Dual Diagnosis

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Application: Dual Diagnosis

Many clients who are diagnosed with substance abuse and addiction disorders also exhibit a psychological disorder. The prevalence and complexity of this phenomenon, known as a dual diagnosis, make it imperative that you, as a counselor, know how to properly diagnose and work with substance abuse clients who also exhibit psychological disorders.

For this Application, you will examine the complexities of dual diagnosis in relation to a specific case.

To prepare for this assignment:

  • Review this week's Learning Resources, focusing on the client symptoms and characteristics that may indicate a dual diagnosis.
  • Consider how the symptoms of substance abuse and those of psychological disorders make dual diagnosis particularly complex.
  • Review the following case study: Jerome.
  • Consider how the case study reflects the complexities of dual diagnosis.

The assignment: (1–2 pages)

  • Analyze the complexity of dual diagnosis as it relates to the case study.
  • Explain how specific symptoms illustrated by the client indicate more than one disorder and make diagnosis difficult.
  • Provide specific examples as well as evidence from the Learning Resources to support your ideas.

Support your Application assignment with specific references to all resources used in its preparation. You are asked to provide a reference list only for those resources not included in the Learning Resources for this course.

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MS PSYC 8728/COUN 8728 Substance Abuse Counseling Case Study Jerome Jerome is a 48-year-old gay-identified African American male who is seeking housing services at the state facility at which you work. Jerome has a long history of homelessness, a 20-year addiction to crack cocaine, and a history of minor arrests. He has supported himself primarily by repairing old, discarded bicycles and selling them. When Jerome comes to the facility, he states he has not used crack for three days. During the initial interview, he does not maintain eye contact, constantly moves and shifts in his seat, and uses a very unique sentence structure that often derails: "I am on top of this whole planet, and it’s hot! I feel like…you ever eat yogurt?" He describes hearing voices that direct him to deliver "the message of the good" to people he meets, and uses religious references in a number of statements about daily living. Jerome expresses his desire to stop using crack, but his concern is that "when I stop, the Devil comes after me." You learn from Jerome’s caseworker that Jerome has had connections to a street gang from whom he buys crack, and that a large part of the reason he is seeking housing at your facility is for safety because of some trouble he has gotten into with a gang member. Chapter 04 6/30/06 10:07 AM Page 43 Is Integrated Treatment of Co-Occurring Disorders More Effective than Nonintegrated Treatment? Brian E. Bride, Samuel A. MacMaster, and Lisa Webb-Robins The integrated treatment model has been touted as more effective than standard approaches to treating individuals with co-occurring substance use and mental health disorders. However, most studies on the effectiveness of integrated treatment lack control or comparison groups, limiting the conclusions that can be drawn. This article reviews studies that compare the effectiveness of integrated and nonintegrated treatment of co-occurring mental and substance use disorders on substance use, mental health, and community stability outcomes. Additional research is clearly needed to determine whether integrated treatment models for co-occurring disorders are, in fact, more effective than nonintegrated models. Key words: integrated treatment; co-occurring disorders; dual diagnosis; substance abuse; mental health Introduction The co-occurrence of substance use and mental disorders is highly prevalent both in the general population and in clinical samples (Kessler et al., 1996). Epidemiological studies suggest that nearly half of the people with a substance use disorder have a co-occurring mental disorder, while as many as 40% of the people with a mental disorder have a co-occurring substance use disorder (Kessler et al., 1996; Regier et al., 1990). In clinical samples of psychiatric populations, 30% of those with depressive disorders, 50% with bipolar disorders, and 50% with psychotic disorders have substance use disorders (Miller, 1994a). Among people with an alcohol use disorder, 37% have a comorbid mental disorder, while 53% of those with drug use disorders report another lifetime mental disorder (Regier et al.). Brian E. Bride, Ph.D., MSW, is assistant professor at the School of Social Work, University of Georgia, Athens. Samuel A. MacMaster, Ph.D., MSSW, is assistant professor at the College of Social Work, University of Tennessee, Knoxville. Lisa Webb-Robins, Ph.D., is director of research and planning for the Tennessee Department of Economic and Community Planning, Nashville. © 2006 Lyceum Books, Inc., Best Practices in Mental Health, Vol. 2, No. 2, Summer 2006 Chapter 04 6/30/06 44 10:07 AM Page 44 Best Practices in Mental Health Recent epidemiological studies have demonstrated similar rates of co-occurrence (Kessler, Chiu, Demler, & Walters, 2005; Weaver et al., 2003). People with cooccurring disorders typically have poorer treatment outcomes than people who have only one disorder, including more frequent psychiatric re-hospitalizations (Caton, Wyatt, Felix, Grunberg, & Dominguez, 1993; Drake, Osher, & Wallach, 1989; Haywood et al., 1995), more severe psychiatric symptoms (Carey, Carey, & Meisler, 1991; Drake, 1989; Osher et al., 1994), higher rates of relapse (Swofford, Kasckow, Scheller-Gilkey, & Indrbitzin, 1996), and housing instability and homelessness (Drake et al., 1989; Drake & Wallach, 1989; Osher et al.). Historically, major mental illness and substance abuse have been treated in separate service systems with differing and sometimes contradictory philosophical orientations in what has been called the serial or sequential treatment model; that is, individuals are treated first by one system (either substance abuse or mental health) and then by the other (Center for Substance Abuse Treatment [CSAT] 1994; Miller, 1994a, 1994b). Typically, a patient is stabilized in an inpatient or outpatient psychiatric unit and then transferred to a separate chemical dependency unit. The staffs treating each disorder often fail to communicate or cooperate with each other in the individual’s treatment, and they may be mutually antagonistic toward each other (Miller, 1994a). Further, the staffs from both sides often are neither knowledgeable, nor skilled in the other treatment approach, resulting in a fragmented treatment experience (Miller, 1994b). The parallel treatment model is a second approach to treating mental health and substance use disorders. In the parallel approach, psychiatric and addiction treatments are provided concurrently, but in different settings and by different staff members. While the parallel model improves upon the serial model by providing concurrent treatment, it also shares the limitation of relying upon separate service systems and treatment philosophies that are often in conflict. In both the serial and parallel treatment models, knowledge and skill deficits of service providers serve to perpetuate a focus on one type of disorder over the other (Pulice, Lyman, & McCormick, 1994). Further, the problem is compounded by philosophical differences between the two fields as to what constitutes appropriate treatment (Young & Grella, 1998). These philosophical differences have historically included a reliance on peer counselors, spiritual recovery, and a self-help approach within a recovery model in the addictions field, as opposed to a medical model with the use of medications, scientifically based treatment approaches, and continuous case management within the mental health field. As such, these treatment approaches inadvertently confound and compartmentalize conditions that are inseparable (Osher, 1996). In response to these limitations, a number of experts have promoted an integrated treatment (IT) model. This model combines methods and skills derived from both psychiatric and addiction treatment practices to treat dually diagnosed individuals in a single setting with a single staff (Drake, Yovetich, Bebout, Harris, & McHugo, 1997; Ho et al., 1999; Minkoff, 1989; Osher, 1996). Clinicians in integrated treatment programs are cross-trained in both mental health and substance Chapter 04 6/30/06 10:07 AM Page 45 Integrated Treatment 45 abuse. Thus, the diagnosis and treatment of both psychiatric and substance use disorders can be implemented simultaneously, minimizing conflicts between the two approaches (CSAT, 1994; Minkoff). Individuals participate in a single program in which their mental disorder and substance use disorder are treated by the same clinicians—clinicians who are trained in assessment and treatment strategies for both problems (Drake, Mercer-McFadden, Mueser, McHugo, & Bond, 1998). The IT model has been touted as a more effective approach to treating people with co-occurring disorders than the serial and parallel treatment models (CSAT, 1994; Drake, Mueser, Brunette, & McHugo, 2004; Minkoff, 1989; Mueser, Bellak, & Blanchard, 1992). However, Drake, Mercer-McFadden, et al. (1998) reviewed 36 research studies on the effectiveness of IT models and concluded that the addition of dual-disorders groups to traditional services, short-term IT in controlled