CHAPTER II: LITERATURE REVIEW

Introduction

This chapter is a review, analysis, and reporting of previous research studies that have examined challenges for diagnosing and treating individuals with co-occurring disorders as well as identifying predictors for treatment outcome. Military personnel with substance use disorder and co-occurring psychiatric disorder typically receive treatment in parallel settings (Brooke Army Medical Center, 2015) despite research supporting an integrated model for treatment. Even non-military treatment settings continue to insist that symptoms of the “other” disorder be addressed and abated before treatment can be considered which has impacted the individual’s motivation to seek treatment and impede a sustained recovery (Biegel et al., 2007).

It is important for clinicians to understand what factors impact recovery for individuals with SUDs and co-occurring psychiatric disorders. Policy makers, program managers, and clinicians must be informed about evidenced-based practices in order to address barriers for treatment and provide integrated services for military personnel with substance use and co-occurring psychiatric disorders.

This chapter is organized into three sections: Practice Guidelines for Assessment and Treatment of  Substance Use and Co-occurring Disorders, Evidenced-Based Therapeutic Interventions for Treating Co-occurring disorders and Predictors of Treatment Outcomes for Substance Use Disorders and Co-occurring Psychiatric Disorders.  In each section, the literature review will address the following research questions:

1. What are the most effective treatment approaches for military personnel with substance abuse and co-occurring psychiatric disorders?
2. What barriers theoretical differences occur when treating civilian and military patients with substance abuse and co-occurring psychiatric disorders?
3. What practice differences occur when treating civilian and military patients with substance abuse and co-occurring psychiatric disorders?
4. What are the best predictors of treatment outcomes for military personnel with substance use and co-occurring psychiatric disorders?

 

Practice Guidelines for Assessment and Treatment of Co-occurring Substance Use Disorders

The ability to screen and identify individuals with just alcohol or drug problems is widely known, acceptable, and available.  However, identifying and screening persons with co-occurring disorders has been considered challenging which has implications for treatment and outcomes for these individuals ( Rosenthal, Nunes, & LeFauve (2012).

Treatment guidelines are important for implementing evidenced-based practices. There were only two guidelines found by Perron, Bunger, Vaughn, & Howard, (2010) while completing a systematic review of treatment guidelines for substance use disorders and serious mental illnesses. Perron et al., 2010 found that the treatment guideline authored by the American Psychiatric Association provided a comprehensive description of the major features of treatment (e.g. case management, family interventions, rehabilitation, pharmacotherapy, and housing) and noted the importance of the same clinicians treating both disorders.  The researchers found that this was also the case for Center for Substance Abuse Treatment. Their overall findings resulted in limited guidelines for treating SUDS and Co-occurring disorders.

Psychiatric management of individuals with SUDs involves the1) establishment and maintenance of a therapeutic relationship, 2) continued monitoring of the patient’s clinical status, 3) management of states of intoxication and withdrawal,4) reduction of morbidity, 5)facilitation of treatment plan adherence and provision of educational materials, and diagnosis and treatment of psychiatric disorders (Rieckmann, Fuller, Saedi, & McCarty, 2010).

There is an increased expectation that patients with a substance use disorder has a co-occurring mental disorder if  the SUD is relatively serious, if the patient began using substances at an early age, is female, is dependent on nicotine, or has a drug use disorder. Rosenthal, Nunes, & LeFauve,( 2012).  Both clinical practice and research can benefit from valid, reliable screening methods and diagnostic procedures for co-occurring substance use disorders (Wusthoff, Waal, Ruud, Roislien, & Grawe, 2011).  The importance of identifying and treating co-occurring disorders is supported by studies that demonstrate the negative impact the presence of a SUD could have on recovery from mental illnesses, including anxiety disorders, bipolar disorder, and schizophrenia (Rosenthal et al., 2012).

Torrens, Rossi, Martinez-Riera, Martines-Sanvisens, & Bulbena, (2012) presented an overview of current opinions pertaining to the choice of site of treatment, the kind of treatment, the kind of intervention, the length of treatment, as well as aims to establish a more effective treatment outcome for individuals with co-occurring and substance abuse disorders.  In their study, the researchers emphasized the significant role that diagnostic accuracy plays in the diagnosis of co-morbid psychiatric disorders in substance users. They acknowledged that accuracy in diagnosing is often problematic.

