1

Dual Diagnoses

Principles of the Minkoff model for treating co-occurring mental

health & substance use disorders

2

1. “Dual diagnoses are an expectation,

not an exception”

According to epidemiological studies, approximately 50% of people with a diagnosis of severe mental illness also meet lifetime criteria for a diagnosis of substance use disorder. (Drake, 1995)

Regier et al, JAMA 1990

Prevalence of substance use disorders with mental illness

0

10

20

30

40

50

60

% of respondents

with substance use disorder

Gen pop Schiz Bipolar Maj dep OCD Panic

4

“Dual diagnoses are an expectation, not an exception”

According to the National Comorbidity Study, people with mania are 9.7 times as likely as the general population to meet the lifetime criteria for alcohol dependence. (Kessler et al, 1996)

5

Prevalence of Co-Occurring Substance Use Disorders with Schizophrenia (ECA Study)

0102030405060708090

100

Alcohol UseDisorder

Drug UseDisorder

Alcohol orDrug UseDisorder

SchizophreniaGeneral Population

% o

f re

spon

dent

s

Regier et al., JAMA, 1990

6

“Dual diagnoses are an expectation, not an exception”

In community studies evaluated for the Epidemiologic Catchment Area (ECA) study, 33.7% of people diagnosed with schizophrenia or schizophreniform disorder and 42.6% of people with bipolar disorder also met the lifetime criteria for an alcohol use disorder (AUD) diagnosis, compared with 16.7% of people in the general population. (Regier et al, 1990)

7

2. “Use the Four-Quadrant model to understand & inform effective

treatment”

HIGH PSYCHIATRIC(SPMI)

HIGH SUBSTANCE (Dependence) IV

LOW PSYCHIATRIC(psychiatrically complicated)

HIGH SUBSTANCEIII (Dependence)

HIGH PSYCHIATRIC(SPMI)

LOW SUBSTANCE (Abuse) II

LOW PSYCHIATRIC(mild psychopathology)

LOW SUBSTANCEI (Abuse)

8

3. “Emphasize the empathic, hopeful, integrated aspects of the treatment

relationship”

The most significant predictor of treatment success is an: (1) empathic, (2) hopeful, (3) continuous treatment relationship in which (4) integrated treatment and (5) coordination of care can take place through multiple treatment episodes.

Within this context, (6) case management / care and (7) empathic detachment / confrontation are appropriately balanced at each point in time.

9

4. “Consider both disorders primary and integrated, and treat accordingly”

Both treatment systems (Mental Health & Substance Abuse) have myths that clinicians can’t treat one illness while also treating the other.

10

4. “Consider both disorders primary and integrated, and treat accordingly”

In fact, treatments for each condition work well together, and staff can learn to integrate both.

Both substance disorders and mental illness fit into the disease-management / recovery model.

11

Leads to lack of control of behavior &/or emotion Symptoms can be controlled with treatment Physical, mental and spiritual disease Progressive illness w/o treatment Disease miscast as a moral issue Affects the entire family Depression & despair Shame and stigma Hereditary factors Biological Illness Guilt and failure Denial factor Incurable Chronic

5. “Apply the Disease / Recovery model with diagnosis-specific and stage-of-

change-specific interventions” (r/d-1)

12

1. Initial phase is stabilization, which may require hospitalization, &/or medication (detox), &/or psychotropic medication

2. Following stabilization, the next phase is rehabilitation

 

3. Rehabilitation involves maintaining stability by following a long-term program (don’t use, attend meetings, work the 12 Steps, etc / take meds, use therapy or other helpful supports / services, etc.)

4. Denial needs to be overcome

“Apply the Disease/Recovery model with diagnosis-specific & stage-of-change-

specific interventions” (d/r-1)

13

5. Powerlessness over the disease needs to be acknowledged

6. Help must be asked for, from a power greater than the self, in order to control symptoms (higher power, AA, NA, sponsor, meds, therapist, doctor, case manager, etc)

7. Recovery proceeds ‘One Day At A Time’

8. Recovery is never done, but gradual progress can be made

 

“Apply the Disease/Recovery model with diagnosis-specific & stage-of-change-

specific interventions” (d/r-1)

14

9. Relapse is always a risk

10. Families / friends benefit from involvement in a program to get help for themselves in dealing with the disease

11. Education about the disease is an important piece

12. Treatment must include focus on feelings about the disease, and feeling good about oneself

13. Recovery is a physical, mental, emotional and spiritual process

“Apply the Disease / Recovery model with diagnosis-specific &

stage-of-change-specific interventions” (d/r-2)

15

6. “Apply the disease / recovery model with diagnosis-specific and stage-of-change-specific interventions” (Prochaska, Norcross, & DiClemente)

Precontemplation

Contemplation

Preparation

Maintenance

Relapse / Recycle

Action

16

Evaluating Stages of Change

Precontemplation (Denial)• “What problem? I’m not thinking

about it.”

Contemplation (Ambivalence)• “I wonder if I might have a problem?

I’m thinking about it but not ready to decide anything yet.”

Preparation / Determination (Admission)• “I have a problem.”

17

18

Evaluating Stages of Change

Action (Taking steps / Making changes)• “I have a problem and I’m ready to

do something about it.” Maintenance (Continuing

what works)• “I’m stabilized and doing well. How

can I support my ongoing recovery?” Relapse / Recycle (Trying

again)• “I’m stabilized but have relapsed.

How can I get back into active recovery?”

19

20

7. “There is no single correct intervention!”Individualize treatment per . . .

. . . Quadrant designation (see)

. . . Diagnoses (DSM-IV)

. . . Level of functioning (evaluate – GAF, other tools)

. . . External constraints (Assessment, Tx plan)

. . . External supports (Assessment, Tx plan)

. . . Phase of Recovery / Stage of Change (see)

. . . Multidimensional assessment of level-of- care requirements (ASAM PPC-2R)

21

8. “There is no single correct destination!”Individualize outcome expectations per . . .

. . . Quadrant designation (see)

. . . Diagnoses (DSM-IV)

. . . Level of functioning (evaluate – GAF, other tools)

. . . External constraints (Assessment, Tx plan)

. . . External supports (Assessment, Tx plan)

. . . Phase of Recovery / Stage of Change (see)

. . . Multidimensional assessment of level-of- care requirements (ASAM PPC-2R)

22

NH Dual Diagnosis Study (1989-1994)

(Drake et al, 1998)

Proportion of Days in Stable Community Housing

0.7

0.8

0.9

1.0

Beginning 6 months 12 months 18 months 24 months 30 months 36 months

All DD Patients (N = 203) Patients in Recovery (N = 54)

23

NH Dual Diagnosis Study (1989-1994)

(Drake et al, 1998)

Percentage of Persons Hospitalized

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

Beginning 6 months 12 months 18 months 24 months 30 months 36 months

All DD Patients (N = 203) Patients in Recovery (N = 54)

24

NH Dual Diagnosis Study (1989-1994)

(Drake et al, 1998)

Number of Arrests and Incarcerations (N=203)

0

10

20

30

40

50

60

Beginning 6 months 12 months 18 months 24 months 30 months 36 months

Arrests Incarcerations in Jails or Prisons

25

NH Dual Diagnosis Study (1989-1994)

(Drake et al, 1998)

Median Treatment Costs: Patients in Recovery (N=54)

$0

$2,000

$4,000

$6,000

$8,000

$10,000

$12,000

$14,000

Beginning 6 months 12 months 18 months 24 months 30 months 36 months

Inpatient Outpatient