Integrated Treatment for Co-Occurring Disorders

Integrating
Treatment for
Co-Occurring
Disorders
Jay Piland MD
Palmetto Addiction
Recovery Center:
86 Palmetto Road
Rayville, LA 71269
jpiland@palmettocenter.com

Medical Director—Addiction Medicine Specialist
Jay L. Piland, MD
Diplomate American Board of Addiction Medicine
Diplomate American Board of Internal Medicine
CMRO
Addiction Medicine Specialist

OBJECTIVES—TIP
 Discuss the prevalence of co-occurring disorders
in substance abuse treatment programs
 Increase familiarity with mental disorders terminology and
criteria—provide advice on how to proceed with COD
 Contrast co-occurring treatment with traditional
addiction treatment
 Give a rationale for integrated treatment
 List instruments helpful for screening
 Describe evidence-based therapies helpful in treating
co-occurring disorders

Part One:
Introduction to
Co-occurring
Disorders

SCOPE OF PRACTICE
An Addiction Professional’s scope of practice varies
with education, training and state requirements.
With many people present today, each practitioner
should keep his or her scope of practice in mind as
we conduct this presentation.

Mental health disorder (MHD):
significant and chronic disturbances with “feelings,
thinking, functioning and/or relationships that are
not due to drug or alcohol use and are not the
result of a medical illness”22
 Bipolar disorder
 Major depressive disorder
 Schizophrenia
 Obsessive-compulsive disorder
 Social phobia
 Borderline personality disorder
 Posttraumatic stress disorder
DEFINING CO-OCCURRING DISORDERS

Substance use disorder (SUD):
a behavioral pattern of continual
psychoactive substance use that can
be diagnosed as either substance
abuse or substance dependence

DSM 5—SUD
DSM 5—SUD—Maladaptive pattern of substance use leading to significant
impairment/distress
1. Recurrent Use leading to failure to fulfill major obligations
2. Recurrent use in hazardous situations
3. Continued use despite persistent or recurrent social problems caused or exacerbated by
effects of substance
4. Tolerance
5. Withdrawal
6. Taken in larger amounts or for longer periods than intended
7. Persistent desire or unsuccessful efforts to control, reduce, or stop
8. Great deal of time spent obtaining, using, or recovering
9. Important activities given up or reduced because of substance use
10. Continued use despite knowledge of physical and psychological problems likely caused
or exacerbated by substance
11. Craving or urge to use substance
Mild 2-3 Moderate 4-5 Severe 6 or more

Co-occurring disorders (COD):
the simultaneous existence of “one or more disorders relating to the
use of alcohol and/or other drugs of abuse as well as one or more
mental [health] disorders.”18

-Individual Level COD
-Service Definition of COD
-Prediagnosis
-Postdiagnosis
-Unitary Disorder and acute signs and/or symptoms of co-occurring
condition
e.g., Suicidal Ideation in context of SUD
Mental Health symptom that creates a severity problem

EXAMPLES OF CO-CCURRING CONDITIONS (COC):
MENTAL DISORDERS
Schizophrenia/Psychoses
Mood Disorders
Anxiety Disorders
Somatoform Disorders
Factitious Disorders
Dissociative Disorders
Sexual Disorders
Eating Disorders
Sleep Disorders
Impulse-control Disorders
Adjustment Disorders
Personality Disorders
Disorders-usually first
diagnosed in infancy,
childhood, or adolescence
ADDICTION DISORDERS
Alcohol Abuse/Depen.
Cocaine/
Amphet./Stimulants
Opiates/Opioids
Marijuana
Polysubstance
combinations
Prescription drugs
Synthetics
Hallucinogens
Dissociatives

SUBSTANCE-INDUCED DISORDERS
-Are Distinct from independent co-occurring mental
disorders in that all or most of the psychiatric
symptoms are the direct result of substance use.
-Substance-Induced Disorders do not preclude co-
occurring mental disorders, only that the specific symptom
cluster at a specific point in time is more likely the result
of substance use, abuse, intoxication, or withdrawal
than of underlying mental illness
-Clients could even have both independent and
substance-induced mental disorders

SUBSTANCE-INDUCED DISORDERS
Substance-Induced Mood Disorder
Substance-Induced Anxiety Disorder
Substance-Induced Psychotic Disorder
Substance-Induced Sexual Dysfunction
Substance-Induced Sleep Disorder
Substance-Induced Delirium
Substance-Induced Persisting Dementia
Substance-Induced Amnestic Disorder
Hallucinogen Persisting Perceptual Disorder

DEFINING CO-OCCURRING
DISORDERS
 50 to 75% of all clients who are
receiving treatment for a substance
use disorder also have another
diagnosable mental health
disorder.
 Further, of all psychiatric clients with a mental health
disorder, 25 to 50% of them also currently have or had
a substance use disorder at some point in their lives.

KEY EPIDEMIOLOGIC FINDINGS SINCE 2002
Current national COD epidemiologic data are derived from 3 major studies: The National Comorbidity Survey and the NCS-
Replication (NIMH); The National Survey on Drug Use and Health (SAMHSA); The National Epidemiologic Study on Alcohol
and Related Conditions (NIAAA+NIDA)
• Substance use disorders are present in more than 9% of
the large numbers of individuals sampled.
• More than 9% of adults have diagnosable mood
disorders, primarily Maj. Dep.
• More than 7.7 million adult U.S. citizens have a serious
mental illness—SMI (2.3 million with SUD & SMI)
SMI = Persons age 18 +, who currently or at any time during the past year,
have had a diagnosable mental, behavioral, or emotional disorder of sufficient
duration to meet DSM-IV diagnostic criteria , resulting in functional
impairment which substantially interferes with or limits one or more major life
activities.)

PAST YEAR SUD & AMI AMONG ADULTS—
2013 NSDUH

PAST YEAR SUD & SMI AMONG ADULTS—
2013 NSDUH

SUD IN THE PAST YEAR AMONG
INDIVIDUALS AGE 12 OR OLDER--2013

COD SUD AND AMI/SMI AMONG ADOLESCENTS
AND ADULTS—2013 NSDUH

COD MI & SUD AMONG ADULTS BY AGE AND
GENDER—2013 NSDUH

MENTAL HEALTH & SUBSTANCE USE
TREATMENT FOR ADULTS WITH AMI & SUD—2013

MENTAL HEALTH AND SUBSTANCE USE TREATMENTS
FOR ADULTS WHO HAD SMI AND SUD—2013

MOST COMMON REASONS FOR NOT RECEIVING TREATMENT AMONG
INDIVIDUALS 12 OR OLDER WHO NEEDED OR MADE AN EFFORT TO
RECEIVE TREATMENT—2010-2013

0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
Mood Disorders Anxiety Disorders Post-Traumatic
Stress Disorders
Antisocial
Personality
Disorders
Borderline
Personality
Disorders
Severe Mental Illness
Addiction Treatment Provider Estimates
by Psychiatric Disorder

WELL, HOW COMMON IS THE PROBLEM?
Estimates of psychiatric co-morbidity among
clinical populations in substance abuse treatment
settings range from 20-80%
Estimates of substance use co-morbidity among
clinical populations in mental health treatment
settings range from 10-45%, with the highest for
those with Schizophrenia and Bipolar Disorder
* Differences in incidence due to: nature of population served (e.g.:
homeless vs. middle class), sophistication of psychiatric diagnostic
methods used (psychiatrist or DSM checklist) and severity of
diagnoses included (major depression vs. dysthymia).

