Dual diagnosis:An Integrated Model for the Treatment of People with Co-occurring Psychiatric and

Substance Disorders

Kenneth Minkoff, M.D.

Kminkov@aol.com

781-932-8792x311

“Co-occurring Psychiatric & Substance Disorders in Managed Care Systems: Standards of Care, Practice

Guidelines, Workforce Competencies & Training Curricula”

WWW.MED.UPENN.EDU/CMHPSR

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American Association of Community Psychiatrists

• PRINCIPLES OF TREATMENT FOR INDIVIDUALS WITH CO-OCCURRING PSYCHIATRIC AND SUBSTANCE DISORDERS

• www.comm.psych.pitt.edu

FIVE SECTIONS OF PANEL REPORT

• I. CONSUMER/FAMILY STANDARDS

• II. SYSTEM STANDARDS/PROGRAM COMPETENCIES

• III. PRACTICE GUIDELINES

• IV. WORKFORCE COMPETENCIES

• V. TRAINING CURRICULA

CONSUMER/FAMILY SYSTEM STANDARDS

WELCOMING

• ACCESSIBLE

• INTEGRATED

• CONTINUOUS

• COMPREHENSIVE

TRENDS LEADING TO COMORBIDITY

• DEINSTITUTIONALIZATION

• CHANGED PATTERNS OF SUBSTANCE ABUSE/DEPENDENCE

• DECADE OF THE BRAIN: INCREASED KNOWLEDGE RE

BRAIN DISORDERS

Beyond the self-medication hypothesis

• People with serious mental illness use substances:

• To alleviate general feelings of isolation, loneliness, boredom, and despair,

• To facilitate peer interaction/socialization

• To create a sense of well-being, and escape from bleak life experience

Vulnerabilities to substance use disorders for SPMI

• 1. Greater extent of dysphonic feelings and sense of despair

• 2. Fewer alternative, healthier coping resources

• 3. Increased brain vulnerability to harmful effects of substances

• 4. Mental illness may inhibit learning from results of adverse drug experience

AREAS OF POOR OUTCOME

• RELAPSE & REHOSPITALIZATION• SUICIDALITY AND VIOLENCE• MEDICAL INVOLVEMENT (HIV/STD)• CRIMINAL INVOLVEMENT• HOMELESSNESS• TRAUMA VULNERABILITY• FAMILY DISRUPTION/ABUSE• HIGH SERVICE UTILIZATION

SAME FACESDIFFERENT PLACES

• Comorbidity is highly prevalent in all systems of care:

• Mental health• Substance treatment• Criminal Justice• Homeless• Primary care• Victim/trauma services• Family protective services

SYSTEM MISFITSin all places

• SYSTEM LEVEL

• PROGRAM LEVEL

• CLINICIAN LEVEL

RESEARCH-BASED TREATMENT MODELS FOR

DUAL DISORDERSIntegrated Intensive Case Mgt Teams

Continuous Treatment Team (CTT)- Drake & MueserIntegrated ACT/PACT Team

Modified Addiction Residential ProgramsModified Therapeutic Community (TC) – Sachs/DeLeonParenting Women Programs

The most significant predictor of treatment success is...

the ability of a program or intervention to provide...

through an individual clinician, team of clinicians, or a community of recovering peers and clinicians...

an empathic, hopeful, continuous treatment relationship, which provides integrated

treatment and coordination of care through the course of multiple treatment episodes.

EMPATHY MANTRA

• When individuals with mental illness and substance disorder are not following recommendations, they are doing their job.

• It is our job to understand their job, to join them in it, and help them to do it better.

• Their job involves coming to terms with the painful reality of having both mental illness and substance disorder, wanting neither one, yet having to build an identity that involves rx for both.

HOPE

• FOUR STEP PROCESS1. Empathize with reality of despair.2. Establish legitimacy of need to ASK for

extensive help.3. Identify meaningful, attainable

measures of successful progress.4. Emphasize a hopeful vision of pride and

dignity to counter self-stigmatization.

INTEGRATED TREATMENT

• Integrated treatment refers to any of a number of mechanisms by which established diagnosis-specific and stage-specific treatments for each disorder are combined into a person-centered coherent whole at the level of the consumer, and each rx can be modified as needed to accommodate issues related to the other disorder.

CONTINUITY

• Course of treatment for individuals with chronic co-morbid conditions ideally combines continuous integrated relationships which are unconditional, with multiple episodic interventions or programmatic episodes of care which have expectations, conditions, and/or time limits.

SUB-GROUPS OF PEOPLE WITH COEXISTING DISORDERS

Patients with “Dual Diagnosis” - combined psychiatric and substance abuse problems - who are eligible for services fall into four major quadrants

PSYCH. HIGH SUBSTANCE HIGH

Serious & Persistent Mental Illness with QUAD Substance Dependence: IV

PSYCH. LOW SUBSTANCE HIGH

Psychiatrically Complicated Substance Dependence QUADRANT III

PSYCH. HIGH SUBSTANCE LOW

Serious & Persistent Mental Illness with Substance Abuse QUAD II

PSYCH. LOW SUBSTANCE LOW

Mild Psychopathology with Substance Abuse QUADRANT i

PSYCH HIGH / SUBSTANCE LOW

SERIOUS & PERSISTENT MENTAL ILLNESS

WITH SUBSTANCE ABUSEQUADRANT II

• Patients with serious and persistent mental illness (e.g. Schizophrenia, Major Affective Disorders with Psychosis, Serious PTSD) which is complicated by substance abuse, whether or not the patient sees substances as a problem.

PSYCH HIGH / SUBSTANCE HIGH

SERIOUS & PERSISTENTMENTAL ILLNESS

WITH SUBSTANCE DEPENDENCEQUADRANT IVA

• Patients with serious and persistent mental illness, who also have alcoholism and or drug addiction, and who need treatment for addiction, for mental illness, or for both. This may include sober individuals who may benefit from psychiatric treatment in a setting which also provides sobriety support and Twelve-step Programs.

