Assessment and Treatment of Patients with Coexisting Mental Illness and Alcohol and Other Drug Abuse Treatment Improvement Protocol (TIP) Series 9 Richard K. Ries, M.D., Consensus Panel Chair U.S. Department of Health and Human Services Public Health Service Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment Rockwall II, 5600 Fishers Lane Rockville, MD 20857 DHHS Publication No. (SMA) 95-3061. Printed 1994. Reprinted 1995. [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 Richard K. Ries, M.D., Chair Director Inpatient Psychiatry and Dual Disorder Programs Harborview Medical Center Seattle, Washington Facilitators: Marcelino Cruces, L.C.S.W. Administrative Coordinator Andromeda Transcultural Mental Health Center Substance Abuse Treatment Division Washington, D.C. Mary Katherine Evans, C.A.D.C., N.C.A.C. II Program Director Evans and Sullivan Beaverton, Oregon James Fine, M.D. Director Addictive Disease Hospital at Kings County Hospital Center Clinical Associate Professor Department of Psychiatry State University of New York Health Service Center at Brooklyn Brooklyn, New York Bonnie Schorske, M.A. Coordinator Special Populations New Jersey Division of Mental Health and Hospitals Trenton, New Jersey Workgroup Members: Stephen J. Bartels, M.D. Medical Director West Central Services, Inc. Research Associate New Hampshire-Dartmouth Psychiatric Research Center Lebanon, New Hampshire Dolores Burant, M.D. Program and Medical Director University Outpatient Recovery Service Madison, Wisconsin Agnes Furey, L.P.N., C.A.P. Primary Care Coordinator Florida Alcohol and Drug Abuse Program Department of Health and Rehabilitation Services Tallahassee, Florida Malcolm Heard, M.S. Director Division on Alcoholism and Drug Abuse Nebraska Department of Public Institutions Lincoln, Nebraska Norman Miller, M.D. Associate Professor of Psychiatry Chief, Addiction Programs Department of Psychiatry University of Illinois at Chicago Chicago, Illinois Ernest Quimby, Ph.D. Assistant Graduate Professor Howard University Department of Sociology and Anthropology Washington, D.C. Henry Jay Richards, Ph.D. Associate Director for Behavioral Sciences Patuxent Institution Jessup, Maryland Candace Shelton, M.S., C. A.C. Clinical Director Pascua Yaqui Adult Treatment Home Tucson, Arizona Virginia Stiepock, A.C.S.W, R.N., C.S. Assistant Center Director Clinical Director Northern Rhode Island Community Mental Health Center Woonsocket, Rhode Island Mathias Stricherz, Ed.D., C.D.C. III Director Student Counseling Center University of South Dakota Vermillion, South Dakota Patricia M. Weisser National Association of Psychiatric Survivors Sioux Falls, South Dakota Joan Ellen Zweben, Ph.D. Executive Director The East Bay Community Recovery Project The 14th Street Clinic and Medical Group Berkeley, California Foreword The Treatment Improvement Protocol Series (TIPs) fulfills CSAT's mission to improve alcohol and other drug (AOD) abuse and dependency treatment by providing best practices guidance to clinicians, program administrators, and payers. This guidance, in the form of a protocol, results from a careful consideration of all relevant clinical and health services research findings, demonstration experience, and implementation requirements. A panel of non-Federal clinical researchers, clinicians, program administrators, and patient advocates employs a consensus process to produce the product. This panel's work is reviewed and critiqued by field reviewers as it evolves. The talent, dedication, and hard work that TIPs panelists and reviewers bring to this highly participatory process have bridged the gap between the promise of research and the needs of practicing clinicians and administrators. I am grateful to all who have joined with us to contribute to advance our substance abuse treatment field. Susan L. Becker Associate Director for State Programs Center for Substance Abuse Treatment Chapter 1 --Introduction Overview The treatment needs of patients who have a psychiatric disorder in combination with an alcohol and other drug (AOD) use disorder differ significantly from the treatment needs of patients with either an AOD use disorder or a psychiatric disorder by itself. This Treatment Improvement Protocol (TIP) consists of recommendations for the treatment of patients with dual disorders. This TIP was developed by a multidisciplinary consensus panel that included addiction counselors, social workers, psychologists, psychiatrists, other physicians, nurses, and program administrators with active clinical involvement in the treatment of patients with dual disorders. Consumers also participated on the panel. This TIP was written principally for addiction treatment staff. However, it contains information and treatment recommendations that can be used by healthcare providers in a variety of treatment settings. For example, it will be useful to people