Assessment and Treatment of Patients with Coexisting Mental Illness and Alcohol and Other Drug Abuse

This publication is part of the Substance Abuse Prevention and Treatment Block Grant technical assistance program. All material appearing in this volume except quoted passages from copyrighted sources is in the public domain and may be reproduced or copied without permission from the Center for Substance Abuse Treatment (CSAT) or the authors. Citation of the source is appreciated. This publication was written under contract number ADM 270-91-0007 from the Center for Substance Abuse Treatment of the Substance Abuse and Mental Health Services Administration (SAMHSA). Anna Marsh, Ph.D., and Sandra Clunies, M.S., served as the Government project officers. Elayne Clift, M.A., Carolyn Davis, Joni Eisenberg, Mim Landry, and Janice Lynch served as writers.

The opinions expressed herein are those of the consensus panel participants and do not reflect the official position of CSAT or any other part of the U.S. Department of Health and Human Services (DHHS). No official support or endorsement of CSAT or DHHS is intended or should be inferred. The guidelines proffered in this document should not be considered as substitutes for individualized patient care and treatment decisions.

DHHS Publication No. (SMA) 95-3061. Printed 1994. Reprinted 1995.

What Is a TIP?

CSAT Treatment Improvement Protocols (TIPs) are prepared by the Quality Assurance and Evaluation Branch to facilitate the transfer of state-of-the-art protocols and guidelines for the treatment of alcohol and other drug (AOD) abuse from acknowledged clinical, research, and administrative experts to the Nation’s AOD abuse treatment resources.

The dissemination of a TIP is the last step in a process that begins with the recommendation of an AOD abuse problem area for consideration by a panel of experts. These include clinicians, researchers, and program managers, as well as professionals in such related fields as social services or criminal justice.

Once a topic has been selected, CSAT creates a Federal Resource Panel, with members from pertinent Federal agencies and national organizations, to review the state of the art in treatment and program management in the area selected. Recommendations from this Federal panel are then transmitted to the members of a second group, which consists of non-Federal experts who are intimately familiar with the topic. This group, known as a non-Federal Consensus Panel, meets in Washington for 3 days, makes recommendations, defines protocols, and arrives at agreement on protocols. Its members represent AOD abuse treatment programs, hospitals, community health centers, counseling programs, criminal justice and child welfare agencies, and private practitioners. A Chair for the panel is charged with responsibility for ensuring that the resulting protocol reflects true group consensus.

The next step is a review of the proposed guidelines and protocol by a third group whose members serve as expert field reviewers. Once their recommendations and responses have been reviewed, the Chair approves the document for publication. The result is a TIP reflecting the actual state of the art of AOD abuse treatment in public and private programs recognized for their provision of high-quality and innovative AOD abuse treatment.

This TIP, titled Assessment and Treatment of Patients With Coexisting Mental Illness and Alcohol and Other Drug (AOD) Abuse, provides practical information about the treatment of patients with dual disorders, including the treatment of AOD patients with mood and anxiety disorders, personality disorders, and psychotic disorders. This TIP also provides pragmatic information about systems and linkage issues relative to the AOD and mental health treatment systems. There is also a discussion about pharmacologic management of patients with dual disorders.

This TIP represents another step by CSAT toward its goal of bringing national leadership to bear in the effort to improve AOD abuse treatment.

Consensus Panel

Richard K. Ries, M.D., Chair
Inpatient Psychiatry and Dual Disorder Programs
Harborview Medical Center
Seattle, Washington

Marcelino Cruces, L.C.S.W.
Administrative Coordinator
Andromeda Transcultural Mental Health Center
Substance Abuse Treatment Division
Washington, D.C.

Mary Katherine Evans, C.A.D.C., N.C.A.C. II
Program Director
Evans and Sullivan
Beaverton, Oregon

James Fine, M.D.
Addictive Disease Hospital at Kings County Hospital Center
Clinical Associate Professor
Department of Psychiatry
State University of New York
Health Service Center at Brooklyn
Brooklyn, New York

Bonnie Schorske, M.A.
Special Populations
New Jersey Division of Mental Health and Hospitals
Trenton, New Jersey
Workgroup Members:

Stephen J. Bartels, M.D.
Medical Director
West Central Services, Inc.
Research Associate
New Hampshire-Dartmouth Psychiatric Research Center
Lebanon, New Hampshire

Dolores Burant, M.D.
Program and Medical Director
University Outpatient Recovery Service
Madison, Wisconsin

Agnes Furey, L.P.N., C.A.P.
Primary Care Coordinator
Florida Alcohol and Drug Abuse Program
Department of Health and Rehabilitation Services
Tallahassee, Florida

Malcolm Heard, M.S.
Division on Alcoholism and Drug Abuse
Nebraska Department of Public Institutions
Lincoln, Nebraska

Norman Miller, M.D.
Associate Professor of Psychiatry
Chief, Addiction Programs
Department of Psychiatry
University of Illinois at Chicago
Chicago, Illinois

Ernest Quimby, Ph.D.
Assistant Graduate Professor
Howard University
Department of Sociology and Anthropology
Washington, D.C.

