The Assessment and Treatment of Patients with Co-Occurring Psychiatric and Substance Abuse Disorders

Johns Hopkins Medicine Director of Community Services Annelle B. Primm, M.D., MPH

Defining Assessment

In the assessment process through the justice system, an individual with co-occurring disorders is characterized by a diverse spectrum of mental health, social, medical, and other problems. As a result, no single clinical approach fits all these persons’ needs, and effective and comprehensive screening and the procedures are of paramount importance in defining the sequence, format, and nature of needed interventions. Assessment of co-occurring disorders are part of a more extensive process of gathering information that begins at the individual’s point of contact with the criminal justice system. The Center for Substance Abuse Treatment TIP monograph #42 (CSAT, 2005a) outlines a set of sequential steps that are often followed in gathering information related to co-occurring disorders. (e.g., history of escape, past aggressive behavior within the institution) and to determine program needs and placement issues. Medical screening identifies health issues and may cover mental health status and substance use history.

Mental health and substance abuse screenings often are included within interviews conducted by pretrial services or other court-related agencies. The assessment of career and educational deficits helps identify services that are needed. Frequently, local corrections staff conducted pre-sentence or post-sentence investigations (PSIs) to determine the judicial disposition assessment.

Assessment is typically conducted through a clinical interview and may include psychological, laboratory, or other testing and compilation of collateral information from family, friends, and others close to the individual. An assessment provides a comprehensive examination of psychosocial needs and problems, including the severity of mental and substance use disorders, conditions associated with the occurrence and maintenance of these disorders, issues affecting treatment, individual motivation for treatment, and areas for treatment interventions. As indicated previously, assessment is an ongoing process that often includes engagement, identification of strengths and weaknesses, an examination of motivation and also stealth for change, review of cultural and other environmental needs, diagnosis, and determination of the appropriate setting and intensity/scope of services necessary to address co-occurring disorders and related conditions. A multistage assessment model for co-occurring disorders is described in several recent monographs published by the Center for Substance Abuse Treatment (CSAT, 2005a; 2006).

In the US, there are about ten million Americans suffering drug and alcohol-related and mental health disorders that cause coexistence (SAMHSA Report, 1996). There is growing evidence that patients with co-occurring psychiatric disorders cause less rehospitalization and have a healthier quality of life when compared to those with a single diagnosis (Drake and Wallach, 1989).

Clinicians’ ability to treat symptomatic substances became more complicated after including patients with substance use disorders and psychological disorders in the assessment. Also, one of the challenges faced by dually identified patients is that the traditional medical treatment system does not fit well along with their dual diagnoses conditions. The conventional view of treatment is that clients are normally treated for one illness at a time rather than a short series of treatments. Patients will be referred to a separate agency to treat their other disorder after a particular kind of disorder has been controlled effectively. Some other common approaches incorporate different parallel treatment approaches. Two different organizations treat one disorder at a time, even though the disorder itself may be of a very different assessment.

Management of noncommunicable diseases is becoming more challenging due to the increased number of detailed assessment techniques. Because the two systems don’t communicate in such a cohesive way, users often find themselves lost in between them. The assessment of these issues by addiction treatment programs has led them to create integrated treatment models. Addiction and mental illness treatment programs help people experience both disorders simultaneously while working within an integrated environment. Ahrens 1998; Bachmann et al. 1997, Bebout et al. 1997; Drake et al. 1997; Drake and colleagues 1998; Hoffman, 1993) have analyzed the effectiveness of integrated treatment programs for alcoholics. Several studies report improved recovery rates, medication compliance, self-help group participation, patient satisfaction, and remission in substance abuse and psychopathology patients assessment.

Quite often, co-occurring substance abuse disorders and non-substance-related mental illnesses are noted in the same individual assessment. There is little evidence-based information available to aid clinicians in helping these patients, who have very specific addictions in addition to non-substance psychiatric problems, determine which type of treatment might be best for them. The limited amount of available research and clinical experience suggest that integrated treatment should address substance abuse and related problems assessment. There are certain exceptions to this rule, even though this rule is generally applied. Different services are most suitable for treating mental disorders and specific substance use disorders, so treatment providers must be flexible. While seemingly logical and pragmatic, this logic may not always work at first glance assessment. Other pharmacological agents may be just as dangerous for people with substance abuse as they are for those who do not abuse these substances. In my experience, a treatment that encompasses both mental illness and substance abuse disorders tends to be the most effective.

