seek funds for the treatment of patients with dual disorders have an increasingly difficult task. In many areas, patients with dual disorders may not be recognized as a priority group for funding.No specific monies are set aside for patients with dual disorders under the block grants. The amount of funds that the Federal Government allocates to States for the AOD and mental health block grant programs changes from year to year and often includes mandated set-asides for specific groups (for example, needle users, women, etc.). Set-asides tend to be different for mental health and AOD abuse treatment and limit the amount available for special groups not specifically targeted. States often do not take advantage of Federal monies that can be used for patients with dual disorders. It is difficult to identify Federal grants that can be used for dual disorders, since grants and announcements are scattered across many agencies such as the Substance Abuse and Mental Health Services Administration (SAMHSA), CSAT, the Center for Substance Abuse Prevention (CSAP), the National Institute on Drug Abuse (NIDA), the National Institute on Alcohol Abuse and Alcoholism (NIAAA), the National Institute of Mental Health (NIMH), and theCenter for Mental Health Services (CMHS), to name a few. Current reimbursement practices inhibit integration of services and effective treatment, and there are several problems related to reimbursement from both public and private third-party payers. These problems include the following:
Solutions1. Facilitate the aggressive pursuit of Federal funds by the following actions:
2. Facilitate the use of block grant funds for treating patients with dual disorders.
3. Promote Requests for Proposals (RFPs) for treating patients with dual disorders.
4. Encourage initiatives within third-party reimbursement mechanisms to cover treatment for patients with dual disorders.
Data Collection and Needs AssessmentProblemsOnly limited treatment and research data are available, and those that are available are not in a standardized format. Existing data also tend to be general and not useful to local planners for developing a continuum of care. Data collection systems are mandated to be separate from each other.It is difficult to gather prevalence data on patients with dual disorders because many of them interact with several treatment agencies or systems, while others do not interact with any. There are systemic disincentives to gathering data on patients with dual disorders. For example, Medicaid may cover a patient who makes a suicide attempt as a result of major depression, but may not cover a patient who makes a drug-induced suicide attempt. SolutionsAt least on the State level, common identifiers in data collection should exist for both AOD abuse and mental health treatment systems. Research should be in a form that allows for evaluation of cost-effectiveness and outcome.Outcomes should be measured across several categories encompassing biopsychosocial issues. Examples might be 1) severity of AOD and psychiatric symptomatology, 2) housing, 3) service involvement and utilization, and 4) vocational involvement. Collaboration with local colleges and universities to conduct such research should be encouraged. State planning bodies should encourage or require local needs and resource assessment and data collection. Local planners should collect data from various systems, examining and comparing data from different groups, programs, and locations. The State could gather all the data and compile them for use in improved planning and in evaluating outcomes. Confidentiality laws must protect the patient, but also must allow for inclusion of anonymous case number data in pools to promote better assessment and treatment outcome studies. There should be aggressive efforts to examine cost-effectiveness and outcomes of specific models of treatment services for patients with dual disorders.These research efforts can be incorporated into State and local initiatives, perhaps involving local colleges and universities. Program DevelopmentProblemsLinkages in the development of programs for treating patients with dual disorders are impeded by several factors:
Solutions
Screening, Assessment, And ReferralProblemsThe screening process amplifies the tendency to look for a single diagnosis.Staff in single-focus screening services are not trained to assess patients for dual disorders. There is no "gold standard" instrument to diagnose dual disorders. Some of the instruments that are used often yield false positive results. Screeners are not adequately trained to make effective referrals across systems, which can result in denial of treatment services. Screening for dual disorders may take longer than screening for a single disorder. For example, psychiatric symptoms can appear or disappear as the AOD-induced symptoms clear. Solutions
Case ManagementProblemsThere frequently is no single person or agency responsible for following up on referrals and ensuring that patients are linked to treatment and that services are coordinated. People with dual disorders need others to help them obtain the services that they require, which are often fragmented. The Public Health Service Act requires that State mental health agencies that receive Federal funds provide case management services to patients with severe mental illness. However, a comparable requirement is not built into the Federal mandate for AOD abuse treatment services. AOD abuse treatment agencies usually do not have enough social service staff to handle the case management functions of linkage or followup for many dual disorder patients. Solutions
StaffingProblemsAll too often, treatment staff are knowledgeable about either mental health or AOD treatment. They lack thorough training and education about dual disorder patients. There is often insufficient staff time available for the level of case management required for dual disorder patients. Staff selection is often driven more by clinicians' academic degree and their ability to provide reimbursable services than by clinicians' expertise in dual disorders. Solutions
