Assessment and Treatment of Patients with Coexisting Mental Illness and Alcohol and Other Drug Abuse
Treatment Improvement Protocol (TIP) Series 9

Case Examples: George and Mary

George is a 37-year-old divorced male who was brought into the emergency room intoxicated. His blood alcohol level was 152, and the toxicology screen was positive for cocaine. He was also suicidal ("I'm going to do it right this time! I've got a gun."). He has a history of three psychiatric hospitalizations and two inpatient AOD treatments. Each psychiatric admission was preceded by AOD use. George has never followed through with psychiatric treatment. He has intermittently attended AA, but not recently.

Mary is a 37-year-old divorced female who was brought into a detoxification unit with a blood alcohol level of 150 and was noted to be depressed and withdrawn. She has never used drugs (other than alcohol), and began drinking alcohol only 3 years ago. However, she has had several alcohol-related problems since then. She has a history of three psychiatric hospitalizations for depression, at ages 19, 23, and 32. She reports a positive response to antidepressants. She is currently not receiving AOD or psychiatric treatment.

Stimulants

Stimulants such as cocaine and the amphetamines cause potent psychomotor stimulation. Stimulant intoxication generally includes increased mental and physical energy, feelings of well-being and grandiosity, and rapid pressured speech. Chronic, high-dose stimulant intoxication, especially when combined with sleep deprivation, may prompt an episode of mania. Symptoms may include euphoric, expansive, or irritable mood, often with flight of ideas, severe impairment of social functioning, and insomnia.

Acute stimulant withdrawal generally lasts from several hours to 1 week and is characterized by depressed mood, agitation, fatigue, voracious appetite, and insomnia or hypersomnia. Depression resulting from stimulant withdrawal may be severe and can be worsened by the individual's awareness of addiction-related adverse consequences. Symptoms of craving for stimulants are likely and suicide is possible.

Protracted stimulant withdrawal often includes sustained episodes of anhedonia and lethargy with frequent ruminations and dreams about stimulant use. There may be bursts of dysphoria, intense depression, insomnia, and agitation for several months following stimulant cessation. These symptoms may be either worsened or lessened by the quality of the patient's recovery program.

Depressants

The general effect of the central nervous system depressants such as alcohol, the benzodiazepines, and the opioids is a slowing down of an individual's psychomotor processes. However, acute alcohol intoxication and opioid intoxication often include two phases: an initial period of euphoria followed by a longer period of relaxation, sedation, lethargy, apathy, and drowsiness.

Alcohol, barbiturates, and the benzodiazepines can cause sedative-hypnotic intoxication, especially when taken in high doses. Psychomotor symptoms include mood lability, mental impairment, impaired memory and attention, loss of coordination, unsteady gait, slurred speech, and confusion.

Hallucinogens, Marijuana, and PCP

The hallucinogens can cause a state of intoxication called hallucinosis, which has several features in common with psychotic disorders and a few in common with mood disorders. Hallucinogens such as LSD and drugs such as MDMA (methylenedioxy-methamphetamine, or Ecstasy) and MDA (methylenedioxyamphetamine) may precipitate intense emotional experiences that may be perceived as positive or negative mood states by the drug user.

These experiences are affected greatly by personality, preexisting mood state, personal expectations, drug dosage, and environmental surroundings. While many users will experience sensory and perceptual distortions, some will experience euphoric religious or spiritual experiences that may resemble aspects of a manic or psychotic episode. Others may have a deeply troubling introspective experience, causing symptoms of depression.

Marijuana, which has sedative and psychedelic properties, can cause a variety of mood-related effects. In the individual who has not developed tolerance for the drug's effects, high doses of marijuana can cause acute marijuana intoxication with euphoria or agitation, grandiosity, and "profound thoughts." Together, these symptoms can mimic mania. Because marijuana is only slowly eliminated from the body, chronic use results in relatively constant marijuana levels. Thus, daily marijuana use can be, in effect, a chronic marijuana intoxication. This state may include symptoms of chronic, low-grade lethargy and depression, perhaps accompanied by anxiety and memory loss. Phencyclidine (PCP) intoxication can include symptoms of euphoria, mania, or depression, in addition to sensory dissociation, hallucinations, delusions, psychotic thinking, altered body image, and disorientation.

