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Addiction Exchange
News from the worlds of research and clinical practice
Volume 3, No. 15: Substance Abuse Disorders and Serious Mental Illness
Sept 17, 2001
Brought to you by FAX, email, and on the web by the Mid-Atlantic
Addiction Technology Transfer Center
Funded by Center
for Substance Abuse Treatment, SAMHSA
Welcome to Addiction Exchange, a forum for the exchange of clinical
practice and research information among clinicians, scientists, educators,
and administrators in the field of addiction. This is part one of a two-part
research series regarding treatment of patients with substance abuse
disorders and serious mental illness (SMI). Part two will feature
a SAMHSA/CSAT-funded program in Virginia that is based on this research.
The program is also based on the recommended treatment approach of Dr.
Thomas Fox, Medical Director of the Division of Alcohol and Drug Prevention
for New Hampshire, and Lindy Fox, Research Associate at the New Hampshire-Dartmouth
Psychiatric Research Center.
Dr. and Mrs. Fox were the keynote speakers at the June 2001 statewide
conference for the Virginia Association of Alcohol and Drug Programs (VADAP).
They presented a review of the research regarding this patient population.
Some of their key points follow:
- Persons with severe mental illness are at increased risk for having
co-morbid substance use disorders (Cuffel, B.J., 1996; Mueser, K.T.
et. al., 1995).
- Assessment of SMI patients and their substances must be based on an
awareness of the reasons they typically engage in substance abuse: a
desire to fit into a peer group; a method of coping with stress; euphoria;
help with side effects of medications; lack of structured time; and
lack of appropriate role models in the family regarding substance use.
These patients also have a high sensitivity to low doses, so typical
substance abuse assessment instruments may not identify their use as
a problem. The Foxes stress that the key factor in assessing SMI patients
for substance abuse is to evaluate consequences and patterns, such as
frequent hospitalizations, violence, suicide attempts, and medication
non-compliance (Lindquist, P. and Allebeck, P., 1989).
- Traditional dual diagnosis treatment services have proven to be ineffective
(Ridgely et. al., 1990). These programs typically provide either
a sequential treatment approach (treat one disorder, then the other)
or a parallel treatment approach (a mental health system and a substance
abuse system each separately treating the patient).
- An integrated treatment approach is more effective for this patient
population
(Drake et. al., 1998).
An integrated treatment approach means that the same clinician or clinical
team provides treatment for both mental illness and substance abuse at
the same time. This approach includes assertive outreach, comprehensiveness,
shared decision-making with the patient and family, long-term commitment,
stage-based treatment, and pharmacotherapy. A major theoretical component
of this approach is the belief that dually diagnosed patients are capable
of participating in their own case management and are able to make progress
with treatment goals. Another component is the active engagement of family
members in the first phase (outreach) and their participation in treatment
decisions. With regard to pharmacotherapy, Dr. Fox cautions against discontinuing
medication for a patient with SMI based only upon the existence of substance
abuse. In the integrated approach, there is close monitoring of the medication
while the clinical team works with the patient to address the substance
abuse problems. Eliminating the pharmacotherapy component of the treatment
increases the probability that the patient will be re-hospitalized or
leave treatment.
A central feature of the delivery of the treatment is the adaptation
of Prochaska’s stages of change model (1984). Osher and Kofoed (1989)
describe this as stages of treatment that coincide with their observations
of the natural course of recovery for this patient population. They also
have developed a rating scale to assist clinicians in evaluating patients
with regard to these stages. The stages are (1) engagement, (2) persuasion,
(3) active treatment, and (4) relapse prevention. The first goal of treatment
(engagement stage) is the establishment of a working alliance between
the patient and clinician or team. The goal of the persuasion stage is
to develop the patient’s awareness of substance abuse as a problem
and create motivation to change. The active treatment stage focuses on
reducing the substance abuse, with a final goal of abstinence. The goal
of the relapse prevention stage is to extend recovery into other areas
of the patient’s life as well as to prevent relapse to substance
abuse.
In our next issue, we will discuss how this model transfers into practice
in a public-sector program.
Mueser, K.T., Drake, R.E., and Noordsy, D.L. (1998). Integrated Mental
Health and Substance Abuse Treatment for Severe Psychiatric Disorders.
Journal of Practical Psychiatry and Behavioral Health, 4(3), p. 129-139.
For further information about this project or to order publications of
these references, go to http://www.dartmouth.edu/~psychrc/. This is the
site for the New Hampshire-Dartmouth Psychiatric Research Center.
Mid-Atlantic Addiction Technology Transfer Center
Funded by Center for Substance Abuse Treatment of
Substance Abuse and Mental Health Services Administration
mid-attc@mindspring.com
http://www.mid-attc.org
804-828-9910
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