Integrated Treatment of Co-Occurring Mental Illness and Substance Use Disorders Lecture Outline

Krishna Balachandra MD, University of Western Ontario (Slide 1)

 

I.                    Introduction

A.     Co-Occurring disorders (COD) are important:  (Slide 2)

1.      ~50% Of serious mental disorders (d/o) have substance use disorders (SUD)1 vs 15-20% in general population

2.      Physicians inadequately trained about SUD2

3.      Patients (Pts) with COD receive suboptimal care3

4.      Pts with COD at risk for:

a.       Relapse and re-hospitalization4

b.      Suicide5

c.       Financial stress6

d.      Violence7

e.       Medical illness8

B.     Definitions (Slide 3)

1.      Independent mental disorders i.e. not substance induced:

a.       Syndrome of behaviors or thinking problems

b.      Associated with:

1)      Psychological distress

2)      Occupational or functional disability

3)      Risk of physical or emotional suffering9

c.       Not due to:

1)      General medical condition

2)      Substances

2.      Substance use disorders (SUD)9

a.       Substance abuse ≥ 1 criteria repeatedly:

1)      Fail role obligations

2)      Physically hazardous use

3)      Legal problems

4)      Social/interpersonal problems

5)      Not dependent

b.      Substance dependence ≥ 3 criteria:

1)      Tolerance

2)      Withdrawal

3)      Taken in larger amounts/longer period

4)      Desire to cut down

5)      Excessive time spent on getting substance

6)      Activities given up

7)      Use despite physical/psychological problems

3.      Co-Occurring disorders (COD) (Slide 4)

a.       Independent mental illness (MI) combined with SUD10

b.      Not substance-induced mental disorders9 which are:

1)      Not true independent disorders11

2)      Require brief (several wks) symptomatic treatment

3)      Defined as syndrome only in context of substances or medical illness

C.     This lecture reviews co-occurring disorder:  (Slide 5)

1.      Epidemiology

2.      Etiology

3.      Treatment (Rx) overall

4.      Relevance of integrated treatment

II.                 Epidemiology of co-occurring disorders12 (Slide 6)

A.     Lifetime prevalence of SUD > in mental illness populations

B.     General population12:

1.      Any SUD →17%

2.      Alcohol use disorder (AUD) →14%

3.      Drug use disorder (DUD) → 6%

C.     Schizophrenia12:

1.      SUD ↑ 3 Xs

2.      AUD ↑ 2.5 Xs

3.      DUD ↑ 4 Xs

D.     Bipolar disorder12:  (Slide 7)

1.      SUD ↑ 3 Xs

2.      AUD ↑ 3 Xs

3.      DUD ↑ 5 Xs

E.      Panic disorder12:

1.      SUD 2 Xs

2.      AUD 2 Xs

3.      DUD 2.5 Xs

F.      Post traumatic stress disorder13,14:

1.      SUD 2 Xs

2.      AUD 1.5 Xs

3.      DUD 2 Xs

G.     Borderline personality disorder15:

1.      SUD 3.5 Xs

2.      AUD 3.5 Xs

3.      DUD 7.5 Xs

H.     Antisocial personality disorder (ASPD)12:  (Slide 8)

1.      SUD 5 Xs

2.      AUD 5 Xs

3.      DUD 7 Xs

III.               Etiology of co-occurring disorders

A.     Three concepts explain COD

B.     SUD + MI share common vulnerability:  (Slide 9)

1.      Genetic factors:

a.       Both conditions share similar genetic vulnerability

b.      Twin study of alcohol use disorder + depression (alcohol dependence in one twin predicts depression in other twin)16

2.      ASPD associated with ↑ prevalence of both MI and SUD17,18

3.      Both conditions associated common pathophysiology

a.       ↓ Function of hypothalamic-pituitary-adrenal axis may ↑ risk for both19

b.      Hippocampus/frontal cortical dysfunction ↑ risk for both20

c.       Abnormalities in cannabinoid, dopamine receptor systems associated with both21

C.     Substance use develops as a response to mental illness22 (Slide 10)

1.      MI occurs first

2.      Substance use occurs as self medication

3.      Self medication achieves23

a.       ↓ Distressing symptoms

b.      Social skills

c.       ↓ Side effects of psychiatric meds

D.     Mental illness develops as a response to substances (Slide 11)

1.      SUD occurs first

2.      Some individuals vulnerable to psychoactive effect of substances

a.       Meta-analysis, cannabis use => 40% enhanced risk of psychosis compared to controls24

b.      Possible mechanism => cannabis users with polymorphism of catechol-O-methyltransferase gene @ risk of psychosis vs cannabis users without polymorphism25