Assessing Danger to Self or Others

It is critical to assess whether patients are threats to themselves or others. This evaluation helps to determine if there is a duty to protect patients from self-harm, interrupt intentions of violence toward others, and/or warn intended victims of patients' announced violent intent.

The responsibility to protect some patients from suicide or violence due to mental illness is not mitigated by confidentiality laws with respect to AOD addiction. Imminent risk, according to the laws of most States, justifies and requires commitment of patients or the warning of potential victims.

Generally, AOD confidentiality laws are very stringent. While some States protect against involuntary commitment for AOD abuse, they do not protect against commitment for AOD-induced psychiatric states which involve danger to oneself or others.

Screening personnel should assess whether suicidal feelings are transitory or reflect a chronic condition. Consider: Do patients have a suicide plan or serious intentions? Have they made past attempts? Whether the patients have had prior psychiatric hospitalization or are in current treatment should be determined. If patients are acutely dangerous to themselves or others, either voluntary or involuntary methods such as commitment should be pursued through local resources. AOD staff should have a thorough knowledge of local resources prior to and in anticipation of crises.

Placement in a safe holding environment can have a positive effect on patients with AOD problems and apparent suicidal intentions. If an intake facility cannot hold such patients, referral to an appropriate facility is recommended. For example, if someone walks into a program at 8:00 a.m. on Monday saying he wants to hurt himself, there should be time to talk the person down, assess treatment needs, and begin treatment or make assessment referrals. When necessary, an assessment should include a rapid triage. See the sections on the assessment of high-risk conditions in Chapter 7 (Personality Disorders) and Chapter 8 (Psychotic Disorders).

In virtually every recent study of successful or attempted suicide, AOD use and major depression are among the top associated conditions. Having both conditions simultaneously leads to even greater risk of suicide.

Patients with manic symptoms that approach psychotic proportions require thorough evaluation and require urgent care. Evaluation of mania should be done on a priority basis and should be monitored during subacute assessments.

Patients who have manic and hypomanic symptoms often minimize AOD and psychiatric disorders. Because of the symptom of grandiosity, manic patients may have poor insight into their AOD disorder, their mania, and their social situation. Manic patients may not see themselves as ill. They are usually hyperactive and irritable, and often become a danger to themselves or others through impulsivity, irritability, and poor judgment. When such people are also intoxicated, most will require involuntary commitment. See Chapter 8 for a discussion of assessment of patients with psychosis.

Medical Assessment

Patients, particularly the elderly, with mood disorders may have life-threatening medical conditions, including hypoglycemia (insulin overdose), stroke, or infections. These conditions, as well as withdrawal and toxic drug reactions, must always be considered and require a thorough physical examination and laboratory assessment. Assessment personnel should make appropriate referrals for medical assessment and treatment. Facilities that have no medical component should train assessment staff in triage and referral.

A plan should be developed to assess and treat medical conditions that precipitate or complicate mood disturbances. Endocrine disorders (such as thyroid problems), neurological disorders (such as multiple sclerosis), and HIV infection should be considered. In addition to obvious medical problems, it can be assumed that basic medical needs of patients with dual disorders are not being met, and a plan should be developed to address these deficits.

Initial Addiction Assessment Using the CAGE Questions

Clinicians can easily use the CAGE questions for screening (see Chapter 3) as well as adapt them for use with patients who may have mood disorders. For example, consider the following questions adapted from the CAGE questionnaire. "Have you ever cut down or increased your AOD use related to being severely depressed (or manic, etc.)?" "Do you ever get more irritable, angry, depressed, or annoyed when using AODs?" "Do you drink or use other drugs to deal with guilt feelings?" "Do you feel more moody in the morning or evening?" "Have you ever been suicidal when intoxicated?"

Initial AOD assessment should focus on recent use of alcohol and other drugs and a behavioral history. The assessor needs to know what drug has been used, in what quantity, with what frequency, and how recently. Past treatments, past episodes of delirium tremens, hallucinosis, blackouts, and destructive behavior should be recorded.

Social Assessment

The social assessment should evaluate the patient's social environment, especially in relation to AOD and psychiatric disorders. It is important to assess whether the patient experiences housing instability or homelessness. Where does the patient live? Does the patient live in a home? With whom does the patient live? With whom does the patient have regular social contact? Are the social and home environments stable?

