Summary Report of The Workshop on Best Practices for Concurrent Mental Health and Substance Use Disorders
Best Practices - Treatment Interventions and Support Services By Diagnosis
Dr. Rush presented the best practices related to integration, sequencing, and methods used for each diagnosis described in the report. Using case scenarios provided by Health Canada, the participants were then asked to choose one of the following four diagnoses and develop a treatment plan.
- Co-occurring Substance Use and Mood and Anxiety Disorders
- Co-occurring Substance Use and Severe and Persistent Mental Disorders
- Co-occurring Substance Use and Personality Disorders
- Co-occurring Substance Use and Eating Disorders
a) Co-occurring Substance Use and Mood and Anxiety Disorders (e.g., alcohol and depression)
Integration: Should occur at either the program or system level.
Sequencing: Research supports addressing substance use first in the majority of people. Close monitoring is key to see the effect of treatment (e.g., does reduction in alcohol use address depression). The process will vary for different individuals and drug combinations. New medication should not be started until the substance use problems are addressed. However, if a person is on prescribed medication, it may not be advisable to stop it. Post-traumatic Stress Disorder is an exception that requires simultaneous treatment.
Methods: A cognitive-behavioural approach is recommended and promising drug treatments also exist. Relapses are very common, so longer-term treatment is required, as is ongoing assessment.
Treatment plan developed by the participants
Assessment: For a client with a chronic history of substance use problems, the primary concern should be safety. A complete assessment should be carried out to determine the severity of the depression, the potential for a personality disorder, and motivation and readiness for change through a ‘stage of change' assessment. A full medical exam should be undertaken to determine the client's physical state, nutritional status and potential pain management issues. Past treatments, all medication use and past periods of sobriety should be reviewed to determine successful strategies.
Treatment: A case conference should take place with the client and any available family members or friends who can provide support. Build the treatment plan on past successes. For example, if the substance use has ceased, treatment should focus on mental health issues. Provide education on medication and alcohol use. Consider whether a day program could provide sufficient structure for this type of client. Cognitive-behavioural therapy could be suggested, depending on the client's history.
b) Co-occurring Substance Use and Severe and Persistent Mental Disorders (e.g., alcohol and schizophrenia)
Integration: Should occur at either the program or system level.
Sequencing: Simultaneous treatment is recommended.
Methods: Mental health services, crisis response, housing or hospitalization may be needed along with motivational interviewing, harm reduction approach, cognitive-behavioural counseling, self-help liaison, work with families, community treatment or less structured inpatient treatment. "Super-sensitivity" may be an issue for this population whereby small amounts of alcohol and drugs can have negative consequences. Clinicians should avoid direct confrontation, as this may affect client retention in the program.
Treatment plan developed by the participants
Assessment: Even though the client has been diagnosed with schizophrenia, a complete assessment and formal review of medication will be beneficial. The previous diagnosis may have been inaccurate and could hinder future treatment. A mental health diagnosis could be difficult to make, due to the client's unstable situation regarding alcohol and drug use.
Treatment: A simultaneous approach to treating the mental illness and substance use is recommended. It is important to address basic needs such as housing and income and also to investigate past connections, for example, with a foster family for a client who lacks a support system. Anger management or Fetal Alcohol Syndrome (FAS) support groups may be required, although difficulties in group situations could hinder this approach.
c) Co-occurring Substance Use and Personality Disorders
Integration: Should occur at either the program or system level.
Sequencing: Should be simultaneous for borderline personality disorder. For anti-social personality, the substance use issues should be dealt with first.
Methods: More research is needed to determine the best approaches. Currently, the best empirically supported treatment for borderline personality and substance use disorders is dialectal behaviour therapy, which includes behavioural skills training. This is a high-needs population that is difficult to reach and often exhibits the revolving door syndrome.
Treatment plan developed by the participants
Assessment: A full review of the client's history and past assessments should be conducted, including forensic, mental health and substance abuse assessments; bio-psycho-social, HIV and HEP testing.
Treatment: Jurisdiction in which clinicians operate will impact treatment options. Case conferencing is recommended, involving the client in planning the treatment. The treatment plan should involve outpatient support. Dialectic behaviour therapy would be the recommended treatment for
borderline personality; however, it would require a psychiatric assessment.
d) Co-occurring Substance Use and Eating Disorders
Integration: Should occur at either the program or system level.
Sequencing: Simultaneous treatment is recommended, unless there are compelling clinical reasons (e.g., life threatening) for focussing on one of the disorders first.
Methods: Combinations of medical management, behavioural strategies and psychotherapy, to effect change in the eating and substance abuse behaviour, must take place.
No participants chose to address a treatment plan for this issue.
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