Henry Jay Richards, Ph.D.
Associate Director for Behavioral Sciences
Patuxent Institution
Jessup, Maryland

Candace Shelton, M.S., C. A.C.
Clinical Director
Pascua Yaqui Adult Treatment Home
Tucson, Arizona

Virginia Stiepock, A.C.S.W, R.N., C.S.
Assistant Center Director
Clinical Director
Northern Rhode Island Community Mental Health Center
Woonsocket, Rhode Island

Mathias Stricherz, Ed.D., C.D.C. III
Student Counseling Center
University of South Dakota
Vermillion, South Dakota

Patricia M. Weisser
National Association of Psychiatric Survivors
Sioux Falls, South Dakota

Joan Ellen Zweben, Ph.D.
Executive Director
The East Bay Community Recovery Project
The 14th Street Clinic and Medical Group
Berkeley, California


The Treatment Improvement Protocol Series (TIPs) fulfills CSAT’s mission to improve alcohol and other drug (AOD) abuse and dependency treatment by providing best practices guidance to clinicians, program administrators, and payers. This guidance, in the form of a protocol, results from a careful consideration of all relevant clinical and health services research findings, demonstration experience, and implementation requirements. A panel of non-Federal clinical researchers, clinicians, program administrators, and patient advocates employs a consensus process to produce the product. This panel’s work is reviewed and critiqued by field reviewers as it evolves. The talent, dedication, and hard work that TIPs panelists and reviewers bring to this highly participatory process have bridged the gap between the promise of research and the needs of practicing clinicians and administrators. I am grateful to all who have joined with us to contribute to advance our substance abuse treatment field.

Susan L. Becker Associate Director for State Programs Center for Substance Abuse Treatment

Chapter 1 –Introduction


The treatment needs of patients who have a psychiatric disorder in combination with an alcohol and other drug (AOD) use disorder differ significantly from the treatment needs of patients with either an AOD use disorder or a psychiatric disorder by itself. This Treatment Improvement Protocol (TIP) consists of recommendations for the treatment of patients with dual disorders.

This TIP was developed by a multidisciplinary consensus panel that included addiction counselors, social workers, psychologists, psychiatrists, other physicians, nurses, and program administrators with active clinical involvement in the treatment of patients with dual disorders. Consumers also participated on the panel.

This TIP was written principally for addiction treatment staff. However, it contains information and treatment recommendations that can be used by healthcare providers in a variety of treatment settings. For example, it will be useful to people who work in primary care clinics, hospitals, and various mental health settings. In addition, there are recommendations that are targeted to administrators and planners of healthcare services.

A thoughtful attempt has been made to include information that the consensus panel felt was clinically relevant. While many clinical topics are explored in depth, some are only briefly mentioned, and a few are avoided altogether.

It is not the goal of this TIP to provide an exhaustive description of all of the possible issues that relate to the treatment of patients with dual disorders. Rather, the primary goal is to provide treatment recommendations that are practical and useful.

Indeed, the usefulness of this TIP can be enhanced by blending these recommendations with those of another TIP such as Intensive Outpatient Treatment for Alcohol and Other Drug (AOD) Abuse. By doing so, treatment protocols can be developed which will meet very specific treatment needs.


Definitions and Models

Chapter 2 — Dual Disorders: Concepts and Definitions — provides descriptions and diagnostic criteria for AOD abuse and dependence. There is also a description of the possible interactions between AOD use and psychiatric symptoms and disorders.

Chapter 3 — Mental Health and Addiction Treatment Systems: Philosophical and Treatment Approach Issue — describes the similarities, differences, strengths, and weaknesses of the treatment systems used by patients with dual disorders: the mental health system, the addiction treatment system, and the medical system. Similarly, there is a description of treatment models most frequently used: sequential treatment of each disorder, parallel treatment of each disorder, and integrated treatment of both disorders. The chapter includes a discussion of critical treatment issues and general assessment issues in providing care to patients with dual disorders.


Chapter 4 — Linkages for Mental Health and AOD Treatment — describes several areas of critical concern for programs that provide services to patients with dual disorders. There are discussions regarding policy and planning; funding and reimbursement; data collection and needs assessment; program development; screening, assessment, and referral; case management; staffing and training; and linkages with social service, health care, and the criminal justice systems.