settings and demonstration projects with high-risk groups (Drake, McHugo, et al., 1998; Mercer-McFadden et al., 1997; Mueser & Noordsy, 1996) failed to demonstrate positive outcomes. In reviewing studies of comprehensive integrated programs, they found more encouraging evidence of the effectiveness of IT for cooccurring disorders. Specifically, they noted that comprehensive IT may result in “significant reductions of substance abuse and, in some cases, in substantial rates of remission, as well as reductions in hospital use and/or improvements in other outcomes” (Drake, Mercer-McFadden, et al., 1998, p. 601). Given these findings, it is surprising that IT has become accepted in most circles as more effective than standard treatment (ST) models. Drake, Mercer-McFadden, et al. (1998) point out that the disappointing results may be a result of the limitations of many of the existing studies. Specifically, the majority of studies included in their review lacked control or comparison groups, thereby limiting conclusions regarding the differential effectiveness of IT as compared to nonintegrated treatment. In addition, many of the studies were limited by small sample sizes, increasing the probability of Type II errors. As such, it is possible that an examination of studies with more methodological rigor, specifically those implementing comparison groups and with a sufficient sample size, would provide more positive results. To that end, this article critically reviews studies that compare the effectiveness of integrated and nonintegrated treatment of co-occurring mental and substance use disorders in substance use, mental health, and community stability outcomes. Methodology Electronic searches were conducted of PsycINFO and Medline databases to identify articles published in refereed journals through June 2005 that examined the effectiveness of IT of co-occurring mental health and substance use disorders as compared to nonintegrated treatment. A start date was not specified as we wished to identify all potential studies regardless of when they were conducted. The following key words were used in the search: dual diagnosis, integrated treatment, substance abuse and mental illness, co-morbidity, and Chapter 04 6/30/06 46 10:07 AM Page 46 Best Practices in Mental Health co-occurring disorders. In addition, the text and bibliographies of identified articles were reviewed for additional references that were not captured by the computerized searches. To be included in the review, articles had to meet three criteria. First, articles had to report on experimental or quasi-experimental designs that compared integrated treatment models with nonintegrated models. Thus, studies that compared different models or modalities of IT without a nonintegrated comparison group were excluded, as were those that simply reported outcomes of an integrated program, but lacked a comparison group. Second, the majority of subjects had to meet the criteria for a serious mental disorder, primarily schizophrenia, schizoaffective disorder, bipolar disorder, or major depressive disorder, in addition to a substance use disorder. Third, included studies were required to have a sample size of 100 or greater. A limitation cited by all prior reviews is that a significant number of studies are limited by small sample sizes. Assuming a medium effect size and a significance level of .05, a sample size greater than or equal to 100 ensures that included studies will have a power of .86 or higher (Cohen, 1988). A total of four empirical studies comparing integrated treatment of individuals with co-occurring disorders to nonintegrated treatment met the inclusion criteria, two of which (Burnam et al., 1995; Drake et al., 1997) were included in the earlier review by Drake, Mercer-McFadden, et al. (1998). Results Description of Reviewed Studies In the first study, Burnam et al. (1995) randomly assigned 276 homeless, dually diagnosed individuals to one of three conditions: a residential social model treatment program, a nonresidential social model program, and a control group. According to the authors, the social model approach combines elements of substance abuse recovery and mental illness management in an effort to assist clients in developing an independent life in the community through abstinence and by enhancing their social and vocational abilities. Common activities of both the residential and nonresidential social model programs included curriculum-based groups, 12-step programs including community-based Alcoholics Anonymous and Narcotics Anonymous meetings, process-oriented groups, individual counseling and case management, psychiatric consultation and medication management, and general community activities. Both the residential and the nonresidential social model programs consisted of a 3-month intensive phase followed by three months during which graduates were encouraged to continue to participate in nonresidential program activities. The control group received no special intervention, but was free to access other available community services in what can be considered a de facto parallel treatment model. Outcome variables associated with substance use, severity of mental illness symptoms, and housing status were collected at 3-, 6-, and 9-month follow-ups. Chapter 04 6/30/06 10:07 AM Page 47 Integrated Treatment 47 In the second study, Drake and colleagues (1997) used a quasi-experimental, non-equivalent comparison group design to compare IT with ST for 217 homeless, dually diagnosed adults over an 18-month period. People in the IT group received integrated mental health treatment, substance abuse counseling, and housing services from one of two multidisciplinary teams within a private, nonprofit mental health center. The treatment model was based on a manual developed by the authors, and extensive training and monitoring were provided to ensure model adherence. Both treatment teams relied heavily on behavioral substance abuse treatment methods, although one emphasized cognitive/behavioral approaches, while the other emphasized social network approaches. Individuals in the ST group received services through multiple agencies in the existing housing, substance abuse, self-help, and community mental health system in a parallel treatment model. According to the investigators, the key difference between the two groups was the level of integration of services. The third study was a three-year, randomized, clinical trial of 223 dually diagnosed individuals that compared integrated mental health and substance abuse treatment within an assertive community treatment (ACT) approach to the treatment provided within a standard case management (SCM) approach (Drake, McHugo, et al., 1998). Both approaches integrated substance abuse treatment with mental health treatment. Both also offered similar features such as a team approach, services provided in the community, engagement of the client’s support system, and a focus on co-occurring disorders. However, ACT teams provided more services directly, had smaller caseloads, greater intensity of services, dual disorders as a specialization, more of a team approach, more individualized substance abuse treatment, and thus more integrated services than the SCM teams. Indeed, other authors have determined that ACT is more integrated than other standard case management approaches (Burns & Santos, 1995). In the fourth study, De Leon, Sacks, Staines, and McKendrick (2000) sequentially assigned 342 homeless adults with co-occurring substance use and mental disorders to one of three groups: a moderate intensity, modified therapeutic community (modified TC1); a low intensity, modified therapeutic community (modified TC2); or treatment as usual (TAU) group. Modified TC1 was similar to standard therapeutic communities in structure, process, and interventions, but was adapted to the psychiatric symptoms, cognitive impairments, and reduced level of functioning often found in people with co-occurring disorders. Thus, compared to standard therapeutic communities, modified TC1 provided increased flexibility, less intensity, and greater individualization in a 12-month program. Modified TC2 was similar in planned duration of stay, stages, and array of interventions to modified TC1. However, modified TC2 differed from modified TC1 in several ways: clients were allowed greater freedom to come and go early in treatment, clients left the facility to attend a day treatment program in the community, peer responsibility was reduced in terms of duties that clients and staff shared for operating the facility, staff provided more direct assistance in running program interventions Chapter 04 6/30/06 48 10:07 AM Page 48 Best Practices in Mental Health and directing client activities, and fewer activities and shorter interactions were used. Thus, modified TC2 placed still fewer demands on clients and was even more flexible in accommodating individual needs and deficiencies than modified TC1. Services received by the TAU group were fewer, less specific to the needs of people with co-occurring disorders, not as well organized, and less related to a cohesive perspective and approach than those received by the modified TC groups. Results of Reviewed Studies Sample characteristics Table 1 presents the sample characteristics for each study as reported in the original publications. Across the four studies included in this review, the mean sample age was similar, ranging from 34 to 37. In three studies, the sample was primarily male, ranging from 72% to 84% male, with only Drake et al. (1997) reporting a primarily female (66.4%) sample. The reported ethnicity Table 1 Sample Characteristics of Reviewed Studies Burnam et al. Drake et al. De Leon et al. (1997) Drake, McHugo, et al. (1998) (1995) Age (mean years) 37a 35.7 34.0 35.1 Gender (%) Female Male 16a 84a 66.4 33.6 25.6 74.4 28.0 72.0 Ethnicity (%) African American Caucasian Other 28a 58a 14a 89.4 9.7 0.9 96.4 3.6 73.0 11.0 16.0 Education (%) < 12 years 12 years > 12 years 28a 34a 38a 45.2 49.3 5.5 36.9 42.8 20.3 58.0 23.0 20.0 Marital Status (%) Never married Married Previously married 49a 6a 45a 59.4 2.3 38.2 61.0 10.7 28.3 79.0 0.0 21.0 7a 38a 53.4 22.4 24.2 37.8 12.0 16.6 30.4 3.2 100b.0 2.7 100.0b Psychiatric Diagnosis (%) Schizophrenia Schizoaffective Bipolar Disorder Major Depression Other Homeless (%) 55a 100a 100.0 (2000) aRepresents “major affective disorders.” Authors did not differentiate between bipolar disorder and major depression. bAuthors did not provide statistics on specific disorders. Chapter 04 6/30/06 10:07 AM Page 49 Integrated Treatment 49 of sample participants was widely variable across the studies, with between 0% and 89.4% African American, 9.7% and 96.4 % Caucasian, and 0.9% and 16% other ethnic groups. The educational level of the samples also varied across studies, with 28% to 58% being high school dropouts, 23% and 49.3% having a high school diploma or GED, and 5.5% to 38% having at least some college. Most of the sample participants either had never married (49% to 79%) or were divorced or widowed (21% to 45%). Only three studies reported specific mental health diagnoses. Burnam at al. (1995) reported the fewest diagnoses of schizophrenia (7%) and the most diagnoses of affective disorders (bipolar disorder and major depressive disorder; 55%), whereas Drake et al. (1997) reported the highest proportion of schizophrenia diagnoses (53.4%). Last, the sample populations in the three studies were entirely of homeless people, with the fourth study (Drake, McHugo, et al., 1998) reporting almost no (2.7%) homeless people. Substance use outcomes A consistent finding across studies was that participants improved on various substance use outcomes over time, regardless of whether they received integrated or nonintegrated treatment. However, it is less clear whether or not integrated treatment approaches resulted in better outcomes than ST. Burnam et al. (1995) found little difference between IT and ST groups in substance use outcomes. In the study conducted by Drake and colleagues (1997), participants with drug use disorder improved more in the IT group than in the ST group. Similarly, Drake, McHugo, et al. (1998) found that IT resulted in greater improvement on measures of alcohol use, although no differences were detected in either alcohol or drug use disorder remission rates. De Leon et al. (2000) found that participants in the low-intensity IT showed greater change on the three alcohol and drug measures than did the nonintegrated group. Mental health outcomes Similar to the findings on substance use outcomes, Burnam et al. (1995) found little difference between integrated and nonintegrated treatment approaches on mental health outcomes. However, they did note improvements in both groups over time on symptoms of depression, anxiety, and self-esteem, although no improvements were found in either group on measures of psychotic symptoms, mania, or anger and hostility. Drake et al. (1997) found similar improvements in both integrated and nonintegrated treatment groups in psychiatric status as measured by the Addiction Severity Index. Drake, McHugo, et al. (1998) found improvements in both groups on overall and subscale scores on the Brief Psychiatric Rating Scale, although no differences between groups were detected. The results obtained by De Leon and colleagues (2000) indicated that all groups showed improvement in anxiety symptoms, only the low-intensity IT group showed improvement on depression symptoms, and only the high-intensity IT group showed improvement in self concept. However, they failed to detect improvement in any group on general psychological distress as measured by the Symptom Checklist-90-Revised (Derogatis, 1990). The only difference found was Chapter 04 6/30/06 50 10:07 AM Page 50 Best Practices in Mental Health greater improvement in the low intensity IT group compared to the high-intensity IT group. Neither of the IT groups showed significantly greater improvements on any mental health outcome measure compared to the nonintegrated group. Community stability outcomes Burnam and colleagues (1995) found that both integrated and nonintegrated treatment groups showed improvement over time in the percentage of time on the streets and percentage of time in independent housing, with no significant differences in the amount of improvement between groups. Drake et al. (1997) reported equivalent reductions in mean days in homeless settings for the IT and ST groups, while days in stable housing increased more in the IT group than in the ST group; days in institutional settings decreased for IT subjects, but remained stable for ST subjects—a significant difference between the IT and ST groups. Drake, McHugo, et al. (1998) noted that both the integrated and nonintegrated treatment groups improved over time on community days and reduced hospital admissions, but no group differences were found between IT and ST groups. Both treatment groups significantly improved over time on community days, but again no differences between IT and ST groups. Moreover, both treatment groups reduced hospital admissions over time, but again no differences between IT and ST groups. De Leon et al. (2000) did not include community stability variables in their analysis. Limitations of Reviewed Studies In evaluating the effectiveness of IT as compared to nonintegrated treatment of co-occurring disorders, it is important to be cognizant of the limitations of the studies from which conclusions are drawn. One such limitation is that the study samples may not be representative of the population of all people with co-occurring mental health and substance use disorders, thereby limiting generalizability. Three of the four studies were conducted with populations of exclusively homeless people, while the fourth study (Drake, McHugo, et al., 1998) classified 80.5% of participants in the ACT group and 78.0% in the SCM group as having an “independent” residential status. In addition to the limitation this places on generalizability beyond homeless populations, any effect these programs may have had on the mental health and substance abuse outcomes of the participants may be confounded by their homeless status. The authors of one of the studies suggested that because the primacy of housing and income needs often take precedence over mental health and substance use issues, samples of homeless people are less than ideal for this type of research (Burnam et al., 1995). A second limitation is related to the fact that two studies were compromised by policy changes that reduced or eliminated the differences between the integrated and nonintegrated conditions. One study was confounded by changes in the New Hampshire mental health system that incorporated many of the principles identified as differentiating the IT and comparison groups (Drake, McHugo, et al., Chapter 04 6/30/06 10:07 AM Page 51 Integrated Treatment 51 1998). Ultimately the differences described in that study between the two groups were a lower average caseload (12 vs. 25) and more individualized substance abuse treatment services in the IT group, although the comparison group actually received more net services. The remaining differences between the two groups were further compromised by extensive statewide trainings, the sharing of staff, and physical proximity of the two conditions. A second study found that the comparison group received similar amounts of services as the treatment group, attributable in part to the implementation of the D.C. Right to Overnight Shelter Law, which guaranteed shelter, treatment, and transitional services to all homeless individuals (Drake et al., 1997). This resulted in a de facto parallel treatment model in which individuals in the comparison group received all of the same types of services, although in separate systems received by those in the IT group, with the exception that self-help groups, presumably 12-step groups, received substance abuse treatment. Two issues related to the measurement of outcomes are additional limitations of the included studies. First, there is the validity of self-report data provided by people with severe mental illness. Self-report of substance use by people with severe mental illness may be inaccurate because of denial and minimization, failure to perceive that substance use problems are related to poor adjustment, and distortions from cognitive, psychotic, and affective factors, as well as because of the appropriateness of traditional instruments specific to the population (Drake, Alterman, & Rosenberg, 1993). In particular, the Addiction Severity Index (ASI), used in three of the reported studies, could be supplemented with clinical measures, laboratory instruments, or multiple measures to attain valid assessments of people with severe mental illness (Drake et al., 1998). Both Burnam et al. (1995) and De Leon et al. (2000) rely solely on single self-report instruments to measure substance use, and Burnam reports using items from the ASI. Second, there is little consistency across studies in the operationalization and measurement of substance use, mental health, and community stability outcomes (see table 2), thereby making an