Dual-Diagnosis Patients: Slow Progress in Improving Care

The therapeutic challenges presented by comorbid psychiatric and substance abuse disorders, along with strategies and initiatives to improve treatment, were the focus of a recent collection of studies and reviews in the Journal of Substance Abuse Treatment. The articles underlined the fact that debility caused by this comorbidity is frequently exacerbated by fragmentation of treatment and inadequacy of health insurance benefits.

Epidemiological studies of this population were reviewed by Westley Clark, MD, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration (SAMHSA), and colleagues¹; they noted that dual-diagnosis patients have inadequate access to treatment, but also that the data have informed initiatives undertaken by SAMHSA to improve both quality and accessibility of treatment.

"Screening and referral must become routine so that mental and substance use disorders receive equal treatment," Clark and colleagues declared. "In addition, there is a need to reach people who have co-occurring mild to moderate mental and substance use disorders before their conditions become more severe."¹

Across the large population surveys reviewed by Clark and colleagues, the rates of alcohol and drug use are higher among individuals with psychiatric illnesses. In one survey, substance abuse disorders occurred in about 20% of persons with mood disorders in comparison to 8% of those without mood disorders; and in about 18% of persons with anxiety disorders, compared with 10% of those without that comorbidity.²

Despite the large numbers of patients with co-occurring mental health and substance use disorders, relatively few were found to have received treatment. Lack of access to treatment and health insurance coverage were most common in traditionally underserved groups such as the elderly, minorities, those with low incomes, and residents of rural areas. The surveys also indicated that many dual-diagnosis patients do not perceive the need for treatment, which Clark and colleagues characterized as a major barrier to providing care.

A lack of cohesive treatment is an additional impediment to care, according to Clark and coauthors. "Persons with [co-occurring disorders] frequently fall through the cracks between the mental health and substance treatment systems, are shuttled between systems that can only treat one type of disorder, or receive simultaneous care from clinicians in segregated treatment systems that do not have the capacity to share information," they said. "The result is often a fragmented, confusing and ineffective treatment experience that cannot appreciate the unique interrelations between an individual's co-occurring disorders."¹

Initiatives to improve care

Several initiatives have been undertaken by SAMHSA to improve the care of patients with dual diagnosis, according to Clark and colleagues. The Co-occurring State Incentive Grant (COSIG) and Co-occurring Center for Excellence provide funding and training to encourage workforce development and adoption of evidence-based practices. SAMHSA has recently emphasized population-based preventive strategies and used the epidemiological data to target particularly susceptible populations for preventive services.

The COSIG program, Clark and colleagues indicate, "makes a major commitment to help states remove infrastructure barriers, or the most critical roadblocks for systems seeking to provide integrated care." One example of a program emerging from COSIG funding is a Web site developed in Pennsylvania for health professionals that provides courses in treating co-occurring disorders (http://www.pa-co-occurring.org). In Virginia, the COSIG funds were leveraged to expand a service integration pilot project into additional facilities.

With epidemiological data indicating distribution patterns of co-occurring disorders, SAMHSA launched a series of regional workshops for state transformation teams, in concert with the National Governors Association Center for Best Practices and the National Association of State Mental Health Program Directors. SAMHSA intends this effort to result in "more effective blending and use of available resources, and improvements in the infrastructure for delivering services to adults and children in need."¹

Readiness and motivation for treatment and change

The lack of perceived need for treatment is considered in a review by Carlo DiClemente, PhD, and colleagues³ from the University of Maryland. Although denial of need for treatment and the absence of readiness for treatment have been studied in patients with substance abuse disorders for more than 20 years, they found the literature on dual-diagnosis patients to be recent and limited.

DiClemente and colleagues note that motivation to change is also important for the progress of patients with mental illness, particularly affecting adherence to medication regimens and responsiveness to psychosocial interventions. They find, however, that there is insufficient research to ascertain how patients with dual diagnosis can be motivated to change.

"The questions include whether these dually diagnosed individuals can access the intentional process of change and make use of decision making, intentionality, commitment, planning, and experiential and behavioral processes of change when they make changes in their substance-abusing or adherence behaviors"³

DiClemente and colleagues call for greater efforts in assessing and influencing motivation to change within the process of treating this population. They suggest, for example, that the choice between referring a patient to an outpatient or to a residential treatment program, aside from available resources and proposed benefits, should take into consideration the motivation and required level of support to change, in addition to traditional considerations of problem severity or the initial treatment setting.

"Clearly, less motivated individuals need more proactive and intense interventions," they wrote.³

Testing treatment strategies: Modified therapeutic community

The efficacy of a modified therapeutic community was compared with that of a basic program for 198 outpatients with dual diagnosis in a study published by Stanley Sacks, PhD, and colleagues⁴ of the National Development and Research Institutes in New York. In this study, the modified treatment community (MTC) program included the basic program services in addition to a psychoeducational seminar, trauma-informed addictions treatment, and case management. The seminar was intended to improve clients' understanding of mental illness, the investigators explained. The particular addictions treatment helped clients discuss issues of addiction and recovery and develop means to cope with past and present trauma. The 12-week intensified outpatient program was provided in 3-hour sessions 3 days a week.