PSYCH LOW / SUBSTANCE HIGH

PSYCHIATRICALLY COMPLICATED SUBSTANCE DEPENDENCE

QUAD III (mild-mod); QUAD IVB (severe)

• Patients with alcoholism and/or drug addiction who have significant psychiatric symptomatology and /or disability but who do NOT have serious and persistent mental illness.

• Includes both substance-induced psychiatric disorders and substance-exacerbated psychiatric disorders.

• Includes the following psychiatric syndromes: – Anxiety/Panic Disorder - Suicidality– Depression/Hypomania - Violence– Psychosis/Confusion - PTSD Symptoms– Symptoms Secondary to Misuse/Abuse of Psychotropic Medication– Personality Traits/Disorder

PSYCH LOW / SUBSTANCE LOW

MILD PSYCHOPATHOLOGYWITH SUBSTANCE ABUSE

QUADRANT I

• Patients who usually present in outpatient setting with various combinations of psychiatric symptoms (e.g. anxiety, depression, family conflict) and patterns of substance misuse and abuse, but not clear cut substance dependence.

DSM III-R Diagnostic Criteria

PSYCHOACTIVE SUBSTANCE ABUSE

• A maladaptive pattern of psychoactive substance use indicated by at least one of the following:

• Continued substance use despite having persistent or recurrent social, occupational, psychological, or physical problems caused or exacerbated by the effects of the substance use

• Recurrent substance use in situations in which it is physically hazardous

• Recurrent substance-related legal problems

• Some symptoms of the disturbance have lasted for at least one month, or have occurred repeatedly over a longer period of time.

• The symptoms have never met the criteria for Substance Dependence for this class of substance.

DSM IV Diagnostic Criteria

PSYCHOACTIVE SUBSTANCE DEPENDENCE

• A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring any time in the same 12-month period:

– Tolerance, as defined by either of the following:• A need for markedly increased amounts of substance to achieve intoxication or desired effect• Markedly diminished effect with continued use of the same amount of the substance

– Withdrawal, as manifested by either of the following:• The characteristic withdrawal syndrome for the substance• The same (or closely related) substance is taken to relieve or avoid withdrawal symptoms

• The substance is often taken in larger amounts or over a longer period than was intended

• There is a persistent desire or unsuccessful efforts to cut down or control substance use

(Continued)

DSM IV Diagnostic Criteria

PSYCHOACTIVE SUBSTANCE DEPENDENCE

(Continued)

• A great deal of time spent in activities necessary to obtain the substance, use the substance, or recover from its effects

• Important social, occupation, or recreational activities are given up or reduced because of substance use

• Continued use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance

NOTE: The following items may not apply to cannabis, hallucinogens, or phencyclidine (PCP)

• Characteristic withdrawal symptoms• Substance often taken to relieve or avoid withdrawal symptoms

Individuals with Co-occurring DisordersTreatment Rules

• All good treatment proceeds from empathic, hopeful, clinical relationship.

• Consequently, promote opportunities to initiate and maintain integrated, continuing, empathic, hopeful relationships whenever possible.

• Specifically, remove arbitrary barriers to initial mental health assessment and evaluation, including initial psychopharmacology evaluation (e.g., length of sobriety, alcohol level, etc.)

Similarly, never deny access to substance disorder evaluation and/or treatment because a patient is on a prescribed non-addictive psychotropic medication.

• Moreover, never discontinue medication for a known serious mental illness because a patient is using substances.

• In fact, when mental illness and substance disorder co-exist, both disorders require specific and appropriately intensive primary treatment.

• There are no rules! The specific content of dual primary treatment for each person must be individualized according to diagnosis, phase of treatment, level of functioning and/or disability, and assessment of level of care based on acuity, severity, medical safety, motivation, and availability of recovery support.

PRINCIPLES

Dual Diagnosis is an expectation, not an exception.

Philosophical & Clinical BARRIERS TO INTEGRATED

TREATMENTAddiction System Mental Health System

Peer Counseling model vs. Medical/Professional model

Spiritual Recovery vs. Scientific treatment

Self Help vs. Medication

Confrontation and expectation vs. Individualized support and flexibility

Detachment/empowerment vs. Case management/care

Episodic treatment vs. Continuity of Responsibility

Recovery ideology vs. Deinstitutionalization ideology

Psychopathology is secondary vs. Substance use is secondaryto addiction to psychopathology

PRINCIPLES

Within the context of the empathic, hopeful, continuous, integrated relationship,

case management/care and empathic detachment/confrontation

are appropriately balanced at each point in time.

PRINCIPLES

When both Mental Illness and Substance Disorder coexist, both diagnoses should be

considered primary.

PRINCIPLES

Both Major Mental Illness and Substance Dependence are examples of primary,

chronic, biologic mental illnesses which fit into a disease and recovery model of

treatment.