CO-OCCURRING DISORDERS: PREVALENCE
National Co-Morbidity Survey
52% of those with AUD at some point in their lifetime also
had a history of at least one mental disorder.
59% of those with other DUD at some point in their
lifetime also had a history of at least one mental
disorder.
84% of those that experienced a lifetime of co-occurrence
report that their mental illness symptoms preceded their
substance use disorder (Kessler et al, 1994).

28
LIFETIME PREVALENCE
OF SUD FOR EACH MHD
Bipolar Disorder 56%
Schizophrenia 47%
Major Depression 27%
Any Anxiety Disorder 24%
PTSD 30-75%
Borderline Personality
Disorder
23%
Eating Disorder 23-55%*

Co-morbidity of Substance Use and Psychiatric Disorders
Among a sample of about 10,000 adults:
13.5% had an alcohol use disorder. Of those, 36.6% also had a
psychiatric disorder.
6.1% had a drug use disorder.
Of those, 53.1% also had a
psychiatric disorder.
22.5% had a psychiatric disorder.
Of those, 28.9% also had an
alcohol or drug use disorder.
Source: Regier et al. 1990

Psychiatric Disorders in Addiction Treatment
Two studies of Prevalence rates in addiction treatment settings had similar findings. Persons with
substance use disorders are also likely to have mood and anxiety disorders.
Source: Cacciola et al, 2001; Ross, Glaser and Germanson 1988

CROSS-CUTTING ISSUES
Suicidality
While suicidality is not a DSM-5 mental disorder per se, it
is a high-risk behavior associated with COD
Nicotine Use Disorder is recognized as a disorder in DSM-
5, and as such a client with nicotine use disorder and a
mental disorder could be considered to have a co-
occurring disorder
Tobacco’s chief effects are medical rather than
behavioral, and it is not conceptualized and presented
as a typical co-occurring addiction disorder

SUICIDALITY
Alcohol abuse is associated with 25-50% of suicides
Between 5-27% of all deaths of people who abuse alcohol
are caused by suicide
Lifetime risk for suicide among alcohol abusers estimated to
be 15%
Strong relationship between substance abuse and suicide in
young people
COD—Alcoholism and Depression increase risk

10 LEADING CAUSES OF DEATH, UNITED STATES
2008, ALL RACES, BOTH SEXES
WISQARSTM
Produced By: Office of Statistics and Programming, National Center for Injury Prevention and Control, CDC
Data Source: National Center for Health Statistics (NCHS), National Vital Statistics System
33

TOUGH REALITIES
50 percent of those who die by suicide were afflicted
with major depression…the suicide rate of people with
major depression is 8 times that of the general
population
90 percent of individuals who die by suicide
had a mental disorder
35
35

*TOUGH REALITIES
~30 % of deaths by suicide involved alcohol
intoxication – BAC at or above legal limit
4 other substances were identified in ~10%
of tested victims – amphetamines,
cocaine, opiates (prescription & heroin),
marijuana
36
36

*MISSED OPPORTUNITIES = LIVES
LOST
37
77 percent of individuals who die by suicide had visited their
primary care doctor w/in the year
45 percent had visited
their primary care
doctor w/in the month
18 percent of elderly patients visited their primary care
doctor on same day as their suicide
THE QUESTION OF SUICIDE WAS SELDOM RAISED . . .

LIKELIHOOD OF A
SUICIDE ATTEMPT
Risk Factor
Cocaine use
Major Depression
Alcohol use
Separation or Divorce
NIMH/NIDA
Increased Odds Of
Attempting Suicide
62 times more likely
8 times more likely
ECA EVALUATION

SUICIDALITY
SUD alone increases suicidality, while the added presence of
some mental disorder doubles an already heightened
risk
Risk of suicide is greatest when relapse occurs after a
substantial period of abstinence—especially if there is
concurrent financial or psychosocial loss

SUICIDALITY
Advice to the Counselor:
Counseling a Client Who Is Suicidal
Screen for suicidal thoughts or plans with anyone who makes suicidal references, appears seriously
depressed, or who has a history of suicide attempts. Treat all suicide threats with seriousness.
Assess the client’s risk of self-harm by asking about what is wrong, why now, whether specific plans
have been made to commit suicide, past attempts, current feelings, and protective factors
Develop a safety and risk management process with the client that involves a commitment on the
client’s part to follow advice, remove the means to commit suicide (e.g., a gun), and agree to seek
help and treatment. Avoid sole reliance on “no suicide contracts.”
Assess the client’s risk of harm to others.
Provide availability of contact 24 hours per day until psychiatric referral can be realized. Refer
those clients with a serious plan, previous attempt, or serious mental illness for psychiatric
intervention or obtain the assistance of a psychiatric consultant for the management of these clients.
Monitor and develop long-term recovery plans to treat substance abuse and strategies to ensure
medication adherence.
Review all such situations with the supervisor and/or treatment team members.
Document thoroughly all client reports and counselor suggestions.

COD—SUD & AFFECTIVE DISORDERS
Co-occurring Substance Use Disorder and
Affective Disorders

DSM 5 MAJOR DEPRESSIVE EPISODE
A. Five (or more) present during the same 2-week period, represent a change, at least one of the
symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
(1) depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g.,
feels sad or empty) or observation made by others (e.g., appears tearful).
(2) markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every
day (as indicated by either subjective account or observation made by others)
(3) significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body
weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider
failure to make expected weight gains.
(4) insomnia or hypersomnia nearly every day
(5) psychomotor agitation or retardation nearly every day (observable by others, not merely subjective
feelings of restlessness or being slowed down)
(6) fatigue or loss of energy nearly every day
(7) feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly
every day (not merely self-reproach or guilt about being sick)
(8) diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective
account or as observed by others)
(9) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific
plan, or a suicide attempt or a specific plan for committing suicide
B. Symptoms do not meet criteria for a Mixed Episode.
C. Symptoms cause clinically significant distress or impairment in functioning.
D. Symptoms are not due to the direct physiological effects of a substance or a medical condition.

BIPOLAR II DISORDER
A. Presence (or history) of one or more Major Depressive Episodes.
B. Presence (or history) of at least one Hypomanic Episode. (Duration 4 days)
C. There has never been a Manic or a Mixed Episode.
D. The mood symptoms in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not
superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise
Specified.
E. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of
functioning.
Bipolar I Disorder
One or more Manic Episodes...or Mixed Episodes...
Often individuals have also had one or more Major Depressive Episodes, but this is not required for diagnosis.
Episodes of Substance-Induced Mood Disorder or of Mood Disorder Due to a General Medical Condition do not count
toward a diagnosis of Bipolar I Disorder
A manic episode is defined in the DSM as a period of seven or more days (or any period if admission to hospital
is required) of unusually and continuously effusive and open elated or irritable mood, where the mood is not
caused by drugs/medication or a medical illness and (a) is causing obvious difficulties at work or in social
relationships and activities, or (b) requires admission to hospital to protect the person or others, or (c) the person
is suffering psychosis, changes in activity and energy as well as mood.
To be classed as a manic episode, while the disturbed mood is present at least three (or four if only irritability
is present) of the following must have been consistently prominent: grand or extravagant style, or expanded
self-esteem; pressured speech; reduced need of sleep (e.g. three hours may be sufficient); talks more often and
feels the urge to talk longer; ideas flit through the mind in quick succession, or thoughts race and preoccupy the
person; over indulgence in enjoyable behaviors with high risk of a negative outcome (e.g., extravagant shopping,
sexual adventures or improbable commercial schemes).[
If the person is concurrently depressed, they are said to be having a mixed episode.