interpretation of the outcomes difficult. The possibility of selection bias is a limitation in three of the four studies, as the individuals assigned to the integrated and nonintegrated portions of the studies may not have initially been equivalent. For example, in the Drake et al. (1997) study, the two groups were similar demographically, and in their history of community stability (i.e., homelessness) and substance use disorder diagnoses. However, the IT group had a significantly higher percentage of participants with a diagnosis of schizophrenia (48.1% vs. 27.1%) and the ST group had a significantly higher percentage (49.2% vs. 23.4%) of participants with a diagnosis of major depression. These differences were also seen in a difference between the groups in the mean number of lifetime psychiatric hospitalizations: 6.6 in the IT group and 3.2 in the ST group. There were also differences in recent history of service receipt. In the 60 days before entering the study, the treatment group averaged almost eight more days of services in an institutional setting than the De Leon et al. (2000) Drake, McHugo, et al. (1998) Drake et al. (1997) Tennessee Self-Concept Subs Scale Symptom Checklist 90-Revised: Global Severity Index Shortened Manifest Anxiety Scale Highest frequency of illicit drug use Beck Depression Inventory Number of different types of illicit drugs used Brief Psychiatric Rating Scale Brief Psychiatric Rating Scale Frequency of alcohol intoxication Self-report of days of alcohol and drug use Addiction Severity Index Drug Use Scale Alcohol Use Scale Addiction Severity Index Alcohol Dependence Scale Not measured Number of psychiatric hospital admissions Number of days living in stable community residences, and not hospitals, jails, homeless, or other institutional settings. Number of days in stable housing Number of days in institutions Number of days in homeless settings 10:07 AM Drug use index: weighting frequency of use by severity of use 6/30/06 Quantity index: abstinence, low quantity, and high quantity consumption Psychiatric Epidemiologic Research Inter- Percentage of last 60 nights spent in independent housing view: self-esteem and mania scales Number of days used any illicit drug in past 30 days 52 Percentage of last 60 nights spent on the streets Number of days consumed alcohol in past 30 days Community Stability Symptom Checklist 90-R: Depression and anxiety scales combined Substance Use Burnam et al. (1995) Mental Health Measurement of Substance Abuse, Mental Health, and Community Stability Outcomes for Reviewed Studies Study Table 2 Chapter 04 Page 52 Best Practices in Mental Health Chapter 04 6/30/06 10:07 AM Page 53 Integrated Treatment 53 comparison group (15.8 vs. 8.0), who had been homeless for eight days more than the treatment group (45.3 vs. 37.2). De Leon et al. (2000) reports that there were unspecified differences on key variables, but no more than would be expected by chance. Study attrition was an issue for each of the included studies. The studies lost a significant number of people during the course of the study, and those dropouts may or may not have differed from those who remained in the study. While Drake, McHugo, et al. (1998) report minimal differences between groups, of the 240 initially screened for the study, only 173 participated in the full study, resulting in a 28% attrition rate, with the IT group having a lower attrition rate than that of the comparison group (3.7% vs. 14% attrition). Although not statistically significant, Drake et al. (1997) experienced differential attrition rates between the treatment and comparison groups (20.3% vs. 11.4%) at 18 months. De Leon and colleagues (2000) also had differential attrition rates with 1-year follow-up rates of 65% and 70% for treatment, and 73% for control groups, and the 2-year follow-up rates of 81% and 85% in treatment and 80% in the comparison group, but solved this by measuring time as an approximate measure. In a more dramatic example, slightly more than a third (38.5%) of the 717 individuals eligible for the Burnam et al. (1995) study agreed to participate. There is no report of an analysis of potential differences between those who participated and those who refused. Further, only 57% of the control group and 76% of the treatment group completed 9-month interviews. Of more concern than the study attrition rates in Burnam et al. (1995) were the treatment attrition rates. Within this study, only 60% of “participants” in the treatment groups received any services, and 92% of the participants in the outpatient program and 76% of the participants in the residential program dropped out of treatment within the first three months of the 9-month treatment protocol. Burnam et al. (1995) discussed the differences in the treatment and control groups as measuring the differences of intention to treat within the randomized clinical trial; however, service utilization rates appear to be very low. Discussion The results of the four studies reviewed in this article indicate that people who suffer from co-occurring substance use and mental health disorders benefit from treatment efforts, as evidenced by improvement in substance use, mental health, and community stability outcomes. However, it is not clear whether those who receive IT improve more than those who receive nonintegrated treatment. Three of four studies demonstrated more improvement in the IT groups on certain substance use outcomes, including drug use disorder (Drake et al., 1997), amount of alcohol use (Drake, McHugo, et al., 1998), and alcohol and drug use (De Leon et al., 2000). However, one study found no difference in substance abuse outcomes (Burnam et al., 1995), and despite the positive finding noted previously, Drake and colleagues (1997) did not find a difference in remission rates for either alcohol or drug Chapter 04 6/30/06 54 10:07 AM Page 54 Best Practices in Mental Health use disorders. In regards to mental health outcomes, in all four of the studies, people treated in integrated settings and people treated in nonintegrated settings demonstrated similar rates of improvement on measures of mental health. Only three studies measured community stability outcomes. In those three studies, only Drake et al. (1997) reported any difference between people receiving IT and those receiving nonintegrated treatment. Integrated clients reported significantly more days in stable housing and significantly fewer days in institutional settings. However, they found no differences between groups in days in homeless settings. Thus, the few available studies that compare integrated and nonintegrated treatment of co-occurring substance use and mental health disorders suggest that IT may improve substance use outcomes, but is no more effective in mental health or community stability outcomes than nonintegrated treatment. However, given the limited number of comparative studies and the significant threats to internal and external validity of the existing research, this conclusion must be viewed with extreme caution. Clearly, claims that the IT model is a more effective approach to treating individuals with co-occurring disorders than the serial and parallel treatment models are not based on unequivocal empirical evidence. On the other hand, it must also be noted that lack of evidence is not the same as evidence to the contrary. That is, it would also be erroneous to conclude based on the extant research that IT is not effective or is less effective than nonintegrated treatment. In fact, not one of the four studies reviewed reported findings that people in the nonintegrated treatment improved more than those in IT on any of the outcomes examined. Therefore, it may be reasonable to conclude that IT is at least as effective as nonintegrated treatment. It should also be noted that even in the absence of unambiguous evidence that the IT approach for people with co-occurring disorders is more effective than nonintegrated approaches, other compelling arguments in favor of implementing IT exist. For one, it would be reasonable to assume that IT—in which mental health and substance abuse interventions are provided in a coordinated fashion in a single setting by clinicians who are trained in the assessment and treatment strategies for both problems—would be less costly than providing services in two entirely separate service systems. Unfortunately, the literature contains little in the way of cost analyses. Second, the streamlining of services that result from an integrated approach to co-occurring disorders goes a long way toward reducing a primary obstacle to services: the burden on service recipients inherent in accessing two separate service systems. In sum, the results of this review underline the need for continued and rigorous research on the effectiveness of IT of co-occurring substance use and mental health disorders. Additional research is clearly needed to determine whether integrated models of treatment for co-occurring disorders are indeed more effective than nonintegrated models. Future research must take steps to address the limitations found in the existing empirical literature, such as issues related to treatment and study attrition, outcome measurement, and treatment fidelity. Until such Chapter 04 6/30/06 10:07 AM Page 55 Integrated Treatment 55 research becomes available, mental health practitioners and policy makers should be cognizant of the limitations of the existing evidence. References Burnam, M. A., Morton, S. C., McGlynn, E. A., Peterson, L. P., Stecher, B. M., Hayes, C., et al. (1995). An experimental evaluation of residential and nonresidential treatment for dually diagnosed homeless adults. Journal of Addictive Diseases, 14, 111–134. Burns, B. J., & Santos, A. B. (1995). Assertive community treatment: An update of randomized trials. Psychiatric Services, 46, 669–675. Carey, M. P., Carey, K. B., & Meisler, A. W. (1991). Psychiatric symptoms in mentally ill chemical abusers. Journal of Nervous and Mental Disease, 179, 136–138. Caton, C. L. M., Wyatt, R. J., Felix, A., Grunberg, J., & Dominguez, B. (1993). Followup of chronically homeless mentally ill men. American Journal of Psychiatry, 150, 1639–1642. Center for Substance Abuse Treatment. (CSAT). (1994). Assessment and treatment of patients with coexisting mental illness and alcohol and other drug abuse: Treatment improvement protocol (TIP) series 9 (DHHS Publication No. SMA 94-2078). Washington, DC: U.S. Department of Health and Human Services. Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). New York: Lawrence Erlbaum Associates. De Leon, G., Sacks, S., Staines, G., & McKendrick, K. (2000). Modified therapeutic community for homeless mentally ill chemical abusers: Treatment outcomes. American Journal of Drug and Alcohol Abuse, 26, 461–480. Derogatis, L. R. (1994). SCL-90-R: Administration scoring and procedures manual. Minneapolis, MN: National Computer Systems. Drake, R. E., Alterman, A. I., & Rosenberg, S. R. (1993). Detection of substance use disorders in severely mentally ill patients. Community Mental Health Journal, 29, 175–192. Drake, R. E., McHugo, G. J., Clark, R. E., Teague, G. B., Xie, H., Miles, K., et al. (1998). Assertive community treatment for patients with co-occurring severe mental illness and substance use disorder: A clinical trial. American Journal of Orthopsychiatry, 68, 201–215. Drake, R. E ., Mercer-McFadden, C., Mueser, K. T., McHugo, G. J., & Bond, G. R. (1998). Review of integrated mental health and substance abuse treatment for patients with dual disorders. Schizophrenia Bulletin, 24, 589– 608. Drake, R. E., Mueser, K. T., Brunette, M. F., & McHugo, G. J. (2004). A review of treatments for people with severe mental illnesses and co-occurring substance use disorders. Psychiatric Rehabilitation Journal, 27, 360–374. Chapter 04 6/30/06 56 10:07 AM Page 56 Best Practices in Mental Health Drake, R. E., Osher, F. C., & Wallach, M. A. (1989). Alcohol use and abuse in schizophrenia: A prospective community study. Journal of Nervous and Mental Disease, 177, 408–414. Drake, R. E., & Wallach, M. A. (1989). Substance abuse among the chronically mentally ill. Hospital and Community Psychiatry, 40, 1041–1046. Drake, R. E., Yovetich, N. A., Bebout, R. R., Harris, M., & McHugo, G. J. (1997). Integrated treatment for dually diagnosed homeless adults. Journal of Nervous and Mental Disease, 185, 298–305. Haywood, T. W., Kravitz, H. M., Grossman, L. S., Cavanaugh, J. L., Davis, J. M., & Lewis, D. A. (1995). Predicting the “revolving door” phenomenon among patients with schizophrenic, schizoaffective, and affective disorders. American Journal of Psychiatry, 152, 856–861. Ho, A. P., Tsuaung, J. W., Liberman, R. P., Wang, R., Wilkins, J. N., Eckman, T. A., et al. (1999). Achieving effective treatment of patients with chronic psychotic illness and comorbid substance dependence. American Journal of Psychiatry, 156, 1765–1770. Kessler, R. C., Chiu, W. T., Demler, O., & Walters, E. E. (2005). Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey. Archives of General Psychiatry, 62, 617–627. Kessler, R. C., Nelson, C. B., McGonagle, K. A., Edlund, M. J., Frank, R. G., & Leaf, P. J. (1996). The epidemiology of co-occurring addictive and mental disorders: Implications for prevention and service utilization. American Journal of Orthopsychiatry, 66, 17–31. Mercer-McFadden, C., Drake, R. E., Brown, N. B., & Fox, R. S. (1997). The community support program demonstrations of services for young adults with severe mental illness and substance use disorders. Psychiatric Rehabilitation Journal, 20, 13–24. Miller, N. S. (1994a). Psychiatric comorbidity: Occurrence and treatment. Alcohol Health & Research World, 18, 261–264. Miller, N. S. (1994b). Prevalence and treatment models for addiction in psychiatric populations. Psychiatric Annals, 24, 399–406. Minkoff, K. (1989). An integrated treatment model for dual diagnosis of psychosis and addiction. Hospital and Community Psychiatry, 40, 261–264. Mueser, K. T., Bellack, A. S., & Blanchard, J. J. (1992). Comorbidity of schizophrenia and substance abuse: Implications for treatment. Journal of Consulting and Clinical Psychology, 60, 845–856. Mueser, K. T., & Noordsy, D. L. (1996). Group treatment for dually diagnosed adults. New Directions for Mental Health Services, 70, 33–51. Osher, F. C., (1996). A vision for the future: Toward a service system responsive to those with co-occurring addictive and mental disorders. American Journal of Orthopsychiatry, 66, 71–76 Osher, F. C., Drake, R. E., Noordsy, D. L., Teague, G. B., Hurlbut, S. C., Biesanz, J. C., et al. (1994). Correlates and outcomes of alcohol use disorder among rural outpatients with schizophrenia. Journal of Clinical Psychiatry, 55, 109–113. Chapter 04 6/30/06 10:07 AM Page 57 Integrated Treatment 57 Pulice, R., Lyman, S., & McCormick, L. (1994). Study of provider perceptions of individuals with dual disorders. Journal of Mental Health Administration, 21, 92–99. Regier, D. A., Farmer, M. E., Rae, D. S., Locke, B. Z., Keith, S. J., Judd, L. L., et al. (1990). Comorbidity of mental disorders with alcohol and other drug abuse: Results from the Epidemiologic Catchment Area (ECA) study. Journal of the American Medical Association, 264, 2511–2518. Swofford, C. D., Kasckow, J. W., Scheller-Gilkey, G., & Indrbitzin, L. B. (1996). Substance use: A powerful predictor of relapse in schizophrenia. Schizophrenia Research, 20, 145–151. Weaver, T., Madden, P., Charles, V., Stimson, C., Renton, A., Tyrer, A., et al. (2003). Comorbidity of substance misuse and mental illness in community mental health and substance misuse services. British Journal of Psychiatry, 183, 304–313. Young, N., & Grella, C. (1998). Mental health and substance abuse treatment services for dually diagnosed clients: Results of a statewide survey of county administrators. Journal of Behavioral Health Services and Research, 25, 83–92 REVIEW Alcohol Dependence and Suicidal Behavior: From Research to Clinical Challenges Vania Modesto-Lowe, MD, MPH, Donna Brooks, MS, and Mohammed Ghani, MD Epidemiological and clinical data suggest high rates of suicidal behavior in alcohol-dependent individuals. Suicide attempters are likely to be young, to be single or separated, and to have made prior attempts. They differ from non-attempters by higher levels of impulsive aggression, drug use, and psychiatric comorbidity, particularly personality and depressive disorders. Treatment-seeking, alcohol-dependent individuals often present with multiple risk factors. Early recognition of suicidal behavior is hindered, however, by insufficient data regarding the acute phenomenology of imminent risk. Similarly, little research is available to guide intervention efforts. Initial trials support the use of fluoxetine for the treatment of suicidal, alcohol-dependent persons with comorbid depressive disorders. Future studies may clarify the relative efficacy of various psychotherapeutic and pharmacological approaches to treating these patients. (HARV REV PSYCHIATRY 2006;14:241–248.) Keywords: alcohol dependence, suicide, suicide attempts, treatment Individuals with alcohol use disorders appear to be at high risk for increased rate of suicide.1 Lifetime prevalence of suicide in alcohol-dependent individuals varies from 7% to 15%.2,3 In addition, retrospective postmortem studies indicate that 25% to 35% of suicides are carried out by persons with an alcohol use disorder.4−9 Suicide rates are also elevated in cocaine- and opioid-dependent individuals.1 Except for cannabis and hallucinogens,9 alcohol-use and other substance-use disorders augment the risk for pre-suicidal events such as ideation and attempts.10−14 From the Department of Psychiatry, University of Connecticut School of Medicine (Dr. Modesto-Lowe); Addiction Services Division, Connecticut Valley Hospital, Middletown, CT. Original manuscript received 4 September 2005; revised manuscript received 13 March 2006, accepted for publication 18 May 2006. Correspondence: Vania Modesto-Lowe, MD, MPH, Connecticut Valley Hospital, P.O. Box 351, Silver St., Middletown, CT 06457. Email: Vania.Modesto-Lowe@po.state.ct.us c 2006 President and Fellows of Harvard College  DOI: 10.1080/10673220600975089 Relative to other substance-dependent populations, the clinical factors associated with suicide in alcohol-dependent individuals have been well characterized. The classic prototype of high suicide risk is an older, Caucasian male who has experienced multiple psychosocial, health, and personal losses.3,4 Contemporary alcohol-dependent persons may differ, however, from cohorts represented in earlier studies in both demographic and clinical features (e.g., more females and ethnic minorities, and more drug use).15,16 The increase in the prevalence of concurrent dependence on alcohol and drugs (e.g., cocaine) also seems to influence the course of alcohol dependence and its relationship to suicidal behavior.15 In general, suicides in alcohol-dependent individuals occur in the context of increased levels of dependence and numerous losses accumulated during a long drinking career,3 whereas individuals with drug use disorders who die from suicide are typically adolescents or young