Several self-report instruments were used to compare the efficacy of the treatment programs. The investigators found a modest advantage to the MTC approach, with significant differential of treatment effect on only 3 of 34 measures. Patients in the MTC appeared to do better on measures of psychiatric severity and housing stability. There was no difference between groups, however, on measures of substance use, crime, or employment. Nevertheless, the investigators said, the findings suggest that "adding a restricted array of targeted and time-limited interventions can improve outpatient substance abuse treatment."

In a separate review of 4 other studies, Sacks and colleagues found that there was support for MTCs when the MTC model is "reshaped to accommodate the individual needs, impairments, and deficits of clients with co-occurring disorders."⁵

Behavioral approach

A randomized prospective trial of a behavioral approach for treating opioid-dependent patients who also had antisocial personality disorder (APD) was reported by Karin Neufeld, MD, and colleagues⁶ from Johns Hopkins University. The investigators compared an experimental condition involving a structured contingency management intervention with a control that used standard methadone maintenance.

Most earlier studies of the treatment response of this population, the authors pointed out, have been retrospective or post hoc evaluations of response to standard treatment programs for drug abuse. "Less is known about the response of these patients to interventions that target both unique and shared symptoms of both disorders," they said.

In this study, 100 patients in a methadone maintenance program for opioid dependence who also met di-agnostic criteria for APD were randomized to either continue in the unchanged methadone maintenance program or receive additional behavioral intervention. The experimental condition protocol consisted of 9 steps of care with rapid delivery of predictable and increasingly positive consequences for attendance at scheduled counseling sessions and abstinence from drug use.

The control group was also offered counseling sessions and was exposed to some positive and negative incentives such as the privilege of a take-home methadone dose or the imposition of a less convenient clinic dose time. The investigators noted that the positive and negative incentives in the control were presented separately and were determined for the individual solely by the clinical staff, rather than being consistently available in conjunction with behavioral targets, and that they were only available after relatively extended periods of treatment.

Attendance at counseling sessions was recorded, as were results of weekly urine tests for presence of opiates, cocaine, sedatives, and alcohol. Clinical assessments were accomplished with the Structured Clinical Interview for DSM-III-R, Psychopathy Checklist-Revised, and the Addiction Severity Index.

The investigators found a significantly higher (4-fold) rate of attendance (80%) at scheduled counseling in the experimental group. They note this rate is also considerably higher than the average of approximately 50% reported in other studies of opioid-dependent patients receiving methadone. There was also a higher incidence of drug-negative urine specimens in the experimental group, although the difference was not statistically significant.

High psychopathy was associated with drug use in both groups, although the association was weakened when treatment condition, number of APD symptoms, and other psychiatric comorbidity were controlled for. The investigators indicate that this suggests that the negative influence of high psychopathy on drug use can be modified by at least some types of treatment.

"While notable clinical improvement may not render this an 'easy to manage' group of patients because of ongoing symptoms of antisocial personality," Neufeld and colleagues commented, "the clinical gains they can achieve provide a strong basis for therapeutic optimism."⁶

In a "Perspective" article, Sacks and colleagues⁷ suggested areas for future research, including those that will inform allocation of treatment resources and those that will promote the conceptualization of addiction as a chronic, rather than an acute condition. They note that most studies of patients with co-occurring disorders have been conducted in mental health settings rather than in substance abuse treatment sites, and so have disproportionately sampled a subgroup with more severe and persistent mental disorders.

Treatment outcomes for this population should be assessed for both mental health and substance use disorders, Sacks and colleagues believe, and ideally comprise a broad array of domains that mark treatment progress and stabilization. For substance abuse, these could include criminal activity, HIV risk behavior, employment, stable housing, and participation in parenting and family activities. Appropriate mental health outcomes include symptom change, medication compliance, and improved psychological well-being.

Applying the results of research and effectively integrating care within the substance abuse and mental health treatment systems, Sacks and colleagues said, "will require each system to augment the treatment it currently provides to meet the full range of its clients' differential needs."⁷

References:

References

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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.

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DiClemente CC, Nidecker M, Bellack AS. Motivation and the stages of change among individuals with severe mental illness and substance abuse disorders.

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4.

Sacks S, McKendrick K, Sacks JY, et al. Enhanced outpatient treatment for co-occurring disorders: main outcomes.

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Sacks S, Banks S, McKendrick K, Sacks JY. Modified therapeutic community for co-occurring disorders: a summary of four studies.

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Neufeld KJ, Kidorf MS, Kolodner K, et al. A behavioral treatment for opioid-dependent patients with anti- social personality.

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Sacks S, Chandler R, Gonzales J. Responding to the challenge of co-occurring disorders: suggestions for future research.

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