COD—AUD/DUD AND AFFECTIVE
DISORDERS

50% of individuals with SUD have an affective or
anxiety disorder at some time in their lives
Among women with SUD—Mood Disorders may be
prevalent with women more likely than men to be
clinically depressed and/or to have PTSD
CO-OCCURRING MOOD DISORDERS &
ANXIETY DISORDERS

Older adults may be the group at highest risk for
combined mood disorder and substance problems
Episodes of mood disturbance generally increase
in frequency with age
COD (mood d/o & SUD)—tend to have more
episodes as they get older, even when their
substance use is controlled
ANXIETY DISORDERS

Medical problems and medications can produce
symptoms of anxiety and mood disorders.
25% of individuals with chronic or serious general
medical conditions, such as diabetes or stroke,
develop major depressive disorder
ANXIETY DISORDERS

Both substance use and discontinuance may be associated
with depressive symptoms
Acute manic symptoms may be induced or mimicked by
intoxication with stimulants, anabolic steroids,
hallucinogens, or poly-drug combinations
Substance use is more often a cause of anxiety symptoms
rather than an effort to cure these symptoms
Since mood and anxiety symptoms may result from SUD,
not an underlying mental disorder—careful and continuous
assessment is essential
ANXIETY DISORDERS

Mood Disorder Intoxication Withdrawal
Depression/ Alcohol, BZD, Alcohol, BZD,
Dysthymia Opioid, Barb., Barb., Opioid,
(Persistent Depressive Disorder) THC, Steroids Steroids,
Stimulants Stimulants
Mania and
Cyclothymia Stimulants, Alcohol, Alcohol,BZD
Hallucinogens, Inh. Barb.,Opioid
Steroid(chronic/acute) Steroid(chronic)
DRUGS THAT PRECIPITATE OR MIMIC
MOOD DISORDERS

ADVICE TO THE COUNSELOR: COUNSELING
A CLIENT WITH A MOOD OR ANXIETY DISORDER
Differentiate among the following: mood and anxiety disorders; commonplace expressions of anxiety and
depression; and anxiety and depression associated with more serious mental illness, medical
conditions and medication side effects, and substance-induced changes.
Although true for most counseling situations, it is especially important to maintain a calm demeanor and a
reassuring presence with these clients.
Start low, go slow (that is, start “low” with general and non-provocative topics and proceed gradually as
clients become more comfortable talking about issues).
Monitor symptoms and respond immediately to any intensification of symptoms.
Understand the special sensitivities of phobic clients to social situations.
Gradually introduce and teach skills for participation in mutual self-help groups.
Combine addiction counseling with medication and mental health treatment.

CO-OCCURRING ANXIETY DISORDERS
Prevalence (NESARC)
17.7% with SUD in past 12 months met criteria for
Independent Anxiety Disorder
15% with Anxiety Disorder in past 12 months had at least one
co-occurring SUD
Relationship between Anxiety Disorders and Drug Use
Disorders (OR 2.8) was stronger than the relationship
between anxiety and alcohol use disorder (AUDS) (OR 1.7)
AUD—12 month prevalence 8.5% & Lifetime
prevalence 30.3%
AUD with AD—OR 1.9/12months & OR 10.4/lifetime

OR were more positive for abuse compared with dependence
and for women compared to men
Most Common Drugs:
Marijuana use disorder—15.1 % in ADs
Cocaine use disorder—5.4% in ADs
Amphetamine use disorder—4.8% in ADs
Hallucinogen use disorder—3.7% in ADs
Sedative use disorder—2.6% in ADs

TREATMENT:
-Maximize use of non-pharmacologic treatments
(AA/NA, IOP, attendance at 12-step recovery programs,
finding a sponsor, and speaking up in groups???)
-CBTs
-Pharmaco-therapeutics
SRI’s first line, SNRI’s alternate first line
Venlafaxine (GAD, PD, and SAD)
Mirtazapine (PD and SAD)
Buspirone (useful for GAD, generally not for PD/SAD)
Anticonvulsants (Pregabalin—GAD, SAD)
Agents Targeting SUD—Naltrexone, Disulfiram

PSYCHOTIC DISORDERS—WITH COD
There is no clear pattern of drug choice among clients with schizophrenia. Instead, it is likely
that whatever substances happen to be available or in vogue will be the substances used
most typically.
• What looks like resistance or denial may in reality be a manifestation of negative symptoms
of schizophrenia.
• An accurate understanding of the role of substance use disorders in the client’s psy-
chosis requires a multiple-contact, longitudinal assessment.
• Clients with a co-occurring mental disorder involving psychosis have a higher risk for self-
destructive and violent behaviors.
• Clients with a co-occurring mental disorder involving psychosis are particularly vulnerable
to homelessness, housing instability, victimization, poor nutrition, and inadequate
financial resources.
• Both psychotic and substance use disorders tend to be chronic disorders with multiple
relapses and remissions, supporting the need for long-term treatment. For clients with
co-occurring disorders involving psychosis, a long-term approach is imperative.

NEGATIVE SYMPTOMS OF SCHIZOPHRENIA
Positive symptoms make treatment seem more
urgent, and they can often be effectively treated
with antipsychotic drugs. But negative symptoms
are the main reason patients with schizophrenia
cannot live independently, hold jobs, establish
personal relationships, and manage everyday
social situations.
Blunted affect
Alogia (poverty of speech)
Anhedonia
Associality (lack of desire to form relationships)
Avolition (lack of motivation)

PREVALENCE SCHIZOPHRENIA
The lifetime prevalence rate for adults with schizophrenia is
between 0.5 and 1.5 percent (APA 2000). The
Epidemiologic Catchment Area (ECA) studies reported
that among clients with schizophrenia, 47 percent met
criteria for some form of a substance use disorder
(Regier et al. 1990). Fifteen years earlier, McLellan and
Druley (1977) also found that about half of male inpatients
with schizophrenia could be expected to have a co-
occurring addiction to amphetamines, alcohol, or
hallucinogens.

PSYCHOTIC DISORDERS
Descriptive Features
The term “psychotic” historically has received a number of different definitions, none of which has achieved universal
acceptance. The narrowest definition of psychotic is restricted to delusions or prominent hallucinations, with the
hallucinations occurring in the absence of insight into their pathological nature. A slightly less restrictive definition also
would include prominent hallucinations that the individual realizes are hallucinatory experiences. Broader still is a
definition that also includes other positive symptoms of schizophrenia (i.e., disorganized speech, or grossly
disorganized or catatonic behavior). Unlike these definitions based on symptoms, the definition used in earlier
classifications (e.g., DSM-II and ICD-9) probably was far too inclusive and focused on the severity of functional
impairment. In that context, a mental disorder was termed “psychotic” if it resulted in “impairment that grossly interferes
with the capacity to meet ordinary demands of life.” The term also has previously been defined as a “loss of ego
boundaries” or a “gross impairment in reality testing.”
Schizophrenia is a disorder that lasts for at least 6 months and includes at least 1 month of active-phase symptoms
(i.e., two or more) of the following: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic
behavior, negative symptoms.
5 subtypes: (1) paranoid type, in which delusions or hallucinations predominate; (2) disorganized type, in which speech
and behavior peculiarities predominate; (3) catatonic type, in which catalepsy or stupor, extreme agitation, extreme
negativism or mutism, peculiarities of voluntary movement or stereotyped movements predominate; (4)
undifferentiated type, in which no single clinical presentation predominates; and (5) residual type, in which
prominent psychotic symptoms no longer predominate.