PARALLELSAlcoholism/Addiction1. A biological illness

2. Hereditary (in part)

3. Chronicity

4. Incurability

5. Leads to lack of control of behavior and emotions

6. Positive and negative symptoms

7. Affects the whole family

8. Progression of the disease without treatment

9. Symptoms can be controlled with proper treatment

Major Mental Illness1. A biological illness

2. Hereditary (in part)

3. Chronicity

4. Incurability

5. Leads to lack of control of behavior and emotions

6. Positive and negative symptoms

7. Affects the whole family

8. Progression of the disease without treatment

9. Symptoms can be controlled with proper treatment

(Continued)

PARALLELS(Continued)

Alcoholism/Addiction10. Disease of denial, relates to

both disease & chronicity of disease

11. Facing the disease can lead to depression and despair

12. Disease is often seen as a “moral issue”, due to personal weakness rather than biological causes

13. Feelings of guilt & failure

14. Feelings of shame & stigma

15. Physical, mental and spiritual disease

Major Mental Illness10. Disease of denial, relates to

both disease & chronicity of disease

11. Facing the disease can lead to depression and despair

12. Disease is often seen as a “moral issue”, due to personal weakness rather than biological causes

13. Feelings of guilt & failure

14. Feelings of shame & stigma

15. Physical, mental and spiritual disease

PARALLELSPROCESS OF RECOVERY

• PHASE 1: Stabilization- Stabilization of active substance use or acute

psychiatric symptoms

• PHASE 2: Engagement/Motivational

Enhancement- Engagement in treatment - Contemplation, Preparation, Persuasion

• PHASE 3: Prolonged Stabilization- Active treatment, Maintenance, Relapse Prevention

• PHASE 4: Recovery & Rehabilitation- Continued sobriety and stability- One year - ongoing

PROCESS OF RECOVERYPHASE 1: Stabilization

Detoxification• Often inpatient, may be

involuntary• Usually need medication• 3-5 days (alcohol) to 2-3 weeks

(opiates, benzos)• Includes assessment for other

diagnoses• Stabilization can occur at any

level of care (ASAM)

Stabilize AcutePsychiatric Illness

• Often inpatient, may be involuntary• Usually need medication• 2 days to 6 months• Includes assessment for effects of

substances, and for addiction• Stabilization may occur at any level

of care (LOCUS)

Level of Care Assessment

ASAM ASSESSMENT DIMENSIONS

1. Intoxication, withdrawal

2. Biomedical complic.3. Emotional/behavior4. Accept/resistance5. Relapse potential6. Recovery env’t

LOCUS ASSESSMENT

DIMENSIONS

1. Risk of harm

2. Functional status

3. Comorbidity

4. Recovery env’t

5. Treatment History

6. Adherence/motiv.

PROCESS OF RECOVERYPHASE 2: Engagement/Motivational

EnhancementAddiction Treatment

• Engagement in ongoing treatment is crucial for recovery to proceed

• Begins with empathy and proceeds through phases of education and empathic confrontation, before patient commits to ongoing active treatment

• Motivational interviewing techniques• Education about substance use,

abuse, and dependence & empathic confrontation of adverse consequences are tools to overcome denial. Patient accepts powerlessness to control drug without help

Psychiatric Treatment• Engagement in ongoing treatment is

crucial for recovery to proceed• Begins with empathy and proceeds

through phases of education and empathic confrontation, before patient commits to ongoing active treatment

• Motivational interviewing techniques• Education about mental illness and

the adverse consequences of treatment non-compliance are tools to overcome denial. Patient accepts powerlessness to control symptoms without help

(Continued)

PROCESS OF RECOVERYPHASE 2: Engagement/Motivational

Enhancement (Continued)

Addiction Treatment• Education of the family, & involving

them in interviews to promote motivation

• Engagement may take place in a variety of treatment settings…may need extended inpatient or day treatment rehabilitation (2-12 weeks)

• Engagement may be initially coerced

• Multiple cycles of relapse usually occur before engagement in ongoing treatment is successful (revolving door)

Psychiatric Treatment• Education of the family, & involving

them in setting limits on non-compliance

• Engagement may take place in a variety of treatment settings…may need extended inpatient or day treatment rehabilitation (1-6 months)

• Engagement may be initially coerced

• Multiple cycles of relapse usually occur before engagement in ongoing treatment is successful (revolving door)

STAGES OF CHANGEProchaska & DiClemente (1992)

• PRECONTEMPLATION

• CONTEMPLATION

• PREPARATION

• ACTION

• MAINTENANCE

STAGES OF TREATMENTOsher & Kofoed (1989)

McHugo et al (1995)1. Pre-engagement

ENGAGEMENT 2. Engagement

3. Early Persuasion

PERSUASION 4. Late Persuasion

5. Early Active Rx

ACTIVE TREATMENT 6. Late Active Rx

7. Relapse Prevention

RELAPSE PREVENTION 8. Remission

PROCESS OF RECOVERYPHASE 3: Prolonged Stabilization

Continued Abstinence• One-Year• Patient consistently attends

abstinence support programs • Usually voluntary, but ongoing

compliance may be coerced or mandated

• Ongoing education about addiction, recovery and skills to maintain abstinence

• Focus on asking for help to cope with urges to use substances and drop out of treatment

• Must learn to accept the illness and deal with shame, stigma, guilt, and despair

Continued Medication Compliance

• One-Year• Patient consistently takes medication

and attends treatment sessions regularly• Usually voluntary, but may be coerced

or mandated• Ongoing education about mental illness,

recovery and skills to prevent relapse• Focus on asking for help to cope with

continuing symptoms and urges to discontinue treatment

• Must learn to accept the illness and deal with shame , stigma, guilt, and despair

(Continued)

PROCESS OF RECOVERYPHASE 3: Prolonged Stabilization

(Continued)

Continued Abstinence• Must learn to cope with “negative

symptoms”: social, affective, cognitive, and personality development

• Family needs ongoing involvement in its own program of recovery to learn empathic detachment and how to set caring limits

• May need intensive outpatient treatment and/or 6-12 months residential placement

• Continuing assessment• Risk of relapse continues

Continued Medication Compliance

• Must learn to cope with “negative symptoms”: impaired cognition, affect, social skills, and lack of motivation/energy

• Family needs ongoing involvement in its own program of recovery to learn empathic detachment and how to set caring limits

• May need extended hospital, day treatment and/or residential placement

• Continuing assessment• Risk of relapse continues

PROCESS OF RECOVERYPHASE 4: Recovery & Rehabilitation

Continued Sobriety• Voluntary, active involvement in

treatment• Stability precedes growth; no

growth is possible unless sobriety is fairly secure. Growth occurs slowly (One Day at a Time)