Wusthoff, Waal, Ruud, Roislien, & Grawe (2011) agreed that there has been mounting evidence of high prevalence of SUDs in our general population however; they found that despite this strong evidence, there is still insufficient application of this knowledge in clinical practice.  These researchers also agree that in order to estimate levels of substance use in a clinical setting, it is imperative that we implement systematic screening procedures with self-administered and validated instruments along with a structured clinical interview and guidelines for practice.

Evidenced-Based Interventions

Historically, individuals with substance use disorders have been treated in different settings apart from those with other mental health diagnoses, despite being classified by the DSM-5 (APA, 2010).  Researchers now agree that a parallel model which provides for the treatment of both addiction and psychiatric disorder is ideal if there is an integration of the systems.  According to, emerging data appears to indicate that the “integrated model” can best meet the needs of individuals with substance use and co-occurring psychiatric disorders.  In my practice setting, we have combined treatment interventions for individuals with co-occurring disorders within the context of the primary treatment relationship or service setting. For example, we address substance use and psychiatric disorder in a combined fashion.  This approach has allowed our service setting to treat both disorders, any related problems, and the whole person more effectively.

 

Clinicians working within the substance service system as well as those working within the mental health service system need to develop skills to identify, assess and competently treat individuals with SUDs and Co-occurring psychiatric disorders as part of their standard practice (Staiger et al., 2011).  Kaufmann, Chen, Crum, & Mojtabai (2014) compared the prevalence and patterns of treatment seeking and barriers to alcohol treatment among individuals with alcohol use orders with and without co-occurring mood or anxiety disorders.  They found that individuals with alcohol use disorders and co-occurring mood or anxiety disorders were more likely to seek alcohol treatment.  They used data from the national epidemiologic survey on alcohol and related conditions to examine alcohol treatment seeking, treatment settings and providers, perceived unmet need for treatment and barriers to such treatment.   They concluded that individuals with alcohol use disorder and co-occurring mood or anxiety disorder would likely benefit from the expansions of financial access to alcohol treatments and integration of services. This study further highlighted  the need for integration of substance and mental health services.

Horsfall et al.(2009) reviewed a number of existing approaches considered to be effective for treating individuals with substance  use disorder and co-occurring psychiatric disorder  including MI, CBT, contingency management, relapse prevention, case management, social skills-straining and  individual counseling, group counseling, and 12-step mutual support.  The researchers posited that regardless of whether services follow integrated or parallel models, they should be well coordinated, take a team approach, be multidisciplinary, have specialist-trained personnel, include a range of program types, and proved for long-term follow-up.

A later study conducted by Perron, Bunger, Vaughn, & Howard (2010) examined

the degree to which practices guidelines targeted to the treatment of substance use disorders addressed treatment of co-occurring disorders.  The researchers found that none of the guidelines made recommendations for treatment of co-occurring disorders or included outcomes that specifically targeted both substance use and mental health disorders.

Staiger et al. (2011) found that treatment needs of individuals with co-occurring were largely overlooked and that there are significant barriers to treatment.   Some of those barriers included access to care and wider environmental issues such as stable housing, future employment and social support. According to the researchers, even with fully integrated treatment considered best practice, the majority of individuals with substance use disorders and co-occurring psychiatric disorders are being treated in separate systems.  The researchers posit that clinicians working within each discipline need to develop skills to identify assess and competently treat these complex cases as standard practice (Staiger et al., 2011).

Researchers have identified several approaches for treating individuals with substance abuse and co-occurring psychiatric disorders.  The initial challenge is engaging and sustaining the patient in treatment programs.  Many individuals with substance use disorder and co-occurring psychiatric disorders tend to be harder to engage and more frequently drop out of long-term treatment programs(Curran, Stecker, Han, & Booth, 2009).

There are specific treatment strategies, therapies, or techniques referred to as interventions which are used to treat one or more disorders.  Some of the interventions may include psychopharmacology, 12-Step recovery, individual or group counseling, cognitive-behavioral therapy, motivational enhancements, or other strategies.  Individuals might receive these interventions in community-based, inpatient, or residential settings.

