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Implications of Comorbidity for Clinical Practice
C H A P T E R
34 Implications of Comorbidity for Clinical Practice David J. Kavanagh Institute of Health & Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia
O U T L I N E People with Co-Occurring Disorders Have a Right 326 to Equal Access to Quality Care Co-Occurring Disorders Are Common and Often Have a Profound Impact Screening for Co-Occurring Problems Should Be Routine A Boutique Service Is Impractical: Existing Agencies Must Address the Issue Universal Interventions Must Be Capable of LargeScale Implementation
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Tobacco Smoking Is Endemic and Affects Morbidity, Mortality, and Functioning 328 Assessment and Interventions Should Include Tobacco Smoking 328 Co-Occurring Problems Are Often Multiple and Closely Interlinked Treatments Should Address the Multiple Issues of Concern
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Better Policies and Practices for Co-Occurring Disorders Require Organizational Change 331 Co-Occurring Disorders Must Be Core Business for the Organization and Practitioners 331 Effective Comorbidity Practice Should Be Recognized and Rewarded 331 Required Skills Must Be Present or Taught, and Cues to Use Them Provided 332 A Culture Supporting the Use of the Intervention Should Be Fostered 332 Conclusion
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In the past, co-occurring substance use and mental health problems have often been missed, because related screening and assessment has not been routine. When co-occurrence has been identified, affected people have often been excluded from services, or were referred to other agencies without assistance to ensure that they arrived and received help. If they did receive treatment, it was often focused on a single problem domain, or was offered by different agencies, which frequently were in Interventions for Addiction, Volume 3 http://dx.doi.org/10.1016/B978-0-12-398338-1.00034-8
Closely Interrelated Problems Require Integrated Treatments A Single Health Agency to Assist an Individual Is Typically Needed Strengths, Resources, Functional Sources of Pleasure Should Be in Assessment and Treatment
different locations, had differing priorities, policies and procedures, and did not share record systems or communicate effectively in other ways. As a result, treatment plans often missed key elements or had conflicting goals and demands. Practitioner training typically focused on either addictive disorders or other mental health problems, and graduates lacked skills and confidence in dealing with problems outside their focal domain. Despite international attempts to improve services for people with
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co-occurring problems, many of the issues remain. However, we now have more information on comorbidity and its management, and on ways to disseminate sound, evidence-based care. This knowledge can guide our development of services that are more responsive to these cooccurring problems. Principles or observations about cooccurring disorders and their implications for practice are summarized in Table 34.1.
disorders to an equal access to the same quality of care as if they had a single problem. The moral imperative presented by this right of access is the guiding assumption underpinning all the recommendations that follow.
PEOPLE WITH CO-OCCURRING DISORDERS HAVE A RIGHT TO EQUAL ACCESS TO QUALITY CARE
In Western countries, 25–30% of people with a mental disorder also have a substance use disorder at some time in their lives. In the landmark US Epidemiologic Catchment Area (ECA) study in 1980–84, this corresponded to 2.7 times the risk of a substance use disorder if the person had a mental disorder. In antisocial personality disorder (84%, OR ¼ 29.6), bipolar I disorder (61%, OR ¼ 5.3), and schizophrenia (47%, OR ¼ 4.6), the lifetime prevalence and increased risks were particularly high. Mental disorders are also common in people with substance use disorders. In the ECA study, the lifetime rate of a mental disorder in people with an alcohol use disorder was 37% (OR ¼ 2.3) or 53% (OR ¼ 4.5) in people with another substance use disorder. Since rates of substance use disorders in the community as a whole are higher among men, and depression and anxiety are more common in women, there are gender differences in risk that reflect these overall trends. Generally, problematic substance use is also more common in younger people. Exact proportions of affected people change across countries, over time, and in specific religious or ethnic groups, with many indigenous groups at particularly high risk of both substance misuse and mental disorder or distress. Community rates of both substance-related and other mental health problems increase even further when subclinical conditions are included. Treatment settings have greater rates of comorbidity than the general community, especially where crisis care is delivered. This is partly because co-occurring issues have synergistic effects on functioning and distress, and crises that trigger demands for treatment can occur from either problem. In many agencies, this means that a substantial majority currently has a cooccurring substance-related problem. Not only are co-occurring disorders common tragically, but they also pose substantially increased risks of morbidity and mortality. Substance use increases the risk of illness and fatality from a variety of causes, some directly related to the substance and its metabolism (e.g. overdose, withdrawal, and vitamin depletion), some as a consequence of psychological or lifestyle impacts (e.g. suicide, injury, being a victim of assault, and hyperthermia), and some related to illegal supply (e.g. toxic additives).
The historical situation described above clearly violated the basic right of people with co-occurring TABLE 34.1
Principles and Observations on Comorbidity Practice and Their Implications for Services
Principle or observation
Implications for services
People with co-occurring disorders have a right to equal access to quality care
Underpins all the implications that follow
Co-occurring disorders are common and often have a profound impact
Screening for co-occurring problems should be routine A boutique service is impractical: existing agencies must address the issue Universal interventions must be capable of large-scale implementation
Tobacco smoking is endemic and affects morbidity, mortality, and functioning
Assessment and interventions should include tobacco smoking
Co-occurring problems are often multiple and closely interlinked
Treatments should address the multiple issues of concern Closely interrelated problems require integrated treatments A single health agency to assist an individual is typically needed Strengths, resources, and functional sources of pleasure should be included in assessment and intervention
Better policies and practices for co-occurring disorders require organizational change
Co-occurring disorders must be core business for the organization and practitioners Effective comorbidity practice should be recognized and rewarded Required skills must be present or taught, and cues to use them provided A culture supporting the use of the intervention should be fostered
Note: These estimates are based on the results from Kavanagh, D. J., & Connolly, J. M. (2009). Interventions for co-occurring addictive and other mental disorders (AMDs). Addictive Behaviors, 34, 838-845.
CO-OCCURRING DISORDERS ARE COMMON AND OFTEN HAVE A PROFOUND IMPACT
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CO-OCCURRING DISORDERS ARE COMMON AND OFTEN HAVE A PROFOUND IMPACT
Co-occurring disorders also tend to have profound and widespread impact on the functioning and quality of life of the individual and their family. Even mild forms of co-occurring disorders can have a powerful functional impact: for example, any substance use at all by someone with severe mental disorder who is unemployed can entail missing meals, going into debt, having housing problems, or foregoing highly valued opportunities for rehabilitation or employment. If cognition, impulse control, motivation, and social skills are substantially impaired, adding intoxication can take the person from marginally appropriate to dysfunctional behavior, with significant and lasting consequences. Families experience economic impacts (e.g. financial burdens of housing, medical care and other support, lost work time, and property stolen to support substance use), as well as emotional hardship and disruption to their social and recreational activities. While the functional impacts of co-occurring disorders are often substantial, the companion disorders are often of mild or moderate severity, partly, because less severe problems are much more common in the general community. So, although the relative risk of bipolar disorder or schizophrenia increases to a greater extent than anxiety disorders in people with addictive disorders, anxiety and unipolar depression are most commonly seen. This observation offers some optimism in approaching co-occurring disorders. For example, a study by Green and colleagues showed that some people with even very severe mental disorders spontaneously reduce consumption of cannabis use in the month after they experience a negative effect from it. This suggests that even this group may often have existing skills in self-control that they can exercise if sufficiently motivated. Together with the moral imperative to provide equal access to service, these observations have important implications for agencies addressing mental health or substance use.
Screening for Co-Occurring Problems Should Be Routine In assessments and reviews of mental health problems, protocols should include questions about all substance use, with brief screening for associated problems, followed by more detailed assessment of affected areas. Similarly, assessments and progress reviews of people with substance use problems should routinely include screening for psychological distress and disorder, with a full symptomatic assessment being conducted where indicated. Universal screening needs to be brief and easily implemented within the agency’s standard assessment protocol if it is to be feasibly
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undertaken without significantly increasing costs per patient. Fortunately, brief screening tests are available to assist (see Screening and Assessment of Comorbidity).
A Boutique Service Is Impractical: Existing Agencies Must Address the Issue Some agencies have nominated a staff member or group of staff to deal with co-occurring disorders. However, if specialist practitioners have to assess and provide ongoing management for patients with cooccurring disorders, the high incidence of these problems either means that they will soon be swamped with referrals (preventing others from receiving treatment), or selecting only some for special attention. There is some merit in devoting specialist time to a subgroup that presents greater challenges for care, as long as that does result in better outcomes. However, a consequence is that a large group would then miss out on that attention, unless the specialist staff became the primary practitioner group. Given the moral imperative of equity of access to care, agencies may be better advised to give specialists in co-occurring disorders the roles of consultants or trainers rather than case managers, so their expertise becomes spread throughout the organization and all affected people can receive appropriate treatment.
