Factors Affecting Prevalence of Co-Occurring Disorders

Some factors found to increase the prevalence of co-occurring disorders among people with substance use disorders include older age, lower socioeconomic status, and residence in urban areas (Kessler et al. 1994); homelessness (North et al. 2001); and incarceration (Robins et al. 1991). Certain mental disorders (e.g., antisocial personality disorder [APD], schizophrenia) and some affective and anxiety disorders (phobias, bipolar depression) have been found to be more prevalent among persons with substance use disorders than in the general population (Regier et al. 1990). However, some of these studies did not determine whether symptoms of co-occurring disorders were related to the pharmacological effects of substances or to an underlying non-substance-related disorder. TIP 42, Substance Abuse Treatment for Persons With Co-Occurring Disorders (CSAT 2005b ), discusses factors affecting the prevalence of co-occurring disorders.

Gender Differences in Prevalence of Co-Occurring Disorders

Rates of co-occurring disorders have been found to differ between men and women. For example, Ward and colleagues (1998b) found that more women than men who were opioid addicted had affective and anxiety disorders, whereas more men than women who were opioid addicted had APD and were dependent on alcohol. A study by Brooner and colleagues (1997) found women were more likely than men to have Axis I diagnoses, particularly major depression; seven times more likely to have borderline personality disorders; only half as likely to be diagnosed with APD; and less likely than men to manifest problems with other substances, including alcohol. Another study indicated that female patients receiving methadone were more likely than male patients to have psychotic and affective disorders (Calsyn et al. 1996). Another study of patients in MAT found that women were more likely than men to have PTSD (Villagomez et al. 1995).

Specific Screening Procedures

OTPs should establish specific screening procedures for co-occurring disorders and train counselors and intake workers to perform these procedures, including how to recognize the presenting symptoms of the most commonly encountered co-occurring disorders. Few significant differences in symptoms of mental disorders exist between patients who are addicted to opioids and other people who are not; therefore, the symptoms described in DSM-IV-TR are applicable during admission screening. When possible, screening for co-occurring disorders should be linked with other assessments to avoid duplicate efforts by staff and unnecessary burdens on patients' time. An OTP's screening procedures for co-occurring disorders should specify

• Questions or instruments to be used
• When and where to conduct screening segments (e.g., address all safety-related questions during initial intake and defer other questions until applicants are no longer intoxicated or in withdrawal—but wait no longer than a specified period after admission)
• Who conducts screenings
• How to record results
• Cutoff scores or other indicators of positive results for co-occurring disorders
• Exactly how to handle positive results (e.g., whom to inform, how, and when; what constitutes a psychiatric emergency and how to address it)
• How extensively a patient's self-reported information must be corroborated with information from other sources (e.g., family and friends, caseworkers, previous treatment records)
• Which staff members to consult if questions arise about these procedures or the results.

Screening for co-occurring disorders usually entails determining

• An applicant's immediate safety and self-control, including any suicide risk, aggression or violence toward others, or domestic or other abuse or victimization and the ability to care for himself or herself (see “Handling Emergency Situations” below).
• Previous diagnosis, treatment, or hospitalization for a mental disorder and, if applicable, why, when, and where, as well as the treatment received and its outcome. Questions about the relationship of mental disorders to substance use—for example, whether a mental disorder was present during abstinence or before the substance use disorder—determine whether a co-occurring disorder is substance induced or independent.
• The applicant's current co-occurring disorder symptomatology based on DSM-IV-TR criteria, including whether any psychotropic medications have been prescribed or are being used (usually included on a screening questionnaire).
• Trauma history (e.g., physical or sexual abuse, living through a natural disaster or war, witnessing death or tragedy). Questions about trauma should be brief and general, without evoking details that might precipitate stress. Several screening instruments for PTSD are described in other TIPs (see the forthcoming TIP Substance Abuse and Trauma [CSAT forthcoming d]; TIP 25, Substance Abuse Treatment and Domestic Violence [CSAT 1997b ]; and the Modified PTSD Symptom Scale: Self-Report in TIP 36, Substance Abuse Treatment for Persons With Child Abuse and Neglect Issues [CSAT 2000d ]).
• Any history of mental disorder-related symptoms among immediate relatives and their diagnoses, treatments, or hospitalization.
• Any unusual aspects of an applicant's appearance, behavior, and cognition. If indications of a cognitive impairment are present, a mental status examination should be conducted.

