Double Jeopardy

Chronic Mental Illness and Substance Use Disorders

Anthony F. Lehman, Lisa Dixon, Anthony F. Lehman, Lisa Dixon

• Publisher: Routledge
• Year: 2016
• ISBN:
  9781315534756
• Edition: 1
• Topic: Psychology
• Subtopic: Addiction in Psychology
• Index: Psychology

Originally published in 1995, this title provides a practical examination of the problems of substance abuse and abuse among persons with chronic mental disorders. Epidemiologic, diagnostic, and treatment issues are examined, as well as the problems of special populations and systems issues. This book will be of interest to practising clinicians in both the mental health and substance abuse treatment sectors.

1

Introduction

ANTHONY F. LEHMAN and LISA B. DIXON

The voices taunt Paul incessantly as they have for years, forcing him to recall horrible past misdeeds, whether real or imagined, he cannot tell. Waves of guilt and depression wrack him. What has he done to deserve this? Attempts over the past few days to drown the tormenting demons with alcohol have provided some hours of relief, only to invite the voices back with even more vengeance. The alcohol no longer provides the escape that it has on so many similar occasions in the past, but the desire to drink is as persistent as the voices. He has tried other escapes — marijuana, downers, even cocaine — but these only make things worse, feeding the voices and driving his family away from him. Paul’s desperation now leads him to one painful conclusion — he must kill himself to be free of his living hell. Paul now waits in the emergency room for your evaluation, pacing and talking loudly to himself.

If you are like most mental health or substance abuse clinicians, your first thought may be to try to figure out whether you can refer Paul to someone who is better equipped than you to handle his problems. You then feel helpless that there seems to be no one out there who can help Paul overcome his vicious cycle of mental anguish and substance abuse. He has been to several hospitals, clinics, and drug rehabilitation centers, some of which have helped for a while, but none for very long. Those who have treated Paul have diagnosed him variably as having schizophrenia, organic hallucinosis, alcohol dependence, cocaine dependence, psychotic depression, borderline personality, and antisocial personality. They have given him antipsychotics, antidepressants, lithium, and Antabuse. He has tried treatment free of all substances in a drug rehabilitation program. It seems nearly impossible to know what illnesses Paul has, why he has them, and what he needs to cope with them.

More and more, mental health and substance abuse clinicians are encountering people like Paul in their offices, clinics, hospitals, and treatment centers. It can seem that Paul’s problems are too complex for us to help or that the services that Paul needs do not exist. However, out of necessity in recent years, clinicians, researchers, and program planners have been struggling to determine how to help patients like Paul, and these efforts now provide a basis for hope. This book offers a practical examination of the problem of substance disorders among persons with chronic mental illnesses. Our intent is to convey much of what is known in order to assist you with Paul in your office today and to identify what we still must learn so that we can do a better job with the Pauls of tomorrow.

The first section focuses on background and diagnostic issues. How common is the co-occurrence of chronic mental illness and substance use? Are particular mental disorders associated with use of specific drugs? Mueser, Bennett, and Kushner address these questions in Chapter 2 and outline a basic conceptual framework within which we can begin to understand the use of drugs and alcohol by persons with severe mental illnesses. In Chapter 3, Westermeyer then explains significant cultural issues related to the use of substances. The country, the neighborhood, and even the street where an individual lives clearly play a role in every person’s decision to use substances. This is no less true for persons with severe and chronic mental illnesses. This chapter equips clinicians with knowledge to understand how these cultural and social factors may influence patients. The last chapter in this section by Drake and Mercer-McFadden describes the detection and diagnosis of substance disorders in the presence of chronic mental illness. The overlapping symptoms of substance use and mental illness, the cognitive deficits associated with mental illness which impede communication, and denial, each hinders recognition of the problem. This chapter reviews the menu of available strategies and provides clinicians with specific recommendations tailored to their treatment setting.

Building upon this review of the scope of the problem, the cultural context, and the obstacles to its detection, the second section of the book provides practical strategies for treating specific patient subgroups. The heterogeneity of chronic mental illnesses and substance disorders and the range of clinical approaches required throughout the life span renders ineffective any single, uniform approach to all patients. However, designing and implementing any treatment for these persons requires a basic vocabulary and repertoire of interventions that draw from both the substance abuse and mental illness fields. All too often, clinicians are comfortable and experienced with one problem, but not the other. The chapter by Schwartz and Lehman first reviews the principles and established techniques for treating chronic mental disorders and substance use disorders when they occur as a single problem. They then summarize the similarities and differences in the treatment of these disorders that must be taken into account when integrating services for dually diagnosed patients. This chapter serves as a reference for subsequent chapters on the treatment of specific patient subgroups.