IV.              Three Rx strategies overall (understanding etiology, how to treat) (Slide 13)

A.     Sequential treatment

1.      Treat SUD then MI or vice versa

2.      Example:  Rx by substance use clinicians then mental health clinicians or vice versa

3.      Advantage homogenous population (pts identify with each other)

4.      Disadvantages

a.       Untreated d/o worsens treated d/o:  e.g. substance use worsens treated psychosis

b.      Inconsistent Rx priority, which d/o to treat 1st

c.       Unclear definition of Rx completion

d.      Pt not referred when 1st Rx complete

e.       Sequential Rx ↑ long-term costs

B.     Parallel treatment

1.      Both conditions treated simultaneously as outpatient

2.      Rx by both mental health + substance use clinicians but @ different sites

3.      Advantages

a.       Both conditions addressed by experts

b.      No delay in Rx of 1 vs other

4.      Disadvantages

a.       Different Rx philosophies:  e.g. case manager assisting pts in mental health viewed as enabling by substance use clinician

b.      Lack of communication between Rx systems:  e.g. records/patient information not shared

c.       Pt has to attend different Rx sites

d.      Pt is responsible for linkage of care:  e.g. keeping multiple appointments

C.     Integrated treatment (Slide 14)

1.      Both conditions treated simultaneously

2.      Rx delivered by the same treaters in one place

3.      Advantages

a.       One location

b.      No delay in Rx of 1 vs other

c.       Ability to meet complex needs:  e.g. homelessness, medical illness, psychiatric instability

4.      Disadvantages

a.       Mental health costs initially:  e.g. $5300/pt vs $6700/pt @ 2 yrs post Rx26

b.      Not widely available

V.                 Details of integrated treatment

A.     Definition:  simultaneous Rx of both MI + SUD in 1 setting by 1 Rx team

B.     Clinical vignette helps illustrate integrated Rx (Slide 15)

1.      27 yr old male bipolar disorder, alcohol dependence

2.      Frequent ER visits

3.      Referred for Rx, rarely keeps appointments

4.      Health professionals frustrated

5.      Drug possession charges

6.      Pt kicked out of home

C.     Limitation of sequential and parallel Rx for this pt:

1.      Pt doesnt keep appointments

2.      Different philosophies:  e.g. one program is harm reduction, other abstinence based

3.      Lack of communication among clinicians

D.     Integrated Rx principles27 (Slide 16)

1.      No wrong door

a.       Welcomed for Rx no matter how/where pt presents:  e.g. detox, court diversion, walk in

b.      Fewer barriers for Rx28:  e.g. affordable, short wait lists

2.      Shared decision making29

a.       Pt involved in decisions, not paternalistic

b.      Comprehensive team shares responsibility with pt

3.      Comprehensive services/professionals30

a.       Social workers

b.      Nurses

c.       Physicians

d.      Occupational therapists

e.       Vocational therapists

f.        Recreational therapists

4.      Assertiveness31

a.       Reaching out to pt

b.      Finding pts in:

1)      Jails

2)      Homeless shelters

5.      Reduction of negative consequences of substance use (Slide 17)

a.       Homelessness:  e.g. obtain shelter

b.      Legal problems:  e.g. court diversion vs incarceration

c.       Health problems:  e.g. treat Hep C

6.      Time unlimited perspective

a.       Ongoing care

b.      Pts may drop in/out of Rx

7.      Multiple psychological therapies can be used

a.       Individual therapy, manualized modalities such as:

1)       Cognitive behavior therapy32:  a form of psychotherapy to alter distorted thoughts and behaviors

2)      12 step facilitation33:  a form of therapy participation in Alcoholics Anonymous (AA)

3)      Motivational enhancement therapy34: a form of therapy to pts own potential to change

b.      Self help:

1)      AA

2)      Narcotics Anonymous

8.      Cultural sensitivity (respect pts cultural needs)

9.      Motivation based Rx pt treated at his/her stage (more details about stage specific interventions to follow) (Slide 18)

a.       Engagement:  Pt has no regular contact with clinician

b.      Persuasion:  Pt has regular contact but not motivated to substance use

c.       Active treatment:  Pt has regular contact + motivated to substance use

d.      Maintenance/Relapse prevention:  Pt has regular contact, substance use by 6 months or is abstinent