SCHIZOPHRENIA--FEATURES
Diagnostic criteria for schizophrenia
Characteristic symptoms: Two (or more) of the following, each present for a significant portion of time during a 1-month
period (or less if successfully treated):
Delusions
Hallucinations
Disorganized speech (e.g., frequent derailment or incoherence)
Grossly disorganized or catatonic behavior
Negative symptoms, i.e., affective flattening, alogia, or avolition
Note: Only one Criterion A symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a
running commentary on the person’s behavior or thoughts, or two or more voices conversing with each other.
Social/occupational dysfunction: For a significant portion of the time since the onset of the disturbance, one or more
major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved
prior to the onset (or when the onset is in childhood or adolescence, failure to achieve expected level of interpersonal,
academic, or occupational achievement).
Duration: Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1
month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active- phase symptoms) and may
include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the
disturbance may be manifested by only negative symptoms or two or more symptoms listed in Criterion A present in an
attenuated form (e.g., odd beliefs, unusual perceptual experiences).
Schizoaffective and Mood Disorder exclusion: Schizoaffective Disorder and Mood Disorder With Psychotic Features
have been ruled out because either (1) no Major Depressive, Manic, or Mixed Episodes have occurred concurrently
with the active-phase symptoms; or (2) if mood episodes have occurred during active-phase symptoms, their total
duration has been brief relative to the duration of the active and residual periods.

SCHIZOPHRENIA-CONTINUED-FEATURES
Criteria:--Continued:
Substance/general medical condition exclusion: The disturbance is not due to the direct physiological effects of a
substance (e.g., a drug of abuse, a medication) or a general medical condition.
Relationship to a Pervasive Developmental Disorder: If there is a history of Autistic Disorder or another Pervasive
Developmental Disorder, the additional diagnosis of Schizophrenia is made only if prominent delusions or
hallucinations also are present for at least a month (or less if successfully treated).
Classification of longitudinal course (can be applied only after at least 1 year has elapsed since the initial onset of active-
phase symptoms):
•Episodic With Inter episode Residual Symptoms (episodes are defined by the reemergence of prominent psychotic
symptoms); also specify if: With Prominent Negative Symptoms
•Episodic With No Inter episode Residual Symptoms
•Continuous (prominent psychotic symptoms are present throughout the period of observation); also specify if: With
Prominent Negative Symptoms
•Single Episode In Partial Remission; also specify if: With Prominent Negative Symptoms
•Single Episode In Full Remission
•Other or Unspecified Pattern
Source: Reprinted with permission from DSM-IV-TR (APA 2000, pp. 298–302, 312–313).

PSYCHOTIC DISORDERS
Although schizophrenia is the illness most strongly
associated with psychotic disorders, people with bipolar
disorder (or what used to be termed “manic depressive
illness”) may experience psychotic states during periods of
mania—the heightened state of excitement, little or no
sleep, and poor judgment described above. Other
conditions also can be accompanied by a psychotic state,
including toxic poisoning, other metabolic difficulties
(infections [e.g., late stage AIDS]), and other mental
disorders (major depression, dementia, alcohol
withdrawal states, brief reactive psychoses, and
others).

PREVALENCE BIPOLAR DISORDER
The lifetime prevalence of bipolar disorder also is roughly
1 percent of the general U.S. population (APA 2000), so
both schizophrenia and bipolar disorder are relatively
rare compared to major depressive illness, which has
lifetime incidences in the general population of 10 to 25
percent for women and 5 to 12 percent for men (APA
2000).

PREVALENCE BIPOLAR DISORDER
The lifetime prevalence of bipolar disorder also is roughly 1 percent of the
general U.S. population (APA 2000), so both schizophrenia and bipolar
disorder are relatively rare compared to major depressive illness, which
has lifetime incidences in the general population of 10 to 25 percent for
women and 5 to 12 percent for men (APA 2000).
People with bipolar disorder also are subject to high rates
of co-occurring substance abuse and dependence,
with even higher rates in specific populations. In the ECA
study, nearly 90 percent of those with bipolar disorder
in a prison population had a co-occurring substance
use disorder (Regier et al. 1990).

CO-OCCURRING AD/HD
Defined as persistent pattern of inattention and/or
hyperactivity-impulsivity that is displayed more frequently
and more serious than is observed typically in individuals
at a comparable level of development

CO-OCCURRING AD/HD PREVELANCE
Prevelance:
Studies of the adult substance abuse treatment
population have found AD/HD in 5 to 25 % of persons
(about 1 in 6 patients)
Approximately 33% of adults with AD/HD have
histories of alcohol abuse or dependence
20% of adults have other drug abuse or dependence

CO-OCCURRING AD/HD
Adults with Persistent symptoms of AD/HD who have a
history of conduct disorder or have co-occurring APD
(antisocial personality disorder) are at the highest risk
for SUD

CO-OCCURRING AD/HD
AD/HD adults found to primarily use alcohol, with marijuana
being the second most common drug of abuse
History of a typical AD/HD substance abuse treatment client
may show early school problems before substance abuse
began
AD/HD substance abuse treatment client may use self-
medication for AD/HD as an excuse for drug use

CO-OCCURRING AD/HD
Most common attention problems in Treatment populations
are secondary to short-term toxic effects of substances,
and these should be substantially better with each month
of sobriety

CO-OCCURRING AD/HD
Most common attention problems in Treatment populations
are secondary to short-term toxic effects of substances,
and these should be substantially better with each month
of sobriety
Presence of AD/HD complicates the treatment of
substance abuse, since clients with these COD may have
more difficulty engaging in Treatment and learning
abstinence skills, be at greater risk for relapse, and have
poorer substance use outcomes

CO-OCCURRING AD/HD
Clients may respond differently to various therapeutic
approaches

CO-OCCURRING AD/HD
Advice to the Counselor Counseling a client who has AD/HD

CO-OCCURRING TREATMENT ADVICE
1) Clarify repeatedly what elements of a question he or
she has responded to and what remains to be addressed
2) Eliminate distracting stimuli from the environment
3) Use visual aides to convey information
4) Reduce the time of meetings and length of verbal
exchanges
5) Encourage the client to use tools (e.g., activity journals,
written schedules, and “to do” lists to organize important
events and information
6) Refer for evaluation of the need for medication
7) Focus on Enhancing client’s knowledge about AD/HD

CLINICAL CASE STUDY:
SELF CANNOT SEE SELF—JERRY M.
Jerry M. is a 59y/o divorced male nurse who is a UR RN for a state
psychiatric hospital who has been in “recovery” from opioid
dependency (IV) since 1993. He had returned to use of alcohol about
5 years after going through Tx in 1993—then 3 years of aftercare with
RNP. He went to AA for a few years but stopped when he resumed his
drinking. Recently, Jerry (who always has been a little “odd”) turned 59
in June of 2014 and felt that he needed to enroll in a “anti-aging”
program—which included regular testosterone injections weekly. He
also felt that he was less attentive and a psychiatrist at his workplace
recommended that he take Adderall to focus better and to treat his
“undiagnosed” AHDH. He got a script for Adderall by his treating
psychiatrist. Had to add Ambien at bedtime about 8 weeks later for his
increasing problem with severe insomnia.
To be continued…..

SEVERITY OF CO-OCCURRING DISORDERS
Co-occurring mental health disorders are often
placed on a continuum of severity.
 Non-severe: early in the continuum and can include
mood disorders, anxiety disorders, adjustment
disorders and personality disorders.
 Severe: include schizophrenia, bipolar disorder,
schizoaffective disorder and major depressive
disorder.

SEVERITY OF CO-OCCURRING DISORDERS
The classification of “severe
and non-severe” is based
on a specific diagnosis and
by state criteria for Medicaid
qualification but can vary
significantly based on
severity of the disability and
the duration of the disorder.