Screening Tools

Many States require specific screening or assessment instruments, such as the Addiction Severity Index (ASI), to document baseline patient data. Other important considerations in selecting a screening tool for co-occurring disorders include its psychometric properties and cultural appropriateness and, if the test is self-administered, the literacy level required. The consensus panel believes that no instrument in an OTP can identify co-occurring disorders satisfactorily, and many of the most thoroughly tested are not in the public domain. The ASI records symptoms of mental disorders but does not diagnose. More information on the ASI and other screening instruments, including Mental Health Screening Form III, the Mini International Neuropsychiatric Interview (M.I.N.I.), and some proprietary instruments, is in TIP 42, Substance Abuse Treatment for Persons With Co-Occurring Disorders (CSAT 2005b ). Other tools focusing on particular disorders or pathologies (e.g., suicide danger, PTSD, AD/HD, depression) can be accessed through the Web sites listed in Appendix 12-A.

DSM-IV-TR Criteria

Although many insurance companies require International Classification of Diseases diagnostic codes for reimbursement purposes, clinicians and researchers in the United States traditionally use the DSM classification system. As this system has evolved over several editions, its authors have made important changes in definitions for substance-related disorders. Specifically, the DSM-IV-TR divides these disorders into two types: substance use disorders and substance-induced co-occurring disorders.

Structured and Semistructured Interview Formats for Psychiatric Diagnoses

A number of carefully designed and tested instruments are available to determine DSM-IV or ICD-10 diagnoses, although a careful clinical interview usually can serve this purpose. Not all instruments have been updated for DSM-IV-TR diagnoses, but DSM-IV diagnoses are similar. Examples include the

• Structured Clinical Interview for DSM-IV Axis I and II Disorders, Clinical Versions
• Composite International Diagnostic Interview, Core Version 2.1
• Psychiatric Research Interview for Substance Abuse and Mental Health Disorders
• Diagnostic Interview Schedule, Version 4
• Alcohol Use Disorder and Associated Disabilities Interview Schedule.

TIP 42, Substance Abuse Treatment for Persons With Co-Occurring Disorders (CSAT 2005b ), discusses these and other screening and assessment instruments and their sources at greater length.

Effects of Co-Occurring Disorders on Treatment Outcomes

The conventional view, which has considerable empirical support, is that unidentified, untreated co-occurring disorders impede progress for patients in MAT and lead to difficulties in engaging patients in treatment, establishing a therapeutic alliance between patients and treatment providers, maintaining adherence to treatment regimens, eliminating substance abuse and other risky behaviors, and preventing premature dropout or early relapse. Conversely, a review by Drake and Brunette (1998) concluded that substance abuse complicates co-occurring disorders, often precipitating relapse to psychopathological symptoms, hospitalization, disruptive behavior, familial problems, residential instability, decreased functional status, HIV infection, or medication noncompliance.

Because research on treatment outcomes for patients with opioid addiction and co-occurring disorders usually examines small groups of subjects and because patients in these groups are not homogeneous, the general applicability of current findings is limited. Many confounding factors exist (Room 1998). Despite these limitations, numerous studies have found that many patients with co-occurring disorders did well when appropriate psychiatric and substance abuse treatments were delivered. The consensus panel recommends more intensive and psychiatrically specific treatment for these patients.

Effects of Symptom Severity

Studies disagree on whether the severity of co-occurring disorder symptoms in patients who are addicted is a useful predictor of treatment outcomes. Early studies found that the severity of co-occurring disorder symptoms, particularly in patients with anxiety or depression, strongly predicted treatment outcomes and that the most severely symptomatic patients had the heaviest substance use and most impaired adjustment, whereas the least symptomatic did best in addiction treatment (McLellan et al. 1993; Rounsaville et al. 1986). However, later studies have found that higher symptom severity, although associated with higher levels of substance use and worse overall adjustment, did not predict treatment response. In one study, drug test results for patients with severe psychopathology improved significantly over time (Belding et al. 1998). In another study, patients in MAT for at least 90 days who had co-occurring disorders and high levels of symptom severity had positive treatment responses (Joe et al. 1995). Patients with more than one co-occurring disorder engaged in treatment more readily than those who were addicted only, and both groups were similar in average incidence of drug use or criminal activity. Patients with depression, anxiety, suicidal ideation, and other pathologies at intake were twice as likely to attend individual—but not group—counseling sessions and significantly more likely to discuss psychological problems than those reporting none of these symptoms.

Consequently, caution is advised in predicting a simple, stable correlation between symptom severity of co-occurring disorders and treatment outcomes. However, the consensus panel believes that co-occurring disorders can improve substantially but that outcomes depend heavily on additional treatment being provided for these disorders and that patients with severe symptoms may require longer, more intensive treatment.

Prognosis for Specific Co-Occurring Disorders

General Treatment Considerations for Patients With Co-Occurring Disorders

Clearly, co-occurring disorders should not exclude people with opioid addiction from admission to an OTP. The consensus panel believes that the best strategy is to stabilize these patients' opioid addiction with methadone, buprenorphine, or levo-alpha acetyl methadol (LAAM) while assessing their co-occurring disorder symptoms and choosing the most appropriate treatment course. Although OTP staff members often focus on the condition that is most severe and threatening, it usually is best to address all of a patient's disorders simultaneously because each can influence the others. TIP 42, Substance Abuse Treatment for Persons With Co-Occurring Disorders (CSAT 2005b ), provides information about treatment planning and implementation for this group.