Biegel et al., (2007) presented a paper discussing the role and function of technical assistance centers to help support the implementation process for agencies to implement Integrated Dual Disorders Treatment (IDDT), an evidenced-based practice for adults with co-occurring substance and mental disorders. In their report they highlighted the problems and service needs of adults with co-occurring disorders and provide a description of the IDDT model.  They also discussed implementation barriers and the role of technical assistance centers.  The authors developed an implementation framework using the five stages of change model including 1) Pre-contemplation (unaware or uninterested), 2) Contemplation (consensus building), 3) Preparation (motivating), 4) Action(implementing) and 5) Maintenance (sustaining). To illustrate the implementation process, they used the experiences of the Ohio Substance Abuse and Mental Illness Coordinating Center (SAMI CCOE). The authors concluded that there are several lessons learned in helping organizations to implement integrated treatment for adults with co-occurring disorders.

Predictors of Treatment Outcomes

(Sloboda, Glantz, & Tarter, 2012) evaluated a brief intervention designed to facilitate outpatient engagement following an inpatient psychiatric stay for individuals with mental illness and substance use.  They looked at (1) Time Limited Care-Coordination (TLC), an eight-week co-occurring disorders intervention and (2) a matched attention (MA) control condition in the form of health education sessions.  The researchers found that an eight-week intervention could improve treatment engagement and that the TLC intervention mitigated some of the problems that occur due to a lack of coordination between service systems. Their findings were consistent with Dixon et. al (2009) who looked at a three-month Brief Critical Time Intervention (B-CTI) developed to assist with treatment engagement during a patient’s transition from inpatient to outpatient care.  In their study, patients had fewer days between their hospital discharge and their first outpatient visit and ultimately participated in more total mental health and substance abuse treatment visits.  This continuity of care avoids gaps in treatment services and strengthens the patients’ motivation and engagement in treatment.

In their examination of day hospitals and residential addiction treatment programs, Witbrodt, Bond, Kaskutas, Weisner, & Pating (2007) did not find substantially higher abstinence rates among patients in community residential treatment in comparison to day hospital clients.  In both groups studied, post-30 day abstinence was associated with length of treatment and participation in 12-step programs.

Timko, Sutkowi, & Moos (2010) compared outpatients with substance use and psychiatric disorders or only substance use disorders on baseline and one-year symptoms, and treatment and 12-step group participation over a course of one year.  They examined whether diagnostic status moderated associations between participation and outcomes with regressions.  Their findings indicated that outcomes were weaker for dual diagnosis patients when assessing their level of participation in the 12-step groups. Specifically, they found that different aspects of 12-step group participation predicted different outcomes.  In patients with psychiatric disorders, working more steps and having a sponsor was associated with better alcohol, drugs, and psychiatric outcomes.  On the other hand, attending more 12-step group meetings and having a sponsor were associated with better alcohol and drug-use-related outcomes.  The risk for relapse and poor outcomes is a primary concern for individuals who abuse.

According to Riper et al. (2013) combined CBT and MI for clinical or a subclinical depressive and alcohol use disorder was determined to have a small but clinically significant effect in treatment outcomes compared with treatment as usual.  Brief session alcohol interventions were suggested as the first-step treatments for co-occurring alcohol problems, then more intensive components for patients who do not respond adequately.

Treatment satisfaction was also considered as a method to predict outcome and sustained recovery. (Schulte, Meier, & Stirling, 2011) completed a systematic review of existing evidence about treatment satisfaction among clients with substance misuse and mental health co-occurring disorder.  From their  review it was determined  that integrated treatment delivery, when simultaneously addresses both addiction and mental health concerns, resulted in high levels of patient satisfaction.  Prior to the opening of our RTP, we had the opportunity to facilitate three iterations of a co-occurring treatment track using an integrated treatment approach.  Our patient satisfaction surveys were consistent with the findings of ).  Patients appreciated the continuity and we are hopeful that this will lower their relapse rate and reduce the severity of their symptoms (DeLeon, 2010).

Curran et al., (2009) conducted a study to investigate patient and program level variables  associated with attrition from outpatient (IOP) substance use treatment using a national VA sample.  In their study, they used National databases to identify a cohort of veterans receiving intensive IOP substance use treatment.  To complete this study, the authors examined patient-level variables consisting of age, gender, race, and psychiatric and medical comorbidities. They found that being older, female, and having psychotic disorder was associated with attrition. They also considered program-level factors and found that the number of hours the program offered treatment was related to attrition rates.  Basically, more treatment was associated with higher attrition.  In their report, discussed implications for Behavioral Health recommending that VA IOP programs focus on interventions to improve retention among female veterans.  Further that therapy groups focusing solely on women veterans or their issues will increase the likelihood that women veterans with substance use disorders will receive adequate treatment in the VA.

 

 

 

 

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