QUADRANTS OF CARE
The quadrantsof care are a conceptualframe work that
classifies clients in four basic groups based on relative
symptom severity, not diagnosis.
• Category I: Less severe mental disorder/
Less severe substance disorder
• Category II: More severe mental disorder/
Less severe substance disorder
• Category III: Less severe mental disorder/
More severe substance disorder
• Category IV: More severe mental disorder/
More severe substancedisorder
(NationalAssociation of State Mental Health
Program Directors [NASMHPD] and
NationalAssociation of State Alcohol and Drug
Abuse Directors [NASADAD] 1999)

QUADRANTS OF CARE
Figure 1: Special Settings as a Function of COD Severity
Source: Adapted from National Association of State Mental Health Program Directors (NASMHPD)
& National Association of State Alcohol and Drug Abuse Directors (NASADAD), 1999.

QUADRANTS OF CARE
Model provides a framework for understanding the range of
co-occurring conditions and the level of coordination
that service systems need to address them.
Four Quadrants of Care provides a structure for moving
beyond minimal coordination to fostering consultation,
collaboration, and integration among systems and
providers in order to deliver appropriate care

MODELS OF TREATMENT
 Clients with co-occurring
disorders have historically
received substance abuse
treatment services in isolation
from mental health treatment
services.
 As more research on co-occurring disorders began to
be conducted, the many limitations this approach places
on the client and his or her success in treatment began
to surface.

A twenty-eight year-old-woman named Anita entered an addiction
treatment center where she was assessed as having alcohol
dependence. Six months earlier, Anita had been diagnosed with
major depressive disorder and was prescribed medication by her
family doctor. At the treatment facility, it was recommended that
Anita be re-assessed and treated, if necessary, at a mental health
clinic, located nearby in town. What model of treatment does
this scenario represent?
 single model of treatment
 sequential model of treatment
 parallel model of treatment
 integrated model of treatment
MODELS OF TREATMENT

 Single model of care - It was believed that once the “primary
disorder" was treated effectively, the client’s substance use
problem would resolve itself because drugs and/or alcohol were
no longer needed to cope.
 Sequential model of treatment - acknowledges the presence of
co-occurring disorders but treats them one at a time.
 Parallel model of treatment - mental health disorders are
treated at the same time as co-occurring substance use
disorders, only by separate treatment professionals and often
at separate treatment facilities.
MODELS OF TREATMENT

INTEGRATED MODEL OF TREATMENT
Integrated model of treatment
an approach to treating co-occurring disorders that
utilizes one competent treatment team at the same
facility to recognize and address all mental health and
substance use disorders at the same time.

WHY IS THIS SO DIFFICULT?
Fear in the SUD treatment community of putting addiction on the back
burner.
High utilization of time and resources.
Primary approach for MI is medications.
Primary approach for SUD after detox is other therapeutic
interventions (pre-Suboxone).
“Denial” by the individual and their family members regarding both.
Fear of placing more and more people in the bind of creating more
stigma, more disability.
(According to the 2004 World Health Report, Maj. Dep. Is the leading
cause of disability in the US and Canada for ages 15-44.)

WHY IS THIS SO DIFFICULT?
Addiction Disorders
• Health problems
• Family/intimacy problems
• Isolation
• Financial problems
• Employment problems
• School problems
• High risk driving/other accidents
• Multiple admissions
• Chronic/relapsing
• Increased suicide
• Has many patterns
• Lack of progress=failure
• Changing diagnostic criteria
Psychiatric Disorders
• Health problems
• Family/intimacy problems
• Isolation
• Financial problems
• Employment problems
• School problems
• High risk driving/other accidents
• Multiple admissions
• Chronic/relapsing
• Increased suicide
• Has many patterns
• Lack of progress=failure
• Changing diagnostic criteria

INTEGRATED MODEL OF TREATMENT
The integrated model of treatment can best be
defined by following seven components:
1) Integration
2) Comprehensiveness
3) Assertiveness
4) Reduction of negative consequences
5) Long-term perspective
6) Motivation-based treatment
7) Multiple psychotherapeutic modalities

BENEFITS OF AN INTEGRATED MODEL
OF CARE
Benefits of an Integrated
Model of Care
 Reduced need for coordination
 Reduced frustration for clients
 Shared decision-making responsibilities
 Families and significant others are included
 Transparent practices help everyone involved share responsibility
 Clients are empowered to treat their own illness and manage their
own recovery
 The client and his/her family has more choice in treatment, more
ability for self-management, and a higher satisfaction with care

 One disorder does not necessarily present as “primary.”
 There isn’t necessarily a causal relationship between co-occurring
disorders.
 These are co-occurring brain diseases that need to be treated
simultaneously.
An integrated model of care assumes that:
CO-OCCURRING DISORDERS INTERACTIONS

SCREENING AND ASSESSMENT
Screening:
The first phase of evaluation where the
potential client is interviewed to determine
if he or she is appropriate for that specific
treatment facility and to determine the
possible presence or absence of a
substance use or mental health problem.

Assessment:
The second phase of evaluation where a
systematic interview is necessary to
verify the potential presence of a mental
health or substance use disorder
detected during the screening process.

Intoxication
Withdrawal
Substance-induced disorders
Motivational factors
Feelings, symptoms, and disorders
Complexities of Screening and Assessment

CO-OCCURRING DISORDERS INTERACTIONS
Substances and Negative Emotions

The choice of screening measures depends on:
1) The skill of the screening professional
2) The cost of the screening materials
3) How simple the scale is to interpret and use across
disciplines
4) Psychometric qualities
5) The relevance of screening to prevalent disorders
6) Movement from very sensitive (generic) measures
to more specific measures

MENTAL HEALTH SCREENING FORM III
Mental Health Screening Form-III
The Mental Health Screening Form III was initially designed as a rough screening
device for clients seeking admission to substance abuse treatment programs.
Each MHSFIII question is answered either “yes” or “no.” All questions reflect the
respondent’s entire life history; therefore all questions begin with the phrase
“Have you ever...”
The MHSFIII features a “Total Score” line to reflect the total number of “yes”
responses.
The maximum score on the MHSFIII is 18 (question 6 has two parts). This feature
will permit programs to do research and program evaluation on the mental
health-chemical dependence interface for their clients.

MENTAL HEALTH SCREENING FORM III
Mental Health Screening Form-III
The first four questions on the MHSFIII are not unique to any particular diagnosis;
however, questions 5 through 17 reflect symptoms associated with the
following diagnoses/diagnostic categories: Q5, Schizophrenia; Q6, Depressive
Disorders; Q7, Posttraumatic Stress Disorder; Q8, Phobias; Q9, Intermittent
Explosive Disorder; Q10, Delusional Disorder; Q11, Sexual and Gender
Identity Disorders; Q12, Eating Disorders (Anorexia, Bulimia); Q13, Manic
Episode; Q14, Panic Disorder; Q15, Obsessive-Compulsive Disorder; Q16,
Pathological Gambling; and Q17, Learning Disorder and Mental Retardation
A “yes” response to any of questions 5 through 17 does not, by itself, ensure that
a mental health problem exists at this time. A “yes” response raises only the
possibility of a current problem, which is why a consult with a mental health
specialist is strongly recommended.