The consensus panel believes that the following principles are essential to manage patients with co-occurring disorders in an OTP:

• Treatment of co-occurring disorders should be integrated or closely coordinated with substance abuse treatment when the former is not available on site.
• Staff members, whether primarily from the substance abuse treatment or mental health fields, should be knowledgeable about treatments for both disorders.
• Psychotropic medications should be prescribed only after patients are stabilized on the treatment medication (which in the panel's experience takes an average of 3 to 7 days for buprenorphine and 3 weeks to a month for methadone), unless an independent co-occurring disorder is evident from past records or clinical examination or significant impairment associated with the symptoms of a co-occurring disorder exists.
• All medications used by patients and patients' adherence to medication regimens should be monitored carefully, for example, via drug testing. Physicians should be careful about prescribing substances with abuse potential, such as benzodiazepines. If such medications are prescribed, the less abusable drugs in a class should be chosen, for example, oxazepam (Serax^®) rather than lorazepam, clonazepam, alprazolam or diazepam.
• Patients resistant to being psychiatrically diagnosed should be assured that it is not shameful but is likely to provide a better understanding of their problems and aid in treatment. Educating patients about co-occurring disorders helps.
• Therapy for patients with co-occurring disorders should be more intensive, on average, than for patients without co-occurring disorders. The primary goal is abstinence from substances. Remission of co-occurring disorder symptoms should be an important secondary goal.

Co-Occurring Disorders and Treatment Planning

Because patients in MAT exhibit a wide range of co-occurring disorders, the consensus panel believes that early treatment planning and resource management should include classifying patients, at least tentatively, into categories based on types and severity of co-occurring disorders, although treatment always should be tailored individually.

Effects of Co-Occurring Disorders on HIV Risk Behaviors and Comorbidity

King and colleagues (2000) found that patients with co-occurring disorders in MAT were at higher risk for contracting and transmitting HIV than those without these disorders. In another study, patients who were HIV seropositive and had co-occurring disorders were more likely than those without co-occurring disorders to continue using drugs, less likely to be prescribed HIV medications or to adhere to medication regimens, and more likely to develop AIDS (Ferrando et al. 1996). People with co-occurring disorders, particularly depression or dysthymia, were more likely than those without Axis I disorders to continue needle sharing and other high-risk behaviors (Camacho et al. 1996). Patients in MAT who injected drugs and had APD were at higher risk for contracting and spreading HIV (Brooner et al. 1993). To decrease the spread of HIV, it is important to treat both substance use and co-occurring disorders and provide education and support for patients who inject drugs. More information on HIV/AIDS and substance abuse treatment, including the combined treatment of HIV/AIDS, substance abuse, and mental illness, can be found in TIP 37, Substance Abuse Treatment for Persons With HIV/AIDS (CSAT 2000e ).

Models of Care

Although it is not always feasible to provide more specialized services on site, patient adherence to medical treatment was found to drop dramatically when such services were provided through offsite referral (Batki et al. 2002). Even when referrals are to services near an OTP, noncompliance may have significant consequences for personal, social, and public health.

If a program cannot provide onsite ancillary services, it is important that staff members identify co-occurring disorders early so that they can refer patients to appropriate resources. It is essential to monitor patient progress and compliance with offsite treatment, which can be done by a counselor, case manager, nurse, or physician's assistant or by assigning one staff member to coordinate and monitor all referrals. Offsite referrals also may be necessary to obtain psychotropic medications and evaluate patients' reactions to them.

Handling Emergency Situations

A high percentage of patients with co-occurring disorders in MAT have reported suicide attempts or difficulty controlling violent behavior during their lifetimes (Cacciola et al. 2001). Patients who present an acute danger to themselves or others or have psychotic symptoms or disordered thinking that could interfere with their safety or that of others should receive immediate, aggressive intervention on admission and throughout treatment. Staff members should be trained to notice indications of suicidal or homicidal risks. These observations should be documented and communicated to designated staff members who can take necessary action, including appropriate medication, notification of family members and involved agencies (e.g., probation office, children's protective services), or transfer of patients to more secure or protective settings. Staff members should understand thoroughly and be prepared to act on an OTP's “duty to warn” (CSAT 2004b ) about potentially violent behavior by patients.

Counseling, Psychotherapy, and Mutual-Help Groups for People With Co-Occurring Disorders in MAT

Chapter 8 discusses counseling, case management, and psychotherapy for patients in MAT. Programs should encourage participation in mutual-help groups that focus on the needs of people with co-occurring disorders. Exhibit 12-3 lists some of the best known of these groups, along with contact information.