E.      Process of integrated Rx (details of stage specific Rx, key part of lecture)

1.      Engagement (Slide 19)

a.       Goal:  Establish a working relationship with pt

b.      Clinical interventions:

1)      Outreach35:  e.g. instead of expecting pt to come for appointment, visit pt in jail

2)      Practical assistance:  e.g. connect pt with social worker to secure bed in a homeless shelter

3)      Crisis intervention:  e.g. pt is suicidal, admit

4)      Support and assistance to social networks:  e.g. drop in center for safe socialization, learn community supports (Slide 20)

5)      Stabilize psychiatric symptoms:  e.g. lithium to stabilize bipolar disorder

6)      Help with legal problems:  e.g. legal aid

7)      Help with arranging family visits

8)      Close monitoring:  e.g. assigning a case manager to maintain contact, med compliance

2.      Persuasion (Slide 21)

a.       Goal:  Develop awareness that substance use is a problem

b.      Clinical interventions:

1)      Individual and family education

2)      Groups to discuss pros/cons of substance use in an open manner

3)      Teach social skills re non substance conditions:  e.g. communication skills to meet sober friends

4)      Structured activity:  e.g. supported employment, volunteering (Slide 22)

5)      Social and recreational activities:  e.g. develop hobbies

6)      Safe damp housing:  e.g. substance use tolerated while pt looks for independent housing

7)      Psychiatric stabilization:  e.g. med monitoring, side effects, dosing, blood levels

3.      Active treatment (Slide 24)

a.       Goal:  substance use, possibly abstinence

b.      Clinical interventions:

1)      Groups to learn strategies to substance use

2)      Social skills training to address substance use:  e.g. refusal skills

3)      Self help support groups:  e.g. Double Trouble discuss both MI + SUD

4)      Individual psychotherapy:  e.g. supportive psychotherapy to address guilt (Slide 25)

5)      Substitute activities:  e.g. employment in workforce, not supported employment

6)      Meds for MI:  e.g. lithium

7)      Meds to substance use

                                                                                                                                       i.      Disulfiram36,37

1.      Mechanism:  causes disulfiram-ethanol reaction if alcohol consumed (flushing, nausea, heart rate)

2.      Dosage:  250 to 500 mg/day

3.      Side effects:  fatigue, lethargy, liver enzymes (LFT)

4.      Efficacy:  with supervised ingestion

                                                                                                                                     ii.      Naltrexone37,38

1.      Mechanism:  reduce reinforcing effects of alcohol

2.      Dosage:  50-150 mg/day

3.      Side effects:  nausea, headache, dizziness, LFT

4.      Efficacy:  ~20% # of drinking days, maintenance of abstinence vs to placebo

8)      Safe dry housing:  e.g. abstinence focused

9)      Stress/coping skills:  e.g. relaxation techniques to use under stress instead of substances

4.      Maintenance/relapse prevention (Slide 26)

a.       Goal: 

1)      Maintain awareness that relapse can occur

2)      Extend recovery to other areas

b.      Clinical interventions:

1)      Support independent employment

2)      Relapse prevention group to maintain abstinence

3)      Self help groups for support:  e.g. Double Trouble

4)      Social skills overall:  e.g. interpersonal relationships

5)      Individual and family problem solving re conflict

6)      Lifestyle improvement:  e.g. smoking cessation (Slide 27)

7)      Independent housing

8)      Develop peer mentoring/role modeling skills

F.      Data on efficacy of integrated Rx (Slide 29)

1.      Retention:  55% in integrated Rx vs 35% Rx as usual in 6 month study39

2.      Substance use:

a.       40% Abstinent for past 6 months vs 2% baseline in 10 yr follow up (FU) of pts with schizophrenia + SUD40

b.      60% Negative urine integrated Rx vs 25% usual Rx in 6 month study39

3.      Financial stress:  (Slide 30)

a.       40% Employed @ FU vs 5% at baseline in 10 yr study40

b.      60% Independent housing @ FU vs 50% baseline in 10 yr study40

c.       70% Had $ for basic needs integrated Rx vs 45% usual Rx in 6 month study39

d.      Criminal justice costs:  e.g. $10300/pt baseline vs $4100/pt @ 2 yrs post integrated Rx26

4.      Hospitalization:  (Slide 31)

a.       30% In 90 days pre-integrated Rx vs 7% in 90 days post-integrated Rx in 6 month study39

b.      No change in usual Rx in 6 month study39

5.      Rate of arrests:

a.       30% Pre-integrated Rx vs 13% post-integrated Rx in 6 month study39

b.      No change in usual Rx in 6 month study39

 


 

References

 

1.         Substance Abuse and Mental Health Services Administration. Results from the 2006 National Survey on Drug Use and Health: National Findings (Office of Applied Studies, NSDUH Series H-32, DHHS Publication No. SMA 07-4293). Rockville, MD. 2007.