Training and StaffingProblemsClinicians in AOD abuse treatment and mental health treatment usually are not trained in the other discipline. The availability of staff trained in both fields is limited. Agencies frequently lack the resources to recruit and retain staff who have sufficient education and experience. There is both a shortage of qualified staff and an inability to financially compensate qualified staff for their specialized abilities. The diagnosis and treatment of dual disorders are not generally understood by staff, administrators, and legislators, let alone the general public.Agency directors and supervisors often assign whom they believe to be the most appropriate staff member to work with dual disorder patients without a clear idea of the knowledge and skills required. Professionals in AOD abuse and mental health treatment have accumulated biases against the other discipline, as well as negative stereotypes of both patients and staff. There are no structured incentives for individuals or programs to develop or take part in training, such as pay differentials and career opportunities specific to dual disorders. Opportunities and incentives for cross-training are lacking. Consumers are not adequately involved in the training process. Relatively few academic programs involve training or research in this field. SolutionsCross-training is one of the most effective tools administrators have for bridging gaps between clinicians and services from different fields. Training programs that provide knowledge about local networking can greatly improve linkages for patients with dual disorders. Solutions for administrators:
Solutions for staff:
Solutions for the community:
Solutions for consumers and their families:
Linkages With Social Service SystemsProblemsA large proportion of patients with dual disorders require social services.The scope of social services is extremely broad, encompassing public and private multisystems. Federally mandated income support programs are notoriously complex, each with its own set of regulations. Some, such as the Social Security Income (SSI) maintenance program, are administered by the Federal Government, while others are administered by the State and vary from State to State. Income support programs include SSI, Medicaid,Medicare, welfare, Aid to Families With Dependent Children (AFDC), and food stamps. Regulations for each program are often not understood by professionals and others who provide services to potential recipients. This makes it even more difficult for the potential recipient to get and retain benefits. Some programs, such as SSI, require proof of a permanent and total disability. Mental health problems often do not neatly fit into categories, making it difficult to obtain this support. Income support programs for single individuals have been cut drastically in recent years. Applications for these income support programs are often taken at a site other than where either mental health or AOD services are provided for the patient. The complexity of the application and appeal process adds to the stress of a person with a dual disorder. Overburdened staff who are processing income support applications often do not understand dual disorders. Federally mandated services for children, youth, and families include services that fall under the child welfare system (for example, child protective services and foster care placement). Child welfare system staff are overburdened and understaffed. A large percentage of caseloads involve family AOD use problems. Most child welfare staff are not trained in recognizing or treating dual disorder problems. Mental health and AOD abuse staff are not trained in child welfare. There is a lack of knowledge of each other's systems and resources. Other social service programs serve a wide range of special needs populations, including the homeless and victims of domestic violence or sexual abuse, who require a broad array of support services. Although many users of these services have mental health and AOD abuse problems, these services are often not available on site. Social service staff often lack knowledge of how to refer people with such problems into these systems. Solutions
Linkages With the Health Care SystemProblemsThe medical system is vast, covering a wide range of public and private programs including primary, secondary, and tertiary care. Public primary care clinics are often overburdened, understaffed, and underfinanced. They are often oriented to treating presenting physical problems, and staff may not be trained in screening for either AOD abuse or mental health problems. The same problems often exist in nonprofit primary care facilities. Staff are often not knowledgeable about how and where to refer patients. Historically, physicians have not received any education about AOD treatment and little education about mental health problems in medical school. Primary care physicians are often unaware of the signs and symptoms of AOD use disorders, and may have only a basic understanding of a few psychiatric problems such as depression and anxiety. For example, persons who experience physical trauma, such as burn injuries or falls, often have AOD use disorders. Yet, when presented with injured patients, primary care physicians may not screen for AOD use disorders. At hospital discharge, personnel often have difficulty dealing with AOD abuse and mental health concerns. Patients are sometimes discharged inappropriately with inadequate discharge planning and linkage with aftercare services. Staff in mental health and AOD abuse treatment systems often do not know how to gain access tomedical systems and therefore are ineffective in providing information and ongoing education. Solutions
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