• Continued work in the AA program, on growing, changing, dealing with feelings

• Thinking begins to clear• New skills for dealing with feelings,

situations

Continued Stability• Voluntary, active involvement in

treatment• Stability precedes growth; no growth

is possible unless stabilization of illness is fairly solid. Growth occurs slowly (One Day at a Time)

• Continued medication, but reduction to lowest level needed for maintenance. Continued work in treatment program

• Thinking begins to clear• New skills dealing with feelings,

situations

(Continued)

PROCESS OF RECOVERYPHASE 4: Recovery & Rehabilitation

(Continued)

Continued Sobriety• Increasing responsibility for illness,

and recovery program brings increasing control of one’s life

• Increasing capacity to work and to have relationships

• Recovery is never “complete”, always ongoing

• Eventual goal is peace of mind and serenity (Serenity Prayer)

Continued Stability• Increasing responsibility for illness,

and recovery programs brings increasing control of one’s life

• Increasing capacity to work and relate (voc rehab, clubhouse)

• Recovery is never “complete”, always ongoing

• Eventual goal is peace of mind and serenity (Serenity Prayer)

SERENITY PRAYER

“Grant me the serenity to accept the things I can not change,

the courage to change the things I can, and the wisdom to know the difference.”

Individuals with Co-occurring Disorders

PRINCIPLES OF SUCCESSFUL TREATMENT:

Dual diagnosis is an expectation, not an exception. This expectation must be incorporated in a welcoming manner

into all clinical contact.

• The Four Quadrant Model is a viable mechanism for categorizing individuals with co-occurring disorders for purpose

of service planning and system responsibility.

Treatment success derives from the implementation of an empathic, hopeful, continuous treatment relationship, which

provides integrated treatment and coordination of care through the course of multiple

treatment episodes.

Within the context of the empathic, hopeful, continuous, integrated relationship,

case management/care (based on level of impairment) and

empathic detachment/confrontation (based on strengths and contingencies)

are appropriately balanced at each point in time.

When substance disorder and psychiatric disorder co-exist, each disorder should be considered primary, and integrated dual

primary treatment is recommended, where each disorder receives appropriately

intensive diagnosis-specific treatment.

Both substance dependence and serious mental illness are examples of primary, chronic, biologic mental illnesses, which can be understood using a disease and recovery model, with parallel phases of

recovery.

There is no one type of dual diagnosis program or intervention.

For each person, the correct treatment intervention must be individualized

according to subtype of dual disorder, and diagnosis, phase of recovery, stage of

treatment, level of functioning, skills, and/or disability, plus goals, problems, and contingencies, associated with each

disorder.

In a managed care system, individualized treatment matching also requires

multidimensional level of care assessment involving acuity, dangerousness,

motivation, capacity for treatment adherence, and availability of continuing

empathic treatment relationships and other recovery supports.

Individuals with Co-occurring DisordersPrinciples of Successful Treatment

• Co morbidity is an expectation, NOT an exception. Four Quadrant Model.

• Treatment success derives from the implementation of an empathic, hopeful, continuous treatment relationship, which provides integrated treatment and coordination of care through the course of multiple treatment episodes.

• Within the context of the empathic, hopeful, continuous, integrated relationship, case management/care and empathic detachment/ confrontation are appropriately balanced at each point in time.

• When substance disorder and psychiatric disorder co-exist, each disorder should be considered primary, and integrated dual primary treatment is recommended, where each disorder receives appropriately intensive diagnosis-specific treatment.

• Both major mental illness and substance dependence are examples of primary mental illnesses which can be understood using a disease and recovery model, with parallel phases of recovery, each requiring phase-specific treatment.

• There is no one type of dual diagnosis program or intervention. For each person, the correct treatment intervention must be individualized according to diagnosis, phase of recovery/treatment, level of functioning and/or disability associated with each disorder, and level of acuity, dangerousness, motivation, capacity for treatment adherence, and availability of continuing empathic treatment relationships and other recovery supports.

ASSESSMENT OF INDIVIDUALS WITH CO-OCCURRING DISORDERS

• Detachment

• Detection

• Diagnosis and Disability

• Determination of treatment needs

• Detailed Description of Situation, Supports, Skills, and Cultural Context

Detachment

• Empathic detachment facilitates gathering accurate information

• Proactively communicate detachment and acceptance of consumer choice

• Use detachment mantra

Detection

• High index of welcoming and expectation• Gather data from multiple sources, expecting

information discrepancies.• Initial screening: do (did) you have a problem?• Screening tools: CAGE, MAST, DALI , RAFFT

(SA); MIDAS (www.ohiosamiccoe.cwru.edu/clinical)

• BSI, MINI, Project Return MH Screening Form (www.asapnys.org/resources) (MH)

• Use urine/saliva/hair screens selectively

Diagnosis

• Integrated, longitudinal, strength-based history• Utilize mental status and medication response

data from past periods of abstinence or limited use

• Low threshold for MH consult in SA setting• Identify patterns of dependence (vs. abuse) by

assessing for awareness of lack of control in the face of serious harm; tolerance and withdrawal are not required.