In the patient's social life, is there a precipitating crisis occurring? What is the patient's existing support structure in the home and community? What role do others have? Is the home free of AODs? Are the home and social environments safe and free from violence? Do the home and social environments support an abstinent lifestyle? If not, it should be assessed whether the patient has the support necessary to overcome the adverse effect of home and social environments that do not support abstinence and recovery.

Violence by Others

During the screening interview, it is important to determine whether the patient's family members are physically abusive. It should be determined whether the patient is in danger. Physical and behavioral observation can be an important aspect of evaluation. The best predictor of future violence is previous violence.

Assessing Mood Symptomatology

During AOD use history taking and psychiatric screening and assessment sessions, patients with AOD disorders may overemphasize or underemphasize their psychiatric symptoms. For instance, patients who feel depressed during the assessment may distort their past psychiatric experiences and unwittingly exaggerate the intensity or frequency of past depressive episodes.

In contrast, patients who are profoundly depressed during the assessment may minimize their depressive illness because they think it represents a normal state. Indeed, some patients may believe that they "deserve" to be depressed, rather than recognizing that depression is a deviation from normal mood states.

Some patients experience feelings of guilt that are excessive and inappropriate. Other patients do not accurately label their depression and fail to remember that they have experienced depression before. Since patients frequently confuse depression with sadness and other emotions, it is important during the assessment to ask such questions as: "Have you ever seen a psychiatrist or therapist?" (If yes: "Why?") "Are you able to get out of bed in the morning or do you feel chronically tired?" "Have there been any recent changes in your sleeping patterns or in your appetite?"

Patients may select details from their psychiatric history consistent with their current mood. Those who are depressed may give a generally negative self-report. Addicted patients tend to emphasize psychiatric symptoms; psychiatric patients often underemphasize them. Unhappy addicted patients in a transient disturbance of mood will often rationalize their histories as lifelong depression. Thus, it is important to obtain collateral information from other people and from documents such as medical and psychiatric records. It is critical to continue the process of evaluation past the period of drug withdrawal.

Patients' responses to questions are often influenced by the way questions are asked. Most patients being interviewed tend to say what they believe the interviewer wants to hear. Therefore, the manner in which the interview is conducted is important. The interviewer should not lead the patient or make suggestions regarding the "correct" answer.

Because of the subjective nature of mood disturbances, the way in which questions are asked is important. Subjective and quantifiable questions should be asked in an objective way. Neutral, open-ended questions can be effective. Questions should be asked about impairment and disturbance of sleep, appetite, and sexual function, as well as other disturbances in functional impairment. Interviewers must be alert to contradictory responses and recognize that AOD-dependent patients have a tendency to distort information.

Medical Assessment

A plan should be developed to assess and treat medical conditions that can precipitate or complicate mood disturbances. Such conditions include endocrine disorders (such as thyroid problems), neurological disorders (such as multiple sclerosis), and HIV infection.

Some medical problems may have a heightened visibility because of their more obvious need for ongoing treatment. However, frequently the primary health care needs of patients with combined AOD and mood disorders are not pursued. For this reason, a plan to assess and meet these treatment needs should be developed.

Psychiatric and Addiction Screening

A subacute nonemergency setting is appropriate for screening and in depth diagnostic interviews for AOD and psychiatric disorders. The following sources can provide valuable information for screening and assessment: psychiatric history, previous medical and psychiatric records, and information from collateral sources such as employers, family members, and laboratory data.

A diagnostic interview, unlike a screening interview, can be done over the course of several sessions. Collateral sources, especially family members, can help clarify diagnostic issues and to help patients recognize the denial that may accompany their disorders.

A thorough history of AOD use, problems, patterns, and treatments should be obtained at this stage. Such information should be collected in a supportive nonjudgmental manner and over multiple interviews when possible. As with the psychiatric assessment, interviews with family and collateral sources are important.

Assessment Instruments

The diagnostic evaluation can include the clinical application of the DSM-III-R (or DSM-IV), perhaps in the form of the Structured Clinical Interview from DSM-III-R (SCID). The Brief Psychiatric Rating Scale, the Hamilton Scale, the Addiction Severity Index (ASI), and the Beck Scale can also be used to assess patients with dual disorders.

The SCID and the ASI are research instruments, but their demonstrated reliability and the advantages of consistent, standardized tools make it reasonable to administer them. Facilities that use these instruments should provide training in their use.