Universal Interventions Must Be Capable of Large-Scale Implementation The most readily implemented minimum standard for a universal intervention to address co-occurring disorders is a treatment that is effective for many affected people, but minimizes additional contact time. There are several potential forms this treatment can take: one to two focused sessions, brief segments within case management sessions, or computerized or webbased intervention with or without therapist coaching. A recent trial of treatments for alcohol and depression by Baker and colleagues found that 10-session interventions had greater impact on outcomes at some points of time, but effects from a single, integrated session were also strong. A small number of sessions are particularly well suited to contexts where ongoing treatment may be impractical – for example, in emergency rooms. Within ongoing, case management short segments about cooccurring problems can be included within routine sessions. Brief segments over several sessions are particularly suited to people who have problems with attention and memory, such as people with psychosis. Efficiencies in delivery may also be increased by supporting the use of computer- or Internet-based interventions. These programs can be applied in various
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ways – for example, as stand-alone adjunctive or primary treatments (where staff may just encourage their use and monitor progress), or with varying degrees of staff support as required. These approaches allow high-fidelity, multicomponent interventions to be delivered inexpensively. When used within treatment sessions, they also build practitioners’ skills and confidence in delivering treatment for co-occurring problems – a training strategy that incurs little or no cost to the agency. Both computerized and web-based treatments have shown strong results in co-occurring depression and substance use problems. In fact, one study by Kay-Lambkin and colleagues found that a computerized treatment for substance use and depression (“SHADE”), which had a few minutes of therapist contact at the start and end of each session, was as effective as giving the same treatment strategies in a face-to-face format. Increased availability of smart phones and of phonebased applications is progressively allowing additional ways to practice skills, cue their application, and monitor changes in the natural environment, while minimizing service costs. Brief treatments are typically preceded by a triage, so that more severely affected people are streamed to more intensive treatment (e.g. people with severe cognitive deficits and risk of self-harm or people with severe substance dependence). Agencies may also offer a form of “stepped care,” where more intensive skills training or supportive treatment is offered in cases where brief interventions do not produce optimal results.
TOBACCO SMOKING IS ENDEMIC AND AFFECTS MORBIDITY, MORTALITY, AND FUNCTIONING The frequencies of substance use in mental disorders that were quoted earlier in this chapter do not include smoking, which is endemic in serious mental disorder: For example, a 1997 Australian community survey of people with psychosis found that 74% currently smoked tobacco (over three times the community prevalence at the time). After suicide, tobacco smoking is the most important contributor to the increased morbidity and early mortality seen in people with serious mental disorders. Smoking also has important impacts in the shorter term: when people are on low incomes, its cost has a substantial impact on money available for both leisure and for essentials such as housing and food. There are also pragmatic reasons to address smoking in conjunction with other substance use. Almost all people with serious mental disorder who smoke cannabis also smoke tobacco, and users with limited money often cut cannabis with tobacco. Where
community-wide campaigns to stop smoking have been implemented, patients can often be more easily engaged initially in an attempt to quit tobacco than to stop using cannabis. Attempts to become more healthy by stopping smoking can sometimes then be generalized to cannabis and other substance use. Despite the cogency of these arguments, we have found it easier to convince staff of mental health services that they should address illegal drug use or problematic drinking than to convince them of the need to assess and manage tobacco smoking. Cannabis, amphetamines, hallucinogens, cocaine, and excessive drinking have obvious mental health impacts, and are also readily seen as important foci by substance use services. Tobacco smoking is commonly seen as the province of the family doctor. However, people with severe mental disorder or with multiple substance use are less likely to attend a family physician regularly, and may need more support to stop smoking than others. Omission of smoking from issues to be assessed and addressed by specialist services is, therefore, particularly problematic.
Assessment and Interventions Should Include Tobacco Smoking Routine screening should include whether the person smokes, and how many cigarettes they smoke each week. Motivational interventions for smoking should be offered, and reengagement after lapses encouraged. Because many people with co-occurring disorders are on very low incomes, financial subsidies for nicotine replacement therapy will often be needed.
CO-OCCURRING PROBLEMS ARE OFTEN MULTIPLE AND CLOSELY INTERLINKED Co-occurring disorders are often referred to as a dual diagnosis. However, multiple substances are commonly used, and the psychological problems often include more than one type of mental disorder – including personality disorders, or subclinical features of other problems (e.g. social anxiety). Physical problems are also commonly experienced, including poor oral health (which is exacerbated by smoking). More than one situational problem is often present (e.g. social, forensic, housing, and employment issues). Some problems can be secondary to others, so that someone only has psychotic symptoms when they are using substances. When the companion problem is truly secondary, there may really be only one disorder. However, the relationship is often more complex: While two or more problems may seem to resolve when one
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CO-OCCURRING PROBLEMS ARE OFTEN MULTIPLE AND CLOSELY INTERLINKED
problem is addressed, if an untreated problem becomes worse, it may still increase the risk of relapse in the treated one. So, depression often resolves after treatment for alcohol dependence, but if the person becomes depressed once more, they tend to be at greater risk of relapse in alcohol misuse. Furthermore, a problem may initially be triggered by substance use, but then develops a momentum of its own (e.g. amphetamine use may trigger psychosis, but later psychotic episodes may occur even when the person is abstinent). Indirect associations can also be seen: For example, one study found that the mechanism by which cannabis use triggered a later psychotic episode in that sample appeared to be conflict within the family (which was greater in people with more cannabis use). Interlinkage between problems is often present, so that exacerbations of each problem may exacerbate the other(s). Close mutual associations between mental health status and substance use appear especially common in people with psychosis; substance use by this group is often triggered by worsening symptoms, but more consumption also puts them at greater risk of psychotic symptoms. These observations also have important implications.
Treatments Should Address the Multiple Issues of Concern Close interlinkage of problems implies that the interventions that are used should impact on all that are required to obtain and maintain change. If as in the example above, conflict with the person’s immediate family is a trigger for later symptomatic relapse, it is important to monitor whether the relationships improve as cannabis use comes under greater control, or whether family intervention for that issue is needed. Furthermore, the vulnerability to conflict suggests that care should also be taken to avoid generating distress within the therapeutic relationship (e.g. by using confrontation). If exacerbations of depression appear to have triggered alcohol use by an individual in the past, even if depression improves after the alcohol treatment, then vulnerability may need to be addressed.
Closely Interrelated Problems Require Integrated Treatments Comparisons of outcomes from integrated treatment of co-occurring problems by a single agent and parallel or sequential treatment of problems clearly favor integrated treatment for people with psychosis. In the case of depression and anxiety, the evidence is less clearcut. Sustained long-term outcomes appear to require
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that treatment of the substance-related problem(s) is provided. One trial on people with both excessive alcohol use and depression demonstrated substantial recovery in depression at 12 months, regardless of whether treatment comprised a single integrated session, gave additional treatment focused on alcohol or depression, or provided extended integrated treatment for both problems. Women had faster short-term recovery in alcohol and depression if they received either integrated or depression-focused treatment, but the latter gave weaker alcohol outcomes for them at 12 months. Men had stronger short-term alcohol-related outcomes from extended treatment that focused on alcohol or on both problems. The central importance of the substancerelated treatment is consistent with other research showing that the alcohol-related treatment is often equally effective in people with and without depression. However, the differential response of women suggests that it may also be important to address depression to maximize the speed of recovery. Having multiple treatment goals does not necessarily mean that the treatment is more complex for the patient, or requires more sessions. A sensitive treatment for cooccurring disorders often involves negotiating targets that address both problems at once rather than burdening the person with a complex set of concurrent behavioral goals. Creative interweaving of treatment elements can then offer positive outcomes for each area. Examples include increasing pleasurable time with non-substance-using friends to improve the person’s mood and reduce their substance use, and helping the person find highly valued housing or employment that precludes heavy substance use. Even when one issue is the primary focus of current treatment (e.g. substance control), relationships with others are explicitly addressed (e.g. negative mood as a trigger for drinking and as an outcome of binges).