who work in primary care clinics, hospitals, and various mental health settings. In addition, there are recommendations that are targeted to administrators and planners of healthcare services. A thoughtful attempt has been made to include information that the consensus panel felt was clinically relevant. While many clinical topics are explored in depth, some are only briefly mentioned, and a few are avoided altogether. It is not the goal of this TIP to provide an exhaustive description of all of the possible issues that relate to the treatment of patients with dual disorders. Rather, the primary goal is to provide treatment recommendations that are practical and useful. Indeed, the usefulness of this TIP can be enhanced by blending these recommendations with those of another TIP such as Intensive Outpatient Treatment for Alcohol and Other Drug (AOD) Abuse.By doing so, treatment protocols can be developed which will meet very specific treatment needs. Contents Definitions and Models Chapter 2 -- Dual Disorders: Concepts and Definitions -- provides descriptions and diagnostic criteria for AOD abuse and dependence. There is also a description of the possible interactions between AOD use and psychiatric symptoms and disorders. Chapter 3 -- Mental Health and Addiction Treatment Systems: Philosophical and Treatment Approach Issue -- describes the similarities, differences, strengths, and weaknesses of the treatment systems used by patients with dual disorders: the mental health system, the addiction treatment system, and the medical system. Similarly, there is a description of treatment models most frequently used: sequential treatment of each disorder, parallel treatment of each disorder, and integrated treatment of both disorders. The chapter includes a discussion of critical treatment issues and general assessment issues in providing care to patients with dual disorders. Linkages Chapter 4 -- Linkages for Mental Health and AOD Treatment -- describes several areas of critical concern for programs that provide services to patients with dual disorders. There are discussions regarding policy and planning; funding and reimbursement; data collection and needs assessment; program development; screening, assessment, and referral; case management; staffing and training; and linkages with social service, health care, and the criminal justice systems. This chapter should be particularly useful for administrators and political planners who address the potential administrative overlaps and gaps that exist between the mental health and addiction treatment systems. The semi-outline format of the chapter will allow planners of services a rapid checkup of specific areas such as funding and reimbursement, program development, and case management. Specific Psychiatric Disorders While entire books can be written regarding specific psychiatric disorders, this TIP describes the disorders that account for the majority of psychiatric problems seen in patients with dual disorders. TIP chapters that address specific psychiatric problems include Chapter 5, Mood Disorders; Chapter 6, Anxiety Disorders; Chapter 7, Personality Disorders; and Chapter 8, Psychotic Disorders. By combining chapters, strategies for treating patients with complex disorders may be developed. For example, by combining techniques recommended for the treatment of personality and mood disorders, borderline syndrome treatment strategies can be developed. Both content and stylistic approaches vary markedly among these chapters, reflecting the differences of consensus panel members who composed them. Since these differences in stylistic approaches may be useful to the reader, they have been retained. Psychopharmacology Chapter 9 -- Pharmacologic Management -- is a brief overview of the types of medications used in psychiatry and addiction medicine and for patients with dual disorders. A stepwise treatment model that can minimize medication abuse risks is discussed, and cautions about drug interactions are reviewed. Addiction treatment program staff are increasingly encountering patients who require prescribed medications in order to participate in recovery. For this reason, it is important for clinical staff to have an understanding of the principle medications used in psychiatry and how they are used. In addition, agencies that hire a consulting psychiatrist may want to review with the psychiatrist the prescribing issues raised in this chapter. A bibliography is provided for further study in Appendix A. A brief overview of sample cost data for the treatment of dual disorders is in Appendix B. It compares three treatment programs on features such as salary ranges and administrative costs. Chapter 2 -- Dual Disorders: Concepts and Definitions The Relationships Between AOD Use and Psychiatric Symptoms and Disorders Establishing an accurate diagnosis for patients in addiction