Description

• Ask more questions to obtain more details about the problems you know least about

• Identify external problem areas and supports (ASI), and explore opportunities for contingencies

• Obtain detailed information about mh symptoms : duration, content, control, perception of cause, factors which exacerbate/lessen, mh disease mgt skills

• Obtained detailed information about substance use: factors which promote/inhibit use, situations of use, cost of use, substance using peers, efforts to control use, substance use mgt skills

• Obtain detailed cultural context information: (peer, traditional, mh system, addiction recovery cultures)

Determination of Treatment Needs

• Assessment of individualized treatment goals using motivational interviewing

• Determination of stage of change/ stage of treatment:– Substance Abuse Treatment Scale (McHugo et al)

– SOCRATES (Miller et al);

– URICA (DiClemente et al)

– Readiness to Change Questionnaire (Rollnick et al)

Treatment Matching ExampleQuadrant IVA

• Continuity

• Acute Stabilization

• Motivational Enhancement

• Active Treatment

• Relapse Prevention/Rehabilitation

PSYCHOPHARMACOLOGY PRACTICE GUIDELINES

• I. GENERAL PRINCIPLES• Not an absolute science• Ongoing, empathic, integrated

relationship• Continuous re-evaluation of dx and rx• Balance case management and care with

contingency management and contracts• Strategies to promote dual recovery

PSYCHOPHARMACOLOGY PRACTICE GUIDELINES

• II. ACCESS AND ASSESSMENT• Promotion of access and continuity of

relationship is the first priority• No arbitrary barriers to psychopharm

assessment in any setting based on length of sobriety or drug/alcohol levels

• No arbitrary barriers to substance assessment based on psychopharm regimen

PSYCHOPHARMACOLOGY PRACTICE GUIDELINES

• III. DUAL PRIMARY TREATMENT• Diagnosis-specific treatment for each disorder

simultaneously• Distinguish abuse and dependence• Specific psychopharm strategies for addictive

disorders are appropriate for individuals with comorbidity

• For a known or presumed psychiatric disorder, continue use of best non-addictive medication for that disorder, regardless of status of SUD.

PSYCHOPHARMACOLOGY PRACTICE GUIDELINES

• III. DUAL PRIMARY TREATMENT

• ADDICTION PSYCHOPHARM

• Disulfiram

• Naltrexone

• Opiate Maintenance Treatment

• Others?

PSYCHOPHARMACOLOGY PRACTICE GUIDELINES

• III. DUAL PRIMARY TREATMENT• PSYCHOPHARM FOR MI

• Atypicals and clozapine for psychosis• LiCO3 vs newer generation mood stabilizers

• Any non-tricyclic antidepressant• Anxiolytics: clonidine, SSRIs, venlafaxine, nefazodone, topiramate, other mood stabilizers,

atypicals, (buspirone not first line)• ADHD: Bupropion, then clonidine, SSRIs,

tricyclics, then stimulants

PSYCHOPHARMACOLOGY PRACTICE GUIDELINES

• IV. DECISION PRIORITIES

• SAFETY

• STABILIZE ESTABLISHED OR SERIOUS MI

• SOBRIETY

• IDENTIFY AND STABILIZE MORE SUBTLE DISORDERS

SAFETY

• Acute medical detoxification should follow same established protocols as for individuals with addiction only.

• Maintain reasonable non-addictive psychotropics during detoxification

• For acute behavioral stabilization, use whatever medications are necessary (including benzodiazepines) to prevent harm.

STABILIZATION OF SMI

• NECESSARY NON ADDICTIVE MEDICATION FOR ESTABLISHED AND/OR SERIOUS MENTAL ILLNESS MUST BE INITIATED AND MAINTAINED REGARDLESS OF CONTINUING SUBSTANCE USE

• More risky behavior requires closer monitoring, not treatment extrusion

• Be alert for subtle symptoms that are substance exacerbated, but still require medication at baseline.

STRATEGIES FOR SOBRIETY

• Medication for addiction is presented as ancillary to a full recovery program that requires work independent of medication. Individuals on proper medication must work as hard as those with addiction only.

• Distinguish normal feelings from disorders with similar names (anxiety, depression)

• Psychiatric medications are directed to known or probable disorders, not to medicate feelings

• Proper medication for mental illness does not take away normal feelings, but permits patients to feel their feelings more accurately.

• Use fixed dosage regimes, not prn meds.

More Strategies for Sobriety

• Avoid use of benzodiazepines or other generic potentially addictive sedative/hypnotics in patients with known substance dependence

• Continued BZD prescription should be an indication for consultation, peer review

• Use contingency contracting to engage individuals who are already on BZDs.

• If indicated, withdrawal from prescribed BZDs using carbamazepine (or VPA, gabapentin), plus phenobarbital taper (1mg clonazepam = 30 mg pb)

• Be alert for prolonged BZD withdrawal syndrome

More Strategies for Sobriety

• Pain Management should occur in collaboration with a prescribing physician who is fully informed about the status of substance use disorder

• Individuals addicted to opiates for non-specific neck, back, etc. conditions can be informed that continued use of opiates worsens perceived pain. Full withdrawal plus alternative pain management strategies can actually improve pain in the long run.

CHANGING THE WORLD

Developing

Comprehensive, Continuous, Integrated Systems of Care (CCISC)

For

Individuals with Co-occurring

Psychiatric and Substance

Disorders

CCISC CHARACTERISTICS

• 1. SYSTEM LEVEL CHANGE

• 2. USE OF EXISTING RESOURCES

• 3. BEST PRACTICES UTILIZATION

• 4. INTEGRATED TREATMENT PHILOSOPHY

CHANGING THE WORLD

• A. SYSTEMS

• B. PROGRAM

• C. CLINICAL PRACTICE

• D. CLINICIAN

12 STEPS OF IMPLEMENTATION

• 1. INTEGRATED SYSTEM PLANNING• 2. CONSENSUS ON CCISC MODEL• 3. CONSENSUS ON FUNDING PLAN• 4. IDENTIFICATION OF PRIORITY

