Integrated Treatment for Dual Disorders

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Integrated Treatment for Dual Disorders

• Kim Mueser, Ph.D.
• Dartmouth Medical School
• NH-Dartmouth Psychiatric Research Center
• Kim.t.mueser_at_dartmouth.edu

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Overview

• Epidemiology
• Why focus on dual disorders?
• Models of etiology
• Assessment
• Treatment principles
• Research
• Avoiding the blame/demoralization trap

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Rates of Lifetime Substance Use Disorder (SUD)
among Recently Admitted Psychiatric Inpatients
(N325) (Mueser et al., 2000)
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Factors Influencing Prevalence of Substance Use
Disorders (SUD) Client Characteristics

• Higher Rates
• Males
• Younger
• Lower education
• Single or never married
• Good premorbid functioning

• History of childhood conduct disorder
• Antisocial personality disorder
• Higher affective symptoms
• Family history SUD

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Factors Influencing Prevalence of Substance Use
Disorders Sampling Location

• Higher Rates
• Emergency rooms
• Acute psychiatric hospitals
• Jails

• Homeless
• Urban setting (drugs)
• Rural setting (alcohol)

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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

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• Frequently abuse moderate to high amounts of
  substances
• Personality Disorders
• Antisocial borderline most common
• Frequently abuse high amounts of substances

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Clinical Epidemiology

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

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Why Focus on Dual Disorders?

• 1. Substance abuse is the most common co-
• occurring disorder in persons with severe
• mental disorders
• 2. Significant negative outcomes related to
• substance abuse
• 1) Clinical relapse rehospitalization
• 2) Demoralization
• 3) Family stress
• 4) Violent behavior

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

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Reasons for High Comorbidity Rates of Severe
Mental Illness and Substance Abuse

• Berksons Fallacy
• Self-medication
• Super-sensitivity to effects of substances
• Socialization motives
• Precipitation of psychosis from substance use

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• Common factors
• Poverty/deprivation
• Neurocognitive impairment
• Conduct disorder/antisocial personality disorder

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• Self-Medication
• More symptomatic clients dont abuse more
  substances
• Substance selection unrelated to type of symptoms
  experienced
• Types of substances abused unrelated to
  psychiatric diagnosis
• Self-medication may contribute to some
  comorbidity but doesnt explain all
• More evidence supporting self-medication in
  anxiety disorders (PTSD)

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

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Stress-Vulnerability Model
Biological Vulnerability
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Status of Moderate Drinkers with Schizophrenia 4
- 7 Years Later (N45)
Source Drake Wallach (1993)
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• Support for Super-sensitivity Model
• Dual disorder clients less likely to develop
  physical dependence on substances
• Standard measures of substance abuse are less
  sensitive in clients with severe mental illness
• Clients are more sensitive to effects of small
  amounts of substances
• Few clients are able to sustain moderate use
  without impairment
• Super-sensitivity accounts for some increased
  comorbidity

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

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Functional Assessment

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

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

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Evaluating Social FactorsAssociated with
Substance Abuse

• Does person have non-substance abusing peers?
• Can person resist offers to use substances?
• Is the person lonely?
• Can the person initiate and maintain
  conversations?
• Is person able to get others to respond
  positively to him/her?
• Can the person express feelings? Resolve
  conflicts?

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Common Symptoms Associatedwith Self-Medication

• Depression, suicidal thoughts
• Anxiety, nervousness, tension
• Hallucinations
• Delusions of reference paranoia
• Sleep disturbance
• Mania/hypomania

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Recreational Skills and Substance Abuse

• What does the person do for fun?
• Hobbies?
• Sports?
• What is persons involvement with others in
  recreational activities?
• Does the person not participate in activities
  which he/she previously did?

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Functional Analysis

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

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• Constructing a Payoff Matrix
• 1. List advantages disadvantages of using
• substances, advantages disadvantages of
• not using substances in Payoff Matrix
• 2. Use all available information from functional
• assessment
• 3. Consider advantages disadvantages from the
• clients 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 and cons of using

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Pay-Off Matrix
Using Substances
Not Using Substances
Advantages
Disadvan-tages
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Common Advantages and Disadvantages of Using
Substances and Not Using Substances
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Examples of Interventions Based on the Payoff
Matrix
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Treatment Planning

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

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

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Treatment Barriers

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

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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

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Other Features of Dual Disorder Programs

• Assertive outreach
• Stage-wise treatment engagement, persuasion,
  active treatment, and relapse prevention
• Long-term commitment
• Comprehensive treatment
• Reduction of negative consequences

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What are the Stages of Treatment?

• 1. Engagement, persuasion,
• active treatment, and relapse
• prevention
• 2. Not linear
• 3. Stage determines goals
• 4. Goals determine interventions
• 5. Multiple options at each stage

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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

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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

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What Do We Do During Active Treatment?

• Goal
• To reduce clients use/abuse of substance
• Clinical Strategies
• 1. Self-monitoring
• 2. Social skills training
• 3. Social network interventions
• 4. Self-help groups

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

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What Do We Do During Relapse Prevention?

• Goals
• To maintain awareness of vulnerability and expand
  recovery to other areas
• Clinical Strategies
• 1. Self-help groups
• 2. Cognitive-behavioral and supportive
  interventions to enhance functioning in
• Work, relationships, leisure activities, health,
  and quality of life

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Relapse Prevention Strategies

• Construction a relapse prevention plan
• Risky situations
• Early warning signs
• Immediate response
• Social supports
• Abstinence violation effect

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Recovery Mountain

• Combat demoralization related to relapses
• Reframe relapses as part of road to recovery
• Dont loose sight of gains made between relapses
• Learning experience, modify relapse prevention
  plan

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Stages of Substance Abuse Treatment

• 1. Pre-engagement No contact with a counselor.
• 2. Engagement Irregular contact with a
  counselor.
• 3. Early Persuasion Regular contact with a
  counselor, but no reduction in substance abuse.
• 4. Late Persuasion Regular contact with a
  counselor and reduction in substance use (lt 1
  month).

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

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Research on Integrated Treatment (IT)

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

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Research on IT (Cont.)

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

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Drake et al. (1998)

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

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NH Dual Diagnosis Study
1. Proportion of days in stable community housing
(regular apartment or house, not in hospital,
jail, homeless setting or doubling with friends
or family) increased for all dual diagnosis
clients. 2. They increased more rapidly for
persons in recovery (no substance abuse for at
least 6 months).
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NH Dual Diagnosis Study
1. Percentage of persons hospitalized during each
six months declined significantly for all
clients. 2. It declined much more for those in
recovery.
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Fidelity to IT Model Improves Outcome
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Limitations of Research

• Lack of standardization of treatments
• No or limited fidelity assessment
• No replication of program effects
• Unclear or variable comparison conditions

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Avoiding the Blame/Demoralization Trap

• Dont blame the client for substance abuse or
  relapses because
• Substance abuse is a disorder for which clients
  are no more responsible than their primary
  psychiatric symptoms
• Clients with most severe substance abuse need
  professional help the most many others improve
  spontaneously
• Remember that the clients are doing the best they
  can

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