SIMPLE SCREENING INSTRUMENT FOR
SUBSTANCE ABUSE (SSI-SA)
SSI-SA (1994)
It is a 16 item scale, although only 14 items are scored so that scores can range
from 0 to 14. These 14 items were selected by the TIP 11 consensus panelists
from existing alcohol and drug abuse screening tools. A score of 4 or greater
has become the established cutoff point for war ranting a referral for a full
assessment.
Peters et al. (2000) found the SSISA to be effective in identifying substance-
dependent inmates, and the SSISA demonstrated high sensitivity (92.6 percent
for alcohol or drug dependence disorder, 87.0 percent for alcohol or drug
abuse or dependence disorder) and excellent test-retest reliability (.97)
Others: TCUDS (Texas Christian University Drug Dependence Screen)
MAST (Michigan Alcohol Screening Test)

Sources for Items Included in the Simple Screening Instrument for
Substance Abuse
Question No. Source Instrument
1 Revised Health Screening Survey (RHSS)
2 Michigan Alcohol Screening Test (MAST)
3 CAGE
4 MAST, CAGE
5 History of Trauma Scale, MAST, CAGE
6 MAST, Drug Abuse Screening Test
(DAST)
7 MAST, Problem-Oriented Screening
Instrument for Teenagers (POSIT)
8 MAST, DAST
9 MAST, DSMIIR
10 POSIT, DSMIIIR
11 POSIT
12 POSIT
13 MAST, POSIT, CAGE, RHSS,
Alcohol Use Disorders Identification
Test (AUDIT), Addiction Severity
Index (ASI)
Note: References for these sources appear at the end of this section.

Domains Measured:
Substance Consumption
Preoccupation and loss of control
Adverse Consequences
Problem recognition
Tolerance and Withdrawal

Short-form of SSI-SA
The four boldfaced questions—1, 2, 3, and 16—constitute the short form of the screening
instrument.
Introductory statement:
“I’m going to ask you a few questions about your use of alcohol and other drugs during the past 6 months. Your
answers will be kept private. Based on your answers to these questions, we may advise you to get a more complete
assessment. This would be voluntary—it would be your choice whether to have an addition al assessment or not.”
During the past 6 months...
1)Have you used alcohol or other drugs? (Such as wine, beer,
hard liquor, pot, coke, heroin or other opioids, uppers, downers,
hallucinogens, or inhalants.) (yes/no)
2)Have you felt that you use too much alcohol or other drugs? (yes/no)
3)Have you tried to cut down or quit drinking or using drugs? (yes/no)
16)Do you feel that you have a drinking or drug problem now? (yes/no)

SSI-SA Self-Administered Form
Figure H3 Simple Screening Instrument for Substance Abuse Self-Administered Form
Directions: The questions that follow are about your use of alcohol and other drugs. Your answers will be kept private. Mark the response that best fits for you. Answer the questions in terms of your experiences in the past 6 months.
During the last 6 months...
1 Have you used alcohol or other drugs? (Such as wine, beer, hard liquor, pot, coke, heroin or other opioids, uppers, downers, hallucinogens, or inhalants)
Yes No
2 Have you felt that you use too much alcohol or other drugs?
Yes No
3 Have you tried to cut down or quit drinking or using alcohol or other drugs?
Yes No
4Have you gone to anyone for help because of your drinking or drug use? (Such as Alcoholics Anonymous, Narcotics Anonymous, Cocaine Anonymous, counselors, or a treatment program.)
Yes No
5 Have you had any health problems? For example, have you:
Had blackouts or other periods of memory loss?
Injured your head after drinking or using drugs?
Had convulsions, delirium tremens (“DTs”)?
Had hepatitis or other liver problems?
Felt sick, shaky, or depressed when you stopped?
Felt “coke bugs” or a crawling feeling under the skin after you stopped using drugs?
Been injured after drinking or using?
Used needles to shoot drugs?
6 Has drinking or other drug use caused problems between you and your family or friends?
Yes No
7 Has your drinking or other drug use caused problems at school or at work?
Yes No

SSI-SA Self-Administered Form
Total Score:______________ (0-14)
Score Degree of Risk for Substance Abuse
0-1 None to Low
2-3 Minimal
>4 Moderate to High
Possible need for assessment
(Do not score 1 and 15)

Integrated Assessment
Process – 12 Steps
1. Engage the Client

2. Identify and Contact Collaterals

3. Screen for and Detect Co-occurring Disorders

4. Determine Quadrant and Locus of Responsibility

5. Determine Level of Care

American Society of Addiction Medicine Patient Placement Criteria –
2nd Edition Revised (ASAM PPC-2R) dimensions of care
 Dimension 1: Acute Intoxication and/or Withdrawal Potential
 Dimension 2: Biomedical Conditions and Complications
 Dimension 3: Emotional, Behavioral or Cognitive Conditions
and Complications
 Dimension 4: Readiness to Change
 Dimension 5: Relapse, Continued Use or Continued Problem
Potential
 Dimension 6: Recovery/Living Environment
DETERMINING LEVEL OF CARE

 Level I: Outpatient treatment.
 Level II: Intensive outpatient treatment, including
partial hospitalization.
 Level III: Residential/medically monitored
intensive inpatient treatment.
 Level IV: Medically managed intensive inpatient
treatment.
DETERMINING LEVEL OF CARE

5. Determine Level of Care
6. Determine Diagnosis

DETERMINE DIAGNOSIS (DDX)
Case 1. Maria M., the 38-year-old Hispanic/Latina female with cocaine
and opioid dependence, initially was receiving methadone
maintenance treatment only. She also used antidepressants prescribed
by her outside primary care physician. She presented to methadone
maintenance program staff with complaints of depression. Maria M.
reported that since treatment with methadone (1 year) she had not
used illicit opioids.
However, she stated that when she does not use cocaine, she often feels
depressed “for no reason.” Nevertheless, she has many stressors
involving her children, who also have drug problems. She reports that
depression is associated with impulses to use cocaine, and
consequently she has recurrent cocaine binges.
These last a few days and are followed by persistent depression.
What is the mental diagnosis?

To answer this question it is important to obtain a mental disorder history
that relates mental symptoms to particular time periods and patterns
of substance use and abuse.
The client’s history reveals that although she grew up with an abusive
father with an alcohol problem, she herself was not abused physically
or sexually. Although hampered by poor reading ability, she stayed in
school with no substance abuse until she became pregnant at age 16
and dropped out of high school. Despite becoming a single mother at
such a young age, she worked three jobs and functioned well, while
her mother helped raise the baby. At age 23, she began a 9-year
relationship with an abusive person with an alcohol and illicit drug
problem, during which time she was exposed to a period of severe
trauma and abuse. She is able to recall that during this relationship,
she began to lose her self-esteem and experience persistent
depression and anxiety.

To answer this question it is important to obtain a mental disorder history
that relates mental symptoms to particular time periods and patterns of
substance use and abuse.
The client’s history reveals that although she grew up with an abusive
father with an alcohol problem, she herself was not abused physically
or sexually. Although hampered by poor reading ability, she stayed in
school with no substance abuse until she became pregnant at age 16
and dropped out of high school. Despite becoming a single mother at
such a young age, she worked three jobs and functioned well, while
her mother helped raise the baby. At age 23, she began a 9-year
relationship with an abusive person with an alcohol and illicit drug
problem, during which time she was exposed to a period of severe
trauma and abuse. She is able to recall that during this relationship,
she began to lose her self-esteem and experience persistent
depression and anxiety.

She began using cocaine at age 27, initially to relieve those symptoms.
Later, she lost control and became addicted. Four years ago, she was
first diagnosed as having major depression, and was prescribed
antidepressant medication, which she found helpful. Two years ago,
she began using opioids, became addicted, and then entered
methadone treatment. She receives no specific treatment for cocaine
dependence. She has noticed that her depression persists during
periods of cocaine and opioid abstinence lasting more than 30 days.
On one occasion, during one of these periods, her medication ran out,
and she noticed her depression became much worse. Even at her
baseline, she remains troubled by lack of self-confidence and
fearfulness, as well as depressed mood.