POPULATIONS WITH 4 BOX MODEL• 5. DDC/DDE PROGRAM STANDARDS• 6. INTERSYSTEM CARE

COORDINATION

12 STEPS OF IMPLEMENTATION

• 7. PRACTICE GUIDELINES

• 8. IDENTIFICATION, WELCOMING, ACCESSIBILITY: NO WRONG DOOR

• 9. SCOPE OF PRACTICE FOR INTEGRATED TREATMENT

• 10. DDC CLINICIAN COMPETENCIES

• 11. SYSTEM WIDE TRAINING PLAN

12 STEPS OF IMPLEMENTATION

• 12. PLAN FOR COMPREHENSIVE PROGRAM ARRAY– A. EVIDENCE-BASED BEST PRACTICE– B. PEER DUAL RECOVERY SUPPORT– C. RESIDENTIAL ARRAY: WET, DAMP,

DRY, MODIFIED TC– D. CONTINUUM OF LEVELS OF CARE

IN MANAGED CARE SYSTEM: ASAM-2R, LOCUS 2.0

A. SYSTEMS CHANGE

• 1. Empower structure to manage change• 2. Consensus building on principles• 3. Regulatory Change

– A. Licensure/certification– B. Reimbursement/funding– C. Program standards/Practice Guidelines– D. Clinician competency/certification4. Quality Management/Outcome Evaluation

B. PROGRAM CHANGE

• 1. STRUCURED PLAN FOR PROGRAMMATIC INTERFACE

• 2. COMPREHENSIVE PROGRAM ARRAY– A. Horizontal integration/ MH and SA– B. Vertical integration/ managed care

B1. PROGRAM INTERFACE

• A. Formal interagency care coordination• B. Mechanisms for administrative and clinical

dispute resolution• C. Longitudinal continuity: interface with

episodes of care• D. Vertical continuity/integration: front door

meets back door• E. MH support to CD system: Emergency/meds• F. CD continuity of connection: MH&CD

B2. COMPREHENSIVE PROGRAM ARRAY

• PROGRAM CATEGORIES• Addiction System (ASAM PPC2R)

• DDC-CD• DDE-CD

• AOS• Mental Health System (Minkoff)

• DDC-MH• DDE-MH

• Peer Involvement/Cultural Competency

Dual Diagnosis Capable: DDC-CD

• Routinely accepts dual patients, provided:• Low MH symptom acuity and/or disability,

that do not seriously interfere with CD Rx• Policies and procedures present re: dual

assessment, rx and d/c planning, meds • Groups address comorbidity openly• Staff cross-trained in basic competencies• Routine access to MH/MD consultation/coord.• Standard addiction program staffing level/cost

Dual Diagnosis Enhanced:DDE-CD

• Meets criteria for DDC-CD, plus:• Accepts moderate MH symptomatology or

disability, that would affect usual rx.• Higher staff/patient ratio; higher cost• Braided/blended funding needed• More flexible expectations re:group work• Programming addresses mh as well as dual• Staff more cross-trained/ senior mh supervision• More consistent on site psychiatry/ psych RN• More continuity if patient slips

Addiction Only Services:AOS

• Not standard for addiction services

• Does not meet DDC criteria

• Dual diagnosis accepted irregularly

• Dual diagnosis not routinely addressed in treatment, nor documented

• Appropriate for a narrowing group of clients

Dual Diagnosis Capable:DDC-MH

• Welcomes people with active substance use• Policies and procedures address dual assessment, rx &

d/c planning• Assessment includes integrated mh/sa hx, substance

diagnosis, phase-specific needs• Rx plan: 2 primary problems/goals• D/c plan identifies substance specific skills• Staff competencies: assessment, motiv.enh., rx

planning, continuity of engagement• Continuous integrated case mgt/ phase-specific groups

provided: standard staffing levels

Dual Diagnosis EnhancedDDE-MH

• Meets all criteria for DDC-MH, plus:• Supervisors and staff: advanced competencies• Standard staffing; specialized programming:

a. Intensive addiction programming in psychiatrically managed setting (dual inpt unit; dry dual dx housing, supported sober house)

b. Range of phase-specific rx options in ongoing care setting: dual dx day treatment; damp dual dx housing

c. Intensive case mgt outreach/motiv. enh.: CTT, wet housing, payeeship management

DUAL DIAGNOSIS CAPABLE

ROUTINELY ACCEPTS DUAL DIAGNOSIS PATIENT

WELCOMING ATTITUDES TO COMORBIDITY

CD PROGRAM: MH CONDITION STABLE AND PATIENT CAN PARTICIPATE IN TREATMENT

MH PROGRAM: COORDINATES PHASE-SPECIFIC INTERVENTIONS FOR ANY SUBSTANCE DX.

POLICIES AND PROCEDURES ROUTINELY LOOK AT COMORBIDITY IN ASSESSMENT, RX PLAN, DX PLAN, PROGRAMMING

CARE COORDINATION RE MEDS (CD)

DUAL DIAGNOSIS ENHANCED (DDE)

MEETS DDC CRITERIA PLUS:

CD: MODIFICATION TO ACCOMMODATE MH ACUITY OR DISABILITY

MH SPECIFIC PROGRAMMING, STAFF, AND COMPETENCIES, INCLUDING MD

FLEXIBLE EXPECTATIONS; CONTINUITY

MH; ADDICTION TREATMENT IN PSYCH MANAGED SETTINGS (DUAL DX INPT UNIT) OR

INTENSIVE CASE MGT/OUTREACH TO MOST SERIOUSLY MI AND ADDICTED PEOPLE

B. PROGRAM COMPETENCIES

• 1. CLINICAL CASE MANAGEMENT• 2. EMERGENCY SERVICES• 3. CRISIS STABILIZATION• 4. DETOXIFICATION• 5. PSYCH INPATIENT• 6. PSYCHIATRIC PARTIAL HOSP/ DAY RX• 7. ADDICTION DAY RX/ INTENSIVE OP• 8. ADDICTION RESIDENTIAL RX• 9. PSYCHIATRIC RESIDENCE PROGRAMS