In recent years, dual diagnosis patients have become more understood, but barriers remain to provide effective service assessments. While the number of addicts in treatment programs continues to decline, it is generally recognized that quality mental health care related to addiction has increased, despite improvements in addiction treatment assessments. They found that nearly half of rehab centers will not accept people with multiple diagnoses, a condition commonly called co-occurring disorders. Because of the aggressive nature of treatments and drugs prescribed as well as using old patients for assessments, traditional addiction treatment programs are not well suited to treating individuals with dual diagnoses. Rohrer and Schonfeld, 1990.

There are several difficulties in treating patients with dual diagnoses and the difficulties of treating only one. Professionals, such as medical practitioners, typically fail to recognize this second diagnosis. Individuals with substance abuse are not usually identified as having a mental health diagnosis, and substance abusers are not usually identified or properly treated for their mental health issues (Breakey et al., 1998, Lin et al., 1998). The reality is that you’re more likely to receive substance abuse treatment for those with a dual diagnosis when compared with those with mental disorders that are not.

Motivation and Readiness for Treatment

As with behavioral health interventions in general, outcomes related to the treatment of co-occurring disorders are highly dependent on personal relationships established with service providers during screening and assessment and the early stages of treatment (CSAT, 2005a, 2006). Individuals with co-occurring disorders generally do not have a history of successful treatment services or vocational and educational achievement. They may have little optimism for successful outcomes within justice treatment settings (Chandler et al., 2004). Moreover, they are often demoralized by financial, service-related, or other barriers or their limitations that affect employment, interpersonal relationships, and emotional well-being.

For these reasons, assessment and treatment planning for co-occurring disorders in the justice system should address an individual’s motivation and readiness for treatment. Motivation is a significant predictor of treatment compliance, dropout, and also outcome. In injustice settings, motivation to participate in therapy is affected by perceived sanctions and incentives (e.g., court orders to complete treatment, probation revocation, “good time” for involvement in correctional treatment). Motivation increases when continued substance abuse threatens current housing, participation in mental health treatment, vocational rehabilitation, family, marriage, or when continuous substance abuse will lead to incarceration in jail (Ziedones & Fisher, 1994). Therefore, motivation for treatment can be increased or decreased by altering any of a variety of criminal justice system incentives and sanctions.

The motivation for treatment and engagement in treatment can also be augmented by providing a welcoming attitude during the screening and assessment process, by showing empathy and respect for justice-involved individuals who are beginning the complex process of treatment and recovery, and by maintaining optimism for individuals’ ability to achieve behavior change and recovery (CSAT, 2006).

People who are in recovery often undergo phase-by-phase changes assessment during their treatment. Motivators for treatment (and treatment needs) change during this period. Often, an individual is unaware of the effects of their substance abuse at the outset and is hesitant to change their assessment. As mentioned previously, most people do not recover from addiction after a lifetime of relapsing, so this makes going through all the stages of change a continuous process, with no single target to achieve. In a recent survey, 52 per cent of people said they were unhappy with an organization’s current stage of development. If the patient has a dual diagnosis, it will be beneficial to provide a comprehensive treatment plan for better outcome assessment.

Several Factors Affect the Outcome of An Assessment

  • Substance abuse and psychiatric disorders,
  • Certain conditions can promote the occurrence of psychiatric disorders.
  • Psychiatric and behavioral problems, including problems of a cultural nature and psychosocial needs and problems.
  • The motivation for the treatment.
  • Areas for treatment intervention.

Whenever patients are prescribed treatment, treatment goals are based on their symptoms and their leading needs. A recent piece of research suggests improved outcomes for patients with dual diagnoses, such as improved assessment and coordination of care, as well as the location of treatment.
Patients with psychiatric and related substance abuse diagnoses pass through an assessment using a detailed history of their symptoms and several physical examination techniques such as blood work, urine analysis, and physical examination. Mental state may be affected by various factors, including the patient’s chief complaint, family history, personal history, medical history, mental state, and past medical history assessment. Drug abuse information can be gathered from: the type, the frequency, the amount, and the route of usage; how long they have used them; the number of detoxifications; the last time they used; the last time they passed a detox. Therefore, the results are also reinforced meaningfully so that the overall assessment is clear.