A Single Health Agency to Assist an Individual Is Typically Needed Integrated treatment is difficult to achieve in practice. As noted at the start of this chapter, mental health and substance use are commonly addressed by different agencies, whose staff have correspondingly different training and expertise. In consequence, a common service model for co-occurring disorders involves multiple agencies, each of which treats a different aspect of the person’s problem in parallel or sequentially. As already mentioned above, these models potentially result in inconsistent treatment or treatment that is insufficiently sensitive to the co-occurring problem. Affected people may miss treatment for one or more
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problems altogether, partly because the low severity of the most common co-occurring problems means that people who need help often do not meet priority criteria for the companion agency (e.g. severe mental disorder or severe substance dependence). Where multiple agencies duplicate assessments, interventions, or monitoring regimes, also waste staffing resources and unnecessarily increase costs for affected people and their families. More people may be effectively treated within a particular budget if fewer agencies are involved, overlaps in functions or duties are minimized, and interagency communication is effective and efficient. Ideally, this would include sharing of patient records. Since these features are difficult to attain, a single agency with primary responsibility for integrated care provides the greatest assurance that required treatment will be received; delays minimized; harmful treatment interactions; duplication, or miscommunication avoided; and costs contained. Which agency should therefore take responsibility in an individual case? There is a risk that uncertainty about this issue could result in each agency consigning the person to the other, resulting in exclusion from service. A heuristic is provided by the 2 2 “quadrant” model proposed by Ries and Miller in 1993 and further explicated by the US Substance Abuse and Mental Health Administration in a 2002 report to Congress. The model describes the severity of the psychiatric disorder and substance use disorder on two dimensions, categorized as low versus high. People with low-severity problems in both domains are seen as being best treated by the general health system (e.g. in primary care). Those with severe psychiatric problems and low-severity problems with substance use are typically seen as being the responsibility of mental health services, and those with severe substance misuse and relatively mild mental health problems are seen as being best managed by alcohol and other drug services. This would leave just one quadrant with a potential need for multiple services: those with high-severity problems in both areas. Health service organizations need to negotiate which agency will have the lead responsibility for this group, calling in assistance from other agencies when needed. In most cases, we suggest that the lead agency will need to be mental health, since that agency is usually better able to provide the level of assertive follow-up, supported care, and engagement of multiple other agencies that this group often requires. The quadrant model clearly needs operationalization (i.e. with clear guidelines on what diagnosis, measure, or dimensional cutoffs are used), if it is to have practical use in agency decision making. Also, it is based on a conceptualization of the problems as dual disorders, and omits consideration of agencies apart from primary care, substance use, and mental health ones. As already
stated, these restrictions frequently oversimplify the true situation. The task of clarifying decision rules still requires negotiation between agencies and is likely to differ across jurisdictions, depending on the roles that particular agencies have. The quadrant model also needs further testing, to show that its application does improve treatment access and outcomes.
Strengths, Resources, Functional Sources of Pleasure Should Be in Assessment and Treatment The number and severity of problems in this group sometimes capture attention of practitioners, and both assessment and treatment often focus exclusively on behaviors that need to be controlled or problems that require solution. The emphasis on symptoms and deficits potentially leaves people demoralized, and the complex array of needs can be overwhelming for all parties. We know that negative mood undermines confidence in being able to make changes, and that sustained changes need to be rewarded, yet much of what we are trying to achieve has at best, a delayed net benefit, and at worst, can leave the person feeling worse off. Assessing and building the strengths, resources, and capabilities of the person increase confidence, which encourages the person to start and persist in their attempt in the face of difficulties. Assessments need to seek out areas that are unaffected or represent significant achievements, summarizing them, showing their relevance to the current challenges, and encouraging the person to rehearse them. Of special importance are ones that show an ability to delay or forego short-term comfort for the sake of greater long-term benefits – for example, maintaining attendance at work or school, practicing a musical instrument, looking after pets, paying rent, and paying off debts. These islands of achievement highlight resources, sources of social support and personal skills, and often give strategies to address current problems. A focus on behaviors that need to be controlled means that some current sources of pleasure or relief (at least in the short term) may be lost (e.g. positive effects of intoxication, a leisure activity that relieves boredom or distracts from negative rumination, or contact with substance using friends – who in some cases are the only people outside the family and other patients who accept them as they are). To maintain change, new sources of pleasure and reward may be needed: highly valued relationships, opportunities for training or employment, and new housing options. While addressing problems sometimes allows these positive changes to occur, they may not do so without therapeutic
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BETTER POLICIES AND PRACTICES FOR CO-OCCURRING DISORDERS REQUIRE ORGANIZATIONAL CHANGE
support. For example, the person may be highly socially anxious or lack skills in forming relationships. A focus on improving quality of life and inclusion of its measurement in monitoring of outcomes will help ensure that practitioners and patients address goals that both see as central.
BETTER POLICIES AND PRACTICES FOR CO-OCCURRING DISORDERS REQUIRE ORGANIZATIONAL CHANGE Even if we continue to have separate agencies for substance misuse and other mental disorders, as well as ones to deal with other health or social problems, there is much that can be done to improve services and make them more integrated and easier to access. However, this typically requires changes to organizations and the way practitioners work. There is now a substantial body of research and theory about the effective diffusion of innovations throughout organizations, and we can also be guided by what we know about individual’s behavior change. Some of these principles are applied to co-occurring disorders below. Overall, the evidence shows that both top–down and bottom–up supports of the change through the organization are needed for optimal uptake.
Co-Occurring Disorders Must Be Core Business for the Organization and Practitioners A corollary of the need for existing agencies to take responsibility for co-occurring disorders is that they must acknowledge that co-occurring disorders represent core business. That in turn requires that this principle is captured by the agency’s mission, addressed in its policies, and reflected in the duty statements of individual staff. Policies need to be translated into procedures or guidelines that clearly communicate how they are translated into routine practice, are publicly supported by senior managers, and are widely promulgated throughout the organization. The organization’s budget must also reflect this priority, providing sufficient staffing for it, including after-hours coverage where required, and consultants with specialist expertise to support use of the interventions by other staff. In some cases, additional prescribers will be needed to ensure that appropriate pharmacological interventions are available. Other resources for specific intervention components may also be required (e.g. space for support groups, cars for assertive follow-up of vulnerable patients, supported housing, computers and fast Internet links for electronic interventions within clinics, facilities to send text messages to remind about
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appointments, cue coping strategies, etc.). Resources to cue high-fidelity use of the practices (e.g. forms, electronic record systems, charts, or computerized tools to use in sessions, brochures, cue cards, etc.) are typically also needed, which in turn involves investment in their development, organizational approval, production, and regular updating (e.g. including new drugs or slang terms, and adapting to new technologies). Similarly, individual practitioners need to view the assessment and management of co-occurring disorders as being core to their role. Where specialist mental health services have a history of being split from services for alcohol and other drug use, staff have tended to see their role only through the narrow lens of their subspecialty. We have found it useful to describe co-occurring disorders as a subtype of “complex presentations”: Practitioners are used to dealing with complexity, and more easily acknowledge it as core business than if the discourse is framed in terms of problems they initially see as the province of another agency.
Effective Comorbidity Practice Should Be Recognized and Rewarded Just as patients need to see a clear net benefit from changing their behavior, the incentive balance for practitioners needs to favor implementation of sound procedures to address co-occurring disorders. If the procedures are seen as incurring cost for little benefit (e.g. effort, time, or financial cost to learn new skills, extra duties, more time for consultations, perceived restriction of practitioner choice, etc.), they are unlikely to be implemented. One aspect of ensuring a high level of implementation is to minimize these costs (e.g. by showing how existing skills can be applied to co-occurring disorders). Positive incentives for uptake are also needed. A strong motivator of uptake of the required practices is to systematically collect data on their use, and then give individuals and teams information comparing their own performance with the performance target (or the average or top performance of the overall group). An incentive for uptake by individual staff is provided by routinely including co-occurring problems in case review meetings, and praising attempts to assess and address them. Inclusion of work on co-occurring disorders in performance reviews of staff at all levels is also highly motivating. Ultimately, both practitioners and organizations are motivated by demonstrably better patient outcomes. Tracking and summarizing positive changes in a patient’s admissions, substance use, symptoms, functioning, or quality of life can help to keep motivation high, even when some other patients appear to have
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gained limited benefit or (as commonly is the case) their outcomes are at least initially unstable. A corollary is that outcomes should be systematically monitored, so that staff are aware of positive changes, and organizations can report on improved outcomes across their serviced population. Reductions in use of high-cost services by individual patients (e.g. inpatient or afterhours interventions) can be especially motivating for managers, since that can substantially impact on organizational costs and on numbers who can be treated within existing budgets. Incentives should not exclusively rely on external rewards for optimal uptake. Individual staff should be encouraged to develop goals for learning and using assessments and interventions for co-occurring problems, to solve problems with their application, and notice their own achievements. Effective self-regulation makes them less reliant on the continued integrity of organizational monitoring and reward systems.