Her depression persists during periods of more than 30 days
of abstinence and responds to some degree to
antidepressants. The fact that her depression persists even
when she is abstinent and responds to antidepressants
suggests strongly a co-occurring affective disorder.
There are also indications of the persistent effects of
trauma, possibly posttraumatic stress disorder. Trauma
issues have never been addressed. Her opioid
dependence has been stabilized with methadone. She has
resisted recommendations to obtain more specific
treatment for cocaine dependence.

7. Determine Disability and
Functional Impairment

DETERMINE DISABILITY AND FUNCTIONAL
IMPAIRMENT
Assessment of Maria M.’s functional capacity at baseline indicated that
she could read only at a second grade level. Consequently,
educational materials presented in written form needed to be
presented in alternative formats. These included audiotapes and
videos to teach her about addiction, depression, trauma, and recovery
from these conditions. In addition, Maria M.’s history of trauma
(previously discussed) led her to experience anxiety in large group
situations, particularly where men were present. This led her counselor
to recommend attending 12-Step meetings that were smaller and/or
women only. The counselor also suggested that she attend in the
company of female peers. Further, the clinician referred her to trauma-
specific counseling.

8. Identify Strengths and Supports

9. Identify Cultural and Linguistic Needs and Supports

IDENTIFY CULTURAL AND LINGUISTIC
NEEDS AND SUPPORTS
Assessment Step 9—Application to Case Maria M.
Maria M. initially had difficulty identifying herself as being a
victim of trauma both because she had normalized her
perception of her early family experience with her abusive
father and because she had received cultural
reinforcement in the past that condoned the behavior of her
abusive boyfriend as “normal machismo.” Referral to a
group that included other Hispanic women who also had
suffered abuse was very helpful to her. With the help of the
group, she began to recognize the reality of the impact that
trauma had had in her life.

10. Identify Problem Domains

11. Determine Stage of Change

11. Determine Stage of Change
12. Plan Treatment

ELEMENTS OF AN INTEGRATED MODEL
Diagnostic process that produces provisional diagnosis of
psychiatric and substance use disorders using:
Substances used (Limitations of but necessity of valid
toxicology results.) and when, how much, how often, last
time.
Review of signs and symptoms (psychiatric and substance
use). Rating scales may be helpful but not better than a
really good history. Collateral information.
Personal history timeline of symptom emergence (what
started when).
Family history of psychiatric/substance use disorders.
Psychiatric/substance use treatment history.
Look for things that cluster.

Initial treatment plan (Days 1-10) that includes:
Choice of a treatment setting appropriate to initially
stabilize medical conditions, psychiatric symptoms and
drug/alcohol withdrawal symptoms
Initiation of medications to control urgent psychiatric
symptoms (psychotic, severe anxiety, etc.)
Implementation of medication protocol appropriate for
treating withdrawal syndrome(s)
Ongoing assessment and monitoring for safety,
stabilization and withdrawal

Early stage treatment plan (Days 2-14) that includes:
Selection of treatment setting/housing with adequate
supervision
Completion of withdrawal medication
Review of psychiatric medications
Completion of assessment in all domains (psychology, family,
educational, legal, vocational, recreational)
Initiation of individual therapy and counseling (extensive use of
motivational strategies and other techniques to reduce
attrition)
Introduction to behavioral skills group and educational groups,
step groups
Introduction to self help programs
Urine testing and breath alcohol testing

Intermediate treatment plan (up to 6 or 8 weeks)
that includes:
Housing plan that addresses psychiatric and substance use needs
Plan of ongoing medication for psychiatric and substance use
treatment with strategies to enhance compliance
Plan of individual and group therapies and psychoeducation with
attention to both psychiatric and substance use needs
Skills training for successful community participation and relapse
prevention
Family involvement in treatment processes
Self-help program participation
Process of monitoring treatment participation (attendance and
goal attainment)
Urine and breath alcohol testing

Extended treatment plan that includes (up to 6
months):
Housing plan
Ongoing medication for psych and substance use treatment
Plan of individual and group therapies and psychoeducation with
attention to both psychiatric and substance use needs
Ongoing participation in relapse prevention groups and appropriate
behavioral skills groups and family involvement
Initiation of new skill groups (e.g.; education, vocational, recreational
skills)
Self help involvement and ongoing testing
Monitoring attendance and goal attainment

Ongoing plan (Continuing Care Plan) of visits for
review of:
Medication needs
Individual therapies
Support groups for psych and substance use conditions
Self help involvement
Instructions to family to recognize relapse to psych and
substance use
In short, a chronic care model is used to reduce
relapse and if/when relapse (psychiatric or substance
use) occurs, treatment intensity can be intensified.

STRATEGIES FOR WORKING WITH CLIENTS
WITH CO-OCCURRING DISORDERS
Key Techniques for Working With Clients Who Have COD
Provide motivational enhancement consistent with the client’s specific
stage of change.
Design contingency management techniques to address specific target
behaviors.
Use cognitive–behavioral therapeutic techniques.
Use relapse prevention techniques.
Use repetition and skills-building to address deficits in functioning.
Facilitate client participation in mutual self-help groups.

EVIDENCE-BASED PRACTICES
In most treatment addiction centers, the three primary
evidence-based practices used are:
 motivational enhancement therapy (MET)
 cognitive-behavioral therapy (CBT)
 twelve step facilitation (TSF)
All of these treatment models are widely used – often
without formal training – by addiction professionals
around the country and can be easily applied to clients
suffering from co-occurring disorders.

EVIDENCE-BASED PRACTICES
The Integrated Combined Therapies model combines
these three EBPs (Evidence-Based Practices) into a
stage-wise treatment plan whereby:
 motivational enhancement therapy is first utilized to
initiate change and engage the client in the therapeutic
process;
 cognitive-behavioral therapy is then used to help make
change within the client; and
 twelve step facilitation is essential to helping maintain
and sustain changes.

STAGES OF CHANGE/
STAGES OF TREATMENT

Guidelines for Developing Successful Therapeutic
Relationships With Clients With COD
•Develop and use a therapeutic alliance to engage the
client in treatment
•Maintain a recovery perspective
•Manage countertransference
•Monitor psychiatric symptoms
•Use supportive and empathic counseling
•Employ culturally appropriate methods
•Increase structure and support

Forming a Therapeutic Alliance
-Demonstrate an understanding and acceptance of the client.
-Help the client clarify the nature of his difficulty.
-Indicate that you and the client will be working together.
-Communicate to the client that you will be helping her to help herself.
-Express empathy and a willingness to listen to the client’s formulation
of the problem.
-Assist the client to solve some external problems directly and
immediately. Foster hope for positive change.

Maintaining a Recovery Perspective
The consensus panel recommends the following approaches for maintaining a
recovery perspective with clients who have COD:
Assess the client’s stage of change (Motivational Enhancement below).
Ensure that the treatment stage (or treatment expectations) is (are) consistent with the
client’s stage of change.
Use client empowerment as part of the motivation for change.
Foster continuous support.
Provide continuity of treatment.
Recognize that recovery is a long-term process and that even small gains by the client
should be supported and applauded.