Psychosocial Assessment

A comprehensive psychosocial and vocational assessment can be an important aspect of the overall assessment. Evaluation of the patient's ongoing support system is important: What is the patient's support network, including friends and family? What patterns of interpersonal and family relationships exist within the nuclear family, the extended family, and the family of choice? What means of financial support does the patient have? What job skills does the patient have? Also, both ethnic and cultural backgrounds may alter a person's experience of both AOD and psychiatric conditions.

Management of Intoxication And Withdrawal

Management of withdrawal is often crucial to patients' safety and comfort. Withdrawal management can foster patient engagement in an ongoing treatment and recovery process. Although withdrawal management does not in itself produce enduring abstinence, it can help to increase retention in the treatment process, which improves long-term outcome.

Treatment strategies for intoxication range from letting patients "sleep it off" to confinement in a medical or psychiatric unit. Treatment for acute sedative-hypnotic withdrawal should include medically managed detoxification. Hospital settings are preferable, especially for depressed patients. Opiate withdrawal, while not life threatening, should also be treated medically and on an inpatient basis when possible. When such hospital-based settings are unavailable, residential or outpatient support with or without medication should be attempted.

Since unassisted withdrawal can cause seizure, psychosis, depression, and suicidal thoughts, it can be dangerous. Thus, successful detoxification is often a lifesaving process. Also, the medical management of withdrawal alleviates patients' suffering. It can provide a safe, supportive, and nonthreatening environment for depressed patients.

Medical Treatment

Acute treatment may be required for medical conditions identified in the medical assessment. For example, thyrotoxicosis (thyroid storm) is a life-threatening imitator of mania. Also, low blood sugar resulting from insulin overdose can resemble intoxication and depression.

Psychiatric Treatment

Patients who are imminently dangerous to themselves or others due to a psychiatric disturbance require emergency psychiatric treatment. Such treatment may involve voluntary or involuntary confinement.

The presence of a coexisting AOD use disorder or the suspicion that the psychiatric disturbance is AOD induced does not mitigate requirements for confinement. Rather, it may necessitate addiction-specific emergency treatment such as detoxification.

Patients not requiring confinement after evaluation may benefit from the support of existing family networks, existing programs, or when available, a rapid referral to a dual disorders treatment program.

Medical management of acute psychiatric symptoms is a treatment strategy during the acute phase regardless of long-term diagnostic results. Patients who experience hallucinations, delusions, mania, or significant disorganization of thought can benefit from medical treatment with antipsychotic medication (such as haloperidol or thioridazine) whether or not their symptoms are AOD induced. If potentially abusable medications are required (such as benzodiazepines for acute mania), a period of tapering or reduction of the medication within 1 or 2 weeks should be built into the original treatment plan.

Matching Patients and Treatment

During subacute treatment, the first decision to be made is whether patients should receive treatment in a psychiatric or addiction setting. In some locations, a third alternative is available: the dual disorders treatment setting. When realistic, both types of treatment should be provided simultaneously; integrated treatment generally is preferable.

Criteria for determining placement include the patient's treatment needs and potential for loss of control, as well as program features such as intensity, structure, and limitations. There are also considerations specific to mood disorders.

For example, if patients are experiencing mania or psychotic depression with disordered thinking, it must be determined whether the program is capable of handling and treating patients with these problems. While psychotic depression or mania is being managed, patients may then be shifted to an addiction or dual disorder setting. Appropriate matching of patients to facilities is important.

Some patients with dual disorders require rare or minimal psychiatric intervention, such as AOD patients whose bipolar disorder is successfully managed with lithium and regular blood level monitoring. Patients who require a strong recovery-oriented AOD abuse treatment program should also receive treatment for their psychiatric disorder (parallel treatment), with an emphasis on AOD treatment.

In contrast, patients who experience chronic and severe psychiatric disturbances and who episodically use AODs in a markedly destructive fashion will be better treated in a psychiatric program that has staff with expertise in addiction treatment. The optimal match for the patient with two active disorders that require treatment is the integrated facility. The intensity of each disorder dictates the relative intensity of each treatment component required.

Referral to an appropriate facility should be based on practical clinical criteria rather than on diagnosis alone. For example, patients' ability to understand, interpret, and tolerate the level of care being provided is most important. Some patients can participate in standard 12-step groups. Others will require 12-step groups that are intended for people with dual disorders (Double Trouble groups). Still others will require professionally run therapy groups that include patients with similar problems.