Required Skills Must Be Present or Taught, and Cues to Use Them Provided If co-occurring disorders are adequately covered in the initial training of practitioners in addiction, mental and general health, additional training to assess and manage comorbidity may be able to focus just on local procedures and on advances in practice. In the meantime, other strategies are needed to increase the knowledge, skills, and confidence of front-line staff. In both mental health and substance use agencies, some effective strategies that are amenable for use on a large scale are already in the skills repertoire of staff. Examples related to assessment are the ability to establish trust and rapport, to take a detailed history, examine triggers and effects of exacerbations, and review contexts, coping strategies, and supports that were associated with periods of better status. Intervention examples include development and maintenance of motivation for agency attendance and behavioral change, and effective goal setting, planning, and problem solving. Some other strategies are relatively easy to communicate, for example the need to use multiple methods to accurately determine consumption (e.g. daily frequency and amount, frequency and amount of purchases, and weekly cost); the use of a “Timeline Followback” (a day-by-day review of recent events to cue recalled consumption); or helping the person identify pleasurable, non-substance-using activities that can help to boost their mood. Some more demanding areas of knowledge and skills can be supported by other resources (e.g. information on the effects and management of withdrawal from a specific drug, or information
about potential drug interactions can be provided) or given by other specialist staff on the team (e.g. pharmacotherapy for mental health symptoms, management of withdrawal, or long-term support of abstinence). Low-intensity interventions for co-occurring substance misuse typically involve motivational interviewing or brief advice, plus goal setting, planning, and problem solving for issues that are likely to arise in early phases of initiating behavior change. In addition to pharmacotherapy for depression, several brief psychological strategies have significant impact, including behavioral activation (to increase pleasurable activity and daily achievements). Problem solving, goal setting, and planning (e.g. to address situational stressors) are applicable to both depression and anxiety. Longer treatments with application to both addictive and mental disorders include mindful meditation, which assists users to reduce rumination and related distress. Where additional skills are needed, one-off workshops by themselves appear to have limited impact: while short-term increases in knowledge and skill can often be demonstrated, unless they are then consolidated in everyday practice, the gains may then be lost. In order for that consolidation to occur, the context must allow it – for example, the new practice may initially take a little longer until it is mastered, and this additional time must be able to be accommodated. Mentoring or supervision may be needed to assist the practitioner to use it effectively and solve problems with its use, and practitioners may need to be cued so they remember to use it (e.g. by items to be checked in patient records of assessment and treatment). Strategies to increase ongoing fidelity may also be required – for example, checklists for key steps in the assessment or intervention.
A Culture Supporting the Use of the Intervention Should Be Fostered “Champions” can develop enthusiasm for comorbidity practice in the organization. Whether they are within management or among practitioners, they model the use of skills in dealing with co-occurring disorders, provide incidental learning, and reward use of the practices by others. However, excessive reliance on champions in the longer term is dangerous, as their loss can mean that use of the intervention collapses. A focus on staff who are already keen to use the intervention (“early adopters”) appears useful; it avoids unproductive conflict with staff who are initially resistant to comorbidity practices, and allows a critical mass of mutually reinforcing users to develop. We have found that provision of mentoring to this group results in
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FURTHER READING
significantly improved rates of screening and intervention for co-occurring disorders being recorded in patient files. Active engagement of staff in development and updating of support materials is another useful strategy; it both increases commitment to their use and helps to consolidate their understanding of the strategies.
CONCLUSION There is no “silver bullet” to meeting the complex needs of people with co-occurring disorders, and ensuring stable positive outcomes. However, adopting sound practices that ensure detection of co-occurring problems and access to the best-known treatments is both an excellent start and a moral necessity.
SEE ALSO Diagnostic Dilemmas in Comorbidity, Treatment for Co-occurring Substance Abuse and Mental Health Disorders
List of Abbreviations ECA Epidemiologic Catchment Area OR odds ratio
Glossary Antisocial personality disorder a disorder that produces pervasive disruptions in interpersonal functioning and is characterized by features such as aggression, deceitfulness, impulsivity, reckless disregard for others, and a lack of remorse. Bipolar disorder a disorder with mania (elevated or irritable mood, often with increased activity and impulsivity), or alternating mania and depression – which may have psychotic features that are consistent with that mood (e.g. grandiose delusions in mania). Incentives these are expected and valued benefits from engaging in a behavior. They increase the likelihood of that behavior occurring. Integrated treatment this treatment is adjusted to take account of the presence of co-occurring problems, and addresses them all. It is typically conducted by a single practitioner or team, and is contrasted with parallel or sequential treatment for different problems, usually by different agencies. Odds ratio the increased chance that a person from a particular group shows a feature (in this case a disorder) in comparison with other people. Psychosis a type of disorder that affects brain processes and is marked by features such as attentional difficulties, delusional beliefs, disorganized speech, and disturbances in perception (e.g. hallucinations). Speech may be disorganized, or be limited in amount or content, and motivation may also be affected. Schizophrenia a psychotic disorder (see above), which is not dominated by mood features. Emotional expression, speech, and motivation may be significantly impaired, and disorganized behavior or immobility seen. It cannot be due to another disorder (e.g. intoxication), causes significant functional disruption, and is
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distinguished from similar disorders by its duration (in the Diagnostic and Statistical Manual of the American Psychiatric Association, persisting disturbance for at least 6 months, including at least a month of acute symptoms). Quadrant model of substance misuse and psychiatric problems a guide for decisions on which service should lead the management of an individual with co-occurring disorders. It is a 2 2 matrix, based on the severity of the psychiatric and addictive problems. Timeline Followback a day-by-day review of events or activities over recent weeks or months to cue recall of consumption.
Further Reading American Psychiatric Association, 1994. Diagnostic and Statistical Manual of Mental Disorders, fourth ed. American Psychiatric Association, Washington, DC. Baker, A.L., Kavanagh, D.J., Kay-Lambkin, F.J., et al., 2010. Randomised controlled trial of CBT for co-existing depression and alcohol problems: short-term outcome. Addiction 105, 87–99. Brady, K.T., Verduin, M.L., Tolliver, B.K., 2007. Treatment of patients comorbid for addiction and other psychiatric disorders. Current Psychiatry Reports 9, 374–380. Deane, F., Kavanagh, D.J., 2010. Adapting low intensity CBT interventions for clients with severe mental illness. In: Bennett-Levy, J., Richards, D., Farrand, P., Christensen, H., Griffiths, K., et al. (Eds.), The Oxford Guide to Low Intensity CBT Interventions. Oxford University Press, Oxford, pp. 357–365. Green, B., Kavanagh, D.J., Young, R.McD., 2007. Predictors of cannabis use in men with and without psychosis. Addictive Behaviors 32, 2879–2897. Hall, S.M., 2007. Nicotine interventions with comorbid populations. American Journal of Preventive Medicine 33, S406–S413. Hides, L., Dawe, S., Kavanagh, D.J., Young, R.McD., 2006. Psychotic symptom and cannabis relapse in recent onset psychosisd prospective study. British Journal of Psychiatry 189, 137–143. Kavanagh, D.J., Connolly, J.M., 2009. Interventions for co-occurring addictive and other mental disorders (AMDs). Addictive Behaviors 34, 838–845. Kavanagh, D.J., Young, R., White, A., et al., 2004. A brief motivational intervention for substance abuse in recent-onset psychosis. Drug and Alcohol Review 23, 151–155. Kay-Lambkin, F.J., Baker, A.L., Lewin, T.J., Carr, V.J., 2009. Computerbased psychological treatment for comorbid depression and/or cannabis use: a randomized controlled trial of clinical efficacy. Addiction 104, 378–388. Pourmand, D., Kavanagh, D.J., Vaughan, K., 2005. Expressed emotion as predictor of relapse in patients with comorbid psychoses and substance use disorder. Australian and New Zealand Journal of Psychiatry 39, 473–478. Regier, D.A., Farmer, M.E., Rae, D.S., et al., 1990. Comorbidity of mental disorders with alcohol and other drug abuse: results from the epidemiological catchment area (ECA) study. Journal of the American Medical Association 264, 2511–2518. Rogers, E.M., 2003. Diffusion of Innovations, fifth ed. Free Press, New York. Sterling, S., Weisner, C., Hinman, A., Parthasarathy, S., 2010. Access to treatment for adolescents with substance use and co-occurring disorders: challenges and opportunities. Journal of the American Academy of Child & Adolescent Psychiatry 49, 637–646. Substance Abuse and Mental Health Services Administration, 2002. Report to Congress on the Prevention and Treatment of Co-occurring Abuse Disorders and Mental Disorders. SAMHSA, Rockville, MD. http://www.samhsa.gov/reports/congress2002/.
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Relevant Websites http://www.dualdiagnosis.org.au/ The link has–Australian and international resources on comorbidity and policy or service development, including toolkits for clinicians.
http://www.ontrack.org.au The link includes–programs for people with co-occurring alcohol and depression issues, and for psychosis-like experiences (including ones triggered by substance use). http://www.samhsa.gov/ The link has–resources on comorbidity.