adults.17−20 Initial studies on the association between alcohol dependence and suicidal states consisted largely of retrospective analysis of completed suicides.1,2,4,6 Subsequent efforts involved prospective studies and focused on suicide attempts.14,15,21 Recently, the search for genetic and neurobiological mechanisms underlying suicidal behavior in this population has received some attention.22,23 Thus far, research on the clinical management of suicidal, 241 Harv Rev Psychiatry 242 Modesto-Lowe et al. alcohol-dependent persons remains scarce. Suicide attempts are a frequent clinical problem and are also a strong predictor of suicide.21 In this review, we explore data associated with suicide attempts in alcohol-dependent individuals. We also present a framework for the clinical approach to suicidal behavior in these patients. A search of the PubMed English-language database was conducted using “alcohol dependence” and “suicide attempts” as search words from the years 2000 to 2005. All types of publications relevant to the relationship between alcohol dependence and suicide attempts were reviewed, with an emphasis on prospective studies with large sample sizes. In addition, selected retrospective studies and references of articles were included if deemed to be of epidemiological or clinical relevance. Studies focusing on alcohol abuse or misuse were excluded. CLINICAL CHARACTERISTICS Alcohol-dependent individuals who display suicidal behavior appear to differ in a number of clinical features from alcohol-dependent persons who do not exhibit suicidality. A U.S. study employing data from the Collaborative Studies on the Genetics of Alcoholism (COGA, a six-center, family study primarily designed to explore the genetic basis of alcohol dependence) compared 3190 alcohol-dependent individuals with and without a history of suicide attempts.14 In this secondary analysis, alcohol-dependent individuals with a history of suicide attempts were more likely to be female, with an earlier onset and more severe course of alcohol dependence than those without a suicide-attempt history. Specifically, suicide attempters received more treatment for alcohol dependence and experienced more alcohol-associated physical problems and more episodes of alcohol-related violence than the alcohol-dependent group without suicide attempts. Suicide attempters also differed significantly from non–suicide attempters by higher levels of comorbid drug use and psychiatric disorders, notably panic, social phobia, and mood disorders. The prevalence of suicide attempts was almost twice as high among the first-degree relatives of the suicide attempters compared to the non-attempters. Of particular interest is a related study also employing COGA data (n = 59 sibling pairs), which showed a significant association between suicide attempts and a gene (or genes) on chromosome 2 in alcohol-dependent persons.22 While straightforward conclusions cannot be drawn from this finding, its replication may provide new insights regarding the genetic correlates of suicide attempts in these patients. Additionally, as part of COGA, a prospective five-year study compared the characteristics of 1237 treatmentseeking, alcohol-dependent individuals who attempted suicide to those who did not attempt suicide.21 Study participants were assessed with semistructured interviews both September/October 2006 at study entry and five-year follow-up. Not surprisingly, alcohol-dependent individuals with suicide attempts (n = 56) during the follow-up period were more likely than subjects with no suicide attempts (n = 1181) to have made prior attempts. Suicide attempters had significantly more-severe alcohol dependence and more comorbid substance-dependence diagnoses and substance-induced psychiatric disorders than non-attempters. Although no gender differences were found in this study, suicide attempters were younger and more likely to be separated or divorced than non-attempters. Interestingly, additional efforts to characterize suicide attempters among alcohol-dependent populations using crosssectional assessments revealed that young females with a family history of suicidal behavior, childhood trauma, and antidepressant treatment were at significantly higher risk for suicide attempts than those in control groups.24 These findings were largely replicated in comparable studies employing samples dependent upon opioids, cocaine, and other drugs.25−27 In sum, high severity of alcohol dependence, past suicide attempts, and comorbid drug use and psychiatric disorders such as anxiety and mood disorders appear to be closely associated with suicidal behavior in alcoholdependent individuals. In this population, depressive disorders may relate to chronic, heavy drinking and either remit with abstinence or constitute an independent depressive disorder likely to persist despite sobriety. This distinction is clinically relevant because of potentially differing courses and prognoses of these disorders. In the first large study (n = 2945) addressing this issue,28 both independent and alcohol-induced depressions were associated with suicidal behavior. Subjects with independent depression, however, had significantly higher rates of suicide attempts (30.3%) than those with alcohol-induced depressions (24.8%). Subsequently, as part of COGA, Preuss and colleagues13 examined alcoholdependent persons with histories of suicide attempts and comorbid depressive disorders. Of the 371 participants, 145 had independent depressive episodes, whereas 226 experienced alcohol-induced depressions only. Of note was that 62% of the sample was female. This study also showed that alcohol-dependent individuals with a history of suicide attempts and independent depression had a higher number of suicide attempts. Contrary to other findings,10,14 however, these patients were less likely to have been drinking during their most severe attempt and reported a less severe history of alcohol dependence. Although these discrepancies may relate to the relatively high number of women in this study, they highlight the heterogeneity of the suicidal behavior among subgroups of alcohol-dependent individuals, suggesting the need to further understand these differences and potential clinical implications. The role of comorbidity in augmenting suicidal behavior is not unique to mood disorders. Alcohol-dependent Harv Rev Psychiatry Modesto-Lowe et al. Volume 14, Number 5 individuals with antisocial personality disorder (ASPD) and borderline personality disorder (BPD) are more likely to attempt suicide than those without personality disorders.10,29 Against a background of chaotic relationships, BPD is characterized by marked mood reactivity; inappropriate and intense anger; impulsive aggression; recurrent suicidal behavior, gestures, or threats; or self-mutilating behavior.30 Individuals with ASPD typically display a wide range of antisocial acts, as well as high levels of impulsive aggression, that overlap with BPD and are intimately related to suicidality and alcohol dependence.10,29−32 In particular, the prominent role of impulsive suicidal acts in the midst of interpersonal strains has been noted for completed suicides in alcohol-dependent individuals regardless of a comorbid personality disorder.3,7,33 Murphy and colleagues33 reported that interpersonal loss, especially disruptions in spousal/significant-other relationships occurring six weeks before the suicide, differentiated suicides in alcohol-dependent persons from suicides in those with a diagnosis of a depressive disorder. Corner and Duberstein34 developed a model of suicidal behavior that may be relevant to understanding the interpersonal distress, impulsive-aggression link observed in many suicidal, alcohol-dependent individuals. According to this model, severe alcohol dependence, high levels of impulsive aggression, and susceptibility to experience negative affect or hopelessness are major predisposing factors to suicidality. Individuals with severe alcohol dependence and certain personality traits (hostility and impulsive aggressive) are prone to develop a relational style that induces frequent disruptions (e.g., domestic violence) and ultimately the loss of valued relationships. Consequently, major depressive episodes and stressful events, particularly loss of close relationships, act as precipitants to suicidal behavior. In this context, many suicide attempts in alcohol-dependent individuals may be construed as impulsive-aggressive acts in the midst of intense dysphoria and hopelessness. Although this model does not account for the role of intoxication in the suicidal act, it represents an important step in integrating research on predisposing and precipitating precursors to suicidal behavior in alcohol-dependent individuals. From a neurobiological standpoint, several lines of evidence suggest that lower serotonin (5-HT) activity is associated with increased impulsive aggression, suicidal behavior, and alcohol dependence.23 Consequently, genes encoding 5HT protein systems have been selected as candidates in the pathophysiology of both alcohol dependence and suicidal behavior. At least two studies employing European alcoholdependent samples revealed an association between suicide attempts and a gene encoding a serotonin (5-HTTL PR-sallele) polymorphism.35,36 While these findings have not yet influenced the clinical management of patients, they offer promise in advancing knowledge of the relationship between alcohol dependence and suicide attempts. 