In their respective chapters, Carey and then Weiss and Wong describe the treatment of substance-using individuals with schizophrenia and mood disorders. Individuals with these disorders have different prognoses, deficits, and patterns of illness and thus require different approaches. The next two chapters, Chapters 8 and 9, focus on both ends of the life span. Substance use and chronic mental disorders often begin during adolescence. Johnson, Posner, and Rolf examine the special needs of these troubled youths and discuss efforts at prevention and early detection. Treatment of the dually diagnosed elderly on the other hand may need to incorporate management of the “end-stage” effects of prolonged comorbidity. Bartels and Liberto explore treatment for this group whose size may increase as the baby boom generation ages and the numbers of elderly persons with chronic mental disorders and substance use grow.

Mahler focuses on another special population, the HIV-infected person with chronic mental illness and substance abuse. Medically vulnerable, this group represents a special challenge both for treatment and prevention. Persons with chronic mental disorders induced by substances are the subject of the chapter by RachBeisel and McDuff. These patients often seek help from the treatment system and suffer from persistent organic mental problems brought on by years of substance use. Are psychopharmacologic and psychosocial interventions the same for these patients as for patients with a primary mental disorder?

Clinical treatment is not delivered in a vacuum. While clinicians have felt confused about how to help persons with chronic mental illness and substance use, social and community systems have also been unprepared. Developing effective treatments for these patients requires involvement of the patient’s family and community. The final section of the book explores important aspects of the system context in which treatment must occur. Most persons with chronic mental illness live with their families. Historically blamed for the mental illness of their family members, families have now asserted themselves as knowledgeable and important participants in providing care for their mentally ill loved ones. The additional problem of substance use may make family life even more difficult and frightening. In their chapter, Sciacca and Hatfield present techniques for assessment and intervention with families of dually diagnosed patients.

Because many of these patients can no longer live safely at home, housing looms as a critical issue. Most housing programs for mentally ill persons exclude substance users. Most residential programs for substance abusers do not tolerate those with chronic mental illness. Homelessness often results. Dixon and Osher discuss the problems and potential solutions for housing these persons.

Frequently, dually diagnosed patients end up spending the night in jail rather than at home, in a safe residence or treatment setting. Dually diagnosed individuals are especially vulnerable to running afoul of the legal system, and disturbing evidence mounts that the jails and prisons are substituting for the hospital and other therapeutic alternatives. Furthermore, these patients are in “double jeopardy” because of their dual stigmas, decreasing their access to basic necessities and services. Champlain and Herr discuss the patterns of contacts between dually diagnosed patients and the legal system, the productive and problematic aspects of the relationships between treatment and legal systems, and special considerations regarding advocacy, confidentiality, involuntary treatment, social control, and the promotion of the welfare of both patient and society. Their notion of “double jeopardy” is so compelling, that we have incorporated it into the title of this book.

The final three chapters address challenges to our current systems of clinical care. Historically, many barriers to providing an adequate level of care to dually diagnosed persons have emerged. Drake, Noordsy and Ackerman explain more optimal coordination of services. The service system, traditionally divided between substance abuse treatment and mental health treatment, requires bridging strategies. Case management and assertive community treatment approaches are emphasized. As system leaders modify the organization of service systems, well-trained personnel must be available to staff these modified systems. Fox and Shumway lay out in Chapter 16 the challenges of training and motivating staff to work with dually diagnosed patients. Finally, Ridgely and Dixon discuss the challenges in public policies that affect the financing and regulation of health care, housing and other human resources and how these must change in order to provide better services for chronically mentally ill persons with substance use disorders.

Although Paul and others like him challenge the limits of our clinical skills and service systems, we hope that this book conveys new knowledge that assists you in caring for such patients. Most important, we would like to convey hope and confidence that treating persons with severe mental illness and substance abuse is worth your time, effort, and perseverance and can make a difference in patients’ lives.

