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- Treatment of Drug-Dependent Individuals With Comorbid Mental Disorders
Treatment of Drug-Dependent Individuals With Comorbid Mental Disorders
- By N.I. D.A.
- Published 01/15/2007
- Dual Diagnosis
- Unrated
The Course and Treatment of Substance Use Disorder in Persons With Severe Mental Illness
Kim T. Mueser, Robert E. Drake, and Keith M. Miles
There is now a widespread acceptance that persons with severe mental illness are at increased risk to develop substance use disorders (alcohol and drug abuse/dependence).
Reviews of the prevalence of substance use disorders in clients with schizophrenia (Mueser et al. 1990), bipolar disorder (Goodwin and Jamison 1990), and the young, chronically mentally ill (Safer 1987) indicate a wide range of prevalence estimates, from as low as 10 percent to over 65 percent.
Variability in prevalence rates can be attributed to differences across studies in factors such as the setting in which clients are sampled (e.g., community mental health center, acute inpatient, chronic inpatient), methods for assessing psychiatric and substance use disorders (e.g., structured clinical interview, chart review), and the demographic mix of the study sample (e.g., proportion of males) (Galanter et al. 1988; Mueser et al. 1995).
Despite the variability in prevalence estimates, strong evidence indicates that the rate of comorbid substance use disorders in people with severe mental disorders is substantially greater than in the general population. The most compelling evidence supporting this is provided by the Epidemiological Catchment Area (ECA) study (Regier et al. 1990), which assessed psychiatric and substance use disorders in over 20,000 persons living in the community and in various institutional settings.
The results of this study indicated that persons with a psychiatric disorder were at increased risk for developing a substance use disorder over their lifetime. Of particular importance, people with severe mental illness were especially vulnerable to substance use disorders.
For example, those with schizophrenia were more than four times more likely to have had a substance use disorder during their lifetime than persons in the general population, and those with bipolar disorder were more than five times as likely to have such a diagnosis.
The high rate of substance use disorders among persons with severe mental illness has important clinical implications, because their substance abuse is associated with an array of negative outcomes.
Common negative consequences include increased vulnerability to 87 relapses and rehospitalizations, greater depression and suicidality, violence, housing instability and homelessness, noncompliance with medications and other treatments, increased vulnerability to human immunodeficiency virus (HIV) infection, increased family burden, and higher service utilization and costs (Bartels et al. 1993; Clark 1994; Bartels et al. 1992; Cournos et al. 1991; Drake et al. 1989; Yesavage and Zarcone 1983).
However, evidence also suggests that as dual-diagnosis clients attain stable remission, their vulnerability to these negative outcomes lessens (Bartels et al. 1993; Zisook et al. 1992).
Thus, interventions that are successful at reducing substance abuse in clients with severe psychiatric disorders may also confer positive benefits in such areas as symptomatology, community functioning, service utilization, and costs of treatment.
In this chapter the authors begin with a discussion of issues in the assessment of substance use disorders in persons with severe psychiatric disorders. Following this, an overview provides a natural history of substance use disorders in both the general population and among the chronically mentally ill.
Next, the failure of the parallel treatment system for dually diagnosed clients is briefly reviewed, followed by a description of more recently developed integrated substance abuse and mental health methods. Preliminary data are then presented from a 3-year study by the New Hampshire-Dartmouth Psychiatric Research Center of integrated treatment for dual-diagnosis clients.
The implications of research on integrated treatment approaches for policy decisions are discussed in a concluding section, as are future directions for research in this area.
ASSESSMENT
Several common difficulties arise when assessing substance disorders among persons with severe mental illness (Drake et al. 1993a; Drake and Mercer-McFadden 1995; Stone et al. 1993). The most common problem is that mental health clinicians often do not obtain a thorough history of substance use (Ananth et al. 1989).
Even when interviewed thoroughly, however, persons with dual disorders are subject to the usual problems of denial, distortion, and minimization that attend self-reports of substance use, especially the use of illicit drugs, in the general population (Aiken 1986; Galletly et al. 1993; Stone et al. 1993). Psychiatric clients are also prone to individual distortions arising from the cognitive, emotional, and other aspects of their mental illness (Mueser et al. 1992).
Another important factor that complicates assessment is the fact that the usual dimensions of substance abuse—pattern, consequences, dependence syndrome, and subjective distress—are qualitatively different in substance abusers who have mental illness compared to those who do not (Drake et al. 1990; Lehman et al. 1994; McHugo et al. 1993).
Specifically, compared with non-mentally ill substance abusers, those with dual disorders use lower amounts of alcohol and drugs, experience different consequences, are less likely to develop a dependence syndrome, and have less subjective distress.
For example, the typical consequences of substance abuse among people with a mental disorder are difficulties with money management, destabilization of illness, unstable housing, and inability to participate in rehabilitation, but not with the items on the Michigan Alcohol Screening Test (Selzer 1971) or the Alcohol Dependence Scale (Skinner and Horn 1984).
