Hostname: page-component-78c5997874-lj6df Total loading time: 0 Render date: 2024-11-15T01:53:56.638Z Has data issue: false hasContentIssue false

Integrated Treatment of Co-Occurring Mental Illness and Addiction: Clinical Intervention, Program, and System Perspectives

Published online by Cambridge University Press:  07 November 2014

Abstract

Individuals with mental illness and addiction comprise at least half of the patients in most mental health treatment systems. This combination results in increased risk for frequent psychiatric relapses, poor medication compliance, violence, suicide, legal problems, and high utilization of the emergency room or inpatient services. Traditional mental health and addiction treatments have not adequately addressed these co-occurring disorders due to clinical interventions, programs, and system flaws that have not addressed the individual's needs. Integrated treatment requires both an understanding of mental illness and addiction and the means to integrate and modify the traditional treatment approaches in both the mental health and addiction treatment fields. There is strong evidence to support the efficacy and effectiveness of integrated treatment in this population. All mental health clinicians should become experienced and skilled in the core psychotherapy approaches to treating substance use disorders, including motivational enhancement therapy, relapse prevention (cognitive-behavioral therapy), and 12-step facilitation. In addition, integrated treatment includes integrating medications for both addiction and mental illness with the behavioral therapies and other psychosocial interventions. This article reviews the clinical intervention, program, and system components of integrated treatment and specific clinical interventions for this population.

Type
Review Articles
Copyright
Copyright © Cambridge University Press 2004

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

REFERENCES

1.Drake, RE, Essock, SM, Shaner, A, et al.Implementing dual diagnosis services for clients with severe mental illness. Psychiatr Serv. 2001;52:469476.CrossRefGoogle ScholarPubMed
2.Glover, RW, Gustafson, JS. National Dialogue on Co-occurring Mental Health and Substance Abuse Disorders. Alexandria, Va: National Association of State Mental Health Program Directors and National Association of State Alcohol and Drug Directors; 1999.Google Scholar
3.Substance Abuse and Mental Health Services Administration. Strategies for Developing Treatment Programs for People With Co-occurring Substance Abuse and Mental Disorders. SAMHSA Publication No. 3782. Rockville, Md: SAMHSA; 2003.Google Scholar
4.SAMHSA. Report to Congress on the Prevention and Treatment of Co-Occurring Substance Abuse Disorders and Mental Disorders. Washington, DC: ; 2002.Google Scholar
5.Substance Abuse and Mental Health Services Administration. Assessment and Treatment of Patients with Coexisting Mental Illness and Alcohol and Other Drug Abuse. Treatment Improvement Protocol (TIP) Series, rev. Rockville, Md: US Department of Health and Human Services. In press.Google Scholar
6.Ziedonis, D, Williams, J. Addressing tobacco use in mental health and addiction settings. Psychiatr Ann. 2003;33:425426.CrossRefGoogle Scholar
7.American Psychiatric Association. Practice Guideline for The Treatment of Patients with Nicotine Dependence. Washington DC: American Psychiatric Press; 1996.Google Scholar
8.Rosenthal, RN, Westreich, L. Treatment of persons with dual diagnoses of substance use disorder and other psychological problems. In: McCrady, BS, Epstein, EE, eds. Addictions: A Comprehensive Guidebook. New York, NY: Oxford University Press; 1999:439475.Google Scholar
9.Baker, F. Coordination of Alcohol, Drug Abuse, and Mental Health Services. Washington, DC: Office for Treatment Improvement, Alcohol, Drug Abuse, and Mental Health Administration; 1991. Technical Assistance Publication Series, No. 4.Google Scholar
