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Integrated Treatment for Dual Disorders

Integrated Treatment for Dual Disorders. Kim Mueser, Ph.D. Dartmouth Medical School NH-Dartmouth Psychiatric Research Center Kim.t.mueser@dartmouth.edu. Overview. Epidemiology Why focus on dual disorders? Models of etiology Assessment Treatment principles Research

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Integrated Treatment for Dual Disorders

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  1. Integrated Treatment for Dual Disorders Kim Mueser, Ph.D. Dartmouth Medical School NH-Dartmouth Psychiatric Research Center Kim.t.mueser@dartmouth.edu

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

  3. Rates of Lifetime Substance Use Disorder (SUD) among Recently Admitted Psychiatric Inpatients (N=325) (Mueser et al., 2000)

  4. 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 Factors Influencing Prevalence of Substance Use Disorders (SUD): Client Characteristics

  5. Higher Rates Emergency rooms Acute psychiatric hospitals Jails Homeless Urban setting (drugs) Rural setting (alcohol) Factors Influencing Prevalence of Substance Use Disorders: Sampling Location

  6. 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

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

  8. 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

  9. 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

  10. 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

  11. Reasons for High Comorbidity Rates of Severe Mental Illness and Substance Abuse • Berkson’s Fallacy • Self-medication* • Super-sensitivity to effects of substances* • Socialization motives • Precipitation of psychosis from substance use

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

  13. Self-Medication: • More symptomatic clients don’t 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 doesn’t explain all • More evidence supporting self-medication in anxiety disorders (PTSD)

  14. 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

  15. Medication Stress Coping Substance Abuse Severity of SMI Stress-Vulnerability Model Biological Vulnerability

  16. Status of Moderate Drinkers with Schizophrenia 4 - 7 Years Later (N=45) Source: Drake & Wallach (1993)

  17. 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

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

  19. 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.

  20. Functional Assessment • Goals:To understand client’s 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)

  21. 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

  22. 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?

  23. Common Symptoms Associatedwith Self-Medication • Depression, suicidal thoughts • Anxiety, nervousness, tension • Hallucinations • Delusions of reference & paranoia • Sleep disturbance • Mania/hypomania

  24. Recreational Skills and Substance Abuse • What does the person do for fun? • Hobbies? • Sports? • What is person’s involvement with others in recreational activities? • Does the person not participate in activities which he/she previously did?

  25. 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 doesn’t happen magically on its own

  26. 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 • client’s 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

  27. Pay-Off Matrix Using Substances Not Using Substances Advantages Disadvan-tages

  28. Common Advantages and Disadvantages of Using Substances and Not Using Substances

  29. Examples of Interventions Based on the Payoff Matrix

  30. 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

  31. 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

  32. 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

  33. 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

  34. 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

  35. 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

  36. 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

  37. 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

  38. What Do We Do During Active Treatment? • Goal: • To reduce client’s use/abuse of substance • Clinical Strategies 1. Self-monitoring 2. Social skills training 3. Social network interventions 4. Self-help groups

  39. 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

  40. 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

  41. Relapse Prevention Strategies • Construction a relapse prevention plan: • Risky situations • Early warning signs • Immediate response • Social supports • Abstinence violation effect

  42. Recovery Mountain • Combat demoralization related to relapses • Reframe relapses as part of road to recovery • Don’t loose sight of gains made between relapses • Learning experience, modify relapse prevention plan

  43. 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 (< 1 month).

  44. 5. Early Active Treatment: Reduction in substance use (> 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.

  45. 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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