Alexis Polles, MD
[email protected]
Perspectives on Mind and Body
34 Milbranch Road, Ste. 60
Hattiesburg, MS 39402
P:601-255-5485 F:601-255-5317
• I: From the ground up
A.Definitions and terminology
B.Integrated Treatment
• II: Making the diagnosis
• III: Treatment
•Coming to be thought of as an outdated term
•Overlap with SUD and MR or LD terms
•Traditionally 2 systems (not 2 diagnoses or even
a “diagnosis” at all)
•Influenced by the biases, perspectives,
experience and training of the evaluator
Substance Abuse and Mental Health
Services Administration (SAMHSA)
Definition of Co-occurring Disorders:
• COD refers to co-occurring substance-related and mental disorders.
Clients said to have COD have one or more substance-related
disorders as well s one or more mental disorders.
• At the individual level, COD exists when at least one disorder of
each type can be established independent of the other and is not
simply a cluster of symptoms resulting from a single disorder.
Definitions and Terms Relating to Co-Occurring Disorders. Tech. no. Overview
Paper 1. Substance Abuse and Mental Health Services Administration, n.d. Web. 19
Jan. 2013. <http://www.samhsa.gov/>.
Examples of Co0ccurring Conditions (COC):
Mood Disorders
Anxiety Disorders
Somatoform Disorders
Factitious Disorders
Dissociative Disorders
Sexual Disorders
Eating Disorders
Sleep Disorders
Impulse-control Disorders
Adjustment Disorders
Personality Disorders
Disorders usually first diagnosed
in infancy, childhood, or
• Alcohol Abuse/Depen.
• Cocaine/
• Opiates/Opioids
• Marijuana
• Polysubstance
• Prescription drugs
• Synthetics
• Hallucinogens
• Dissociatives
Well, How Common Is The Problem?
• Estimates of psychiatric co-morbidity among clinical
populations in substance abuse treatment settings
range from 20-80%
• Estimates of substance use co-morbidity among
clinical populations in mental health treatment
settings range from 10-35%, with the highest for
those with Schizophrenia and Bipolar Disorder
* Differences in incidence due to: nature of population served (e.g.:
homeless vs. middle class), sophistication of psychiatric diagnostic
methods used (psychiatrist or DSM checklist) and severity of diagnoses
included (major depression vs. dysthymia).
Key Epidemiologic Findings Since 2002
Current national COD epidemiologic data are derived from 3 major studies: The National Comorbidity Survey and the NCS-Replication
(NIMH); The National Survey on Drug Use and Health (SAMHSA); The National Epidemiologic Study on Alcohol and Related Conditions (NIAAA+NIDA)
• Substance use disorders are present in more than 9% of the large
numbers of individuals sampled.
• More than 9% of adults have diagnosable mood disorders,
primarily Maj. Dep.
• More than 5 million adult U.S. citizens have a serious mental
(SMI = Persons age 18 +, who currently or at any time during the past year, have
had a diagnosable mental, behavioral, or emotional disorder of sufficient
duration to meet DSM-IV diagnostic criteria , resulting in functional impairment
which substantially interferes with or limits one or more major life activities.)
Why Is This So Difficult?
• Fear in the SUD treatment community of putting addiction on
the back burner.
• High utilization of time and resources.
• Primary approach for MI is medications.
• Primary approach for SUD after detox is other therapeutic
interventions (pre-Suboxone).
• “Denial” by the individual and their family members regarding
• Fear of placing more and more people in the bind of creating
more stigma, more disability.
• (According to the 2004 World Health Report, Maj. Dep. Is the leading cause of
disability in the US and Canada for ages 15-44.)
Why Is This So Difficult?