10.Ridgely, MS, Goldman, HH, Willenbring, M. Barriers to the care of persons with dual diagnoses: organizational and financing issues. Schizophr Bull. 1990;16:123132.CrossRefGoogle Scholar
11.O'Connor, PG, Ziedonis, DM. Linkages between substance abuse, primary care, and mental health services. In: Miller, N, ed. Principles of Addiction Medicine. New York, NY: American Society of Addiction Medicine; 1999:353363.Google Scholar
12.Prochaska, JO, DiClemente, CC, Norcross, JC. In search of how people change. Applications to addictive behaviors. Am Psychol. 1992;47:11021114.CrossRefGoogle ScholarPubMed
13.Ziedonis, DM, Fisher, W. Motivation based assessment and treatment of substance abuse in patients with schizophrenia. New Directions in Psychiatry. 1996:18.Google Scholar
14.Carey, KB. Substance use reduction in the context of outpatient psychiatric treatment: a collaborative, motivational, harm reduction approach. Community Ment Health J. 1996;32:291306.CrossRefGoogle ScholarPubMed
15.Drake, RE, Xie, H, McHugo, GJ, Green, AI. The effects of clozapine on alcohol and drug use disorders among patients with schizophrenia. Schizophr Bull. 2000;26:441449.CrossRefGoogle ScholarPubMed
16.Drake, RE, Osher, FC, Noordsy, DL, Hurlbut, SC, Teague, GB, Beaudett, MS. Diagnosis of alcohol use disorders in schizophrenia. Schizophr Bull. 1990;16:5767.CrossRefGoogle ScholarPubMed
17.Minkoff, K. An integrated treatment model for dual diagnosis of psychosis and addiction. Hosp Community Psychiatry. 1989;40:10311036.Google ScholarPubMed
18.Noordsy, DL. Group intervention techniques for people with dual disorders. Psychosocial Rehabilitation Journal. 1991;15:6778.CrossRefGoogle Scholar
19.Rosenthal, RN, Hellerstein, DJ, Miner, CR. A model of integrated services for out-patient treatment of patients with comorbid schizophrenia and addictive disorders. American Journal on Addictions. 1992;1:339348.Google Scholar
20.Schollar, E. The long term treatment of the dually diagnosed. In: Solomon, J, Zimberg, S, Schollar, E, eds. Dual Diagnosis: Evaluation, Treatment, Training, and Program Development. New York, NY: Plenum Medical Book Co; 1993.Google Scholar
21.Ziedonis, DM, D'Avanzo, K. Schizophrenia and substance abuse. In: Kranzler, HR, Rounsaville, BJ, eds. Dual Diagnosis and Treatment: Substance Abuse and Comorbid Medical and Psychiatric Disorders. New York, NY: Marcel Dekker; 1998:427465.Google Scholar
22.Marlatt, GA, Tapert, SF. Harm reduction: reducing the risks of addictive behaviors. In: Baer, JS, Marlatt, GA, eds. Addictive Behaviors Across The Life Span: Prevention, Treatment, and Policy Issues. Newhury Park, Calif: Sage Publications, 1993:243273.Google Scholar
23.Shaner, A, Eckman, T, Roberts, LJ, Fuller, T. Feasibility of a skills training approach to reduce substance dependence among individuals with schizophrenia. Psychiatr Serv. 2003;54:12871289.CrossRefGoogle ScholarPubMed
24.Roberts, LJ, Shaner, A, Eckman, TA. Overcoming Addictions: Skills Training for People with Schizophrenia. New York, NY: W. W. Norton & Co, Inc; 1999.Google Scholar
25.Ho, AP, Tsuan, JW, Liberman, RP, et al.Achieving effective treatment of patients with chronic psychotic illness and comorbid substance dependence. Am J Psychiatry. 1999;156:17651770.CrossRefGoogle ScholarPubMed
26.Shaner, A, Khalsa, ME, Roberts, L, Wilkins, J, Anglin, D, Hsieh, SC. Unrecognized cocaine use among schizophrenic patients. Am J Psychiatry. 1993;150:758762.Google ScholarPubMed
27.Rosenberg, SD, Drake, RE, Wolford, GL, et al.Dartmouth Assessment of Lifestyle Instrument (DALI): a substance use disorder screen for people with severe mental illness. Am J Psychiatry. 1998;155:232238.CrossRefGoogle Scholar