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34 Implications of Comorbidity for Clinical Practice David J. Kavanagh Institute of Health & Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia
O U T L I N E People with Co-Occurring Disorders Have a Right 326 to Equal Access to Quality Care Co-Occurring Disorders Are Common and Often Have a Profound Impact Screening for Co-Occurring Problems Should Be Routine A Boutique Service Is Impractical: Existing Agencies Must Address the Issue Universal Interventions Must Be Capable of LargeScale Implementation
326 327 327 327
Tobacco Smoking Is Endemic and Affects Morbidity, Mortality, and Functioning 328 Assessment and Interventions Should Include Tobacco Smoking 328 Co-Occurring Problems Are Often Multiple and Closely Interlinked Treatments Should Address the Multiple Issues of Concern
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329 329 330
Better Policies and Practices for Co-Occurring Disorders Require Organizational Change 331 Co-Occurring Disorders Must Be Core Business for the Organization and Practitioners 331 Effective Comorbidity Practice Should Be Recognized and Rewarded 331 Required Skills Must Be Present or Taught, and Cues to Use Them Provided 332 A Culture Supporting the Use of the Intervention Should Be Fostered 332 Conclusion
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In the past, co-occurring substance use and mental health problems have often been missed, because related screening and assessment has not been routine. When co-occurrence has been identified, affected people have often been excluded from services, or were referred to other agencies without assistance to ensure that they arrived and received help. If they did receive treatment, it was often focused on a single problem domain, or was offered by different agencies, which frequently were in Interventions for Addiction, Volume 3 http://dx.doi.org/10.1016/B978-0-12-398338-1.00034-8
Closely Interrelated Problems Require Integrated Treatments A Single Health Agency to Assist an Individual Is Typically Needed Strengths, Resources, Functional Sources of Pleasure Should Be in Assessment and Treatment
different locations, had differing priorities, policies and procedures, and did not share record systems or communicate effectively in other ways. As a result, treatment plans often missed key elements or had conflicting goals and demands. Practitioner training typically focused on either addictive disorders or other mental health problems, and graduates lacked skills and confidence in dealing with problems outside their focal domain. Despite international attempts to improve services for people with
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Copyright Ó 2013 Elsevier Inc. All rights reserved.
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co-occurring problems, many of the issues remain. However, we now have more information on comorbidity and its management, and on ways to disseminate sound, evidence-based care. This knowledge can guide our development of services that are more responsive to these cooccurring problems. Principles or observations about cooccurring disorders and their implications for practice are summarized in Table 34.1.
disorders to an equal access to the same quality of care as if they had a single problem. The moral imperative presented by this right of access is the guiding assumption underpinning all the recommendations that follow.
PEOPLE WITH CO-OCCURRING DISORDERS HAVE A RIGHT TO EQUAL ACCESS TO QUALITY CARE
In Western countries, 25–30% of people with a mental disorder also have a substance use disorder at some time in their lives. In the landmark US Epidemiologic Catchment Area (ECA) study in 1980–84, this corresponded to 2.7 times the risk of a substance use disorder if the person had a mental disorder. In antisocial personality disorder (84%, OR ¼ 29.6), bipolar I disorder (61%, OR ¼ 5.3), and schizophrenia (47%, OR ¼ 4.6), the lifetime prevalence and increased risks were particularly high. Mental disorders are also common in people with substance use disorders. In the ECA study, the lifetime rate of a mental disorder in people with an alcohol use disorder was 37% (OR ¼ 2.3) or 53% (OR ¼ 4.5) in people with another substance use disorder. Since rates of substance use disorders in the community as a whole are higher among men, and depression and anxiety are more common in women, there are gender differences in risk that reflect these overall trends. Generally, problematic substance use is also more common in younger people. Exact proportions of affected people change across countries, over time, and in specific religious or ethnic groups, with many indigenous groups at particularly high risk of both substance misuse and mental disorder or distress. Community rates of both substance-related and other mental health problems increase even further when subclinical conditions are included. Treatment settings have greater rates of comorbidity than the general community, especially where crisis care is delivered. This is partly because co-occurring issues have synergistic effects on functioning and distress, and crises that trigger demands for treatment can occur from either problem. In many agencies, this means that a substantial majority currently has a cooccurring substance-related problem. Not only are co-occurring disorders common tragically, but they also pose substantially increased risks of morbidity and mortality. Substance use increases the risk of illness and fatality from a variety of causes, some directly related to the substance and its metabolism (e.g. overdose, withdrawal, and vitamin depletion), some as a consequence of psychological or lifestyle impacts (e.g. suicide, injury, being a victim of assault, and hyperthermia), and some related to illegal supply (e.g. toxic additives).
The historical situation described above clearly violated the basic right of people with co-occurring TABLE 34.1
Principles and Observations on Comorbidity Practice and Their Implications for Services
Principle or observation
Implications for services
People with co-occurring disorders have a right to equal access to quality care
Underpins all the implications that follow
Co-occurring disorders are common and often have a profound impact
Screening for co-occurring problems should be routine A boutique service is impractical: existing agencies must address the issue Universal interventions must be capable of large-scale implementation
Tobacco smoking is endemic and affects morbidity, mortality, and functioning
Assessment and interventions should include tobacco smoking
Co-occurring problems are often multiple and closely interlinked
Treatments should address the multiple issues of concern Closely interrelated problems require integrated treatments A single health agency to assist an individual is typically needed Strengths, resources, and functional sources of pleasure should be included in assessment and intervention
Better policies and practices for co-occurring disorders require organizational change
Co-occurring disorders must be core business for the organization and practitioners Effective comorbidity practice should be recognized and rewarded Required skills must be present or taught, and cues to use them provided A culture supporting the use of the intervention should be fostered
Note: These estimates are based on the results from Kavanagh, D. J., & Connolly, J. M. (2009). Interventions for co-occurring addictive and other mental disorders (AMDs). Addictive Behaviors, 34, 838-845.
CO-OCCURRING DISORDERS ARE COMMON AND OFTEN HAVE A PROFOUND IMPACT
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CO-OCCURRING DISORDERS ARE COMMON AND OFTEN HAVE A PROFOUND IMPACT
Co-occurring disorders also tend to have profound and widespread impact on the functioning and quality of life of the individual and their family. Even mild forms of co-occurring disorders can have a powerful functional impact: for example, any substance use at all by someone with severe mental disorder who is unemployed can entail missing meals, going into debt, having housing problems, or foregoing highly valued opportunities for rehabilitation or employment. If cognition, impulse control, motivation, and social skills are substantially impaired, adding intoxication can take the person from marginally appropriate to dysfunctional behavior, with significant and lasting consequences. Families experience economic impacts (e.g. financial burdens of housing, medical care and other support, lost work time, and property stolen to support substance use), as well as emotional hardship and disruption to their social and recreational activities. While the functional impacts of co-occurring disorders are often substantial, the companion disorders are often of mild or moderate severity, partly, because less severe problems are much more common in the general community. So, although the relative risk of bipolar disorder or schizophrenia increases to a greater extent than anxiety disorders in people with addictive disorders, anxiety and unipolar depression are most commonly seen. This observation offers some optimism in approaching co-occurring disorders. For example, a study by Green and colleagues showed that some people with even very severe mental disorders spontaneously reduce consumption of cannabis use in the month after they experience a negative effect from it. This suggests that even this group may often have existing skills in self-control that they can exercise if sufficiently motivated. Together with the moral imperative to provide equal access to service, these observations have important implications for agencies addressing mental health or substance use.
Screening for Co-Occurring Problems Should Be Routine In assessments and reviews of mental health problems, protocols should include questions about all substance use, with brief screening for associated problems, followed by more detailed assessment of affected areas. Similarly, assessments and progress reviews of people with substance use problems should routinely include screening for psychological distress and disorder, with a full symptomatic assessment being conducted where indicated. Universal screening needs to be brief and easily implemented within the agency’s standard assessment protocol if it is to be feasibly
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undertaken without significantly increasing costs per patient. Fortunately, brief screening tests are available to assist (see Screening and Assessment of Comorbidity).
A Boutique Service Is Impractical: Existing Agencies Must Address the Issue Some agencies have nominated a staff member or group of staff to deal with co-occurring disorders. However, if specialist practitioners have to assess and provide ongoing management for patients with cooccurring disorders, the high incidence of these problems either means that they will soon be swamped with referrals (preventing others from receiving treatment), or selecting only some for special attention. There is some merit in devoting specialist time to a subgroup that presents greater challenges for care, as long as that does result in better outcomes. However, a consequence is that a large group would then miss out on that attention, unless the specialist staff became the primary practitioner group. Given the moral imperative of equity of access to care, agencies may be better advised to give specialists in co-occurring disorders the roles of consultants or trainers rather than case managers, so their expertise becomes spread throughout the organization and all affected people can receive appropriate treatment.