Standard instruments, such as the addiction Severity Index (McLellan et al. 1980), are relatively insensitive to clinically important levels of abuse among persons with psychiatric disorders. One last but critical problem is that dual-disordered clients are typically in a premotivational state regarding their substance abuse, even if they are well engaged in mental health treatment (Drake et al. 1990).
To be useful for treatment planning and monitoring, assessment instruments must be sensitive to stages of motivation and to changes that occur prior to attaining abstinence. The authors and others, thus, recommend the use of multiple tests (Carey, this volume; Drake et al. 1990), multimodal testing (Stone et al. 1993), and an explicit assessment of the stage of treatment (McHugo et al. 1995).
Furthermore, there is a need to develop new instruments sensitive to the presence of substance use disorders in the population of persons with severe psychiatric disorders (Drake et al. 1993a; Lehman et al. 1993b).
NATURAL HISTORY OF SUBSTANCE USE DISORDERS
As a backdrop to understanding the longitudinal course of psychiatric and substance use disorders, it is helpful to review what is known about the course of primary alcohol and drug use disorders. Vaillant's (1983) seminal work on the natural history of alcoholism provides compelling evidence that for most clients the disorder is lifelong and is associated with a substantial risk for early mortality.
Despite the overall negative (and often progressively negative) longterm outlook for alcoholics, a cumulative proportion of individuals 89 achieve abstinence, even in the absence of professional treatment. Vaillant (1983) estimated that approximately 3 percent of alcoholics become abstinent each year without the benefit of formal treatment programs, and between 1 and 2 percent of abstinent alcoholics resume social drinking.
Although the efficacy of treatment for alcoholism continues to be debated, Vaillant (1983) estimated that treatment of alcoholics increases their recovery rate to approximately 6 percent yearly. Fewer data are available on the longitudinal course of primary drug use disorders, although in general the findings are compatible with those reported by Vaillant (1983) for alcoholism (Vaillant 1973, 1988; Simpson et al. 1986).
In one of the largest and longest longitudinal studies published to date, Hser and associates (1993) reported 24-year outcomes for 581 narcotics addicts who had been admitted to the California Civil Addict Program between 1962 and 1964.
Data on the long-term outcome of these patients' drug use disorders revealed high mortality rates and a rate of spontaneous remission in the absence of treatment that was somewhat lower than that reported by Vaillant (1983) for alcoholics.
At the end of the followup period, 28 percent of the sample were dead, and only 19 percent had attained stable abstinence, which was defined as not using drugs for the prior 3 years.
~~~
Continued on source document:
NIDA Research Monograph, Number 172
Kim T. Mueser, Robert E. Drake, and Keith M. Miles
There is now a widespread acceptance that persons with severe mental illness are at increased risk to develop substance use disorders (alcohol and drug abuse/dependence).
Reviews of the prevalence of substance use disorders in clients with schizophrenia (Mueser et al. 1990), bipolar disorder (Goodwin and Jamison 1990), and the young, chronically mentally ill (Safer 1987) indicate a wide range of prevalence estimates, from as low as 10 percent to over 65 percent.
Variability in prevalence rates can be attributed to differences across studies in factors such as the setting in which clients are sampled (e.g., community mental health center, acute inpatient, chronic inpatient), methods for assessing psychiatric and substance use disorders (e.g., structured clinical interview, chart review), and the demographic mix of the study sample (e.g., proportion of males) (Galanter et al. 1988; Mueser et al. 1995).
Despite the variability in prevalence estimates, strong evidence indicates that the rate of comorbid substance use disorders in people with severe mental disorders is substantially greater than in the general population. The most compelling evidence supporting this is provided by the Epidemiological Catchment Area (ECA) study (Regier et al. 1990), which assessed psychiatric and substance use disorders in over 20,000 persons living in the community and in various institutional settings.
The results of this study indicated that persons with a psychiatric disorder were at increased risk for developing a substance use disorder over their lifetime. Of particular importance, people with severe mental illness were especially vulnerable to substance use disorders.
For example, those with schizophrenia were more than four times more likely to have had a substance use disorder during their lifetime than persons in the general population, and those with bipolar disorder were more than five times as likely to have such a diagnosis.
The high rate of substance use disorders among persons with severe mental illness has important clinical implications, because their substance abuse is associated with an array of negative outcomes.
Common negative consequences include increased vulnerability to 87 relapses and rehospitalizations, greater depression and suicidality, violence, housing instability and homelessness, noncompliance with medications and other treatments, increased vulnerability to human immunodeficiency virus (HIV) infection, increased family burden, and higher service utilization and costs (Bartels et al. 1993; Clark 1994; Bartels et al. 1992; Cournos et al. 1991; Drake et al. 1989; Yesavage and Zarcone 1983).
However, evidence also suggests that as dual-diagnosis clients attain stable remission, their vulnerability to these negative outcomes lessens (Bartels et al. 1993; Zisook et al. 1992).