CASE STUDY: USING MET WITH A CLIENT
WHO HAS COD
Gloria M. is a 34-year-old African-American female with a 10-year history of alcohol dependence and 12-year history of bipolar
disorder. She has been hospitalized previously both for her mental disorder and for substance abuse treatment. She has been
referred to the outpatient substance abuse treatment provider from inpatient substance abuse treatment services after a severe
alcohol relapse.
Over the years, she sometimes has denied the seriousness of both her addiction and mental disorders. Currently, she is psychiatrically
stable and is prescribed Valproic acid to control the bipolar disorder. She has been sober for 1 month.
At her first meeting with Gloria M., the substance abuse treatment counselor senses that she is not sure where to focus her recovery
efforts—on her mental disorders or her addiction. Both have led to hospitalization and to many life problems in the past.
Using motivational strategies, the counselor first attempts to find out Gloria M.’s own evaluation of the severity of each
disorder and its consequences to determine her stage of change in regard to each one.
Gloria M. reveals that while in complete acceptance and an active stage of change around alcohol dependence, she is starting to
believe that if she just goes to enough recovery meetings she will not need her bipolar medication. Noting her ambivalence,
the counselor gently explores whether medications have been stopped in the past and, if so, what the consequences have been.
Gloria M. recalls that she stopped taking medications on at least half a dozen occasions over the last 10 years; usually, this led
her to jail, the emergency room, or a period of psychiatric hospitalization. The counselor explores these times, asking: Were
you feeling then as you were now—that you could get along? How did that work out? Gloria M. remembers believing that if
she attended 12-Step meetings and prayed she would not be sick. In response to the counselor’s questions, she observes, “I
guess it hasn’t ever really worked in the past.”
The counselor then works with Gloria M. to identify the best strategies she has used for dual recovery in the past. “Has there been a
time you really got stable with both disorders?” Gloria M. recalls a 3-year period between the ages of 25 and 28 when she was
stable, even holding a job as a waitress for most of that period. During that time, she recalls, she saw a psychiatrist at a local
mental health center, took medications regular ly, and attended AA meetings frequently. She recalls her sponsor as being
supportive and helpful. The counselor then affirms the importance of this period of success and helps Gloria M. plan ways to use
the strategies that have already worked for her to maintain recovery in the present.

WHO HAS COD
disorder. She has been hospitalized previously both for her mental disorder and for sub stance abuse treatment. She has been
alcohol relapse.
mental health center, took medications regular ly, and attended AA meetings frequently. She recalls her sponsor as being

WHO HAS COD
disorder. She has been hospitalized previously both for her mental disorder and for sub stance abuse treatment. She has been
alcohol relapse.
mental health center, took medications regularly, and attended AA meetings frequently. She recalls her sponsor as being

 Double Trouble in Recovery
 Mental Illness Anonymous
 Dual Disorders Anonymous
 Dual Recovery Anonymous
 Dual Diagnosis Anonymous
DUAL-RECOVERY MUTUAL SELF-HELP
Specific dual-recovery groups can provide essential
peer support:

GUIDING PRINCIPLES OF RECOVERY
 There are many pathways to recovery.
 Recovery is self-directed and empowering, involving personal
recognition of the need for change and transformation.
 Recovery exists on a continuum of improved health and wellness.
 Recovery involves addressing discrimination and transcending
shame and stigma.
 Recovery is supported by peers and allies, and involves joining
and rebuilding a life in the community.
 Recovery is a reality.
 (from CSAT’s Regional Recovery Meetings, May 2008)

12 STEP VERSUS COGNITIVE BEHAVIORAL TREATMENT (SELF-
MANAGEMENT AND RECOVERY TRAINING) IN DUAL DIAGNOSIS
(BROOKS & PENN, AM J OF ALCOHOL AND DRUG ABUSE, 29 (2), 359-383, 2003.
12 Step
More effective in
decreasing alcohol use
and increasing social
interactions
Worsening of medical
problems, health,
employment, psychiatric
hospitalizations
Cognitive Behavioral
• More effective in
improving overall health
and work status
N=50
½ went to 12 step treatment
and ½ to SMART. One year
observation. Findings
drawn from those who
finished 3 months of
treatment.(Brooks & Penn, 2003)

DOES PARTICIPATION IN SELF-HELP GROUPS
REDUCE DEMAND FOR HEALTH CARE?
N=1774, 1 YEAR FOLLOW-UP HUMPHREYS ET AL , 2001
Outpt Inpt days Abstinence
Visits Rates
12 Step 13.1 10.5 45.7
Cog Beh 17 17 36.2
* all p< .001 ** 64% higher cost for CBT
.

One year ABSTINENCE was predicted by:
• AA involvement ( n=377 men and 277 women)
• Not having pro-drinking influences in one's network
• Having support for reducing consumption from people met
in AA
• In contrast, having support from non-AA members was
not a significant predictor of abstinence.
Kaskutas: Addiction 2002

DOUBLE TROUBLE RECOVERY (DTR)
OUTCOMES
Members of 24 DTR groups (n=240) New York City, 1 year
outcomes
Drug/alcohol abstinence = 54% at baseline, increased to
72% at follow-up.
More attendance = better medication adherence,
Better medication adherence = less hospitalization
Magura Add Beh 2003, Psych Serv 2002

EVIDENCE-BASED PRACTICES REGARDING SELF-HELP
J OF SUB. ABUSE TREATMENT, VOL 26, ISSUE 3, PP. 151-158, APRIL, 2004.
Summary of status of U.S. self-help groups
A diverse set of self-help organizations has developed for all substances of significant public health concern (Most
research done on AA/NA/DTR)
Collectively, these self-help organizations are both appealing and affordable to a broad spectrum of people.
Clinical, agency and governmental procedure and policy influence the prevalence, organizational stability, and availability
of addiction-related self-help groups
Synthesis of effectiveness research results
Longitudinal studies associate AA and NA participation with greater likelihood of abstinence, improved social
functioning, and greater self-efficacy. Participation seems more helpful when members engage in other group
activities in addition to attending meetings.
Twelve-step self-help groups significantly reduce health care utilization and costs, removing a significant burden
from the health care system.
Self-help groups are best viewed as a form of continuing care rather than as a substitute for acute treatment services
(e.g., detoxification, hospital-based treatment, etc.)
Randomized trials with coerced populations suggest that AA combined with professional treatment is superior to AA
alone.

psychiatric hospital who has been in “recovery” from opioid
dependency (IV) since 1993. He had returned to use of alcohol about
5 years after going through Tx in 1993—then 3 years of aftercare with
RNP. He went to AA for a few years but stopped when he resumed his
drinking. Recently, Jerry (who always has been a little “odd”) turned 59
in June of 2014 and felt that he needed to enroll in a “anti-aging”
program—which included regular testosterone injections weekly. He
also felt that he was less attentive and a psychiatrist at his workplace
recommended that he take Adderall to focus better and to treat his
“undiagnosed” AHDH. He got a script for Adderall by his treating
psychiatrist. Had to add Ambien at bedtime about 8 weeks later for his
increasing problem with severe insomnia.
Jerry M. was in an MVA (second time) in his rental car 2 days before
Christmas and charged with DUI (second offense in 30 days) with his
immediate transfer to Trauma center after being extracted from car.

psychiatric hospital was then admitted to the ICU after having a BAL of
0.125%. He was transferred the next day for 7 days of “detox” on the
mental health ward—diagnosed with Bipolar Disorder (Mania) and
placed on Lithium. His mental status improved after the intoxication
from alcohol and Ambien resolved, but he still had flight of ideas,
pressured speech, disheveled appearance, and a recollection of his
prior “hallucinations” he had prior to his initial MVA/DUI. On the
seventh day he was transferred to a long term inpatient residential
treatment center—now off Adderal, Testosterone injections, Ambien,
but now on Lithium. Diagnosis?? Assessments? Treatment Plan?

JAY PILAND MD
Thank You for your participation

Integrated Treatment for Co-Occurring Disorders

Recomendados

Recomendados

Mais conteúdo relacionado

Mais procurados

Mais procurados (20)

Destaque

Destaque (20)

Semelhante a Integrated Treatment for Co-Occurring Disorders

Semelhante a Integrated Treatment for Co-Occurring Disorders (20)

Último

Último (20)

Integrated Treatment for Co-Occurring Disorders