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

,; ,; ,; ,

Behavioral Health

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

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

PDF Download

References

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: APA; 2013.

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.

3. Conway KP, Compton W, Stinson FS, et al. Lifetime comorbidity of DSM-IV mood and anxiety disorders and specific drug use disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry. 2006;67:247-257.

4. Kessler RC, Berglund P, Demler O, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62:593-602.

5. Grant BF, Stinson FS, Dawson DA, et al. Prevalence and co-occurrence of substance use disorders and independent mood and anxiety disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry. 2004;61:807-816.

6. Dixon L. Dual diagnosis of substance abuse in schizophrenia: prevalence and impact on outcomes. Schizophr Res. 1999;35(suppl):S93-S100.

7. Merikangas KR, Jin R, He JP, et al. Prevalence and correlates of bipolar spectrum disorder in the World Mental Health Survey Initiative. Arch Gen Psychiatry. 2011;68:241-251.

8. Cottler LB, Compton WM 3rd, Mager D, et al. Posttraumatic stress disorder among substance users from the general population. Am J Psychiatry. 1992;149:664-670.

9. Kessler RC, Angermeyer M, Anthony JC, et al. Lifetime prevalence and age-of-onset distributions of mental disorders in the World Health Organization’s World Mental Health Survey Initiative. World Psychiatry. 2007;6:168-176.

10. Burns L, Teesson M, O’Neill K. The impact of comorbid anxiety and depression on alcohol treatment outcomes. Addiction. 2005;100:787-796.

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.

12. Boschloo L, Vogelzangs N, van den Brink W, et al. Alcohol use disorders and the course of depressive and anxiety disorders. Br J Psychiatry. 2012;200:476-484.

13. Schuckit MA. Comorbidity between substance use disorders and psychiatric conditions. Addiction. 2006;101(suppl 1):76-88.

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.

16. Torrens M, Gilchrist G, Domingo-Salvany A. Psychiatric comorbidity in illicit drug users: substance-induced versus independent disorders. Drug Alcohol Depend. 2011;113:147-156.

17. Buckner JD, Timpano KR, Zvolensky MJ, et al. Implications of comorbid alcohol dependence among individuals with social anxiety disorder. Depress Anxiety. 2008;25:1028-1037.

18. Kushner MG, Abrams K, Borchardt C. The relationship between anxiety disorders and alcohol use disorders: a review of major perspectives and findings. Clin Psychol Rev. 2000;20:149-171.

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.

27. American Psychiatric Association. Practice Guideline for the Treatment of Patients with Major Depressive Disorder. https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd.pdf. Published October 2010. Accessed July 23, 2019.

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.

29. American Psychiatric Association. Practice guideline for the pharmacological treatment of patients with alcohol use disorder. https://psychiatryonline.org/doi/pdf/10.1176/appi.books.9781615371969. Accessed August 2, 2019.

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

31. Petrakis IL, Nich C, Ralevski E. Psychotic spectrum disorders and alcohol abuse: a review of pharmacotherapeutic strategies and a report on the effectiveness of naltrexone and disulfiram. Schizophr Bull. 2006;32:644-654.

32. McIntyre RS, Yoon J. Efficacy of antimanic treatments in mixed states. Bipolar Disord. 2012;14(suppl 2):22-36.

33. Volpicelli JR, Alterman AI, Hayashida M, et al. Naltrexone in the treatment of alcohol dependence. Arch Gen Psychiatry. 1992;49:876-880.

34. Lee JD, Nunes EV Jr, Novo P, et al. Comparative effectiveness of extended-release naltrexone versus buprenorphine-naloxone for opioid relapse prevention (X:BOT): a multicentre, open-label, randomized controlled trial. Lancet. 2018;391:309-318.

35. US Department of Justice. DEA requirements for DATA waived physicians (DWPs). Drug Enforcement Administration, Diversion Control Division Web site. www.deadiversion.usdoj.gov/pubs/docs/dwp_buprenorphine.htm. Accessed August 2, 2019.

36. SAMHSA. Buprenorphine waiver management. https://www.samhsa.gov/medication-assisted-treatment/buprenorphine-waiver-management. SAMHSA Web site. Updated May 7, 2019. Accessed August 2, 2019.

37. Bowen S, Chawla N, Witkiewitz K. Mindfulness-based relapse prevention for addictive behaviors. In: Baer RA, ed. Mindfulness-Based Treatment Approaches: A Clinician’s Guide to Evidence Base and Applications. London, UK: Elsevier; 2014.

38. Dixon L, McFarlane W, Lefley H, et al. Evidence-based practices for services to families of people with psychiatric disabilities. Psychiatr Serv. 2001;52:903-910.

39. Hayes SC, Levin M, Plumb-Vilardaga J, et al. Acceptance and commitment therapy and contextual behavioral science: examining the progress of a distinctive model of behavioral and cognitive therapy. Behav Ther. 2013;44:180-198.

40. Osilla KC, Hepner KA, Muñoz RF, et al. Developing an integrated treatment for substance use and depression using cognitive behavioral therapy. J Subst Abuse Treat. 2009;37:412-420.

41. Martino S, Carroll K, Kostas D, et al. Dual diagnosis motivational interviewing: a modification of motivational interviewing for substance-abusing patients with psychotic disorders. J Subst Abuse Treat. 2002;23:297-308.

42. Rollnick S, Miller WR. What is motivational interviewing? Behav Cogn Psychother. 1995;23:325-334.

43. Garland EL. Disrupting the downward spiral of chronic pain and opioid addiction with mindfulness-oriented recovery enhancement: a review of clinical outcomes and neurocognitive targets. J Pain Palliat Care Pharmacother. 2014;28:122-129.

44. Garland EL, Manusov EG, Froeliger B, et al. Mindfulness-oriented recovery enhancement for chronic pain and prescription opioid misuse: results from an early-stage randomized controlled trial. J Consult Clin Psychol. 2014;82:448-459.

45. Marlatt GA, Donovan DM. Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors, 2nd ed. New York, NY: Guilford Press; 2007.

46. Zgierska A, Rabago D, Chawla N, et al. Mindfulness meditation for substance use disorders: a systematic review. Subst Abus. 2009;30:266-294.

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

Continue to: Medications for the mental health component