28.Miller, WR, Tonigan, JS. Assessing drinkers motivation for change: the stages of change readiness an treatment eagerness scale (SOCRATES). Psychol Addict Behav. 1996;10:8189.CrossRefGoogle Scholar
29.McConnaughy, EN, Prochaska, JO, Velicer, WF. Stages of change in psychotherapy: measurement and sample profiles. Psychotherapy. 1983;20;368375.CrossRefGoogle Scholar
30.Mueser, KT, Nishith, P, Tracy, JI, DeGirolamo, J, Molinaro, M. Expectations and motives for substance use in schizophrenia. Schizophr Bull. 1995;21:367378.CrossRefGoogle ScholarPubMed
31.Ziedonis, D, Stern, R. Dual recovery therapy for schizophrenia and substance abuse. Psychiatr Ann. 2001;31:255264.CrossRefGoogle Scholar
33.Project MATCH Research Group. Project MATCH: rationale and methods for a multisite clinical trial matching patients to alcoholism treatment. Alcohol Clin Exp Res. 1993;17:11301145.CrossRefGoogle Scholar
34.Sullivan, HS. Schizophrenia as a Human Process. New York, NY: W.W.Norton & Co; 1962.Google Scholar
35.Marlatt, GA, Gordan, JR. Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors. New York, NY: Guilford Press; 1985.Google Scholar
36.Bandura, A. Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev. 1977;84:191215.CrossRefGoogle Scholar
37.Liberman, RP, Mueser, KT, Wallace, CJ, Jacobs, HE, Eckman, T, Massel, HK. Training skills in the psychiatrically disabled: learning coping and competence. Schizophr Bull. 1986;12:631647.CrossRefGoogle ScholarPubMed
38.Foy, DW, Wallace, CJ, Liberman, RP. Advances in social skills training for chronic mental patients. In: Craig, KD, McMahon, MJ, eds. Advances in Clinical Behavior Therapy. New York, NY: Brunner/Mazel; 1983.Google Scholar
39.Bellack, AS, DiClemente, CC. Treating substance abuse among patients with schizophrenia. Psychiatr Serv. 1999;50:7580.CrossRefGoogle ScholarPubMed
40.Nowinski, J, Baker, S, Carroll, K. Twelve Step Facilitation Therapy Manual. Rockville, Md: US Department of Health and Human Services. NIH Publication No. 94-3722; 1995.Google Scholar
41.Chappel, JN. Effective use of Alcoholics Anonymous and Narcotics Anonymous in treating patients. Psychiatric Annals. 1992;22:409418.CrossRefGoogle Scholar
42.McCrady, BS, Miller, WR. Research on Alcoholics Anonymous: Opportunities and Alternatives. New Brunswick, NJ: Rutgers Center of Alcohol Studies; 1993.Google Scholar
43.Miller, WR, Rollnick, S. Motivational Interviewing: Preparing People to Change Addictive Behavior. New York, NY: Guilford Press; 1991.Google Scholar
44.Ziedonis, DM, Krejci, J. Dual recovery therapy: blending psychotherapies for depression and addiction. In: Westermeyer, J, Weiss, R, Ziedonis, D, eds. Integrated Treatment for Mood and Substance Use Disorders. Baltimore, Md: John Hopkins University Press; 2003:90121.Google Scholar
45.Miller, WR, Zweben, A, DiClemente, CC, Rychtarik, RG. Motivational Enhancement Therapy Manual. Rockville, Md: US Department of Health and Human Services. NIH Publication No. 94-3723; 1995.Google Scholar
46.Center for Substance Abuse Treatment. Cultural Issues in Substance Abuse Treatment. Rockville, Md: US Department of Health and Human Services; 1999.Google Scholar
47.Ziedonis, DM, Rayford, BS, Bryant, KJ, Rounsaville, BJ. Psychiatric comorbidity in white and African-American cocaine addicts seeking substance abuse treatment. Hosp Community Psychiatry. 1994;45:4349.Google ScholarPubMed
48.Frank, E, ed. Gender and Its Effects on Psychopathobgy. Washington DC: American Psychiatric Press; 2000.Google Scholar
49.Shaner, A, Eckman, TA, Roberts, LJ, et al.Disability income, cocaine use, and repeated hospitalization among schizophrenic cocaine abusers--a government-sponsored revolving door? N Engl J Med. 1995;333:777783.CrossRefGoogle ScholarPubMed
50.Rosenheck, R. Disability payments and chemical dependence: conflicting values and uncertain effects. Psychiatr Serv. 1997;48:789791.Google ScholarPubMed