1. Case Management (DDC/DDE)

• Integrated, continuous care coordination• High, medium, and low intensity

• Incorporated into existing front-line case management for SPMI

• Developed for high utilizers who are non-SPMI as well as SPMI

• Mechanism for supportive administrative case coordination

2. Emergency Services (DDC)

• Mission defined as welcoming into appropriate treatment for MH and CD

• Barrier-free access-assessment begins when client able to participate

• Diagnostic and level of care assessment for both MH and substance disorder

• Capacity to engage in ongoing crisis intervention and motivational strategies

3. Crisis Stabilization (DDC)

• Routine acceptance of substance-using patients who do not need medical detoxification

• Stabilizes substance exacerbated psychiatric symptoms, with meds if necessary

• Utilizes motivational and active treatment strategies to address substance use

• Participates with primary case coordination team in implementation of treatment contracts

• May provide access to intensive outpatient addiction treatment (DDC or DDE)

4A. Detoxification (DDC)

• Provides detoxification for psychiatrically stable individuals with mental illness who are not severely disabled

• Meets ASAM PPC2R defined criteria for DDC programs

4B. Psychiatrically-Enhanced Detoxification (DDE)

• Provides ASAM Level III detoxification for psychiatrically impaired or unstable (e.g., suicidal) individuals who are voluntary and can contract for safety

• Medical monitoring provided by psychiatrist or psychiatric nurse

• Psychopharmacologic adjustment provided• Space, staffing, and staff training permit closer

monitoring• Meets ASAM PPC2R DDE criteria

5A.Inpatient Psych Unit (DDC)

• Program standards address dual diagnosis competency• Required basic staff and MD competencies, included in

job description• Welcoming staff attitudes• Competence in detox protocols• Demonstrated assessment competency• Documentation of substance disorder interventions in

treatment planning/notes• Daily substance related group programming• Competent substance disorder d/c planning

5B.Inpatient Dual Unit (DDE)

• Meets all DDC criteria, plus• Staff routinely have expertise in both psych and

addiction• Full addiction program, incorporating dual dx

groups• Routine access to 12-step programs• Provides addiction rx for patients with severe

psychiatric acuity and instability• Specialized expertise in dual diagnosis

assessment and psychopharmacology

6. Psychiatric Day Treatment and Partial Hosp. (DDC-MH)

• Acute Partial: Same as DDC inpatient, except for detox, plus specific policies to address substance use while in treatment

• Intermediate/long-term Day Treatment: routine assessment and rx planning; phase-specific groups, including motivational interventions for non-abstinent patients. No reject for substance use. Specific policies to address substance use in rx.

6B: Dual Diagnosis Partial Hosp and Day Rx (DDE)

• Acute Partial: Similar to DDE inpatient; abstinence-oriented, with strict limits on use in program

• Intermediate/Long-Term Day Rx: Program may be abstinence-oriented, or may provide intensive motivational/harm reduction groups for long-term clients who are still using, OR BOTH (2 tracks). Extensive addiction/dual programming. Specific policies on substance use which promote continuity even if pt. discharged.; Dual dx specialist supervisors.

7A. Addiction Residential Treatment (DDC)

• Sober environment for episode of addiction treatment. DDC program meets all standard criteria for DDC-CD.

• Relapses not tolerated, but in long-term programs, first-offense may not result in discharge

• Discharge is an opportunity for learning; individual welcome to return

• Discharge coordinated with mh provider and criteria for readmission established

• Collaborative relationship with mh system re: acute crisis intervention

7B. Psychiatrically Enhanced Addiction Residential Rx(DDE)• DDE Program meets all DDC-CD residential

criteria, plus all DDE-CD criteria.• Residential addiction rx for individuals (SMI and

non-SMI) with moderate psychiatric acuity and/or disability

• Dual Diagnosis Acute Residential Treatment (DDART) is a short-term (10-14 day) DDE program in Mass.

• Modified Therapeutic Community (Sacks, DeLeon) is an example of a long-term DDE program

8. Psychiatric Residential Programs

• Primarily HOUSING programs for people with psychiatric disabilities

• All programs designed to be DDC• Programs must accommodate a range of ability and

willingness to address substance use: WET, DAMP, DRY

• DRY (DDE) Housing for individuals with dual disorder who want sober support. Multiple (but finite) slips permitted, with intervention plan

• DAMP (DDC) Abstinence recommended, not required. Substance use addressed if safety issues emerge.

Psych Residential (cont’d)

• WET: Consumer choice housing; no requirement to limit use to have housing support. Pathways to Housing (NYC) Usually supported housing model

• Case Managed Supported Sober Housing: Combines Oxford House concept with MH supported housing concept. Inexpensive method to create sober housing

C. CLINICAL PRACTICE STANDARDS I

• 1. WELCOMING PHILOSOPHY• 2. ACCESS TO BARRIER-FREE

ASSESSMENT: “NO WRONG DOOR”• 3. SCREENING & ASSESSMENT:

INCENTIVES FOR IDENTIFICATION• 4. LEVEL OF CARE ASSESSMENT: ASAM

PPC2R, LOCUS,CHOICE-DUAL• 5. SCOPE OF PRACTICE/SERVICE CODE

C. CLINICAL PRACTICE STANDARDS II

• 6. CONTINUITY OF CARE: MH & CD• 7. PHASE-SPECIFIC RX MATCHING• 8. PSYCHOPHARM GUIDELINES:

CONTINUITY, QUALITY, BENZOS• 9. CONSISTENT RX MANUALS• 10. OUTCOME MEASURES:

UTILIZATION, HARM, STAGE OF CHANGE, ABSTINENCE/USE

SCOPE OF PRACTICE FOR INTEGRATED TREATMENT

• 1. WELCOMING, EMPATHY, DUAL RECOVERY• 2. SCREENING FOR COMORBIDITY• 3. ASSESS ACUTE MH/DETOX RISK • 4. OBTAIN ASSESSMENT OF COMORBIDITY• 5. AWARENESS OF DIAGNOSIS AND RX PLAN• 6. SUPPORT TREATMENT ADHERENCE/ MED

