Quick GuideFor Clinicians

Based on TIP 9 Assessment and Treatment of Patients With Coexisting Mental Illness and Alcohol and Other Drug Abuse

What is a TIP?

• The TIP series provides the substance abuse treatment and related fields with consensus-based, field-reviewed guidelines on substance abuse treatment topics of vital current interest.

• This presentation is based on TIP 9 Assessment and Treatment of Patients With Coexisting Mental Illness and Alcohol and Other Drug Abuse (see last slide for ordering information).

• For more detailed information, readers are referred by page number to the publication mentioned above.

Introduction

• Treatment needs of patients who have a psychiatric disorder in combination with a substance abuse disorder differ significantly from the treatment needs of patient with either a substance abuse disorder or a psychiatric disorder by itself.

• Clinicians must discriminate between psychiatry and substance abuse disorders by obtaining a thorough history of symptoms and disorders.

See TIP 9, pp.1-3.

Dual Disorders

Concepts and DefinitionsFor more information, see TIP 9, pp.3-7.

Relationships: Substance Abuse and Psychiatric Symptoms and Disorders

• Substance abuse may mask psychiatric symptoms, complicating the diagnostic process.

• Terminology of dual disorders:– MICA: mentally ill chemical abusers– MISA: mentally ill substance abuser– CAMI: chemical abuse and mental illness– SAMI substance abuse and mental illness

Relationships

• Patients with mental disorders have an increased risk for substance abuse disorders, and

• Patients with substance abuse disorders have an increased risk for mental disorders.

Signs & Symptoms of Dependency/Addiction

• Pathologic, often progressive and chronic process.• Compulsion and preoccupation with obtaining a

drug or drugs.• Loss of control over use or substance abuse-

induced behavior.• Continued use despite adverse consequences.• Tendency for relapse after period of abstinence.• Increased tolerance and characteristic withdrawal.

Components of Drug Dependence1

• Psychologic dependence: centers on the user’s need of a drug to reach a level of functioning or feeling or well-being.

• Physical dependence: refers to the issues of physiologic dependence, establishment of tolerance, and evidence of an abstinence syndrome, or withdrawal upon cessation of substance abuse.

1 American Society of Addiction Medicine.

Symptoms: Substance Abuse

• Significant impairment or distress resulting from use.

• Failure to fulfill roles at work, home, or school.• Persistent use in physically hazardous

situations.• Recurrent legal problems related to use.• Continued use despite interpersonal problems.

Medication Misuse

• Describes the use of prescription medications outside of medical supervision or advice.

• Not an abuse problem, it is a high-risk behavior.• May or may not involve or lead to substance abuse.• May promote the reemergence of psychiatric

symptoms.• May cause toxic effects and psychiatric symptoms if

it involved overdose.

Mental Health and Addiction Treatment Systems

For more information, see TIP 9, pp.9-17.

Similarities of Mental Health and Addiction Treatment Systems

• Variety of treatment settings and program types.

• Public and private settings.• Multiple levels of care.• Biopsychosocial models.• Increasing use of case and care

management.

Mental Health and Addiction Treatment Systems

• Potential pitfall is prescribing psychoactive medications to psychiatric patient without first determining if the individual has a substance abuse disorder.

• In treating dual disorders, a balance must be made between behavioral interventions and psychiatric medications as needed for the recovery process.

Treatment Models

• Sequential: patient is treated by one system (addiction or mental health) and then by the other.

• Parallel: simultaneous involvement of the patient in both mental health and addiction treatment settings.

• Integrated: combines elements of both mental health and addiction treatment into a unified program for patients with dual disorders.

Critical Treatment Issues for Dual Disorder Treatment

• Treatment engagement: initiating and sustaining patient’s participation.

• Treatment continuity: between treatment programs and treatment components.

• Comprehensiveness: includes collaborative integrated programs.

• Treatment phases: detoxification, subacute stabilization, and long-term stabilization.

• Continual reassessment and rediagnosis: involves collaboration across multiple systems.

Mood Disorders

For more information, see TIP 9, pp.30-42.

Mood Disorders

• Most common psychiatric diagnosis among patients with a substance abuse disorder.

• More prevalent among patients using methadone and heroin.

• Depression is common over the first months of sobriety whose symptoms may fade over time.

• Mood disorder symptoms may be related to acute withdrawal symptoms from substances; adequate time should lapse prior to diagnosis of an independent mood disorder.

Substances That Precipitate or Mimic Mood Disorders

• Depression and Dysthymia– During use (intoxication): alcohol,

benzodiazepines, opioids, barbituates, cannabis, steroids (chronic), stimulants (chronic).