Universal Interventions Must Be Capable of Large-Scale Implementation The most readily implemented minimum standard for a universal intervention to address co-occurring disorders is a treatment that is effective for many affected people, but minimizes additional contact time. There are several potential forms this treatment can take: one to two focused sessions, brief segments within case management sessions, or computerized or webbased intervention with or without therapist coaching. A recent trial of treatments for alcohol and depression by Baker and colleagues found that 10-session interventions had greater impact on outcomes at some points of time, but effects from a single, integrated session were also strong. A small number of sessions are particularly well suited to contexts where ongoing treatment may be impractical – for example, in emergency rooms. Within ongoing, case management short segments about cooccurring problems can be included within routine sessions. Brief segments over several sessions are particularly suited to people who have problems with attention and memory, such as people with psychosis. Efficiencies in delivery may also be increased by supporting the use of computer- or Internet-based interventions. These programs can be applied in various
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ways – for example, as stand-alone adjunctive or primary treatments (where staff may just encourage their use and monitor progress), or with varying degrees of staff support as required. These approaches allow high-fidelity, multicomponent interventions to be delivered inexpensively. When used within treatment sessions, they also build practitioners’ skills and confidence in delivering treatment for co-occurring problems – a training strategy that incurs little or no cost to the agency. Both computerized and web-based treatments have shown strong results in co-occurring depression and substance use problems. In fact, one study by Kay-Lambkin and colleagues found that a computerized treatment for substance use and depression (“SHADE”), which had a few minutes of therapist contact at the start and end of each session, was as effective as giving the same treatment strategies in a face-to-face format. Increased availability of smart phones and of phonebased applications is progressively allowing additional ways to practice skills, cue their application, and monitor changes in the natural environment, while minimizing service costs. Brief treatments are typically preceded by a triage, so that more severely affected people are streamed to more intensive treatment (e.g. people with severe cognitive deficits and risk of self-harm or people with severe substance dependence). Agencies may also offer a form of “stepped care,” where more intensive skills training or supportive treatment is offered in cases where brief interventions do not produce optimal results.
TOBACCO SMOKING IS ENDEMIC AND AFFECTS MORBIDITY, MORTALITY, AND FUNCTIONING The frequencies of substance use in mental disorders that were quoted earlier in this chapter do not include smoking, which is endemic in serious mental disorder: For example, a 1997 Australian community survey of people with psychosis found that 74% currently smoked tobacco (over three times the community prevalence at the time). After suicide, tobacco smoking is the most important contributor to the increased morbidity and early mortality seen in people with serious mental disorders. Smoking also has important impacts in the shorter term: when people are on low incomes, its cost has a substantial impact on money available for both leisure and for essentials such as housing and food. There are also pragmatic reasons to address smoking in conjunction with other substance use. Almost all people with serious mental disorder who smoke cannabis also smoke tobacco, and users with limited money often cut cannabis with tobacco. Where
community-wide campaigns to stop smoking have been implemented, patients can often be more easily engaged initially in an attempt to quit tobacco than to stop using cannabis. Attempts to become more healthy by stopping smoking can sometimes then be generalized to cannabis and other substance use. Despite the cogency of these arguments, we have found it easier to convince staff of mental health services that they should address illegal drug use or problematic drinking than to convince them of the need to assess and manage tobacco smoking. Cannabis, amphetamines, hallucinogens, cocaine, and excessive drinking have obvious mental health impacts, and are also readily seen as important foci by substance use services. Tobacco smoking is commonly seen as the province of the family doctor. However, people with severe mental disorder or with multiple substance use are less likely to attend a family physician regularly, and may need more support to stop smoking than others. Omission of smoking from issues to be assessed and addressed by specialist services is, therefore, particularly problematic.
Assessment and Interventions Should Include Tobacco Smoking Routine screening should include whether the person smokes, and how many cigarettes they smoke each week. Motivational interventions for smoking should be offered, and reengagement after lapses encouraged. Because many people with co-occurring disorders are on very low incomes, financial subsidies for nicotine replacement therapy will often be needed.
CO-OCCURRING PROBLEMS ARE OFTEN MULTIPLE AND CLOSELY INTERLINKED Co-occurring disorders are often referred to as a dual diagnosis. However, multiple substances are commonly used, and the psychological problems often include more than one type of mental disorder – including personality disorders, or subclinical features of other problems (e.g. social anxiety). Physical problems are also commonly experienced, including poor oral health (which is exacerbated by smoking). More than one situational problem is often present (e.g. social, forensic, housing, and employment issues). Some problems can be secondary to others, so that someone only has psychotic symptoms when they are using substances. When the companion problem is truly secondary, there may really be only one disorder. However, the relationship is often more complex: While two or more problems may seem to resolve when one
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CO-OCCURRING PROBLEMS ARE OFTEN MULTIPLE AND CLOSELY INTERLINKED
problem is addressed, if an untreated problem becomes worse, it may still increase the risk of relapse in the treated one. So, depression often resolves after treatment for alcohol dependence, but if the person becomes depressed once more, they tend to be at greater risk of relapse in alcohol misuse. Furthermore, a problem may initially be triggered by substance use, but then develops a momentum of its own (e.g. amphetamine use may trigger psychosis, but later psychotic episodes may occur even when the person is abstinent). Indirect associations can also be seen: For example, one study found that the mechanism by which cannabis use triggered a later psychotic episode in that sample appeared to be conflict within the family (which was greater in people with more cannabis use). Interlinkage between problems is often present, so that exacerbations of each problem may exacerbate the other(s). Close mutual associations between mental health status and substance use appear especially common in people with psychosis; substance use by this group is often triggered by worsening symptoms, but more consumption also puts them at greater risk of psychotic symptoms. These observations also have important implications.
Treatments Should Address the Multiple Issues of Concern Close interlinkage of problems implies that the interventions that are used should impact on all that are required to obtain and maintain change. If as in the example above, conflict with the person’s immediate family is a trigger for later symptomatic relapse, it is important to monitor whether the relationships improve as cannabis use comes under greater control, or whether family intervention for that issue is needed. Furthermore, the vulnerability to conflict suggests that care should also be taken to avoid generating distress within the therapeutic relationship (e.g. by using confrontation). If exacerbations of depression appear to have triggered alcohol use by an individual in the past, even if depression improves after the alcohol treatment, then vulnerability may need to be addressed.
Closely Interrelated Problems Require Integrated Treatments Comparisons of outcomes from integrated treatment of co-occurring problems by a single agent and parallel or sequential treatment of problems clearly favor integrated treatment for people with psychosis. In the case of depression and anxiety, the evidence is less clearcut. Sustained long-term outcomes appear to require
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that treatment of the substance-related problem(s) is provided. One trial on people with both excessive alcohol use and depression demonstrated substantial recovery in depression at 12 months, regardless of whether treatment comprised a single integrated session, gave additional treatment focused on alcohol or depression, or provided extended integrated treatment for both problems. Women had faster short-term recovery in alcohol and depression if they received either integrated or depression-focused treatment, but the latter gave weaker alcohol outcomes for them at 12 months. Men had stronger short-term alcohol-related outcomes from extended treatment that focused on alcohol or on both problems. The central importance of the substancerelated treatment is consistent with other research showing that the alcohol-related treatment is often equally effective in people with and without depression. However, the differential response of women suggests that it may also be important to address depression to maximize the speed of recovery. Having multiple treatment goals does not necessarily mean that the treatment is more complex for the patient, or requires more sessions. A sensitive treatment for cooccurring disorders often involves negotiating targets that address both problems at once rather than burdening the person with a complex set of concurrent behavioral goals. Creative interweaving of treatment elements can then offer positive outcomes for each area. Examples include increasing pleasurable time with non-substance-using friends to improve the person’s mood and reduce their substance use, and helping the person find highly valued housing or employment that precludes heavy substance use. Even when one issue is the primary focus of current treatment (e.g. substance control), relationships with others are explicitly addressed (e.g. negative mood as a trigger for drinking and as an outcome of binges).