and mental health settings is an important and multifaceted aspect of the treatment process. Clinicians must discriminate between acute primary psychiatric disorders and psychiatric symptoms caused by alcohol and other drugs (AODs). To do so, clinicians must obtain a thorough history of AOD use and psychiatric symptoms and disorders. There are several possible relationships between AOD use and psychiatric symptoms and disorders. AODs may induce, worsen, or diminish psychiatric symptoms, complicating the diagnostic process. The primary relationships between AOD use and psychiatric symptoms or disorders are described in the following classification model (Landry et al., 1991a; Lehman et al., 1989; Meyer, 1986). All of these possible relationships must be considered during the screening and assessment process. AOD use can cause psychiatric symptoms and mimic psychiatric disorders. Acute and chronic AOD use can cause symptoms associated with almost any psychiatric disorder. The type, duration, and severity of these symptoms are usually related to the type, dose, and chronicity of the AOD use. Acute and chronic AOD use can prompt the development, provoke the reemergence, or worsen the severity of psychiatric disorders. AOD use can mask psychiatric symptoms and disorders. Individuals may use AODs to purposely dampen unwanted psychiatric symptoms and to ameliorate the unwanted side effects of medications. AOD use may inadvertently hide or change the character of psychiatric symptoms and disorders. AOD withdrawal can cause psychiatric symptoms and mimic psychiatric syndromes. Cessation of AOD use following the development of tolerance and physical dependence causes an abstinence phenomenon with clusters of psychiatric symptoms that can also resemble psychiatric disorders. Psychiatric and AOD disorders can coexist. One disorder may prompt the emergence of the other, or the two disorders may exist independently. Determining whether the disorders are related may be difficult, and may not be of great significance, when a patient has long-standing, combined disorders. Consider a 32-year-old patient with bipolar disorder whose first symptoms of alcohol abuse and mania started at age 18, who continues to experience alcoholism in addition to manic and depressive episodes. At this point, the patient has two well-developed independent disorders that both require treatment. Psychiatric behaviors can mimic behaviors associated with AOD problems. Dysfunctional and maladaptive behaviors that are consistent with AOD abuse and addiction may have other causes, such as psychiatric, emotional, or social problems. Multidisciplinary assessment tools, drug testing, and information from family members are critical to confirm AOD disorders. The symptoms of a coexisting psychiatric disorder may be misinterpreted as poor or incomplete "recovery" from AOD addiction. Psychiatric disorders may interfere with patients' ability and motivation to participate in addiction treatment, as well as their compliance with treatment guidelines. For example, patients with anxiety and phobias may fear and resist attending Alcoholics Anonymous or group meetings. Depressed people may be too unmotivated and lethargic to participate in treatment. Patients with psychotic or manic symptoms may exhibit bizarre behavior and poor interpersonal relations during treatment, especially during group-oriented activities. Such behaviors may be misinterpreted as signs of treatment resistance or symptoms of addiction relapse. AOD Use and Psychiatric Symptoms AOD use can cause psychiatric symptoms and mimic psychiatric syndromes. AOD use can initiate or exacerbate a psychiatric disorder. AOD use can mask psychiatric symptoms and syndromes. AOD withdrawal can cause psychiatric symptoms and mimic psychiatric syndromes. Psychiatric and AOD use disorders can independently coexist. Psychiatric behaviors can mimic AOD use problems. The Terminology of Dual Disorders The term dual diagnosis is a common, broad term that indicates the simultaneous presence of two independent medical disorders. Recently, within the fields of mental health, psychiatry, and addiction medicine, the term has been popularly used to describe the coexistence of a mental health disorder and AOD problems. The equivalent phrase dual disorders also denotes the coexistence of two independent (but invariably interactive) disorders, and is the preferred term used in this Treatment Improvement Protocol (TIP). The acronym MICA, which represents the phrase mentally ill chemical abusers, is occasionally used to designate people who have an AOD disorder and a markedly severe and persistent mental disorder such as schizophrenia or bipolar disorder. A preferred definition is mentally ill chemically affected people, since the word affected better describes their condition and is not pejorative. Other acronyms are also used: MISA (mentally ill substance abusers), CAMI (chemical abuse and mental illness), and SAMI (substance abuse and mental illness). Common examples of dual disorders include the combinations of major depression with cocaine addiction, alcohol addiction with panic disorder, alcoholism and polydrug addiction with schizophrenia, and borderline personality disorder with episodic polydrug abuse. Although the focus of this volume is on dual disorders, some patients have more than two disorders, such as cocaine addiction, personality disorder, and AIDS. The principles that apply to dual disorders generally apply also to multiple disorders. The combinations of AOD problems and psychiatric disorders vary along important dimensions, such as severity, chronicity, disability, and degree of impairment in functioning. For example, the two disorders may each be severe or mild, or one may be more severe than the other. Indeed, the severity of both disorders may change over time. Levels of disability and impairment in functioning may also vary. Thus, there is no single combination of dual disorders; in fact, there is great variability among them. However, patients with similar combinations of dual disorders are often encountered in certain treatment settings. For instance, some methadone treatment programs treat a high percentage of opiate-addicted patients with personality disorders. Patients with schizophrenia and alcohol addiction are frequently encountered in psychiatric units, mental health centers, and programs that provide treatment to homeless patients. Patients with mental disorders have an increased risk for AOD disorders, and patients with AOD disorders have an increased risk for mental disorders. For example, about one-third of patients who have a psychiatric disorder also experience AOD abuse at some point (Regier et al., 1990), which is about twice the rate among people without psychiatric disorders. Also, more than half of the people who use or abuse AODs have experienced psychiatric symptoms significant enough to fulfill diagnostic criteria for a psychiatric disorder (Regier et al., 1990; Ross et al., 1988), although many of these symptoms may be AOD related and might not represent an independent condition. Compared with patients who have a mental health disorder or an AOD use problem alone, patients with dual disorders often experience more severe and chronic medical, social, and emotional problems. Because they have two disorders, they are vulnerable to both AOD relapse and a worsening of the psychiatric disorder. Further, addiction relapse often leads to psychiatric decompensation, and worsening of psychiatric problems often leads to addiction relapse. Thus, relapse prevention must be specially designed for patients with dual disorders. Compared with patients who have a single disorder, patients with dual disorders often require longer treatment, have more crises, and progress more gradually in treatment. Psychiatric disorders most prevalent among dually diagnosed patients include mood disorders, anxiety disorders, personality disorders, and psychotic disorders. Each of these clusters of disorders and symptoms is dealt with in more detail in separate chapters. AOD Abuse, Addiction, Dependence, Misuse The characteristic feature of AOD abuse is the presence of dysfunction related to the person's AOD use. The Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R), produced by the American Psychiatric Association and updated periodically, is used throughout the medical and mental health fields for diagnosing psychiatric and AOD use disorders. It provides clinicians with a common language for communicating about these disorders and for making clinical decisions based on current knowledge. For each diagnosis, the manual lists symptom criteria, a minimum number of which must be met before a definitive diagnosis can be given to a patient. Criteria for AOD abuse hinge on the individual's continued use of a drug despite his or her knowledge of "persistent or recurrent social, occupational, psychologic, or physical problems caused or exacerbated by the use of the [drug]" (American Psychiatric Association, 1987). Alternately, there can be "recurrent use in situations in which use is physically hazardous." The DSM-IV draft continues this emphasis (American Psychiatric Association, 1993). Thus, AOD abuse is defined as the use of a psychoactive drug to such an extent that its effects seriously interfere with health or occupational and social functioning. AOD abuse may or may not involve physiologic dependence or tolerance. Importantly, evidence of physiologic dependence and tolerance is not sufficient for diagnosis of AOD abuse. For example, use of AODs in weekend binge patterns may not involve physiologic dependence, although it has adverse effects on a person's life. AOD Abuse Significant impairment or distress resulting from use