Thus, interventions that are successful at reducing substance abuse in clients with severe psychiatric disorders may also confer positive benefits in such areas as symptomatology, community functioning, service utilization, and costs of treatment.
In this chapter the authors begin with a discussion of issues in the assessment of substance use disorders in persons with severe psychiatric disorders. Following this, an overview provides a natural history of substance use disorders in both the general population and among the chronically mentally ill.
Next, the failure of the parallel treatment system for dually diagnosed clients is briefly reviewed, followed by a description of more recently developed integrated substance abuse and mental health methods. Preliminary data are then presented from a 3-year study by the New Hampshire-Dartmouth Psychiatric Research Center of integrated treatment for dual-diagnosis clients.
The implications of research on integrated treatment approaches for policy decisions are discussed in a concluding section, as are future directions for research in this area.
ASSESSMENT
Several common difficulties arise when assessing substance disorders among persons with severe mental illness (Drake et al. 1993a; Drake and Mercer-McFadden 1995; Stone et al. 1993). The most common problem is that mental health clinicians often do not obtain a thorough history of substance use (Ananth et al. 1989).
Even when interviewed thoroughly, however, persons with dual disorders are subject to the usual problems of denial, distortion, and minimization that attend self-reports of substance use, especially the use of illicit drugs, in the general population (Aiken 1986; Galletly et al. 1993; Stone et al. 1993). Psychiatric clients are also prone to individual distortions arising from the cognitive, emotional, and other aspects of their mental illness (Mueser et al. 1992).
Another important factor that complicates assessment is the fact that the usual dimensions of substance abuse—pattern, consequences, dependence syndrome, and subjective distress—are qualitatively different in substance abusers who have mental illness compared to those who do not (Drake et al. 1990; Lehman et al. 1994; McHugo et al. 1993).
Specifically, compared with non-mentally ill substance abusers, those with dual disorders use lower amounts of alcohol and drugs, experience different consequences, are less likely to develop a dependence syndrome, and have less subjective distress.
For example, the typical consequences of substance abuse among people with a mental disorder are difficulties with money management, destabilization of illness, unstable housing, and inability to participate in rehabilitation, but not with the items on the Michigan Alcohol Screening Test (Selzer 1971) or the Alcohol Dependence Scale (Skinner and Horn 1984).
Standard instruments, such as the addiction Severity Index (McLellan et al. 1980), are relatively insensitive to clinically important levels of abuse among persons with psychiatric disorders. One last but critical problem is that dual-disordered clients are typically in a premotivational state regarding their substance abuse, even if they are well engaged in mental health treatment (Drake et al. 1990).
To be useful for treatment planning and monitoring, assessment instruments must be sensitive to stages of motivation and to changes that occur prior to attaining abstinence. The authors and others, thus, recommend the use of multiple tests (Carey, this volume; Drake et al. 1990), multimodal testing (Stone et al. 1993), and an explicit assessment of the stage of treatment (McHugo et al. 1995).
Furthermore, there is a need to develop new instruments sensitive to the presence of substance use disorders in the population of persons with severe psychiatric disorders (Drake et al. 1993a; Lehman et al. 1993b).
NATURAL HISTORY OF SUBSTANCE USE DISORDERS
As a backdrop to understanding the longitudinal course of psychiatric and substance use disorders, it is helpful to review what is known about the course of primary alcohol and drug use disorders. Vaillant's (1983) seminal work on the natural history of alcoholism provides compelling evidence that for most clients the disorder is lifelong and is associated with a substantial risk for early mortality.
Despite the overall negative (and often progressively negative) longterm outlook for alcoholics, a cumulative proportion of individuals 89 achieve abstinence, even in the absence of professional treatment. Vaillant (1983) estimated that approximately 3 percent of alcoholics become abstinent each year without the benefit of formal treatment programs, and between 1 and 2 percent of abstinent alcoholics resume social drinking.
Although the efficacy of treatment for alcoholism continues to be debated, Vaillant (1983) estimated that treatment of alcoholics increases their recovery rate to approximately 6 percent yearly. Fewer data are available on the longitudinal course of primary drug use disorders, although in general the findings are compatible with those reported by Vaillant (1983) for alcoholism (Vaillant 1973, 1988; Simpson et al. 1986).
In one of the largest and longest longitudinal studies published to date, Hser and associates (1993) reported 24-year outcomes for 581 narcotics addicts who had been admitted to the California Civil Addict Program between 1962 and 1964.
Data on the long-term outcome of these patients' drug use disorders revealed high mortality rates and a rate of spontaneous remission in the absence of treatment that was somewhat lower than that reported by Vaillant (1983) for alcoholics.
At the end of the followup period, 28 percent of the sample were dead, and only 19 percent had attained stable abstinence, which was defined as not using drugs for the prior 3 years.
~~~
Continued on source document:
NIDA Research Monograph, Number 172