– After use (withdrawal): alcohol, benzodiazepines, barbituates, opiates, steriods (chronic), stimulants (chronic).

Substances That Precipitate or Mimic Mood Disorders

• Mania and Cyclothymia– During use (intoxication): stimulants, alcohol,

hallucinogens, inhalants (organic solvents), steroids (chronic, acute).

– After use (withdrawal): alcohol, benzodiazepines, barbituates, opiates, steroids (chronic).

Stages of Assessment

• Assessing danger to self or others• Medical assessment• Initial addiction assessment• Social assessment• Violence towards others• Assessing mood symptomatology• Medical assessment• Psychiatric and addiction screening• Assessment instruments• Psychosocial assessment

Acute Treatment Strategies

• Management of intoxication and withdrawal

• Medical treatment• Psychiatric treatment

Subacute

Treatment Issues

• Matching patients and treatment• Psychiatric medications• Case management• Counseling and psychotherapy for depression• Levels of care• Family involvement in treatment settings• Professional and vocational planning• AIDS and HIV risk reduction

Long-Term Treatment Goals

• Addiction treatment• Psychiatric treatment• Long-term treatment needs• Family issues• Eating disorders and gambling

Anxiety Disorders

For more information, see TIP 9, pp.46-50.

Substance-Induced

• Never assume anxiety symptoms or depersonalization are related to substance abuse.

• Substance-induced conditions:– Panic– Phobias– Posttraumatic stress disorder– Obsessive-compulsive disorder

Anxiety

• Most common symptom of people with substance abuse disorders.

• Treatment of mild anxiety can be postponed to see if it resolves as addiction treatment progresses.

Long-Term Treatment

• Medications are not a substitute for addiction treatment.

• Cognitive-behavioral techniques are often as effective as medications, but generally take longer to achieve an equivalent response in the treatment of anxiety disorders.

• For dual diagnosis patients, psychotherapy has significant advantages over substance abuse counseling alone, and can be incorporated into the substance abuse treatment.

Anxiety Treatment

• Can be postponed unless anxiety interferes with substance abuse treatment.

• Anxiety symptoms may resolve with abstinence and substance abuse treatment.

• Affect-liberating therapies should be postponed until the patient is stable.

• Psychotherapy, when required, should be recovery oriented.

Anxiety Treatment

• Nonpsychoactive medications should be used when medications are needed.

• Antianxiety treatments such as relaxation techniques can be used with and without medications.

• A healthy diet, aerobic exercise, and avoiding caffeine can reduce anxiety.

Personality Disorders

For more information, see TIP 9, pp.53-73.

Personality Disorders

• Rigid, inflexible, and maladaptive behavior patterns of sufficient severity to cause significant impairment in functioning or internal stress.

• If a personality disorder coexists with substance abuse, only the personality disorder will remain during abstinence.

• Substance use often relates to the disorder to diminish symptoms, to enhance low self-esteem, to decrease feelings of guilt, and to amplify feelings of diminished individuality.

Most Challenging to Treat

• Antisocial personality disorder, which involves a history of chronic antisocial behavior that begins before the age of 15 and continues into adulthood.

• Borderline personality disorder, which is characterized by unstable mood and self-image, and unstable intense, interpersonal relationships.

• Narcissistic personality disorder, which describes a pervasive pattern of grandiosity, lack of empathy, and hypersensitivity to evaluation by others.

• Passive-aggressive personality disorder, which involves covertly hostile but dependent relationships.

Key Issues and Concerns

• Patient contracting may involve a patient’s promise to avoid certain self-harm or high-risk behavior.

• Transference and countertransference both rely on the mechanism of projection, a combination of personal past experiences along with feelings experienced during the course of therapy.

• Clear boundaries are ethical and practical ground rules that help a therapist to be therapeutically helpful to patients.

Key Issues and Concerns

• Changing roles of people with personality disorders may include: the victim, the persecutor, and the rescuer.

• Resistance involves patients with personality disorders who often exhibit acting-out behaviors that were developed as psychological defenses and survival techniques.

• Subacute withdrawal may include mood swings, irritability, impairment in cognitive functioning, short- and long-term memory problems, and intense craving for substances.

Key Issues and Concerns

• Symptom substitutions are compulsive behaviors that includes eating disorders, compulsive spending, gambling, and sex.

• Somatic complaints: therapists should watch for use of prescription and over-the-counter drugs and for drug- seeking behaviors.

