1. CO-OCCURRING DISORDERS
David Mays, MD, PhD

2. Substance Use Disorders

3. Mental Illness in Substance Abusers

4. Co-occurring Disorders
Epidemiologic studies show that psychiatric disorders increase the risk of substance abuse, and substance abuse increases the risk of psychiatric disorder. Individuals with multiple dependencies experience the highest rate of psychiatric problems.
The reason for the high degree of comorbidity is not known, but certain biochemical commonalities have been observed. The co-occurrence is not coincidental.

5. Co-occurring Disorders
The inter-relationship is complex:
Both may co-occur
Substances may cause or exacerbate a mental illness
The psychiatric condition may cause or increase the substance abuse
Both may be caused by something else
Substance use and withdrawal may look like a psychiatric disorder
Drug and alcohol use may mask a psychiatric disorder

6. Characteristics of COD’s
Worse treatment outcomes for both disorders
Higher health care utilization and higher medical costs
Increased risk of violence, trauma, suicide, child abuse, neglect and criminal justice involvement

7. Psychiatric Clients with Substance Abuse
Show faster progression to dependence
Less likely to comply with psychiatric treatment
More likely to be hospitalized
More likely to commit suicide
Relapse faster

8. Assessing for COD
Use assessment tools for substance abuse: CAGE, MAST, etc.
People who have mental illness symptoms during periods of sobriety or 30 days after abstinence can be considered to have a primary mental illness.
It criteria for both are met, assume both are primary.
Female clients need to be assessed for PTSD.

9. Principles of COD Treatment
Some patients will have worse substance abuse, some worse mental illness.
Treatment success is more likely when there is “integrated” treatment, either by program or practitioner.
Patience (4 years for 50% to achieve abstinence) and flexibility is required - wet, damp or dry
Treatment for the mental illness does not depend on the presence of substance abuse, except to avoid benzodiazepines (tranquilizers) and stimulants.

10. Principles of Treatment
Clients probably benefit from mental health treatment even when they are actively abusing substances.
Some modifications are needed in substance abuse treatment for mentally ill clients, especially those with schizophrenia and bipolar disorder.

11. Some General Modifications
Smaller caseload
Shorter meetings
Simplified educational components
Increase repetition
Education about the proper use of medication
Useful versus harmful drugs
Low confrontation, high support
Special preparation for 12 step programs
Specific social skills training - how to ask for help, use phone numbers, resist peer pressure, etc.

12. Specific Medication Issues
Abstinence is highly desirable before treatment, but not necessary.
Avoid benzodiazepines (tranquilizers) and stimulants.
Beware of overdose in clients with poor judgment or suicidal behavior.
Keep track of prescriptions.
Psychotic disorders:
First generation antipsychotics may worsen substance abuse. Second generation may benefit, especially clozapine.

13. Specific Medication Issues
Affective disorders
Selective serotonin reuptake inhibitors (SSRI’s) are better than tricyclic antidepressants when there is alcohol abuse.
Anxiety disorders
Avoid benzodiazepines. Try instead gabapentin, SSRI’s, serotonin norepinephrine reuptake inhibitors (SNRI’s), clonidine, second generation antipsychotics
ADHD
Stimulants only after sobriety is established
Can also try bupropion, clonidine, atomoxetine

14. What Do Clients Say Helps Them the Most?
Stable housing
“Positive” social support
Relying on a higher power
Participating in meaningful activity
Changing how they think about their lives
Attention to eating well, sleeping well, and looking good

15. Standard Programs Treat Mental Illness and Substance Abuse First
Clients are moved from a shelter to transitional housing after their mental illness is stabilized. Then they are moved to permanent housing after they have “earned it” by staying sober and “complying” with psychiatric treatment.

16. The Standard Model
Housing providers set up services requiring people not to be mentally ill and addicted. These programs are not designed to help people who can’t or won’t meet these criteria, ever.
If you relapse, you’re back into homelessness.
These programs have limited success.

17. An Alternative Model: Treat Homelessness First
A different model is based on belief that housing is a basic right and treatment should be separated from housing. Relapse is expected and does not result in housing loss. If a client leaves for long-term inpatient services, his home will be waiting when treatment is finished.

18. “Pathways to Housing” Model
Research results show housing retention rates at 85%, reduced psychiatric symptoms, reduced homelessness, improved residential stability, and 30% reduction in homelessness (NYC and 30 other cities).

19. Research Outcomes
Clients in this kind of supported housing show reductions in service needs (NY Supportive Housing Initiative)
Veterans Affordable Housing Program: permanent housing for homeless vets results in better outcomes than intensive case management or standard care.