Effective treatment is based on what patients can understand and tolerate, which is not always predicted by diagnosis. Some psychotic patients function well in traditional programs, while others require special settings. An individual plan and a flexible ongoing reassessment of effectiveness are the best ways to ensure fit.

Psychiatric Medications

The judicious use of antidepressant and mood-regulating medication is appropriate for AOD patients with mood disorders. For example, patients who experience debilitating, misery-provoking, and incapacitating depressive symptoms may require antidepressant medication to participate in addiction recovery. (See Chapter 9 for further discussions of psychiatric medications.)

When depressive symptoms interfere with functioning, antidepressant medication can provide symptom relief and allow participation in recovery activities and activities of daily living. Relief from depression and anxiety can be significant motivating factors in recovery. Left untreated, symptoms can keep patients from taking part in recovery activities.

Patients who have difficulty engaging in Alcoholics Anonymous and other support groups and who do not exhibit evidence of a personality disorder may be depressed. Depression may manifest as social withdrawal, reclusiveness, or inability to complete activities of daily living such as going to work. Regularly spending many hours a day in bed or having serious insomnia may be cardinal signs of depression but are often seen among patients with AOD disorders during the first weeks and months of abstinence.

When prescribing antidepressants for people participating in addiction treatment, the acronym MASST is a reminder for clinicians of the areas of AOD recovery that need to be continually assessed. MASST is an acronym that reminds clinicians to assess patients' treatment needs regarding: 1) Meetings, 2) Abstinence from all psychoactive drugs, 3) Sponsor (or other helping people), 4) Social support systems, and 5) overall Treatment efforts. (See the discussion on the use of 12-step programs in Chapter 6.)

Case Management

Case management is crucial when patients are receiving simultaneous AOD and psychiatric care at separate settings (parallel treatment). There must be good linkages between the two treatment programs or providers. For example, patients might see their mental health counselor three times a week, go to both AOD self-help group meetings and mental health support group meetings, and receive AOD counseling. This level and mix of treatment can be overwhelming and confusing for the patient. An effective case manager can help with planning sensible treatment. Case managers can also facilitate the use of self-help groups. (See the discussion on the use of 12-step programs and other self-help groups in Chapter 6).

The separate disorders, their distinct treatment needs, and the divergent treatment approaches can cause staff splitting and turf problems that exacerbate the patient's denial and can cause other treatment problems. These problems can be avoided in almost all cases by effective communication and coordinated treatment planning. Good psychiatric and addiction treatment efforts are rarely truly conflicting.

Counseling and Psychotherapy For Depression

It is beyond the scope of this TIP to provide comprehensive details on the use of psychotherapeutic treatment. However, there are numerous resources regarding counseling and psychotherapy and depression. Recent publications written for both counselors and patients include The Good News About Depression by M.S. Gold and When Self-Help Fails by P. Quinnet.

Levels of Care

Once psychiatric and addiction severity has been determined, the treatment intensity, structure, and level of care required must be decided. From the least to the greatest intensity, the levels of care are:

1. Individual treatment with a psychotherapist or counselor. This is the least intensive level of care and includes few, if any, additional treatment services such as education.
2. Outpatient treatment. Within this level of care are services that vary greatly in structure and intensity. They include weekly to daily individual or group counseling, often in combination with additional treatment services such as detoxification, education, medical services, and specially focused groups. A multidisciplinary treatment team that includes assertive and intensive case management services may be needed for patients with severe and persistent mood disorders coexisting with AOD disorders.
3. Intensive outpatient treatment. This level of care includes treatment models such as partial hospitalization (which includes day treatment, evening, and weekend programs). For example, patients in day treatment generally participate in a full day of treatment for 5 or more days per week. Intensive outpatient treatment represents a range of treatment intensities. The level of intensity of a given program is based primarily on the number of treatment services offered. Generally, intensive outpatient treatment programs offer several treatment components such as group therapy, educational sessions, and social support services.
4. Halfway houses. These are settings that serve as safe AOD-free homes for people who can manage independent daily activities and can benefit from a structured and recovery-oriented group living arrangement. They vary widely in style and purpose.
5. Residential rehabilitation setting. Participation can vary from 30 days to 3 months or more, with patients removed from familiar surroundings and separated from AODs. In residential settings, patients receive education about dual disorders and learn important recovery skills such as utilizing groups, building trust, and talking about feelings. Therapy and support groups provide socialization and support and are the core of treatment. They prepare the patient for increased reliance on group support systems after discharge.
6. Therapeutic communities. Long-term therapeutic communities often require patient participation lasting from 6 months to 2 years. They are generally considered to be appropriate for patients with severe AOD disorders who have significant social and vocational deficits and who require long-term and intensive support, skill building, interpersonal abilities refinement, and trauma resolution.
7. Hospitals. Psychiatric or AOD hospitalization may be required for acute and subacute stabilization. In this age of managed care, hospitalization episodes have become much shorter and more acute than a few years ago. This puts more responsibility and risk on outpatient treatment providers.

