# Presentation: 059487

## Quick Guide

***For 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 Definitions
*For 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.