Psychiatric Disorders
• Health problems
• Family/intimacy problems
• Isolation
• Financial problems
• Employment problems
• School problems
• High risk driving/other accidents
• Multiple admissions
• Chronic/relapsing
• Increased suicide
• Has many patterns
• Lack of progress=failure
• Changing diagnostic criteria
Addiction Disorders
• Health problems
• Family/intimacy problems
• Isolation
• Financial problems
• Employment problems
• School problems
• High risk driving/other accidents
• Multiple admissions
• Chronic/relapsing
• Increased suicide
• Has many patterns
• Lack of progress=failure
• Changing diagnostic criteria
The Four Quadrant Framework for
Co-Occurring Disorders Classifies Patients Into 4 Quadrants of
Care Based on Symptom Severity, Not Diagnosis
Less severe
mental disorder/
more severe
abuse disorder
Less severe
mental disorder/
less severe
abuse disorder
This framework is
suggested to guide
systems integration and
resource allocation in
treating individuals with
co-occurring disorders
1998; NY State; Ries,
1993; SAMHSA Report to
Congress, 2002)
More severe
mental disorder/
more severe
abuse disorder
More severe
mental disorder/
less severe
abuse disorder
And what about Quadrants I and III
• As in Addiction Treatment settings
• As in Criminal Justice settings, police encounters
• As in Primary Care settings such as community health clinics, HIV or
Hep C treatment settings, primary care offices
• As in ER’s, especially with suicidal pts., ICUs, trauma centers
• As in unemployment offices, homeless shelters, schools, workplace
settings, faith-based settings
• 53% of people with serious psychological distress and a SUD receive no
treatment. (2005 National Survey on drug Use and Health)
• There is a problem.
• It has been documented it for a long time.
• More information to figure out
• The current state of affairs, especially longer term outcomes.
• What to do about it.
Current Models for Treatment of Co-occurring
• Treatment System Paradigms
Independent, disconnected
Sequential, disconnected
Parallel, connected
Treatment of Co-occurring Disorders
• Integrated Model
• Model with best conceptual rationale
• Treatment coordinated best
• Challenges
Funding/ payment streams
Staff integration
Threatens existing systems
Short term cost increases (better long term cost outcomes ?)
Elements of an Integrated Model
• Preliminary assessment of mental health and substance use urgent
conditions (Safety First)
Risk to self or others
Withdrawal potential
Medical risks associated with alcohol/drug use
Case 1
• 24 year old white male. No prior treatment for SUD or
MI reported by mother. Parents noted “strange
behavior” for several weeks prior to his disappearance
for 2 months. Found by family 3 days before
presenting to you, living in another state, with an
older man he had met in a Mexican restaurant. Family
suspected methamphetamine abuse. PMH: Negative.
FH: None known. He was noted to be disheveled with
flat affect, sparse verbal interaction with some grunts,
and occasional standing in position without moving for
prolonged periods. Vitals were normal. 5’7” 160 #. He
was oriented but not to place. Urine dip showed THC.
• What are your thoughts?
Elements of an integrated model
• Diagnostic process that produces provisional diagnosis of
psychiatric and substance use disorders using:
• Substances used (Limitations of but necessity of valid
toxicology results.) and when, how much, how often, last
• Review of signs and symptoms (psychiatric and substance
use). Rating scales may be helpful but not better than a
really good history. Collateral information.
• Personal history timeline of symptom emergence (what
started when).
• Family history of psychiatric/substance use disorders.
• Psychiatric/substance use treatment history.
• Look for things that cluster.
• Unbelievably, he was transferred for psychiatric hospitalization to a
large university setting twice. He was initially admitted there after he
physically blocked exit from the nurses’ station and was holding body
positions for more than an hour (10 days after arrival at your center).
He was there for 2 or so days and thought to have a substance abuse
problem. He refused antipsychotic medications from you. The second
time was 3 to 4 days later after his peers reported him putting garbage
in his pockets, not showering or standing in the shower with all his
clothes on, and not performing other ADLs. No active
hallucinations/delusions were noted, though mutism/catatonia
continued. He was admitted again to university and after 3 days
returned on no medications. He attended activities but little to no
verbal input (17 days after coming in). Told nurse that he wanted to be
silent because he “found a new way.” Reported to nurse that he had a
psychiatric visit at school 2 years prior for stress. Quit college because
he “got tired of the routine.” No relationships for 2+ years, since
college. Roommates in treatment think he has schizophrenia.
• Positive symptoms make treatment seem more
urgent, and they can often be effectively treated
with antipsychotic drugs. But negative symptoms
are the main reason patients with schizophrenia
cannot live independently, hold jobs, establish
personal relationships, and manage everyday social
• Blunted affect
• Alogia (poverty of speech)
• Anhedonia
• Associality (lack of desire to form relationships)
• Avolition (lack of motivation)
Case 2 Prozac Nation
• http://movieclips.com/QMxW-prozac-nation-movie-health-hazard/
DSM IV Major Depressive Episode
A. Five (or more) present during the same 2-week period, represent a change, at least one of
the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
(1) depressed mood most of the day, nearly every day, as indicated by either subjective report
(e.g., feels sad or empty) or observation made by others (e.g., appears tearful).