2.         Miller NS, Sheppard LM, Colenda CC, Magen J. Why physicians are unprepared to treat patients who have alcohol- and drug-related disorders. Acad Med. 2001;76:410-418.

3.         Ouimette P, Jemelka R, Hall J, Brimner K, Krupski A, Stark K. Services to patients with dual diagnoses: findings from Washington's mental health service system. Substance Use & Misuse. 2007;42:113-127.

4.         Haywood TW, Kravitz HM, Grossman LS, Cavanaugh JL, Jr., Davis JM, Lewis DA. Predicting the "revolving door" phenomenon among patients with schizophrenic, schizoaffective, and affective disorders. The American Journal of Psychiatry. 1995;52:856-861.

5.         Perenyi A, Forlano R. Suicide in schizophrenia. Neuropsychopharmacol Hung. 2005;7:107-117.

6.         Shaner A, Eckman TA, Roberts LJ, et al. Disability income, cocaine use, and repeated hospitalization among schizophrenic cocaine abusers--a government-sponsored revolving door? The New England Journal of Medicine. 1995;333:777-783.

7.         Swanson JW, Swartz MS, Van Dorn RA, et al. A national study of violent behavior in persons with schizophrenia. Archives of General Psychiatry. 2006;63:490-499.

8.         Rosenberg SD, Drake RE, Brunette MF, Wolford GL, Marsh BJ. Hepatitis C virus and HIV co-infection in people with severe mental illness and substance use disorders. AIDS. 2005;19:S26-33.

9.         American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th edition, text revision. Washington, DC: American Psychiatric Press Inc.; 2000.

10.       Center  for Substance Abuse Treatment. Substance Abuse Treatment for Persons With Co-Occurring Disorders. Treatment Improvement Protocol (TIP) Series 42. DHHS Publication No. (SMA) 05-3922. Rockville, MD: Substance Abuse and Mental Health Services Administration. 2005.

11.       Schuckit MA. Comorbidity between substance use disorders and psychiatric conditions. Addiction. 2006;101:S76-88.

12.       Regier D.A, Farmer M.E, Rae D.S, et al. Comorbidity of mental disorders with alcohol and other drug abuse:  Results from the Epidemiologic Catchment Area (ECA) study. Journal of the American Medical Association. 1990;264:2511-2518.

13.       Cottler LB, Compton WM, 3rd, Mager D, Spitznagel EL, Janca A. Posttraumatic stress disorder among substance users from the general population. The American Journal of Psychiatry. 1992;149:664-670.

14.       Helzer JE, Robins LN, McEvoy L. Post-traumatic stress disorder in the general population. Findings of the epidemiologic catchment area survey. The New England Journal of Medicine. 1987;317:1630-1634.

15.       Zanarini MC, Frankenburg FR, Dubo ED, et al. Axis I comorbidity of borderline personality disorder. The American Journal of Psychiatry. 1998;155:1733-1739.

16.       Prescott CA, Aggen SH, Kendler KS. Sex-specific genetic influences on the comorbidity of alcoholism and major depression in a population-based sample of US twins. Archives of General Psychiatry. 2000;57:803-811.

17.       Mueser KT, Crocker AG, Frisman LB, Drake RE, Covell NH, Essock SM. Conduct disorder and antisocial personality disorder in persons with severe psychiatric and substance use disorders. Schizophrenia Bulletin. 2006;32:626-636.

18.       Fu Q, Heath AC, Bucholz KK, et al. Shared genetic risk of major depression, alcohol dependence, and marijuana dependence: contribution of antisocial personality disorder in men. Archives of General Psychiatry. 2002;59:1125-1132.

19.       Sher L. The role of the hypothalamic-pituitary-adrenal axis dysfunction in the pathophysiology of alcohol misuse and suicidal behavior in adolescents. International Journal of Adolescent Medicine and Health. 2007;19:3-9.

20.       Chambers RA, Krystal JH, Self DW. A neurobiological basis for substance abuse comorbidity in schizophrenia. Biological Psychiatry. 2001;50:71-83.