Psychoeducation for Patients With Co-Occurring Disorders in MAT

Group sessions presenting information about topical issues can help patients with co-occurring disorders and their families. Patients can explore relevant themes by emphasizing positive coping strategies and sharing experiences. Possible topics for psychoeductional groups are presented in Exhibit 12-4

Pharmacotherapy for Patients With Co-Occurring Disorders in MAT

Several pharmacological treatments for co-occurring disorders are available and should be used when indicated. Most medications are more effective when used with counseling or psychotherapy in comprehensive MAT.

In many ways, an OTP is an optimal setting to initiate and monitor psychiatric pharmacotherapy for co-occurring disorders because patients attend daily (at least in the early stages of treatment) and onsite physicians and other staff can observe their reactions to psychotropic medications as well as to methadone or other addiction treatment medications.

When psychotropic medications are used in an OTP, they should be prescribed

• In a comprehensive program that integrates medical, psychiatric, and social interventions and supports patient compliance with medication dosing schedules.
• In the context of a multidisciplinary-team approach in which regularly scheduled team meetings ensure that all members are aware of the patient's progress in treatment.
• With careful selection of medications because some patients may attempt to get high on any medication prescribed. Some medications (e.g., amitriptyline, tramadol, benzodiazepines) have little abuse potential in other populations but pose a significant risk of abuse in this population (Cicero et al. 1999).

If patients in an OTP are prescribed other medications in addition to addiction treatment medications, the consensus panel recommends the following procedures:

• All prescribed psychotropic medications should be to treat suspected or confirmed co-occurring disorders, not to alleviate normal discomfort (Minkoff 2000).
• Fixed, rather than “prn” or “as needed,” doses of psychotropic medications should be prescribed because, especially early in MAT, patients addicted to opioids have difficulty regulating medications of any kind (Minkoff 2000). Whenever possible, given resource availability, potentially abusable medications should be dispensed by OTP staff along with addiction treatment medication.
• Patients receiving psychotropic medications should be educated about each drug's expected benefits, potential disadvantages and limitations, side effects, implications for pregnancy and breast-feeding, length of time before full effects should begin, and potential to cause tolerance and withdrawal. This education can be done individually or in a group, but all information should be communicated both in writing and orally.
• An onsite (full- or part-time) physician or psychiatrist should have regular contact with each patient with a co-occurring disorder to review medication response and compliance. This professional also should supervise counselor interactions with these patients and participate in team meetings to discuss treatment plans.

OTPs should consider a hierarchical approach to treating patients with co-occurring disorders, starting with psychosocial interventions such as increased counseling or psychotherapy (unless the patient has a disorder clearly needing medication). Depending on severity and acuity of symptoms, treatment providers may be able to use nonpharmacological approaches such as psychotherapy, either alone or with psychiatric medications. If these psychosocial approaches are ineffective or of limited benefit, providers should select psychiatric medications with the lowest abuse potential that are likely to be effective. TIP 37, Substance Abuse Treatment for Persons With HIV/AIDS (CSAT 2000e , pp. 83–84), provides a summary of abuse potential for psychiatric medications. The psychiatric medications should be, in most instances, adjunctive to other ongoing interventions, not a substitute for them. However, other factors to consider include

• The potential effect of medication side effects on compliance
• Potential negative interactions with addiction treatment medication or other drugs
• Lethality if the drug is used impulsively or intentionally for suicide
• Potential effects on a patient's physical condition—for example, whether the drug might injure an already damaged liver or increase blood pressure in a hypertensive patient.

Some studies have found that methadone may, by itself, relieve some symptoms of mood and anxiety disorders but not Axis II personality disorders (Calsyn et al. 2000a ; Musselman and Kell 1995). From a practical viewpoint and assuming sufficient time to observe patients before further intervention, the consensus panel believes that the best approach is careful observation during the first weeks of MAT to determine whether symptoms of co-occurring disorders diminish before psychiatric medications are considered.

Collaboration Between Counselors and Physicians

Many counselors have little or no psychiatric background and need training in

• Working with patients who may have co-occurring disorders but who resist evaluation or respond only partially to treatment
• Exploring stereotypes and feelings about what it means to have a co-occurring disorder
• Helping patients keep physician appointments, understand information, and follow physician recommendations
• Supporting patients to try medication if recommended
• Supporting patients to tolerate side effects long enough to determine whether medications help
• Providing guidance about when to contact a physician to report side effects or lack of relief from or worsening symptoms
• Supporting patients to continue taking medication, even when they feel better.

Physicians need training or guidance in

• Providing education to OTP staff about co-occurring disorders and medications
• Recognizing common misunderstandings about and resistances to medication in addiction treatment
• Creating protocols that make good use of counselor ability to provide detailed observations and ongoing feedback on patients' conditions (Zweben 2003).