A Single Health Agency to Assist an Individual Is Typically Needed Integrated treatment is difficult to achieve in practice. As noted at the start of this chapter, mental health and substance use are commonly addressed by different agencies, whose staff have correspondingly different training and expertise. In consequence, a common service model for co-occurring disorders involves multiple agencies, each of which treats a different aspect of the person’s problem in parallel or sequentially. As already mentioned above, these models potentially result in inconsistent treatment or treatment that is insufficiently sensitive to the co-occurring problem. Affected people may miss treatment for one or more
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problems altogether, partly because the low severity of the most common co-occurring problems means that people who need help often do not meet priority criteria for the companion agency (e.g. severe mental disorder or severe substance dependence). Where multiple agencies duplicate assessments, interventions, or monitoring regimes, also waste staffing resources and unnecessarily increase costs for affected people and their families. More people may be effectively treated within a particular budget if fewer agencies are involved, overlaps in functions or duties are minimized, and interagency communication is effective and efficient. Ideally, this would include sharing of patient records. Since these features are difficult to attain, a single agency with primary responsibility for integrated care provides the greatest assurance that required treatment will be received; delays minimized; harmful treatment interactions; duplication, or miscommunication avoided; and costs contained. Which agency should therefore take responsibility in an individual case? There is a risk that uncertainty about this issue could result in each agency consigning the person to the other, resulting in exclusion from service. A heuristic is provided by the 2 2 “quadrant” model proposed by Ries and Miller in 1993 and further explicated by the US Substance Abuse and Mental Health Administration in a 2002 report to Congress. The model describes the severity of the psychiatric disorder and substance use disorder on two dimensions, categorized as low versus high. People with low-severity problems in both domains are seen as being best treated by the general health system (e.g. in primary care). Those with severe psychiatric problems and low-severity problems with substance use are typically seen as being the responsibility of mental health services, and those with severe substance misuse and relatively mild mental health problems are seen as being best managed by alcohol and other drug services. This would leave just one quadrant with a potential need for multiple services: those with high-severity problems in both areas. Health service organizations need to negotiate which agency will have the lead responsibility for this group, calling in assistance from other agencies when needed. In most cases, we suggest that the lead agency will need to be mental health, since that agency is usually better able to provide the level of assertive follow-up, supported care, and engagement of multiple other agencies that this group often requires. The quadrant model clearly needs operationalization (i.e. with clear guidelines on what diagnosis, measure, or dimensional cutoffs are used), if it is to have practical use in agency decision making. Also, it is based on a conceptualization of the problems as dual disorders, and omits consideration of agencies apart from primary care, substance use, and mental health ones. As already
stated, these restrictions frequently oversimplify the true situation. The task of clarifying decision rules still requires negotiation between agencies and is likely to differ across jurisdictions, depending on the roles that particular agencies have. The quadrant model also needs further testing, to show that its application does improve treatment access and outcomes.
Strengths, Resources, Functional Sources of Pleasure Should Be in Assessment and Treatment The number and severity of problems in this group sometimes capture attention of practitioners, and both assessment and treatment often focus exclusively on behaviors that need to be controlled or problems that require solution. The emphasis on symptoms and deficits potentially leaves people demoralized, and the complex array of needs can be overwhelming for all parties. We know that negative mood undermines confidence in being able to make changes, and that sustained changes need to be rewarded, yet much of what we are trying to achieve has at best, a delayed net benefit, and at worst, can leave the person feeling worse off. Assessing and building the strengths, resources, and capabilities of the person increase confidence, which encourages the person to start and persist in their attempt in the face of difficulties. Assessments need to seek out areas that are unaffected or represent significant achievements, summarizing them, showing their relevance to the current challenges, and encouraging the person to rehearse them. Of special importance are ones that show an ability to delay or forego short-term comfort for the sake of greater long-term benefits – for example, maintaining attendance at work or school, practicing a musical instrument, looking after pets, paying rent, and paying off debts. These islands of achievement highlight resources, sources of social support and personal skills, and often give strategies to address current problems. A focus on behaviors that need to be controlled means that some current sources of pleasure or relief (at least in the short term) may be lost (e.g. positive effects of intoxication, a leisure activity that relieves boredom or distracts from negative rumination, or contact with substance using friends – who in some cases are the only people outside the family and other patients who accept them as they are). To maintain change, new sources of pleasure and reward may be needed: highly valued relationships, opportunities for training or employment, and new housing options. While addressing problems sometimes allows these positive changes to occur, they may not do so without therapeutic
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BETTER POLICIES AND PRACTICES FOR CO-OCCURRING DISORDERS REQUIRE ORGANIZATIONAL CHANGE
support. For example, the person may be highly socially anxious or lack skills in forming relationships. A focus on improving quality of life and inclusion of its measurement in monitoring of outcomes will help ensure that practitioners and patients address goals that both see as central.
BETTER POLICIES AND PRACTICES FOR CO-OCCURRING DISORDERS REQUIRE ORGANIZATIONAL CHANGE Even if we continue to have separate agencies for substance misuse and other mental disorders, as well as ones to deal with other health or social problems, there is much that can be done to improve services and make them more integrated and easier to access. However, this typically requires changes to organizations and the way practitioners work. There is now a substantial body of research and theory about the effective diffusion of innovations throughout organizations, and we can also be guided by what we know about individual’s behavior change. Some of these principles are applied to co-occurring disorders below. Overall, the evidence shows that both top–down and bottom–up supports of the change through the organization are needed for optimal uptake.
Co-Occurring Disorders Must Be Core Business for the Organization and Practitioners A corollary of the need for existing agencies to take responsibility for co-occurring disorders is that they must acknowledge that co-occurring disorders represent core business. That in turn requires that this principle is captured by the agency’s mission, addressed in its policies, and reflected in the duty statements of individual staff. Policies need to be translated into procedures or guidelines that clearly communicate how they are translated into routine practice, are publicly supported by senior managers, and are widely promulgated throughout the organization. The organization’s budget must also reflect this priority, providing sufficient staffing for it, including after-hours coverage where required, and consultants with specialist expertise to support use of the interventions by other staff. In some cases, additional prescribers will be needed to ensure that appropriate pharmacological interventions are available. Other resources for specific intervention components may also be required (e.g. space for support groups, cars for assertive follow-up of vulnerable patients, supported housing, computers and fast Internet links for electronic interventions within clinics, facilities to send text messages to remind about
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appointments, cue coping strategies, etc.). Resources to cue high-fidelity use of the practices (e.g. forms, electronic record systems, charts, or computerized tools to use in sessions, brochures, cue cards, etc.) are typically also needed, which in turn involves investment in their development, organizational approval, production, and regular updating (e.g. including new drugs or slang terms, and adapting to new technologies). Similarly, individual practitioners need to view the assessment and management of co-occurring disorders as being core to their role. Where specialist mental health services have a history of being split from services for alcohol and other drug use, staff have tended to see their role only through the narrow lens of their subspecialty. We have found it useful to describe co-occurring disorders as a subtype of “complex presentations”: Practitioners are used to dealing with complexity, and more easily acknowledge it as core business than if the discourse is framed in terms of problems they initially see as the province of another agency.
Effective Comorbidity Practice Should Be Recognized and Rewarded Just as patients need to see a clear net benefit from changing their behavior, the incentive balance for practitioners needs to favor implementation of sound procedures to address co-occurring disorders. If the procedures are seen as incurring cost for little benefit (e.g. effort, time, or financial cost to learn new skills, extra duties, more time for consultations, perceived restriction of practitioner choice, etc.), they are unlikely to be implemented. One aspect of ensuring a high level of implementation is to minimize these costs (e.g. by showing how existing skills can be applied to co-occurring disorders). Positive incentives for uptake are also needed. A strong motivator of uptake of the required practices is to systematically collect data on their use, and then give individuals and teams information comparing their own performance with the performance target (or the average or top performance of the overall group). An incentive for uptake by individual staff is provided by routinely including co-occurring problems in case review meetings, and praising attempts to assess and address them. Inclusion of work on co-occurring disorders in performance reviews of staff at all levels is also highly motivating. Ultimately, both practitioners and organizations are motivated by demonstrably better patient outcomes. Tracking and summarizing positive changes in a patient’s admissions, substance use, symptoms, functioning, or quality of life can help to keep motivation high, even when some other patients appear to have
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gained limited benefit or (as commonly is the case) their outcomes are at least initially unstable. A corollary is that outcomes should be systematically monitored, so that staff are aware of positive changes, and organizations can report on improved outcomes across their serviced population. Reductions in use of high-cost services by individual patients (e.g. inpatient or afterhours interventions) can be especially motivating for managers, since that can substantially impact on organizational costs and on numbers who can be treated within existing budgets. Incentives should not exclusively rely on external rewards for optimal uptake. Individual staff should be encouraged to develop goals for learning and using assessments and interventions for co-occurring problems, to solve problems with their application, and notice their own achievements. Effective self-regulation makes them less reliant on the continued integrity of organizational monitoring and reward systems.