243 From a clinical perspective, the utility of risk factors for suicide attempts is limited by the abundance of demographic, clinical, and psychosocial risk factors typically seen in these populations. In addiction-treatment settings, women undergoing addiction treatment are often unemployed young females with histories of sexual abuse, BPD, or a depressive disorder—which places them at risk for suicide attempts. Alternatively, the typical male patient may have type II alcohol dependence characterized by early age of onset, conduct disorder, high levels of impulsive aggression, and psychopathology. These patients usually have a more severe subtype of alcohol dependence, with increased intensity of drinking and family histories of alcohol dependence or depressive disorders, and have a high risk for suicidal behavior. Overall, the high number of suicide risk factors in patients with substance use disorders suggests the need for a high level of vigilance in detecting signs of acute suicide risk. Unfortunately, there are little data to guide clinical practice regarding clinical correlates of imminent suicide in such high-risk patients. Preliminary efforts to examine this issue employed retrospective data from patients with mood disorders that completed suicide.37 In one study, 79% of patients showed severe agitation and anxiety (e.g., severe psychic anxiety, global insomnia, panic attacks, and agitation) within one week prior to completing suicide.38 In contrast, suicide in alcohol-dependent persons has been characterized as impulsive, in the context of intoxication, reactive to personal loss, and with little premeditation.39 Nevertheless, even among alcohol-dependent patients, persistent suicidal ideation and planning may precede suicidal behavior.40 While impulsive attempters may enter suicidal states rapidly, individuals who premeditate a suicide attempt may communicate suicidal thoughts, providing a window of opportunity for interventions. Future research may elucidate the complex dynamics of suicidal behavior in various subgroups of the alcohol-dependent population, including women and ethnic minorities. SUICIDE RISK ASSESSMENT Empirical data on the assessment of suicidal symptoms in alcohol-dependent individuals is scarce. However, the risk factors recognized in these patients closely parallel those of the general psychiatric population,41 suggesting common underlying processes. We discuss a framework that calls for appraisal of substance-use and psychiatric status, predisposing/protective factors, precipitants to suicidal behavior, and current and previous suicidal symptoms.41 Alcohol-dependent individuals may report suicidal ideation following periods of relapse, increased use, or early withdrawal. Significant depressive symptoms, recent changes in psychosocial status (e.g., loss of children, Harv Rev Psychiatry 244 Modesto-Lowe et al. incarceration), and interpersonal loss, in particular, indicate periods of heightened risk.42 While suicidal ideation is not a reliable indicator of immediate risk,37 it is a common antecedent of suicidal behavior.15 Among alcohol-dependent individuals, suicide attempts preceded by persistent suicidal ideation (of at least a week’s duration) appear to be associated with greater intent to die and are more likely to require medical attention than impulsive suicide attempts.40 Consequently, an explicit inquiry about current or past ideation, its magnitude, and its transient versus persistent character should be undertaken. It is essential to elicit any specific suicidal plans and the degree to which the individual is inclined to carry them out. Since a past suicide attempt is a robust predictor of subsequent attempts,21 exploring the features of previous attempts may prove to be useful. In particular, a chronological account of the attempts— including precipitants, methods, intoxication status, and severity of attempt—may reveal pertinent data. Collateral information from family and friends may provide additional perspectives on such attempts, including any suicidal communications43 and availability of lethal means (e.g., firearms, medications). It may also uncover relevant family history,22 childhood sexual or physical abuse, or level of family dysfunction. Further, the clinician needs to ascertain the nature and extent of alcohol and drug use, including medical, interpersonal, and psychiatric sequelae. Severe alcohol dependence is a predisposing factor to suicidal behavior in alcohol-dependent individuals.34 In addition, interpersonal disruptions have special salience as a precipitant to suicidal behavior in these patients.34 It is also important to determine if the individual is experiencing withdrawal states that may require attention or complicate psychiatric evaluation. Cocaine withdrawal, for instance, is manifested by depressed mood, anhedonia, appetite changes, sleep disturbances, and occasional suicidal ideation and hopelessness. Whether these symptoms persist after a sustained period of abstinence is a relevant question. If the mood symptoms precede the onset of substance use or persist despite sustained abstinence, the diagnosis of an autonomous depressive disorder should be considered.28 Accurate diagnosis is particularly relevant in such cases since a current depressive episode is also a precipitant to suicidal behavior in alcohol-dependent persons. Also note that Axis II disorders (BPD, ASPD) or traits (impulsive aggression, susceptibility to experience hopelessness) have been conceptualized as predisposing factors to suicidal behavior in these patients.34 Although severe anxiety, panic attacks, and global insomnia have been recognized as precursors to suicidal behavior,38 it is unclear if such symptoms are relevant to alcohol-dependent individuals. No research has been conducted to identify specific protective factors, but levels of social support, religious affiliation, 12-step involvement, and September/October 2006 other potential variables need to be considered in the assessment. In non-alcohol-dependent persons, ethnic variability regarding both the predisposition to self-report the presence of suicidal ideation44 and resilience against suicidal behavior43 has been reported in the United States. Protective factors, such as responsibility to family and moral objections to suicide, may be particularly high in Latino groups.45 African Americans may also have higher moral objections to suicide, and they report more reasons to live than their Caucasian counterparts.44 It would be of interest to examine if these ethnic differences are replicated in alcohol-dependent populations. The question of whether the suicide evaluation in alcohol-dependent individuals should significantly differ from that of other at-risk groups deserves further study. Research is also needed to clarify protective factors and clinical correlates of imminent suicidal behavior in these patients. Meanwhile, increased understanding of predisposing and precipitant risk factors for suicidal behavior may inform clinical practice. INTERVENTIONS Despite the clinical importance of suicide attempts in alcohol-dependent persons, there are scant data evaluating specific interventions for this subgroup of patients. We consider basic principles that may be useful in efforts to decrease acute suicidal risk, as well as to modify predisposing or precipitating risk factors. In particular, we are proposing immediate attention to suicidal symptoms in addition to specific treatment for alcohol dependence and comorbid disorders. Every effort must be taken to develop an alliance with the patient and formulate a plan to decrease acute risk. The plan must include level of care and psychosocial, environmental, and pharmacological measures. Patients with suicidal ideation, depressive symptoms, recent loss, and current drinking warrant particularly aggressive interventions that may include involuntary hospitalization. There are no empirically based criteria for hospitalizing suicidal, alcohol-dependent individuals. Hospitalization needs to be considered, however, in the presence of a suicide plan or intent, especially in the context of past suicide attempts, hopelessness, and high levels of impulsive aggression.41 Environmental safeguards such as continuous observation or varying levels of suicide precautions may be warranted for inpatients. Similarly, outpatients may benefit from removal of weapons, poisons, or dangerous medications. Pharmacological interventions may include detoxification or may target putative “high risk” symptoms (e.g., anxious mood, agitation, global insomnia, and panic attacks).38 While benzodiazepines generally alleviate sleep and anxiety symptoms, their addictive properties and serious interactions with alcohol complicate use in substance Harv Rev Psychiatry Volume 14, Number 5 users other than to treat acute withdrawal states. Alternative agents with sedative properties (e.g., trazodone), anticonvulsants (e.g., gabapentin),46 and atypical antipsychotics (e.g., quetiapine)47 have been used in patients experiencing protracted withdrawal symptoms but have not been systematically studied in these populations. In light of the significant associations between suicidal behavior and comorbid mood disorders,13,21,28 it is essential to treat co-occurring mood disorders. While a crosssectional examination of substance-induced mood symptoms may be similar in phenomenology and intensity to independent mood disorders, the former may precede substance use and usually require long-term pharmacotherapy.28 Since substance-induced depressive disorders subside with abstinence, the use of medications usually is postponed for one or two weeks following initiation of abstinence. In