• Therapist well-being can be compromised when working with patients with personality disorders. Therapists should join or develop support systems with others in the field.

Borderline Personality Disorder

• Therapist should engage patient by acknowledging/joining the patient’s need for safety.

• Assessment should include: history of substance abuse and mental health treatment, suicidal planning, dissociative experiences, psychosocial history, history of sexual abuse, and a history of psychotic thinking. Could require a neurological examination.

• Avoid psychodynamic confrontations with patient.• Long-term care may include individual counseling, group

therapy, 12-step participation, and the continuum of care.

Antisocial Personality

• In engaging the patient, it is useful to join with the patient’s world view.

• Assessment should include a thorough family history, including a sexual history that includes questions about animals and objects. Other topics should be bonding, parasitic relationships, head injuries, fighting, and being hit.

• Avoid angry confrontations since patients may engage in dangerous physical behavior to avoid unpleasant situations or activities.

• Long-term care includes individual counseling, group therapy, and the continuum of care.

Narcissistic Personality Disorder

• To engage, therapeutically address patient traits such as hypersensitivity, need for control, rage, and depression.

• Assessment should include survival skills/self-care, monitor use of OTC drugs, treatment provider history, psychosocial and substance abuse history, medication evaluations for antidepressants, and identification of typical passive- aggressive maneuvers of patient.

• Several issues, such as responses to abusive relationships, obtaining safe housing, and receiving emergency psychiatric admissions for suicidal crises must be managed by the therapist.

• Long-term care may include individual counseling, group therapy, 12-step participation, and the continuum of care.

Coordination of Care

• Maintaining ongoing contacts is essential for all patients with personality disorders.

• Issues to remember in coordination of care:– Primary case manager– Legal issues– Managed care– Funding issues– Staffing and cross-training– Medical issues– Integration into 12-step self-help groups

Psychotic Disorders

For more information, see TIP 9, pp.76-85.

Psychotic Disorders• Stimulant-Induced Symptoms

– Acute stimulant intoxication (chronic) can cause symptoms of psychosis. Included are: delirium, delusions, prominent hallucinations, incoherence, and loosening of associations. Stimulant delirium often includes formication (a tactile hallucination of bugs crawling on or under the skin).

• Depressant-Induced Symptoms– Acute withdrawal from alcohol, barbiturates, and benzodiazepines can

produce a withdrawal delirium, especially with heavy use and high tolerance due to a concomitant physical illness.

• Psychedelic- and Hallucinogen-Induced Symptoms– Psychotic symptoms are possible in chronic, high-dose patterns due to

virtue of drugs’ stimulant properties. Can cause hallucinogenic hallucinosis, characterized by perceptual distortions, maladaptive behavioral changes and impaired judgment.

Engaging the Chronically Psychotic Patient

• Noncoercive Engagement Techniques– Assistance obtaining food, shelter, and clothing– Assistance obtaining entitlements and social services– Drop-in centers as entry to treatment– Recreational activities– Low-stress, nonconfrontational approaches– Outreach to patient’s community

• Coercive Engagement Techniques– Involuntary commitment– Mandated medications– Representative payee strategies

Pharmacological Management

For more information, see TIP 9, pp.91-97.

Pharmacologic effects

• Therapeutic effects include indicated purposes and desired outcomes such as a decrease in the frequency and severity of episodes of depression produced by antidepressants.

• Detrimental effects include unwanted side effects, such as dry mouth or constipation resulting from antidepressant use.

Dual Disorder Patients

• Special attention should be given to detrimental effects, in terms of:– Medication compliance– Abuse and addiction potential– Substance abuse disorder relapse– Psychiatric disorder relapse

Pharmacologic Risk Factors• Psychoactive Potential

– Not all psychiatric medications are psychoactive.– Psychoactive medications can cause acute psychomotor effects and a

relatively rapid change in mood or thought.• Reinforcement Potential

– Some drugs promote reinforcement or increased likelihood of repeated use.

– Can occur by either the removal of negative symptoms or conditions, or the amplification of positive symptoms or states.

– Involves strengthening that a certain behavior will be repeated for reward and satisfaction, as with drug-induced euphoria.

• Tolerance and Withdrawal Potential– Long-term or chronic use can cause tolerance to therapeutic effects and

dosage increases to recreate desired effects.– Drugs that promote tolerance and withdrawal generally have higher

risks for abuse and addiction.

Prescribing Medication

• High-risk patients should include a benefit analysis that considers:– The risk of medication abuse.– The risk of undertreating a psychiatric problem.– The type and severity of the psychiatric problem.– The relationship between the psychiatric disorder and

the substance abuse disorder for the individual patient.