Section I:


Background and Diagnostic Issues

2

Epidemiology of Substance Use Disorders Among Persons with Chronic Mental Illnesses

KIM T. MUESER, MELANIE BENNETT, and MATTHEW G. SHNER

In recent years there has been a growing awareness that persons with severe mental illness have an increased risk for the development of substance abuse or dependence disorders compared to the general population. The high vulnerability to alcohol and drug abuse among psychiatric patients presents a myriad of problems to clinicians treating such patients. Patients often deny substance abuse, which may resemble the symptoms of psychiatric disorders, creating diagnostic dilemmas. Furthermore, substance abuse often compromises the protective effects of psychotropic medications, leading to frequent relapses and rehospitalizations. Last, the problem of substance abuse can be frustrating to professionals, who must face the limitations of current treatment options for psychiatric patients with comorbid substance abuse disorders.

In this chapter, we take the first step towards helping clinicians deal more effectively with this pressing problem by reviewing information on the epidemiology of substance abuse in patients with severe mental illness. An understanding of the prevalence of substance abuse in this population and its correlates is necessary in order to facilitate the recognition of patients with these comorbid conditions. We begin with a brief discussion of methodological issues in epidemiological research on substance abuse in psychiatric patients. Next, data on the prevalence of comorbid substance abuse disorders in psychiatric patients is reviewed, as well as the diagnostic and demographic correlates of abuse in this population. Finally, we consider different theories that may account for the high rate of substance abuse in persons with severe mental illness.

ETHODOLOGICAL ISSUES

There are several methodological issues which may influence the results of epidemiological studies on the prevalence of substance abuse in psychiatric patients and contribute to the diverse findings in this area, including diagnostic factors, sampling methods, and demographic characteristics.

Diagnostic Factors

Assessing the prevalence of substance abuse in psychiatric patients requires reliable and valid diagnostic methods for each disorder. Studies that employ different definitions of substance abuse naturally will produce prevalence estimates that are difficult to compare. For example, some studies have examined substance use, others have focussed on abuse or dependence, while still others have not specified the definition of substance abuse employed.

A related diagnostic issue is that the methods used to determine diagnoses can influence findings of comorbidity. Diagnoses can be established by structured clinical interviews, non-structured interviews, self-report ratings, and reviews of medical records. Structured clinical interviews generally yield the most reliable diagnoses (Drake, Osher, Noordsy, Hurlbut, Teague & Beaudett, 1990), but not all epidemiological studies of substance abuse in psychiatric patients use such interviews.

In addition, establishing psychiatric diagnoses in patients with comorbid substance abuse may be problematic because the symptoms of substance use and withdrawal can mimic psychiatric disorders (Schuckit, 1983; Schuckit & Monteiro, 1988). For example, chronic alcohol abuse and withdrawal from alcohol can produce psychotic symptoms resembling schizophrenia, as can amphetamine abuse. Alcohol abuse and withdrawal are also associated with increases in depression and anxiety (Kushner, Sher & Beitman, 1990), whereas stimulant abuse and withdrawal from sedatives can lead to panic symptoms and obsessive-compulsive behavior (Schuckit, 1983). Because the symptoms of substance use and withdrawal can resemble psychiatric symptoms, a psychiatric diagnosis can only be confidently established when the patient is not currently abusing alcohol or drugs.

Sampling Methods

The location from which patients are sampled can have an important bearing on estimates of the prevalence of substance abuse in persons with chronic mental illness. For example, surveys conducted in hospital emergency rooms tend to yield higher rates of substance abuse disorders than other settings (Barbee, Clark, Crapanzano, Heintz & Kehoe, 1989; Galanter, Castaneda & Ferman, 1988). Similarly, surveys conducted with psychiatric inpatients may result in lower rates of comorbid substance abuse than outpatients, because severely impaired patients may have less access to drugs or alcohol (Arndt, Tyrell, Flaum & Andreasen, 1992; Cohen & Klein, 1970; Mueser et al., 1990; Mueser, Bellack & Blanchard, 1992-a).

An additional consideration is the population from which the sample is obtained. Estimated rates of comorbidity for any two medical conditions are higher if the sample is drawn from a clinical population (e.g., patients in a hospital or day treatment program) than from the general population (e.g., the community), because of a phenomenon known as “Berkson’s fallacy” (Berkson, 1949). This discrepancy is due to the fact that either of the two comorbid disorders may propel patients into treatment, artificially inflating the rate of comorbidity observed in clinical settings. Thus, estimates of the prevalence of substance abuse in severely mentally ill patients bas...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Original Title Page
• Original Copyright Page
• Table of Contents
• Introduction to the Series
• List of Contributors
• 1 Introduction
• Section I Background and Diagnostic Issues
• Section II Treatment
• Section III Social System Issues
• Index