Required Skills Must Be Present or Taught, and Cues to Use Them Provided If co-occurring disorders are adequately covered in the initial training of practitioners in addiction, mental and general health, additional training to assess and manage comorbidity may be able to focus just on local procedures and on advances in practice. In the meantime, other strategies are needed to increase the knowledge, skills, and confidence of front-line staff. In both mental health and substance use agencies, some effective strategies that are amenable for use on a large scale are already in the skills repertoire of staff. Examples related to assessment are the ability to establish trust and rapport, to take a detailed history, examine triggers and effects of exacerbations, and review contexts, coping strategies, and supports that were associated with periods of better status. Intervention examples include development and maintenance of motivation for agency attendance and behavioral change, and effective goal setting, planning, and problem solving. Some other strategies are relatively easy to communicate, for example the need to use multiple methods to accurately determine consumption (e.g. daily frequency and amount, frequency and amount of purchases, and weekly cost); the use of a “Timeline Followback” (a day-by-day review of recent events to cue recalled consumption); or helping the person identify pleasurable, non-substance-using activities that can help to boost their mood. Some more demanding areas of knowledge and skills can be supported by other resources (e.g. information on the effects and management of withdrawal from a specific drug, or information
about potential drug interactions can be provided) or given by other specialist staff on the team (e.g. pharmacotherapy for mental health symptoms, management of withdrawal, or long-term support of abstinence). Low-intensity interventions for co-occurring substance misuse typically involve motivational interviewing or brief advice, plus goal setting, planning, and problem solving for issues that are likely to arise in early phases of initiating behavior change. In addition to pharmacotherapy for depression, several brief psychological strategies have significant impact, including behavioral activation (to increase pleasurable activity and daily achievements). Problem solving, goal setting, and planning (e.g. to address situational stressors) are applicable to both depression and anxiety. Longer treatments with application to both addictive and mental disorders include mindful meditation, which assists users to reduce rumination and related distress. Where additional skills are needed, one-off workshops by themselves appear to have limited impact: while short-term increases in knowledge and skill can often be demonstrated, unless they are then consolidated in everyday practice, the gains may then be lost. In order for that consolidation to occur, the context must allow it – for example, the new practice may initially take a little longer until it is mastered, and this additional time must be able to be accommodated. Mentoring or supervision may be needed to assist the practitioner to use it effectively and solve problems with its use, and practitioners may need to be cued so they remember to use it (e.g. by items to be checked in patient records of assessment and treatment). Strategies to increase ongoing fidelity may also be required – for example, checklists for key steps in the assessment or intervention.
A Culture Supporting the Use of the Intervention Should Be Fostered “Champions” can develop enthusiasm for comorbidity practice in the organization. Whether they are within management or among practitioners, they model the use of skills in dealing with co-occurring disorders, provide incidental learning, and reward use of the practices by others. However, excessive reliance on champions in the longer term is dangerous, as their loss can mean that use of the intervention collapses. A focus on staff who are already keen to use the intervention (“early adopters”) appears useful; it avoids unproductive conflict with staff who are initially resistant to comorbidity practices, and allows a critical mass of mutually reinforcing users to develop. We have found that provision of mentoring to this group results in
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significantly improved rates of screening and intervention for co-occurring disorders being recorded in patient files. Active engagement of staff in development and updating of support materials is another useful strategy; it both increases commitment to their use and helps to consolidate their understanding of the strategies.
CONCLUSION There is no “silver bullet” to meeting the complex needs of people with co-occurring disorders, and ensuring stable positive outcomes. However, adopting sound practices that ensure detection of co-occurring problems and access to the best-known treatments is both an excellent start and a moral necessity.
SEE ALSO Diagnostic Dilemmas in Comorbidity, Treatment for Co-occurring Substance Abuse and Mental Health Disorders
List of Abbreviations ECA Epidemiologic Catchment Area OR odds ratio
Glossary Antisocial personality disorder a disorder that produces pervasive disruptions in interpersonal functioning and is characterized by features such as aggression, deceitfulness, impulsivity, reckless disregard for others, and a lack of remorse. Bipolar disorder a disorder with mania (elevated or irritable mood, often with increased activity and impulsivity), or alternating mania and depression – which may have psychotic features that are consistent with that mood (e.g. grandiose delusions in mania). Incentives these are expected and valued benefits from engaging in a behavior. They increase the likelihood of that behavior occurring. Integrated treatment this treatment is adjusted to take account of the presence of co-occurring problems, and addresses them all. It is typically conducted by a single practitioner or team, and is contrasted with parallel or sequential treatment for different problems, usually by different agencies. Odds ratio the increased chance that a person from a particular group shows a feature (in this case a disorder) in comparison with other people. Psychosis a type of disorder that affects brain processes and is marked by features such as attentional difficulties, delusional beliefs, disorganized speech, and disturbances in perception (e.g. hallucinations). Speech may be disorganized, or be limited in amount or content, and motivation may also be affected. Schizophrenia a psychotic disorder (see above), which is not dominated by mood features. Emotional expression, speech, and motivation may be significantly impaired, and disorganized behavior or immobility seen. It cannot be due to another disorder (e.g. intoxication), causes significant functional disruption, and is
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distinguished from similar disorders by its duration (in the Diagnostic and Statistical Manual of the American Psychiatric Association, persisting disturbance for at least 6 months, including at least a month of acute symptoms). Quadrant model of substance misuse and psychiatric problems a guide for decisions on which service should lead the management of an individual with co-occurring disorders. It is a 2 2 matrix, based on the severity of the psychiatric and addictive problems. Timeline Followback a day-by-day review of events or activities over recent weeks or months to cue recall of consumption.
Further Reading American Psychiatric Association, 1994. Diagnostic and Statistical Manual of Mental Disorders, fourth ed. American Psychiatric Association, Washington, DC. Baker, A.L., Kavanagh, D.J., Kay-Lambkin, F.J., et al., 2010. Randomised controlled trial of CBT for co-existing depression and alcohol problems: short-term outcome. Addiction 105, 87–99. Brady, K.T., Verduin, M.L., Tolliver, B.K., 2007. Treatment of patients comorbid for addiction and other psychiatric disorders. Current Psychiatry Reports 9, 374–380. Deane, F., Kavanagh, D.J., 2010. Adapting low intensity CBT interventions for clients with severe mental illness. In: Bennett-Levy, J., Richards, D., Farrand, P., Christensen, H., Griffiths, K., et al. (Eds.), The Oxford Guide to Low Intensity CBT Interventions. Oxford University Press, Oxford, pp. 357–365. Green, B., Kavanagh, D.J., Young, R.McD., 2007. Predictors of cannabis use in men with and without psychosis. Addictive Behaviors 32, 2879–2897. Hall, S.M., 2007. Nicotine interventions with comorbid populations. American Journal of Preventive Medicine 33, S406–S413. Hides, L., Dawe, S., Kavanagh, D.J., Young, R.McD., 2006. Psychotic symptom and cannabis relapse in recent onset psychosisd prospective study. British Journal of Psychiatry 189, 137–143. Kavanagh, D.J., Connolly, J.M., 2009. Interventions for co-occurring addictive and other mental disorders (AMDs). Addictive Behaviors 34, 838–845. Kavanagh, D.J., Young, R., White, A., et al., 2004. A brief motivational intervention for substance abuse in recent-onset psychosis. Drug and Alcohol Review 23, 151–155. Kay-Lambkin, F.J., Baker, A.L., Lewin, T.J., Carr, V.J., 2009. Computerbased psychological treatment for comorbid depression and/or cannabis use: a randomized controlled trial of clinical efficacy. Addiction 104, 378–388. Pourmand, D., Kavanagh, D.J., Vaughan, K., 2005. Expressed emotion as predictor of relapse in patients with comorbid psychoses and substance use disorder. Australian and New Zealand Journal of Psychiatry 39, 473–478. Regier, D.A., Farmer, M.E., Rae, D.S., et al., 1990. Comorbidity of mental disorders with alcohol and other drug abuse: results from the epidemiological catchment area (ECA) study. Journal of the American Medical Association 264, 2511–2518. Rogers, E.M., 2003. Diffusion of Innovations, fifth ed. Free Press, New York. Sterling, S., Weisner, C., Hinman, A., Parthasarathy, S., 2010. Access to treatment for adolescents with substance use and co-occurring disorders: challenges and opportunities. Journal of the American Academy of Child & Adolescent Psychiatry 49, 637–646. Substance Abuse and Mental Health Services Administration, 2002. Report to Congress on the Prevention and Treatment of Co-occurring Abuse Disorders and Mental Disorders. SAMHSA, Rockville, MD. http://www.samhsa.gov/reports/congress2002/.
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34. IMPLICATIONS OF COMORBIDITY FOR CLINICAL PRACTICE
Relevant Websites http://www.dualdiagnosis.org.au/ The link has–Australian and international resources on comorbidity and policy or service development, including toolkits for clinicians.
http://www.ontrack.org.au The link includes–programs for people with co-occurring alcohol and depression issues, and for psychosis-like experiences (including ones triggered by substance use). http://www.samhsa.gov/ The link has–resources on comorbidity.
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