Kenneth Minkoff, MD
Senior system consultant, ZiaPartners, Inc, which provides consulting services for co-occurring disorders. Part-time assistant professor of psychiatry at Harvard Medical School.
Dr. Minkoff has disclosed that he has no relevant financial or other interests in any commercial companies pertaining to this educational activity.
Patients with co-occurring disorders (COD, also known as “dual diagnosis”) are often regarded as among the most challenging patients to treat. You need to track two conditions that interact in unpredictable ways, with patients who may not be inclined to follow your recommendations. It’s no surprise that such patients typically have poorer outcomes than those with either disorder in isolation. And these patients are far from rare. For example, approximately 30% of people with unipolar mood disorder—and at least 60% of those with bipolar disorder—have lifetime substance use disorder (Regier DA, JAMA 1990;264(19):2511–2518). Based on this, many years ago I coined the phrase: “Co-occurring disorders are an expectation, not an exception.”
After over 30 years of treating patients with COD and teaching clinicians about best practices in COD treatment, I’ve developed a system of steps you might find helpful. If you learn to do this work well, not only will you begin to master the challenge these individuals present, but you may actually have more fun helping these interesting patients toward dual recovery.
Three assessment steps
Step 1: Welcome your co-occurring patients. According to the intake form, your next patient just got out of alcohol detox and wants treatment for depression and anxiety. Inwardly, you might groan. You worry this will be a complicated and time-consuming evaluation, possibly including one of your least favorite situations: a person with addiction requesting benzodiazepines or other addictive drugs.
My first message is to relax. Treating people with COD is a slow process in which patients make small steps of progress for each condition. It’s important for psychiatrists to adjust their expectations accordingly. We don’t have to “fix” anything in the first meeting; we just have to begin a relationship that will be helpful over time. Welcoming is a key step.
Whenever I see a new COD patient, I start with a simple mantra: “The people I work with are going to be exactly who they are, no matter how much I might hope they are someone else.” It makes me less prone to frustration, and the work more successful, if I welcome the patient with that in mind.
Here’s a basic welcoming “script” that I often use: “I know you’re having a hard time. Thank you for coming. You are in the right place. I know my job is not to ‘fix’ you but rather to get to know you, inspire you with hope, and help you figure out how to get connected to me (and members of my team) so we can help you address all your issues to make progress step-by-step toward a happy, hopeful, and meaningful life.”
Step 2: Identify your patient’s goals. The next step in the process is to identify the person’s goals, which helps to instill hope. This helps shift the discussion from an immediate focus on symptom relief to the critical question of how any interventions contribute to helping the person experience meaning and purpose.
“Can you tell me what your vision of a successful life looks like?” I ask the patient. “What kind of help would you most like to achieve that vision?”
With this approach, you create a context in the first 10 minutes of your evaluation that will make the rest of the information gathering go more smoothly, in addition to creating a platform for ongoing partnership.
Step 3: Follow four rules in establishing a diagnosis in COD:
a. The assessment begins immediately. Some readers may remember being taught to wait several weeks or months to see whether a patient’s depression, anxiety, or psychosis “clears up” once the patient has stopped using a substance. However, the current standard of care is that treatment of mood and anxiety symptoms should begin immediately, even when the person is currently using or has recently used substances. An integrated, longitudinal assessment will help clarify the course of both the mental illness and the substance use disorder, delineate how they intersect, and lead to better treatment decisions. (You can find a good review of the evidence for this type of treatment from SAMHSA at https://store.samhsa.gov/shin/content/SMA08-4367/TheEvidence-ITC.pdf.)
For example, I once evaluated a 52-year-old man with heroin addiction who was admitted to the hospital for treatment of severe depression. I learned during the history that—remarkably—he had functioned with heroin addiction for decades, holding a job and maintaining family relationships. Recently, however, his brother had died, and he had been laid off. His heroin use continued as before, but over the past several months, for the first time, he developed classic symptoms of major depression, severe enough to lead to psychiatric admission.
The “traditional” approach would be to insist on heroin detox and a “drug-free” period before initiating antidepressants. Instead, I viewed this patient as having a diagnosis of long-standing opioid addiction, lately with an additional diagnosis of major depression—not different from someone with cardiac disease who might develop depression unrelated to that illness. I started him immediately on antidepressants, at the same time beginning to explore his willingness to consider opioid maintenance treatment for his addiction. He responded to antidepressants, and agreed to an evaluation for opioid maintenance after discharge from the hospital.
b. Diagnoses are established by history, not by symptoms alone. If someone comes into your office drunk, you can’t conclude that the person has alcoholism—you can only diagnose alcohol intoxication. In order to diagnose substance use disorder, you need to get a history of substance use over time. Similarly, if a person comes in without drinking for five years, but reports undergoing many prior detoxification admissions and now attends AA daily, that history allows you to diagnose alcohol use disorder in remission, and you need to take that into account while addressing any comorbid psychiatric conditions. The same thing applies if the person presents with current symptoms of hearing voices or anxiety attacks, with or without recent substance use. The only way to make a diagnosis is to get a good history, discover whether or not there is a long-standing established disorder that needs continuing care, and proceed accordingly.
c. If a patient has a long-standing established psychiatric diagnosis by history, that patient likely still has it, even with current or recent substance use. When patients present with both psychiatric issues and active substance abuse, it may seem as if the substances are causing or aggravating the symptoms. In such cases, it may be tempting to assume that the cure for the psychiatric symptoms is simply to stop the substance use. That’s not necessarily the case.