Patients with severe and persistent mood and AOD disorders frequently require intensive and assertive treatment approaches as outlined in Chapter 8 on psychotic disorders. These patients will benefit from programs that can provide concurrent, integrated dually focused treatment. Also, these patients may require assertive case management to encourage medication compliance and to help them secure all psychiatric, addiction, and social services that they may need.

While some programs for dual disorders exist at all levels of care and in several program models, few AOD or mental health residential programs are dually focused, and many AOD programs refuse to accept patients who have histories of psychiatric disorders or who currently are prescribed medication for psychiatric disorders.

Traditional biases in the addiction field against psychiatric medication should be shed in light of the evidence that medicating existing disorders is humane, can be provided safely, and is necessary for some patients to engage in treatment. It is helpful to use psychiatrists who are skilled and are perhaps specialists in the treatment of coexisting psychiatric and AOD disorders.

Similarly, traditional psychiatric biases regarding rapid medication intervention and some clinicians' emphases on "getting in touch with feelings" can impede or reverse the AOD recovery process. Encouraging emotional expression without regard for the patient's stage of AOD recovery and stability can aggravate AOD disorders. Many residential facilities in the mental health system are inadequately controlled for the presence of AODs, are not abstinence based, and are not safe environments for AOD users.

Family Involvement In Treatment Settings

In all of the above settings, patients should receive family therapy and education, addiction and recovery counseling, and psychiatric counseling. Special attention must be focused on the chronic and cyclical nature of addiction and mood disorders and the likelihood of relapse.

Manic patients' uncontrolled grandiose behaviors have frequently caused their families great stress. Thus, family members need education about the nature of addiction, mania, and recovery. It is necessary for staff to ally with family members to ensure cooperation with treatment and reduce collusion between family members and the patient.

Similarly, the depressed patient is frequently seen as a family burden. Families need assistance to engage the depressed patient. The combination of depression and addiction can be very difficult for family members, and the challenges for the family must be considered.

Family and friends are often mistakenly afraid that they might exacerbate or aggravate depression or mania if they confront the dangerous and maladaptive behaviors and denial that result from addiction and mood disorders. Such fears are ungrounded. In fact, supportive intervention by the patient's social network is helpful with respect to both disorders.

The patient's family should be encouraged to confront the patient rather than remain reticent, and they should be coached to confront the patient in a supportive way. Support for and education of family members are necessary to encourage their constructive involvement and to help them avoid collusion in the patient's drug-using behavior or denial of psychiatric disturbance.

Professional and Vocational Planning

While some patients with dual disorders have severe and poorly remitting mood and AOD disorders, most patients improve, especially with careful psychiatric treatment. Since these disorders are generally well controlled, patients can experience very high levels of vocational, social, and creative functioning. As a result, vocational planning should be long term and accentuate patient strengths.

AIDS and HIV Risk Reduction

Studies demonstrate that HIV/AIDS risk reduction measures can make a difference in the rate of HIV infection. Potential and actual risk behaviors that are identified in evaluation should be addressed by referral to specific educational, training, and intervention programs.

Staff at these programs should be sensitive to patients' cultural and ethnic backgrounds, and understand how these can influence AOD use, sexual behaviors, and patients' receptivity to risk reduction measures. Programs should be proficient in communicating with patients using culturally sensitive language. However, the most culturally insensitive position is to avoid raising these issues out of fear or hesitancy.

With respect to risk reduction, special attention should be paid to the fact that, while depressed, many patients may be sexually abstinent, but this behavior may not reflect their typical behavior patterns. If patients are assessed while they are depressed, they should be asked to describe their sexual behavior during times when not depressed, or perhaps they should be assessed when they are not depressed. Mania and active AOD use markedly elevate the potential for high-risk behaviors and should be seen as extremely dangerous situations for the transmission of HIV and other sexually transmitted diseases.