51.Rosenheck, R, Lam, J, Randolph, F. Impact of representative payees on substance use by homeless persons with serious mental illness. Psychiatr Serv. 1997;48:800806.Google ScholarPubMed
52.Rosen, MI, Rosenheck, RA, Shaner, A, Eckman, T, Gamache, G, Krebs, C. Veterans who may need a payee to prevent misuse of funds for drugs. Psychiatr Serv. 2002;53:9951000.CrossRefGoogle Scholar
53.Rosen, MI, Rosenheck, RA, Shaner, AL, Eckman, TA, Gamache, GR, Krebs, CW. Substance abuse and the need for money management assistance among psychiatric inpatients. Drug Alcohol Depend. 2002;67:331334.CrossRefGoogle ScholarPubMed
54.Miller, AL, Hall, CS, Buchanan, RW. The Texas Medication Algorithm Project antipsychotic algorithm for schizophrenia: 2003 update. J Clin Psychiatry. 2004;65:500508.CrossRefGoogle ScholarPubMed
55.Allen, JP, Litten, RZ. Techniques to enhance compliance with disulfiram. Alcohol Clin Exp Res. 1992;16:10351041.CrossRefGoogle ScholarPubMed
56.West, SL, Carey, TS, Jackman, AM, et al.Pharmacotherapy for Alcohol Dependence. Evidence Report. Rockville, Md: Agency for Health Care Policy and Research. Technology Assessment No, 3. AHCPR Publication Number 99-E004; 1999.Google Scholar
57.Petrakis, IL, O'Malley, S, Rounsaville, B, et al.Naltrexone augmentation of neuroleptic treatment in alcohol abusing patients with schizophrenia. Psychopharmacology (Berl). 2004;172:291297.CrossRefGoogle ScholarPubMed
58.Batki, S, Dimmock, J, Cornell, M, Wade, M, Carey, K, Maisato, S. Naltrexone treatment of alcohol dependence in schizophrenia: relationship of alcohol use to psychtisis severity and antipsychotic medication. Poster presented at annual meeting of the American Academy of Addiction Psychiatry. December 12-15, 2002; Las Vegas, Nev.Google Scholar
59.American Psychiatric Association. Practice Guideline for Treatment of Patients with Substance Use Disorders: Alcohol, Cocaine, Opioids. Washington, DC: America Psychiatric Press; 1995.Google Scholar
60.Ziedonis, DM, Kosten, TR. Pharmacotherapy improves treatment outcome in depressed cocaine addicts. J Psychoactive Drugs. 1991;23:417425.CrossRefGoogle ScholarPubMed
61.Ling, W, Shoptaw, S. Integration of research in pharmacotherapy for addictive disease: where are we? Where are we going? J Addict Dis. 1997:16:83102.Google ScholarPubMed
62.Agency for Health Care Policy and Research. Clinical Practice Guidelines #18: Helping Smokers Quit. Washington, DC: US Government Printing Office. AHCPR Publication No. 96-0693; 1996.Google Scholar
63.Fiore, MC, Bailey, WC, Cohen, SJ, et. Al.Treating Tobacco Use and Dependence: Clinical Practice Guidelines. Rockville, Md: US Department of Health and Human Services. Public Health Service; 2000.Google Scholar
64.Hughes, JR. Combining behavioral therapy and pharmacotherapy for smoking cessation: an update, in integrating behavioral therapies with medications in the treatment of drug dependence. In: Onken, LS, Blaine, JD, eds. National Institute of Drug Abuse Research Monograph Series. Rockville, Md: US Department of Health and Human Services; 1995.Google Scholar
65.Baille, A, Mattick, R, Hall, W, Webster, P. Meta-analytic review of the efficacy of smoking cessation interventions. Drug Alcohol Rev. 1994;13:179192.Google Scholar
66.Ziedonis, DM, George, TP. Schizophrenia and nicotine use: report of a pilot smoking cessation program and review of neurobiological and clinical issues. Schizophr Bull. 1997;23:247254.CrossRefGoogle ScholarPubMed
67.Evins, AE, Mays, VK, Rigotti, NA, Tisdale, T, Cather, C, Goff, DC. A pilot trial of bupropion added to cognitive behavioral therapy for smoking cessation in schizophrenia. Nicotine Tob Res. 2001;3:397403.CrossRefGoogle ScholarPubMed
68.Hall, SM, Reus, VI, Munoz, RF, et al.Nortriptyline and cognitive-behavioral therapy in the treatment of cigarette smoking. Arch Gen Psychiatry. 1998;55:683690.CrossRefGoogle ScholarPubMed