Consider the following: A young man came in to see me with significant panic and daily cannabis use. A detailed history revealed that he had been treating his anxiety with cannabis for many years. While this strategy seemed helpful for a while, recently he had been having more anxiety, and using more cannabis, which in turn was interfering with his work and relationships. I pointed out that while cannabis apparently eased his anxiety initially, there is a well-known phenomenon in which increasing use can actually worsen anxiety. We initiated an SSRI for his panic disorder, and then worked on helping him taper off the cannabis. I warned him that even though his anxiety would initially be exacerbated as he tapered the cannabis, in the long run, this approach was his best shot at treating his long-standing anxiety disorder successfully. The patient was compliant with this approach, and over time, it worked to reduce his use and assist with his anxiety.
d. Do an INTEGRATED assessment—don’t artificially divide mental health and substance use history. It is common practice to obtain mental health history and substance use history separately; in fact, these are often split into different categories on standard evaluation forms. In my experience, this approach often results in disjointed and unhelpful information. Instead, I recommend you try obtaining an integrated history to get a more accurate understanding of the problem. A good technique is to use the history of present illness method we all learned in medical school, in which we start by asking when the patient was last doing well, and then find out when and how the current illness episode began.
In order to keep my information gathering efficient and quick, I have learned not to focus on the details of what led to each admission or relapse. Instead, I am most interested in looking for the last time the patient did well. This type of assessment focuses on multiple issues that occur during a period of success. Therefore, I have come to call this approach “integrated, longitudinal, and strength-based.” (See the Zia Tools link at http://www.ziapartners.com for more information on how to document such an assessment.)
For example, I might start with, “Lately it seems like you’ve been going through a chaotic period, but before that there was a period when you were doing well. Please give me a picture of what was going on. Where did you live, who were you living with, and how were you supporting yourself? What kind of treatment were you receiving for your bipolar disorder? What were you doing to stay sober?” I’m trying to get an integrated view of one brief “good” period. Granted, in someone with a persistent and disabling mental illness, this period might not be wonderful, but it does represent a baseline period when the person was managing life’s challenges relatively well.
Next, I ask, “So how did things start to unravel? What were you doing differently?” In response, I typically hear about the person stopping medication, skipping AA meetings or therapy sessions, spending time with friends who were using, etc. In response, I say something like, “I’m glad you’re here; you did the right thing to come for help. The good news is we know from your history exactly what helps you manage both your mental health and substance use conditions. You’ve gotten a little off track, and now that we know what works, let’s get you back on track as quickly as possible and help you learn some skills so things go even better in the future.”
Tip 1: Use the stages of change approach to help measure treatment progress and manage your expectations. The stages of change (pre-contemplation, contemplation, preparation, action, and maintenance) have been covered in the January 2014 issue of CATR (I like to divide the action stage into “early” and “late”). These stages describe the process everyone goes through to make improvements in their lives, including health, nutrition, and relationships—as well as mental health and substance use. The staging language helps us understand that the pace of change is incremental and slow.
Here are two useful facts about stages of change:
—Stages of change are problem-specific, not person-specific. Each person has many issues and may be in different stages of change for each one. For example, a patient in the late action stage for mental illness treatment (receiving medication and therapy) may still be in the pre-contemplation stage for substance abuse (using drugs and not wanting to discuss even the possibility of change).
—Interventions and outcomes have to be stage-matched. Your intervention should be tailored to your patient’s stage of change. For example, don’t skip ahead and discuss a prescription for naltrexone with someone who is in “contemplation” about a drinking problem—that is, a patient who is willing to discuss the problem but not yet interested in change. Instead, for this individual, you might continue to treat the psychiatric illness, while helping the patient self-examine as follows: “What is the right amount of substance use for me to achieve my most important life goals?” Look for small successes, and work with patients where they are.
In consulting with treatment agencies, I often hear about clinicians’ frustration with the pace of clients’ improvement. For example, I spoke with one psychiatrist who had treated a young woman for psychosis for two years, yet she was “still using.” I asked for more details, and learned that the patient came into the clinic addicted to alcohol and methamphetamine, unwilling to even discuss her substance use. Over the two years, she engaged with her doctor and team, received medication for her psychosis, and gradually progressed. Recently, she had two three-month periods of sobriety, and she had stopped using meth. I pointed out that although this client was still actively drinking, she had moved beyond pre-contemplation and was now in the early action stage. This is real progress, because moving through stages of change normally takes months or years in a person like this.
I suggest memorizing the stages and learning to “stage” your patients for each issue. Your patients may be progressing more than you realize—and if you are stage-matched in what you do, they will progress even faster.
Tip 2: It is a standard of practice to prescribe necessary non-addictive psychotropics for known serious mental illness even if the patient is using substances. Just like other medications, psychotropic medications for a known illness, taken as prescribed, continue to work—albeit perhaps less effectively—even when the person is using substances.
While combining prescribed medications and substances can be risky, using substances is risky in and of itself, whether or not people are on medication. For most people with severe mental illness, the risk of a bad outcome increases when they are unmedicated, and even more so if they are disconnected from care.
CATR Verdict: Invest time and energy in connecting with your COD patients and carefully sequencing their histories. Progress will still be slow, as it may be for any single disorder, but it will occur.