HIV counseling and testing is appropriate and advisable for patients with coexisting AOD and mood disorders. There is no evidence that people with mood disorders become suicidal or experience thought disorganization in response to HIV testing.

Addiction Treatment

The long-term management of addiction includes participation in 12-step programs and other support groups, individual and group counseling, and in some cases, continued participation in a treatment program. The severity of a patient's illness should be matched with the appropriate treatment intensity and level of care.

Patients with dual disorders who experience low levels of psychiatric impairment require a level of care that can be provided in traditional low-structure abstinence-oriented addiction treatment programs. Dual disorder patients who experience severe psychiatric symptoms or cognitive impairment require a more intense level of care such as that provided by a highly structured dual disorders treatment program. Matching patients to the appropriate treatment and level of care can help achieve desired outcomes.

Psychiatric Treatment

The majority of patients receiving treatment for combined mood disorders and addiction improve in response to treatment. When they don't improve, there should be a reevaluation of the treatment plan. For example, a patient receiving antidepressant medication who is abstinent from AODs but anhedonic (unable to feel pleasure or happiness) requires a careful evaluation and assessment to identify resistant psychiatric conditions that require treatment. In this example, based on assessment, an additional treatment service such as psychotherapy may be added. Indeed, psychotherapy has been shown to improve the efficacy of addiction treatment and of psychiatric treatment that involves antidepressant medication.

When patients do not improve as expected, it is not necessarily because of treatment failure or patient noncompliance. Patients may be compliant and plans may be adequate, but disease processes remain resistant. Persistent attention to the addictive process and its complications as well as meticulous attention to psychiatric therapy usually leads to improvement. However, patients with severe and persistent AOD and mood disorders should not be seen as resistant, manipulative, or unmotivated but as extremely ill and requiring intensive treatment.

Long-Term Treatment Needs

Patients who have experienced sexual, physical, or psychological abuse may have problems that surface during acute treatment or that are identified during long-term treatment evaluations. Treatment needs resulting from these types of abuse should be addressed in the long-term treatment plan.

The resolution of problems related to sexual, physical, and psychological abuse usually requires specialized, long-term treatment. However, these problems should be addressed whenever they surface in any phase of treatment for AOD and mood disorders.

For example, addressing these problems during early recovery should be viewed from the perspective of anxiety reduction and consolidation of abstinence. At that phase of recovery, the treatment goal is to have patients contain or express their potent and surfacing feelings without using alcohol and other drugs. Later in recovery, these problems can be dealt with in terms of long-term stabilization and psychological resolution.

Continuing addiction counseling and participation in group support activities are useful to help consolidate abstinence. These recovery maintenance activities include participation in social clubs, 12-step programs, religious organizations, and other cultural institutions. Community-based activities can provide long-term stability to these patients.

At this stage of treatment, special treatment needs can be identified through targeted testing in such areas as neurologic, cognitive, and personality disorders. Special treatment needs should be specifically addressed by the appropriate treatment strategy. STD and HIV risk reduction, evaluated throughout the progression of illness, should now address the importance of long-term stable changes in behavior.

Family Issues

Family members should be evaluated for AOD problems in acute and subacute stages when the family members begin to become involved in the patient's treatment. There is usually adequate time to deal with family issues in the subacute phase, when personnel and family members become acquainted. Family members include household members as well as members of the patient's support system.

The family often needs and should receive treatment. After careful evaluation of family dynamics, the presence of addictive disorders or codependent behavior in the family should be evaluated. The presence of AOD and mood disorders in the patient is the best predictor of AOD and mood disorders in the family. A family history of one disease increases the risk for the other; a family history of both disorders multiplies the risk factor.

Family therapy can be provided on site. Individual family members should be referred for the treatment of specific problems when required. It is often necessary to help families "mop up the rage" that has accumulated. It is important to determine when to deal with the family as a group to resolve conflicts and when members need to work with a therapist alone to develop independence from dysfunctional reliance. Participation in Al-Anon and related self-help groups for family members should be encouraged and incorporated in the treatment schedule for family members.

Eating Disorders and Gambling

Other conditions that coexist with dual disorders include eating disorders and pathologic gambling. It may be helpful to refer patients to support groups that deal with these conditions. Eating disorders are more commonly diagnosed in women, and pathologic gambling is more commonly diagnosed in men.