21.       Laviolette SR, Grace AA. The roles of cannabinoid and dopamine receptor systems in neural emotional learning circuits: implications for schizophrenia and addiction. Cell Mol Life Sci. 2006;63:1597-1613.

22.       Kessler RC. The epidemiology of dual diagnosis. Biological Psychiatry. 2004;56:730-737.

23.       Khantzian EJ. The self-medication hypothesis of substance use disorders: a reconsideration and recent applications. Harvard Review of Psychiatry. 1997;4:231-244.

24.       Moore TH, Zammit S, Lingford-Hughes A, et al. Cannabis use and risk of psychotic or affective mental health outcomes: a systematic review. Lancet. 2007;370:319-328.

25.       Caspi A, Moffitt TE, Cannon M, et al. Moderation of the effect of adolescent-onset cannabis use on adult psychosis by a functional polymorphism in the catechol-O-methyltransferase gene: longitudinal evidence of a gene X environment interaction. Biological Psychiatry. 2005;57:1117-1127.

26.       Judd PH, Thomas N, Schwartz T, Outcalt A, Hough R. A dual diagnosis demonstration project: treatment outcomes and cost analysis. J Psychoactive Drugs. 2003;35:S181-192.

27.       Mueser KT, Noordsy DL, Drake RE, Fox L. Integrated Treatment for Dual Disorders A Guide to Effective Practice. New York: The Guildford Press; 2003. 470 p.

28.       Clark HW, Power AK, Le Fauve CE, Lopez EI. Policy and practice implications of epidemiological surveys on co-occurring mental and substance use disorders. J Subst Abuse Treat. 2008;34:3-13.

29.       Deegan PE, Drake RE. Shared decision making and medication management in the recovery process. Psychiatric Services. 2006;57:1636-1639.

30.       Goldman HH, Thelander S, Westrin CG. Organizing mental health services: an evidence-based approach. J Ment Health Policy Econ. 2000;3:69-75.

31.       Meisler N, Blankertz L, Santos AB, McKay C. Impact of assertive community treatment on homeless persons with co-occurring severe psychiatric and substance use disorders. Community Ment Health J. 1997;33:113-122.

32.       Kadden R, Carroll KM, Donovan D, et al. Cognitive-behavioral coping skills therapy manual: A clinical research guide for therapists treating individuals with alcohol abuse and dependence. Project MATCH Monograph Series, Vol. 3. DHHS Publication No. 94-3724. Rockville, MD: NIAAA. 1994.

33.       Nowinski J, Baker S, Carroll KM. Twelve step facilitation therapy manual: A clinical research guide for therapists treating individuals with alcohol abuse and dependence. Project MATCH Monograph Series, Vol. 1. DHHS Publication No. 94-3722. Rockville, MD: NIAAA. 1994.

34.       Miller WR, Zweben A, DiClemente CC, Rychtarik RG. Motivational enhancement therapy manual: A clinical research guide for therapists treating individuals with alcohol abuse and dependence. Project MATCH Monograph Series, Vol. 2. DHHS Publication No. 94-3723. Rockville MD. National Institute on Alcohol Abuse and Alcoholism, 1994.

35.       Drake RE, McHugo GJ, Clark RE, et al. Assertive community treatment for patients with co-occurring severe mental illness and substance use disorder: a clinical trial. The American Journal of Orthopsychiatry. 1998;68:201-215.

36.       Mueser KT, Noordsy DL, Fox L, Wolfe R. Disulfiram treatment for alcoholism in severe mental illness. Am J Addict. 2003;12:242-252.

37.       Kranzler HR, Ciraulo DA. Clinical Manul of Addiction Psychopharmacology. Washington, D.C: American Psychiatric Publishing Inc.; 2005. 384 p.

38.       Petrakis IL, Nich C, Ralevski E. Psychotic spectrum disorders and alcohol abuse: a review of pharmacotherapeutic strategies and a report on the effectiveness of naltrexone and disulfiram. Schizophrenia Bulletin. 2006;32:644-654.

39.       Bellack AS, Bennett ME, Gearon JS, Brown CH, Yang Y. A randomized clinical trial of a new behavioral treatment for drug abuse in people with severe and persistent mental illness. Archives of General Psychiatry. 2006;63:426-432.

40.       Drake RE, McHugo GJ, Xie H, Fox M, Packard J, Helmstetter B. Ten-year recovery outcomes for clients with co-occurring schizophrenia and substance use disorders. Schizophrenia Bulletin. 2006;32:464-473.