(2) markedly diminished interest or pleasure in all, or almost all, activities most of the day,
nearly every day (as indicated by either subjective account or observation made by others)
(3) significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of
body weight in a month), or decrease or increase in appetite nearly every day. Note: In children,
consider failure to make expected weight gains.
(4) insomnia or hypersomnia nearly every day
(5) psychomotor agitation or retardation nearly every day (observable by others, not merely
subjective feelings of restlessness or being slowed down)
(6) fatigue or loss of energy nearly every day
(7) feelings of worthlessness or excessive or inappropriate guilt (which may be delusional)
nearly every day (not merely self-reproach or guilt about being sick)
(8) diminished ability to think or concentrate, or indecisiveness, nearly every day (either by
subjective account or as observed by others)
(9) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a
specific plan, or a suicide attempt or a specific plan for committing suicide
B. Symptoms do not meet criteria for a Mixed Episode.
C. Symptoms cause clinically significant distress or impairment in functioning.
D. Symptoms are not due to the direct physiological effects of a substance or a medical
E. Symptoms are not better accounted for by Bereavement (After the loss of a loved one, the symptoms persist for
longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic
symptoms, or psychomotor retardation.)
Bipolar II Disorder
A. Presence (or history) of one or more Major Depressive Episodes.
B. Presence (or history) of at least one Hypomanic Episode. (Duration 4 days)
C. There has never been a Manic or a Mixed Episode.
•D. The mood symptoms in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed
on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
•E. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of
functioning .
Bipolar I Disorder (See the wonderful movie Silver Linings Playbook, out now)
A.One or more Manic Episodes...or Mixed Episodes...
Often individuals have also had one or more Major Depressive Episodes, but this is
not required for diagnosis. Episodes of Substance-Induced Mood Disorder or of
Mood Disorder Due to a General Medical Condition do not count toward a diagnosis
of Bipolar I Disorder
• A manic episode is defined in the DSM as a period of seven or more days (or any period if admission to hospital is required) of
unusually and continuously effusive and open elated or irritable mood, where the mood is not caused by drugs/medication or
a medical illness and (a) is causing obvious difficulties at work or in social relationships and activities, or (b) requires
admission to hospital to protect the person or others, or (c) the person is suffering psychosis.
• To be classed as a manic episode, while the disturbed mood is present at least three (or four if only irritability is present) of
the following must have been consistently prominent: grand or extravagant style, or expanded self-esteem; pressured
speech; reduced need of sleep (e.g. three hours may be sufficient); talks more often and feels the urge to talk longer; ideas
flit through the mind in quick succession, or thoughts race and preoccupy the person; over indulgence in enjoyable behaviors
with high risk of a negative outcome (e.g., extravagant shopping, sexual adventures or improbable commercial schemes). [
• If the person is concurrently depressed, they are said to be having a mixed episode.
Elements of an integrated model
• Initial treatment plan (Days 1-10) that includes:
• Choice of a treatment setting appropriate to initially stabilize medical
conditions, psychiatric symptoms and drug/alcohol withdrawal symptoms
• Initiation of medications to control urgent psychiatric symptoms
(psychotic, severe anxiety, etc.)
• Implementation of medication protocol appropriate for treating
withdrawal syndrome(s)
• Ongoing assessment and monitoring for safety, stabilization and
Elements of an integrated model
• Early stage treatment plan (Days 2-14) that includes:
• Selection of treatment setting/housing with adequate
• Completion of withdrawal medication
• Review of psychiatric medications
• Completion of assessment in all domains (psychology, family,
educational, legal, vocational, recreational)
• Initiation of individual therapy and counseling (extensive use
of motivational strategies and other techniques to reduce
• Introduction to behavioral skills group and educational
groups, step groups
• Introduction to self help programs
• Urine testing and breath alcohol testing
Elements of an integrated model
• Intermediate treatment plan (up to 6 or 8 weeks)
that includes:
• Housing plan that addresses psychiatric and substance use
• Plan of ongoing medication for psychiatric and substance use
treatment with strategies to enhance compliance
• Plan of individual and group therapies and psychoeducation
with attention to both psychiatric and substance use needs
• Skills training for successful community participation and
relapse prevention
• Family involvement in treatment processes
• Self-help program participation
• Process of monitoring treatment participation (attendance
and goal attainment)
• Urine and breath alcohol testing
Elements of an integrated model
• Extended treatment plan that includes (up to 6
• Housing plan
• Ongoing medication for psych and substance use treatment
• Plan of individual and group therapies and psychoeducation
with attention to both psychiatric and substance use needs
• Ongoing participation in relapse prevention groups and
appropriate behavioral skills groups and family involvement
• Initiation of new skill groups (e.g.; education, vocational,
recreational skills)
• Self help involvement and ongoing testing
• Monitoring attendance and goal attainment
Elements of an integrated model
• Ongoing plan of visits for review of:
• Medication needs
• Individual therapies
• Support groups for psych and substance use conditions
• Self help involvement
• Instructions to family to recognize relapse to psych and
substance use
In short, a chronic care model is used to reduce relapse and
if/when relapse (psychiatric or substance use) occurs,
treatment intensity can be intensified.