69.Bobo, JK, McIlvain, HE, Lando, HA, Walker, RD, Leed-Kelly, A. Effect of smoking cessaton counseling on recovery from alcoholism: findings from a randomized community intervention trial. Addiction. 1998;93:877887.CrossRefGoogle Scholar
70.Clemmey, P, Brooner, R, Chutuape, MA, Kidorf, M, Stitzer, M. Smoking habits and attitudes in a methadone maintenance treatment population. Drug Alcohol Depend. 1997;44:123132.CrossRefGoogle Scholar
71.Hurt, RD, Offord, KP, Croghan, IT, et al.Mortality following inpatient addictions treatment. Role of tobacco use in a community-based cohort. JAMA. 1996;275:10971103.CrossRefGoogle Scholar
72.Brown, S, Inskip, H, Barraclough, B. Causes of the excess mortality of schizophrenia. Br J Psychiatry. 2000;177:212217.CrossRefGoogle ScholarPubMed
73.Dixon, L, Postrado, L, Delahanty, J, Fischer, PJ, Lehman, A. The association of medical comorbidity in schizophrenia with poor physical and mental health. J Nerv Ment Dis. 1999;187:496502.CrossRefGoogle ScholarPubMed
74.Dalack, GW, Healy, DJ, Meador-Woodruff, JH. Nicotine dependence in schizophrenia: clinical phenomena and laboratory findings. Am J Psychiatry. 1998;155:14901501.CrossRefGoogle ScholarPubMed
75.Stroup, TS, Gilmore, JH, Jarskog, LF. Management of medical illness in persons with schizophrenia. Psychiatr Ann. 2000;30:3540.CrossRefGoogle Scholar
76.Lasser, K, Wesley, BJ, Woolhandler, S, et al.Smoking and mental illness: a population-based prevalence study. JAMA. 2000;284:26062610.CrossRefGoogle ScholarPubMed
77.Williams, JM, Hughes, JR. Pharmacotherapy treatments for tobacco dependence among smokers with mental illness or addiction. Psychiatr Ann. 2003;33:457468.CrossRefGoogle Scholar
78.Steinberg, ML, Ziedonis, DM, Krejci, JA, Brandon, TH. Motivational interviewing with personalized feedback: a brief intervention for motivating smokers with schizophrenia to seek treatment for tobacco dependence. J Consult Clin Psychol. 2004;72:723728.CrossRefGoogle ScholarPubMed
79.Ziedonis, DM, Williams, JM. Management of smoking in people with psychiatric disorders. Curr Opin Psychiatry. 2003;16:305315.CrossRefGoogle Scholar
80.Weiner, E, Ball, MP, Summerfelt, A, Gold, J, Buchanan, RW. Effects of sustainedrelease buproprion and supportive group therapy on cigarette consumption in patients with schizophrenia. Am J Psychiatry. 2001;158:635637.CrossRefGoogle Scholar
81.George, TP, Vessicchio, JC, Termine, A, et al.A placebo controlled trial of bupropion for smoking cessation in schizophrenia. Biol Psychiatry. 2002;52:5361.CrossRefGoogle ScholarPubMed
82.Addington, J. Group treatment for smoking cessation among persons with schizophrenia. Psychiatr Serv. 1998;49:925928.CrossRefGoogle ScholarPubMed
83.George, TP, Ziedonis, DM, Feingold, A, et al.Nicotine transdermal patch and atypical antipsychotic medications for smoking cessation in schizophrenia. Am J Psychiatry. 2000;157:18351842.CrossRefGoogle ScholarPubMed
84.Steinberg, ML, Hall, SM, Rustin, T. Psychosocial therapies for tobacco dependence in mental health and other substance use populations. Psychiatr Ann. 2003;33:469478.CrossRefGoogle Scholar
85.Stuyt, EB, Order-Connors, B, Ziedonis, DM. Addressing tobacco through program and system change in mental health and addiction settings. Psychiatr Ann. 2003;33:446456.CrossRefGoogle Scholar
86.Ziedonis, DM, Trudeau, K. Motivation to quit using substances among individuals with schizophrenia: implications for a motivation-based treatment model. Schizophr Bull. 1997;23:229238.CrossRefGoogle ScholarPubMed
87.Center for Substance Abuse Treatment. Assessment and Treatment of Patients with Coexisting Mental Illness and Alcohol and Other Drug Use. Rockville, Md: US Department of Health and Human Services. Treatment Improvement Protocol Series No, 9; 1994.Google Scholar