COMPLIANCE• 7. IDENTIFY STAGE OF CHANGE FOR EACH DX• 8. 1-1 & GROUP INTERVENTIONS FOR

EDUCATION & MOTIVATION ENHANCEMENT

SCOPE OF PRACTICE (continued)

• 9. SPECIFIC SKILLS TRAINING TO REDUCE USE• 10. MANAGE FEELINGS AND SYMPTOMS

WITHOUT USING• 11. HELP CLIENT ADVOCATE WITH OTHER

PROVIDERS REGARDING MH NEEDS• 12. HELP CLIENT ADVOCATE RE: CD NEEDS

13. COLLABORATE WITH OTHER PROVIDERS.14. EDUCATE CLIENT RE: MEDS AND 12 STEP

15. MODIFY SKILLS TRAINING RE: DISABILITY16. PROMOTE DUAL RECOVERY MEETING USE

D. CLINICIAN STANDARDS

• 1. COMPETENCY/CERTIFICATION• A. Required basic competencies:

Attitudes, values, knowledge, and skill

Competency Assessment Tools• B. Place/train: job descriptions• C. Certifications for career ladders• D. Advanced competencies for trainers and

supervisors.

D. CLINICIAN STANDARDS

• 2. TRAINING

• A. System wide training plan

• B. Training program guidelines

• C. Train trainers for each site

• D. Curriculum guideline dissemination

• E. On-site case based continuing training

• F. Experiential learning/ staff exchange

CHANGING THE WORLD:

• DEVELOPING AN INTEGRATED

SYSTEM OF CARE

IN A

STATE MENTAL HOSPITAL

SYSTEMS LEVEL CHANGE

1. Develop a structure to manage changeA. Integrated Team of discipline/dept. heads.B. Continuous Quality Improvement

1. Defines bidirectional, multilevel process

2. Identifies measurable outcomes3. Meets JCAHO requirements

SYSTEMS LEVEL CHANGE

2. Build Consensus on Principles

A. Use TDMHMR Principles to start

B. Include “firestarters”

C. Begin with management team

D. All staff involved, emphasize attitudes

E. Measure consensus (outcome)

SYSTEMS LEVEL CHANGE

3. Establish Standards

A. Program Competency Standards

B. Practice Guidelines: Assessment, continuity, discharge planning, rx plan psychopharm (algorithm project)

C. Program Plan for service matching

D. Clinician Competencies

SYSTEMS LEVEL CHANGE

4. Identify OutcomesA. Structure

1. Consensus, standards established2. Program elements in place

B. Process1. Screening tools used2. Consumers identified and treated

C. Outcome: Satisfaction, stage of change, skill, relapse prevention, community linkage

PROGRAM LEVEL CHANGES

1. Develop program array based on needs assessment

2. Implement general program standards hospital wide

3. Develop content and protocols for specialized interventions

4. Implement hospital wide mechanisms to monitor program interface

5. Implement strategies for managing community interface & promoting continuity

Program Array

1. Needs assessment based on categories:a. Severe mh impairment vs. non-severeb. Substance Abuse vs. Dependencec. Stage of change/Phase of Recoveryd. Long stay vs. short stay

2. Program matching categoriesa. Detoxb. Motivational Enhancement (mh hi vs. lo)c. Active Rx/Relapse Prevention: SubstancAbused. Specialized Addiction Rx (mh hi vs. lo)

Program Standards/DDC

1. Uniform screening and assessment2. Assessment includes abuse/dep, stage of

change, recovery skills and supports3. Document diagnosis, formulation using

treatment matching algorithm4. Problem-specific rx plan and d/c plan5. Stage-specific groups with range of

educational materials

Specialized Program Model/DDE

1. Addiction group program with mh modifications (high vs low disability)

2. Policies defining behavioral expectations and consequences

3. Dual competent clinical leadership4. In vivo skills training and role playing5. Contingent learning interventions6. Plans to promote community continuity

Intrahospital Program Interface

1. Clinical Review Committee

a. Chaired by Medical Director/Clin Dir

b. Conferences complex cases

c. Reviews policies & contingency plans

d. Addresses interprogram disputes

2. Program Admission/D/C Criteria

a. Seamless b. Incentives/sanctions

Hospital-Community Interface

1. Interagency care coordination

a. Admission/readmission criteria

b. Contingency based transitions

c. Skills training for community setting

d. Case conferences

2. Consistent hospital/community manuals

3. Recovery program (AA, DRA) linkage

CLINICAL STANDARDS

1. Welcoming attitudes2. Accessible admission/readmission 3. Standard screening and assessment tools4. Multi dimensional assessment including CIWA,

diagnosis, description, stage of change, recovery skills and supports

5. Detox and urine screening protocols6. Behavioral criteria for pass or discharge7. Psychopharmacology guidelines (TMAP)/ Peer

review

Behavioral Criteria

1. Pass Skills (for pts w/ identified issue)

a. I have a problem

b. I want to change

c. I am at risk on pass

d. I agree to a risk plan

e. I will demonstrate skills to not use

f. I will agree to monitoring and incentives.

Behavioral Criteria

2. Specialized program criteriaa. Positive incentives for entry and successb. Point or token systemc. Consequences for non-compliance and/or use, including ultimate time limited transfer to more restricted setting.

CLINICIAN COMPETENCY

1. Consensus basic competency related to job descriptionsa. Amend HR policy, and evaluation toolb. Self-learning workbook and exam

2. Training and supervision plana. Assign supervisory resource to each unit.b. Combine didactics with on the job learning.c. Community internships and staff exchange