Abstinence & Relapse
• Goal for COD recovery
• Controlled usage ?
• Abstinence ?
• Ultimately: Developing a personally meaningful life
• Contracts to Quit: Clarifies Commitment to Change
• Relapse
• Return to old drug abuse patterns
• This is the rule rather than the exception
• Treat them as setbacks or opportunities for learning, instead
of failures
• Contributing causes include stress, strong emotional states,
conflicts with family or friends, social pressures, other
addictions ?
12 Step Versus Cognitive Behavioral Treatment (SelfManagement and Recovery Training) In Dual Diagnosis (Brooks &
Penn, Am J of Alcohol and Drug Abuse, 29 (2), 359-383, 2003.
12 Step
• More effective in decreasing
alcohol use and increasing social
• Worsening of medical problems,
health, employment, psychiatric
(Brooks & Penn, 2003)
Cognitive Behavioral
• More effective in improving
overall health and work status
½ went to 12 step treatment and
½ to SMART. One year
observation. Findings drawn from
those who finished 3 months of
Does participation in self-help groups reduce demand for health
n=1774, 1 year follow-up Humphreys et al , 2001
Inpt days
• 12 Step
• Cog Beh
* all p< .001
** 64% higher cost for CBT
One year ABSTINENCE was predicted by:
• AA involvement ( n=377 men and 277 women)
Not having pro-drinking influences in one's network
• Having support for reducing consumption from people met
in AA
• In contrast, having support from non-AA members was
not a significant predictor of abstinence.
Kaskutas: Addiction 2002
Double Trouble Recovery (DTR) Outcomes
• Members of 24 DTR groups (n=240) New York City, 1 year
• Drug/alcohol abstinence = 54% at baseline, increased to 72% at
• More attendance = better medication adherence,
• Better medication adherence = less hospitalization
• Magura Add Beh 2003, Psych Serv 2002
Evidence-based practices regarding self-help
J of Sub. Abuse Treatment, Vol 26, Issue 3, Pp. 151-158, April, 2004.
• Summary of status of U.S. self-help groups
A diverse set of self-help organizations has developed for all substances of significant
health concern (Most research done on AA/NA/DTR)
Collectively, these self-help organizations are both appealing and affordable to a broad
spectrum of people.
Clinical, agency and governmental procedure and policy influence the prevalence,
organizational stability, and availability of addiction-related self-help groups
• Synthesis of effectiveness research results
Longitudinal studies associate AA and NA participation with greater likelihood of abstinence,
improved social functioning, and greater self-efficacy. Participation seems more helpful when
members engage in other group activities in addiction to attending meetings.
Twelve-step self-help groups significantly reduce health care utilization and costs, removing a
significant burden from the health care system.
Self-help groups are best viewed as a form of continuing care rather than as a substitute for
acute treatment services (e.g., detoxification, hospital-based treatment, etc.)
Randomized trials with coerced populations suggest that AA combined with professional
treatment is superior to AA alone.
Definition of Insanity?
• Same applies to treatment so---Those who do not experience an adequate response to treatment
should receive timely reassessment and a change in their treatment!
Primary References
• ASAM Review Course in Addiction Medicine. Chicago: ASAM, 2012.
Print. “Co-occurring Addiction and Mental Disorders,” presented by
Richard Ries, MD.
• "Substance Abuse & Mental Health Services Administration." The
Substance Abuse and Mental Health Services Administration.
SAMHSA, n.d. Web. 20 Jan. 2013. <http://www.samhsa.gov/>.

Co-occurring addiction and mental disorders