20. Conclusion
The “low demand model”, which does not require participation in treatment services or abstinence, compared to “supportive housing with requirements” has better housing outcomes without worsening substance use or psychiatric disorders.
In terms of good outcome, the homeless mentally ill have more in common with their homelessness, than their mental illness. i.e. providing housing works, regardless of the kind of mental illness.

21. Addiction
From a biological perspective, addiction is characterized by 1) uncontrollable, sometimes compulsive drug seeking and drug use, in spite of severe aversive consequences, and 2) the experience of craving, often for years or decades after abstinence has been obtained. It is distinct from tolerance and habituation.

22. Addiction
Presently, “loss of control” is a primary criterion of addiction. This loss of control neutralizes any economic valuation of the subject, producing an alteration in salience, and finally, loss of choices for the person.
Addicted individuals tend to select preferentially small immediate rewards over larger delayed ones (delay discounting).
Treatment of addictions that utilize small immediate rewards, such as contingency management do better than long term later rewards.

23. Alcoholism
Alcoholism behaves like other mental disorders. It often follows a relapsing-remitting course characterized by partial remission.
DSM-5 removes the word “dependence” and substitutes “addiction” to emphasize the compulsive, destructive use. “Alcohol abuse” would not longer be a diagnosis since there is no clear difference between abuse and dependence in research studies.
Most alcohol dependence is mild to moderate with impaired control, sequestered drinking, insomnia, etc.

24. Kinds of Alcohol Dependence
Age-limited heavy drinking: 30% of people with alcohol dependence are symptomatic between the ages of the problems are usually gone by 25 to 30 years old. They seldom seek help.
Variable onset: 40% have an average age of onset of about 35, but this is highly variable. The symptoms are relatively moderate and it usually resolves without intervention.
Familial/ Early onset: 30% with onset in the mid teens have a strong family history, chronicity and recurrence % of these end up in rehab.

25. Treatment
Most of those who change their problem drinking do so without treatment of any kind, including self-help groups.
A significant percentage maintain their recovery with follow-up periods of more than 8 years.
Many problem drinkers can maintain a pattern of non-problematic moderate use of alcohol without becoming re-addicted.
Those who seek treatment have more severe alcohol and related problems than those who do not.

26. Alcohol Interventions
The Physicians’ Guide to Helping Patients With Alcohol Problems:
Brief, supportive intervention - 1 or more sessions in the clinician’s office consisting of education, negotiated plan, follow-up.
Motivational interviewing
Pharmacotherapy: disulfiram, naltrexone, acamprosate
Self-help groups

27. Behavioral Therapies Contingency management
Cognitive behavioral therapies
Relapse prevention
Motivational interviewing
Empathy
Develop discrepancy
Avoid arguments
Roll with resistance
Support self-efficacy
Couples/ Family Treatment
12-Step groups

28. Behavioral Therapies Brief Interventions Alternative Therapies
10-15 minutes counseling for feedback, education and goal setting, follow-up visits
Alternative Therapies
Exercise
Mindfulness training
Biofeedback
Acupuncture

29. Schizophrenia and Substance Abuse
Substance abuse and psychosis commonly appear together. 50% are substance dependent, >70% are nicotine dependent. In prisoners, >90% of those with schizophrenia have substance abuse. Among homeless, >70%.
People with schizophrenia rapidly move to dependence.
Substance abuse worsens the prognosis and the economic status of the user, however, CATIE showed substance use and disorder related to better psychosocial functioning. Clients report that substance abuse helps with symptoms, boredom, anxiety, sadness, friends.

30. Why? Five Hypotheses
1) Schizophrenia leads to substance abuse (the self-medication hypothesis)
Patients abuse whatever substances are available, not those that would alleviate symptoms
The order of preference (alcohol, marijuana, stimulants) is the same in the non-schizophrenic population. So are the reasons for use (decrease depression, relax, have fun, increase energy, go along with the crowd)
Nicotine may be the exception

31. Schizophrenia and Nicotine
Smoking may reduce auditory hallucinations, improve concentration, decrease EPSE’s, and be an antidepressant. This may be due to the fact that nicotine receptors in the ventral tegmentum cause dopamine release in the prefrontal cortex, which can relieve negative symptoms and improve concentration.
Smoking also reduces the blood level of various antipsychotics.

32. Effects of Substance Abuse in Schizophrenia
Reduced memory and attention
Decreased treatment adherence and higher relapse
Increased cost of care
Decreased employment
Increased homelessness
Increased suicide
Increased victimization and violence
Increased rates of arrest
Greater medical problems

33. The Challenge
Substance abuse disorders in people with schizophrenia are accompanied by more severe psychiatric symptoms, worse clinical outcomes, poorer medication compliance, more frequent relapses and hospitalizations, higher rates of violence, suicide, and homelessness,
All the evidence points to the need for integrated treatments, but most clients do not have access to these models for institutional and financial reasons. Furthermore, there is little guidance as to how to integrate the treatment and what strategies should be employed.

