Behavioral Health

Caring for patients with co-occurring mental health & substance use disorders

J Fam Pract. 2019 September;68(7):400-404

References

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2. SAMHSA. Key substance use and mental health indicators in the United States: results from the 2017 National Survey on Drug Use and Health. 2017. https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHFFR2017/NSDUHFFR2017.htm#cooccur2. Accessed August 16, 2019.

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11. Magidson JF, Liu SM, Lejuez CW, et al. Comparison of the course of substance use disorders among individuals with and without generalized anxiety disorder in a nationally representative sample. J Psychiatr Res. 2012;46:659666.

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14. Buckley PF. Prevalence and consequences of the dual diagnosis of substance abuse and severe mental illness. J Clin Psychiatry. 2006;67(suppl 7):5-9.

15. Salo R, Flower K, Kielstein A, et al. Psychiatric comorbidity in methamphetamine dependence. Psychiatry Res. 2011;186:356-361.

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19. McHugh RK. Treatment of co-occurring anxiety disorders and substance use disorders. Harv Rev Psychiatry. 2015;23:99-111.

20. National Alliance on Mental Illness. Dual diagnosis. NAMI Web site. www.nami.org/Learn-More/Mental-Health-Conditions/related-conditions/dual-diagnosis. Reviewed August 2017. Accessed July 23, 2019.

21. SAMSHA. Substance Abuse Treatment for Persons with Co-Occurring Disorders. Treatment Improvement Protocol (TIP) series No. 42. HHS Publication No. (SMA) 13-3992. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2013.

22. SAMHSA. Treatment of co-occurring disorders. In: Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2005.

23. Drake RE, Mueser KT, Brunette MF, et al. A review of treatments for people with severe mental illnesses and co-occurring substance use disorders. Psychiatr Rehabil J. 2004;27:360-374.

24. Kola LA, Kruszynski R. Adapting the integrated dual-disorder treatment model for addiction services. Alcohol Treat Q. 2010;28:437-450.

25. American Psychiatric Association. Practice guideline for the treatment of patients with schizophrenia, 2nd ed. https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/schizophrenia.pdf. Published 2010. Accessed August 2, 2019.

26. American Psychiatric Association. Practice guideline for the treatment of patients with bipolar disorder, 2nd ed. https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/bipolar.pdf. Published 2010. Accessed August 2, 2019.

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28. American Psychiatric Association. Practice guideline for the treatment of patients with panic disorder, 2nd ed. https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/panicdisorder.pdf. Published January 2009. Accessed August 2, 2019.

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MAKING THE DIAGNOSIS

To make an accurate diagnosis of co-occurring disorder, it is essential to take a complete history focusing on the timeline of symptoms, previous diagnoses and treatments, if any, and substance-free periods. Details gathered from these inquiries will help to separate symptoms of a primary mental health disorder from adverse effects of medication, withdrawal symptoms, or symptoms related to an underlying chronic medical condition.

Optimally, the diagnosis of a mental health disorder should be considered following a substance-free period. If this is not possible, a chart review may reveal a time when the patient did not have a substance use disorder.¹⁸

A diagnosis of substance use disorder requires that the patient manifest at least 2 of 11 behaviors listed in the DSM-5 over a 12-month period.¹ The criteria focus on the amount of substance used, the time spent securing the substance, risky behaviors associated with the substance, and tolerance to the substance.

DON'T DEFER MENTAL HEALTH Tx

It is necessary to treat co-occurring disorders simultaneously. The old idea of deferring treatment of a mental health issue until the substance use disorder is resolved no longer applies.^19,20 Treating substance use problems without addressing comorbid mental health issues can negatively impact treatment progress and increase risk for relapse. In a similar way, leaving substance use problems untreated is associated with nonadherence in mental health treatment, poor engagement, and dropout.^21,22

Integrated services. Due to this condition’s level of clinical complexity, the optimal treatment approach is an interdisciplinary one in which integrated services are offered at a single location by a team of medical, mental health, and substance use providers (see “The case for behavioral health integration into primary care” in the June issue). An evidence-based example of such an approach is the Integrated Dual Disorder Treatment (IDDT) model—a comprehensive, integrated method of treating severe mental health disorders, including substance use disorders.^21,22 IDDT combines coordinated services such as pharmacologic, psychological, educational, and social interventions to address the needs of patients and their family members. The IDDT model conceptualizes and treats co-occurring disorders within a biopsychosocial framework. Specific services may include medical detoxification, pharmacotherapy, patient and family education, behavioral and cognitive therapies, contingency management, self-help support groups, supported employment, residential/housing assistance, and case management services.^23,24

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