the context of acute suicidal behavior, however, it may be difficult to justify deferral of potentially effective interventions. Data on the pharmacological treatment of depressed alcoholics are increasing and suggest the utility of antidepressants combined with chemical-dependence interventions.48 Among these studies only two evaluating fluoxetine included suicidal, depressed, alcohol-dependent individuals. In the first open pilot trial (n = 12), all patients (at baseline) reported prominent suicidal ideation and a past lifetime suicide attempt, and half had made a recent suicide attempt that was deemed to be serious.49 Participants experienced significant reductions in depressive symptoms, suicidal ideation, and alcohol consumption with no worsening of suicidality. However, substantial residual depressive symptoms and drinking persisted at the end of the 8week study. In a follow-up, double-blind, placebo-controlled 12-week study (n = 51), all subjects were diagnosed with comorbid alcohol dependence and major depressive disorder, and most displayed significant suicidality.50 Specifically, 39% had made a suicide attempt during their current depressive episodes, 61% had made a lifetime suicide attempt, and 90% reported suicidal ideation within a week of hospital admission. This study showed that fluoxetine was effective in decreasing depressive symptoms, suicidal ideation, and drinking measures compared to placebo. Although replication is required, these initial findings suggest the benefits of fluoxetine for the treatment of suicidal, alcohol-dependent persons with comorbid depressive disorders. In clinical practice, selective serotonin reuptake inhibitors (SSRIs) have become widely employed in the treatment of alcohol-dependent patients with comorbid depressive disorders with or without suicidality. Before reaching a decision to commence antidepressants in this population, prescribers must consider a few caveats. First, recent changes in U.S. Food and Drug Administration labeling suggest that antidepressants may conceivably increase or induce de novo suicidality in some patients.51 Sec- Modesto-Lowe et al. 245 ond, SSRIs may worsen protracted withdrawal symptoms such as tremor, anxious mood, irritability, restlessness, insomnia, or alcohol-induced sexual dysfunction. Third, earlyonset alcoholics started on fluvoxamine may experience intense activation symptoms52 or worsened drinking outcomes compared to placebo treatment.53 These considerations highlight the need to monitor these patients closely for several weeks for signs of agitation, akathisia, suicidality, or increased drinking, as well as for improvements in depressive symptoms. As opposed to the questionable “suicidogenic” effects of SSRIs, the use of lithium to treat bipolar patients has caused significant reductions in suicide.54 Of interest is whether lithium’s antisuicidal effects apply to bipolar patients with comorbid substance use disorders. Initial studies of this subgroup suggest that these patients often present with mixed mania,55 which may be less responsive to lithium than pure manic episodes. Additional concerns in prescribing lithium to these patients are poor compliance, more impulsivity, and potential overdose-related toxicity. While the possible effects of anticonvulsants on suicidal behavior have not been settled, both carbamazepine and valproic acid appear to be effective in mixed manias.56 The anticonvulsant topiramate holds promise for its “anticraving” effects,57 and the spectrum of its efficacy merits examination. There may also be a role for more established antidipsotropic medications such as acamprosate58 and naltrexone59 in the pharmacological management of these patients. Similar to environmental and pharmacological measures, the immediate goal of psychosocial interventions is to modify acute suicidal behavior. To date, no controlled study of a specific psychotherapeutic approach for suicidal, alcoholdependent persons has been tested. Cognitive-behavioral therapy (CBT), however, may facilitate challenging the cognitive constriction, self-hatred, sense of worthlessness, hopelessness, and narrow range of suicidal thinking.60 Of interest is a study examining a CBT intervention developed to prevent suicide attempts.61 The approach focuses on identifying stressors and cognitions associated with past attempts and on developing adaptive skills to respond to them. In the only trial evaluating this intervention, 120 adults who attempted suicide and were evaluated at a hospital emergency room within 48 hours of the attempt, were randomized to receive treatment as usual (TAU) or 10 CBT sessions.61 Participants in the CBT group had significantly lower reattempt rates, and at six-month follow-up reported significantly less depression and hopelessness than the usual care group. Specific vulnerability factors addressed in the sessions included social isolation, treatment noncompliance, hopelessness, impaired problem solving, and impulse dyscontrol. Noteworthy is the observation that these factors are also associated with suicidality in alcohol-dependent individuals.34 CBT has been shown to be effective in treating alcohol dependence,62 as Harv Rev Psychiatry 246 Modesto-Lowe et al. well as depressive disorders.60 This approach may also be suitable to improve suicidal symptoms in alcohol-dependent persons, but needs further study. The use of dialectical behavior therapy (DBT) may also be useful in a subgroup of alcohol-dependent persons with high levels of impulsive aggression. DBT focuses on managing affective instability and the acquisition of distress tolerance skills. It shows promise in treating the core symptoms of BPD such as impulsivity and suicidal behavior.63 While no trials have focused on alcohol-dependent persons with BPD, preliminary evidence supports its use in other BPD populations with substance use disorders.30,32 In a 52-week, randomized clinical trial, the effects of DBT and TAU were assessed in 58 female BPD patients with (n = 31) and without (n = 27) substance abuse.32 Patients receiving DBT showed significantly lower levels of alcohol use and of impulsive and parasuicidal behavior than those assigned to TAU. No differential effects on drug-use measures were seen in this study. In another study, DBT showed promising results in combination with a 12-step program and an opioid agonist in reducing drug use in opioid-dependent BPD women.30 These preliminary findings suggest that DBT in combination with 12step involvement needs to be studied in alcohol-dependent individuals with BPD symptoms. Also, the overlap of symptoms (e.g., impulsive aggression) among ASPD, BPD, and alcohol dependence suggests that DBT, combined with a 12-step program, might be adopted to address some of the disruptive behaviors associated with ASPD that may contribute to suicidal behavior. Central to the 12-step movement is the notion of character defects (callousness, remorseless use of others)—an approach that may be of value to some individuals with alcohol-related antisocial behavior. Involvement in the 12-step program also appears to be associated with a more active religious life and internal locus of control, as well as better social and employment adjustment.64 In addition, 12-step participation may provide a sense of hope, a sober support network, and a practical approach to cope with life’s adversities. Alternative efforts to positively involve the family or strengthen a patient’s social support may likewise yield protective effects against suicide risk. CONCLUSIONS The risk of suicidal behavior in alcohol-dependent patients is of epidemiological and clinical significance. Among alcoholdependent persons, suicide attempters are likely to present with high levels of drug use, impulsive aggression, and psychiatric comorbidity (predominantly personality and depressive disorders). In most studies evaluating the relationship between suicide attempts and alcohol dependence, suicide attempters are young, single individuals with severe alcohol dependence. Despite advances in understanding the clini- September/October 2006 cal profile of alcohol-dependent individuals at risk for suicidal behavior, there is more to be discovered. While both impulsive-aggressive personality traits and comorbid mood disorders are significant risk factors, the nature of suicide attempts may differ among subgroups at risk. In addition, the effects of gender and ethnicity on the expression of suicidality in this population warrant further study. Thus far, no data are available either on specific resilience factors or clinical correlates of imminent suicidal behavior. In addition, little is known on the relative efficacy of specific psychotherapeutic and pharmacological approaches in treating suicidal, alcohol-dependent persons. Pilot trials supporting the use of fluoxetine for suicidal, alcohol-dependent individuals with comorbid depressive disorders are encouraging. 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Dual Diagnosis
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Analyze the complexity of dual diagnosis as it relates to the case study.
Dual diagnosis is referred to as the existence of psychoactive substance use disorder as
well as psychiatric disorders within the same individual. An individual in dual diagnosis exhibits
both mental disorders and drug abuse related issues. The conditions can happen concurrently or
the problem mental illness happens which leads to substance abuse as a remedy (Searby, Maude
& McGrath, 2015). Jerome is exhibiting signs of du...

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