34. What We Do Know
We cannot just apply the treatments designed for people with primary substance abuse disorders to those people with schizophrenia and expect them to work.
Three principles to guide dual diagnosis treatment:
1) integration of substance abuse and mental health treatment
2) harm reduction
3) accommodation to cognitive and motivational deficits

35. 1) Integration of Treatment
Individuals with severe and persistent mental illnesses (SPMI) are often excluded from substance abuse treatment programs. It is often difficult for them to negotiate their way through separate systems, multiple clinicians, and different funding streams.
There is considerable research that demonstrates better outcomes when substance abuse and mental health services are combined.

36. 2) Harm Reduction
The priority is on behaviors that may reduce risks associated with drug use rather than on abstinence as the only goal.
SPMI individuals usually use more than one substance, which makes abstinence harder to achieve, especially early in treatment when motivation may be low. We don’t want to exclude anyone.
CATIE demonstrated some benefit to substance abuse in this population.
Research shows that any reduction in intensity of drug use decreases the risk of negative outcomes.

37. 3) Cognitive and Social Deficits
Deficits in attention, memory, and abstract reasoning make it difficult to engage in self-reflection and learning from experience. They interfere with participation in treatment and learning behavior change strategies.
Social impairments cause difficulties in achieving goals or getting needs met.

38. Other Principles to Keep in Mind
Adaptation is necessary for low motivation, poor self-efficacy, and maladaptive personal skills. The therapist needs to be active and treatment ongoing.
A therapeutic alliance is very important. Clients need a nonjudgmental, nurturing ally.
First generation antipsychotics may worsen substance abuse.
Residential and vocational support are crucial.

39. Six Components: Group Meetings Twice/Week for 6 Months
Individual motivational interviews
Contingency management
Collaborative goal setting
Social skills training
Psychoeducation
Relapse prevention training

40. Contingency Management
Each session begins with a urinalysis. A clean test is rewarded with praise from leaders and group. Participants earn $1.50 for the first clean test, increased by $0.50 for each clean test up to $3.50 maximum. A dirty test is followed by a discussion about the situation where the drug use occurred and problem solving to prevent it from happening. Contingency payments return to zero.

41. Goal Setting
Each member of the group collaborates with the therapist to establish an objective to work on between sessions. Goals may include saving money, abstaining from drugs, coming to the next meeting, etc. There is brief problem solving and setting of strategies. There is a lot of repetition!

42. Social Skills Training
The first several weeks are spent in drug refusal skills training:
Make eye contact
Tell the person you don’t want to use
Give the reason why you don’t want to use
Suggest an alternative or leave the situation
Clients use role-playing that involves people in their lives.

43. Psychoeducation
Clients are taught about how drug use affects the brain and their medications, why people use drugs, and about addiction and craving. They learn about other risks involving drugs and how to use condoms.
Coping skills are taught for how to deal with stress, depression, etc

44. Relapse Prevention
A range of situations are discussed that may lead to relapse: side effects of mediations, boredom, depression, anger…
Alternative behavioral strategies are given.

45. Summary
Topics are broken down into steps for easy understanding and learning.
A few key skills are learned well so that they can be used without much thought in high stress situations.
Clients are taught to seek out alternative activities.
Educational material is presented in multiple forms.
An emphasis is placed on creating a positive and supportive therapeutic atmosphere.

46. Anxiety and Substance Abuse
18% of substance abusers suffer from an independent anxiety disorder. 70% of alcoholics have anxiety problems, mostly caused by the alcoholism. 15% of anxiety disorder clients have substance abuse problems. The relationship is bidirectional and complex.
Alcohol relieves anxiety in the short term, but chronic drinking makes agoraphobia and social phobia worse.

47. Anxiety and Substance Abuse
It is difficult to detect substance dependence in the presence of an anxiety disorder. 98% will report anxiety while drinking/withdrawing, but only 4% after 3 months of abstinence.
Anxiety can be precipitated by caffeine, diet pills, androgenic steroids, etc. Clients with anxiety disorders usually stop the use of marijuana and hallucinogens, but increase the abuse of alcohol and benzodiazepines.

48. Rules for Pharmacotherapy
It is important to keep control over dosage schedules, amounts dispensed, and refills.
In general, benzodiazepines should not be used because of their abuse potential.
Medication needs to be stopped when it is not helpful.