The treatment needs of patients who have a psychiatric disorder in combination
with an alcohol and other drug (AOD) use disorder differ significantly from
the treatment needs of patients with either an AOD use disorder or a psychiatric
disorder by itself. This Treatment Improvement Protocol (TIP) consists of recommendations
for the treatment of patients with dual disorders.
This TIP was developed
by a multidisciplinary consensus panel that included addiction counselors,
social workers, psychologists, psychiatrists, other physicians, nurses, and program
administrators with active clinical involvement in the treatment of patients with dual
disorders. Consumers also participated on the panel.
This TIP was written
principally for addiction treatment staff. However, it contains information and treatment
recommendations that can be used by healthcare providers in a variety of treatment settings.
For example, it will be useful to people who work in primary care clinics,
hospitals, and various mental health settings. In addition, there are recommendations
that are targeted to administrators and planners of healthcare services.
A thoughtful attempt has been made to include information that the consensus
panel felt was clinically relevant. While many clinical topics are explored
in depth, some are only briefly mentioned, and a few are avoided altogether.
It is not the goal of this TIP to provide an exhaustive description
of all of the possible issues that relate to the treatment of patients with
dual disorders. Rather, the primary goal is to provide treatment recommendations
that are practical and useful.
Indeed, the usefulness of this TIP can
be enhanced by blending these recommendations with those of another TIP such
as Intensive Outpatient Treatment for Alcohol and Other Drug (AOD) Abuse.By doing so, treatment protocols can be developed which will meet
very specific treatment needs.
Chapter 2
-- Dual Disorders: Concepts and Definitions -- provides descriptions
and diagnostic criteria for AOD abuse and dependence. There is also a description
of the possible interactions between AOD use and psychiatric symptoms and
disorders.
Chapter 3 -- Mental Health and Addiction Treatment
Systems: Philosophical and Treatment Approach Issue -- describes the similarities,
differences, strengths, and weaknesses of the treatment systems used by patients with
dual disorders: the mental health system, the addiction treatment system, and
the medical system. Similarly, there is a description of treatment models
most frequently used: sequential treatment of each disorder, parallel treatment
of each disorder, and integrated treatment of both disorders. The chapter
includes a discussion of critical treatment issues and general assessment issues
in providing care to patients with dual disorders.
Chapter 4 -- Linkages for Mental Health and AOD Treatment
-- describes several areas of critical concern for programs that provide
services to patients with dual disorders. There are discussions regarding policy
and planning; funding and reimbursement; data collection and needs assessment;
program development; screening, assessment, and referral; case management;
staffing and training; and linkages with social service, health care, and
the criminal justice systems.
This chapter should be particularly useful
for administrators and political planners who address the potential administrative
overlaps and gaps that exist between the mental health and addiction treatment systems.
The semi-outline format of the chapter will allow planners of services
a rapid checkup of specific areas such as funding and reimbursement, program
development, and case management.
While entire books can be written regarding specific psychiatric disorders, this
TIP describes the disorders that account for the majority of psychiatric problems
seen in patients with dual disorders. TIP chapters that address specific psychiatric
problems include Chapter 5, Mood Disorders;Chapter
6,Anxiety Disorders; Chapter 7, Personality
Disorders; and Chapter 8,Psychotic Disorders.
By combining chapters, strategies for treating patients with complex disorders
may be developed. For example, by combining techniques recommended for the
treatment of personality and mood disorders, borderline syndrome treatment strategies
can be developed.
Both content and stylistic approaches vary markedly
among these chapters, reflecting the differences of consensus panel members who
composed them. Since these differences in stylistic approaches may be useful to
the reader, they have been retained.
Chapter 9 -- Pharmacologic Management -- is a
brief overview of the types of medications used in psychiatry and addiction medicine
and for patients with dual disorders. A stepwise treatment model that can
minimize medication abuse risks is discussed, and cautions about drug interactions
are reviewed.
Addiction treatment program staff are increasingly encountering
patients who require prescribed medications in order to participate in recovery.
For this reason, it is important for clinical staff to have an understanding
of the principle medications used in psychiatry and how they are used. In
addition, agencies that hire a consulting psychiatrist may want to review with the
psychiatrist the prescribing issues raised in this chapter.
A bibliography is
provided for further study in Appendix A. A brief overview
of sample cost data for the treatment of dual disorders is in Appendix B. It compares three treatment programs on features such as salary
ranges and administrative costs.
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