– The therapeutic benefits of resolving the psychiatric and substance abuse problems.

Nonpharmacologic

Approaches

• Psychotherapy• Cognitive therapy• Behavioral therapy • Relaxation skills• Meditation• Biofeedback

• Acupuncture• Hypnotherapy• Self-help groups• Support groups

exercise• Education

Antihistamines

• Frequently prescribed for mild anxiety and insomnia.

• Exert mild anxiolytic and hypnotic effects, lack euphoric properties, and do not promote physical dependence.

• High doses can cause acute delirium, alter mood, or cause morning-after depression.

• Patients in recovery should be discouraged from purchasing and using OTC antihistamines.

Antidepressants

• Effective for treatment of depression, anxiety disorders, including generalized anxiety disorder, phobias, and panic disorder.

• They are not euphorigenic and do not cause acute mood alterations.

• Some exert a mild sedating effect, while others exert a mild stimulating effect.

• Anticholinergic effects include: dry mouth, blurred vision, constipation, urinary hesitancy, and toxic-confusional states.

• Adrenergic activation symptoms may include: tremor, excitement, palpitation, orthostatic hypotension, and weight gain.

β-Blockers

• Used to treat hypertension, cardiac arrhythmias, and angina pectoris.

• Can’t be used for extended periods of time due to the rapid tolerance of anti-panic effects.

• These drugs are consistent with a psychoactive- drug-free philosophy, does not compromise recovery from addiction, and can be important adjunct to anxiety management.

Benodiazepines

• Promote sedation, central nervous system depression, and muscle relaxation.

• Effective for anxiety reduction and short-term management of insomnia.

• Use of these drugs after the medical management of withdrawal is not consistent with a psychoactive-drug-free philosophy and may compromise recovery from addiction.

• However, they can be used in the management of acute and severe withdrawal, panic, and psychosis.

Buspirone

• Useful for generalized anxiety disorder, chronic anxiety symptoms, anxiety with depressive features, and anxiety among elderly patients.

• Is not psychoactive, mood altering, or euphorigenic.

• Is consistent with a psychoactive-drug-free philosophy, and does not compromise recovery from addiction.

• Enhances recovery from anxiety disorders.

Clonidine

• Used for treatment of symptoms of hypertension, including hypertensive symptoms that occur during withdrawal of depressant drugs, especially opioids.

• May be useful for short-term use in the treatment of refractory anxiety with panic.

• This drug is consistent with a psychoactive-drug- free philosophy and does not compromise recovery from addiction.

• May be an adjunct in the treatment of anxiety symptoms.

Neuroleptic

(Antipsychotic) Medications

• Most effective in suppressing the positive symptoms of psychosis such as hallucinations, delusions, and incoherence.

• May help reduce disturbances of arousal, affect, psychomotor activity, thought content, and social adjustment.

• Many can cause sedation as a side effect, but adaptation develops within days or weeks.

• These drugs allow patients who often experience significant biopsychosocial problems to engage in problem-solving and recovery-oriented interpersonal activities.

Lithium

• Initial symptoms managed by Lithium include increased psychomotor activity, pressured speech, and insomnia.

• Later it diminishes the symptoms of expansive mood, grandiosity, and intrusiveness.

• Common adverse effects include thirst, urinary frequency, tremor, and gastrointestinal distress.

• Allows patients who may have seriously disabling symptoms to engage in problem- solving and recovery-oriented interpersonal activities.

Anticonvulsants

• Have a role in the management of bipolar disorders, mania, schizoaffective disorder, and alcohol and benzodiazepine withdrawal.

• Typical side effects such as sedation and nausea may emerge as treatment is initiated.

• These medications are consistent with a psychoactive drug-free philosophy, and may enhance the abilities of those who need them to participate in the recovery process.

Ordering Information

• TIP 9 related products:– TIP 9 Assessment and Treatment of Patients With Coexisting

Mental Illness and Alcohol and Other Drug Abuse– KAP Keys for Clinicians based on TIP 9– Quick Guide for Clinicians based on TIP 9

• To obtain free copies:– Call SAMHSA’s National Clearinghouse for Alcohol and Drug

Information (NCADI) at 800-729-6686, TDD (hearing impaired) 800-487-4889

– Visit CSAT’s Web site at www.csat.samhsa.gov

Disclaimer

Do not reproduce or distribute this presentation for a fee without specific, written authorization from the Office of Communications, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services.