This chapter should be particularly useful for administrators and political planners who address the potential administrative overlaps and gaps that exist between the mental health and addiction treatment systems. The semi-outline format of the chapter will allow planners of services a rapid checkup of specific areas such as funding and reimbursement, program development, and case management.

Specific Psychiatric Disorders

While entire books can be written regarding specific psychiatric disorders, this TIP describes the disorders that account for the majority of psychiatric problems seen in patients with dual disorders. TIP chapters that address specific psychiatric problems include Chapter 5, Mood Disorders; Chapter 6, Anxiety Disorders; Personality Disorders; and Chapter 8, Psychotic Disorders.

By combining chapters, strategies for treating patients with complex disorders may be developed. For example, by combining techniques recommended for the treatment of personality and mood disorders, borderline syndrome treatment strategies can be developed.

Both content and stylistic approaches vary markedly among these chapters, reflecting the differences of consensus panel members who composed them. Since these differences in stylistic approaches may be useful to the reader, they have been retained.


Chapter 9 — Pharmacologic Management — is a brief overview of the types of medications used in psychiatry and addiction medicine and for patients with dual disorders. A stepwise treatment model that can minimize medication abuse risks is discussed, and cautions about drug interactions are reviewed.

Addiction treatment program staff are increasingly encountering patients who require prescribed medications in order to participate in recovery. For this reason, it is important for clinical staff to have an understanding of the principle medications used in psychiatry and how they are used. In addition, agencies that hire a consulting psychiatrist may want to review with the psychiatrist the prescribing issues raised in this chapter.

A bibliography is provided for further study in Appendix A. A brief overview of sample cost data for the treatment of dual disorders is in Appendix B. It compares three treatment programs on features such as salary ranges and administrative costs.

Chapter 2 — Dual Disorders: Concepts and Definitions

Chapter 2 — Dual Disorders: Concepts and Definitions The Relationships Between AOD Use and Psychiatric Symptoms and Disorders Establishing an accurate diagnosis for patients in addiction and mental health settings is an important and multifaceted aspect of the treatment process. Clinicians must discriminate between acute primary psychiatric disorders and psychiatric symptoms caused by alcohol and […]

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Chapter 4 — Linkages For Mental Health and AOD Treatment

Chapter 4 — Linkages For Mental Health and AOD Treatment Overview Conventional boundaries between single-focus agencies have impeded the clinical progress of patients who have psychiatric disorders and alcohol and other drug (AOD) use disorders (Baker, 1991; Schorske and Bedard, 1988). The treatment of patients with dual disorders is a clinical challenge, as well as […]

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Chapter 5 — Mood Disorders

Chapter 5 — Mood Disorders Definitions and Diagnoses The term mood describes a pervasive and sustained emotional state that may affect all aspects of an individual’s life and perceptions. Mood disorders are pathologically elevated or depressed disturbances of mood, and include full or partial episodes of depression or mania. A mood episode (for example, major […]

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Chapter 6 — Anxiety Disorders

Chapter 6 — Anxiety Disorders Definitions and Diagnoses The anxiety disorders are the most common group of psychiatric disorders. The term anxiety refers to the sensations of nervousness, tension, apprehension, and fear that emanate from the anticipation of danger, which may be internal or external. Anxiety disorders describe different clusters of signs and symptoms of […]

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Chapter 8 — Psychotic Disorders

Chapter 8 — Psychotic Disorders Dual-Focus Perspective This chapter is an overview of current assessment and treatment principles for patients with alcohol and other drug (AOD) use disorders and psychosis. Along with an increased awareness of the treatment needs of patients with these dual disorders, an increased emphasis on service systems has evolved. These and […]

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Chapter 9 — Pharmacologic Management

Chapter 9 — Pharmacologic Management Pharmacologic Risk Factors Addiction is not a fixed and rigid event. Like psychiatric disorders, addiction is a dynamic process, with fluctuations in severity, rate of progression, and symptom manifestation and with differences in the speed of onset. Both disorders are greatly influenced by several factors, including genetic susceptibility, environment, and […]

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Appendix A — Bibliography

Appendix A — Bibliography Africa, B., and Schwartz, S.R. Schizophrenic disorders. In: Goldman, H.H., ed. Review of General Psychiatry, Third Edition. Norwalk, Connecticut: Appleton & Lange, 1992. pp. 226-241. American Psychiatric Association.Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised. Washington, D.C.: American Psychiatric Association, 1987. American Psychiatric Association.DSM-IV Draft Criteria, 3/1/93. Washington, D.C.: […]

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Appendixes B, C, D

Appendix B — Treatment of Patients With Dual Disorders: Sample Cost Data To provide readers with illustrative data on the costs of running programs for patients with dual disorders, the consensus panel Chair obtained data on actual costs during fiscal year 1991-1992 from three programs in urban areas. One program, on the West Coast, provided […]

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