Psychosocial interventions in patients with dual diagnosis

Abstract

Management of patients with dual diagnosis (Mental illness and substance use disorders) is a challenge. A lack of improvement in either disorder can lead to a relapse in both. The current consensus opinion favours an integrated approach to management of both the disorders wherein the same team of professionals manages both the disorders in the same setting. The role of pharmacotherapy for such dual diagnosis patients is well established but the non-pharmacological approaches for their management are still evolving. After stabilization of the acute phase of illnesses, non-pharmacological management takes centre stage. Evidence points to the beneficial effect of psychosocial approaches in maintaining abstinence, adherence to medication, maintenance of a healthy life style, better integration in to community, occupational rehabilitation and an overall improvement in functioning. Psychosocial approaches although beneficial, are difficult to implement. They require teamwork, involving professionals other than psychiatrists and psychologists alone. These approaches need to be comprehensive, individualized and require training to various levels that is difficult to achieve in most Indian settings.

In this article we provide a brief review of these approaches.

INTRODUCTION

The concept of dual diagnosis dates back to time immemorial, but the term dual diagnosis was formally outlined in 1994. The National Library of Medicine (NLM) introduced a new Medical subject heading (MeSH) as “Diagnosis, Dual (Psychiatry)” defined as “the co-existence of a substance use disorder with a psychiatric disorder. The diagnostic principle was based on the fact that it has been found often that chemically dependent patients also have psychiatric problems of various degrees of severity” (MeSH, NLM, 1994). Ries (1995) listed the various terms being used to address the co-morbid severe mental illness and substance use disorders and among these, dual diagnosis seems to have emerged as the favoured term¹. 3238 references are listed under the MeSH (Medical subjects headings) in Pubmed database in December, 2017.

SUDs are highly comorbid with borderline and antisocial personality, bipolar, psychotic, depression, and anxiety disorders². In USA, around half of the people seeking treatment for SUD are diagnosed as having a co-occurring mental health disorder³. The Epidemiological catchment area study in USA showed a lifetime prevalence of comorbid SUD in patients with Schizophrenia to be around 47% and in patients with Bipolar disorder to be around 61%⁴. There are no nationally representative studies of prevalence of dual diagnosis in India. A recent well-conducted study from a clinic in North India showed that one-third (32.4%) of patients seeking treatment for SUD were diagnosed as having a co-occurring mental health disorder. Majority of the cases had affective disorder (12.3%), anxiety disorder (11.2%) and psychotic disorder (5%)⁵. Most patients with BPAD (affective disorders) report improvement in mood symptoms upon using substances⁶. Patients with Dual Diagnosis have high rates of mortality and morbidity²,³,⁵,⁶.

The need for a comprehensive and individualized management was recognized since a long time, but various conflicting models of management have evolved. Among these, the integrated model of management is now accepted as a norm. The integrated model refers to the focus of treatment on two or more conditions simultaneously and to the use of multiple treatments, such as the combination of psychotherapy and pharmacotherapy⁷.

The pharmacological treatments are mainly directed towards the neurobiological changes associated with mood disorders, anxiety disorders and psychotic disorders, management of acute episodes and exacerbations and maintenance treatment for prevention of relapse. Psychosocial treatments are not a stand-alone treatment for dual diagnosis patients. The narrow benefits of adding psychosocial interventions to usual medical treatment include reductions in relapse, time spent with symptoms, hospitalization and improved functioning⁸. This article will cover the different psychosocial interventions, principles and their effectiveness in managing severe mental illness like Bipolar Affective Disorders and psychotic illness like Schizophrenia comorbid with substance use disorders.

Management strategies for dual diagnosis patients include:

1. Pharmacological treatment- The mainstay for drug treatment of psychiatric illness include use of appropriate mood stabilizers, anti-psychotics and anti-depressants.

The main pharmacological treatments for management of substance use disorders include medications for assisting smoother withdrawal, maintenance medications and agents for managing craving. The evidence base for the pharmacological management in dual diagnosis has been covered extensively in the previous clinical practice guidelines published by Indian Psychiatry Society specialty section⁹,¹⁰,¹¹,¹²

• 2.Non-pharmacological treatment- These include a number of approaches:
  1. Psychosocial treatments- There are various psychosocial interventions like family interventions, motivational interviewing, motivation enhancement therapy, relapse prevention counseling, contingency management, cognitive behaviour therapies and other behaviour therapies etc., either alone or in combination that have been conducted individually or in group format. Newer therapies include mindfulness based approaches for stress reduction (MBSR), relaxation techniques etc.,¹³.
  2. Somatic treatments- They include electroconvulsive therapy (ECT), rTMS for depression and biofeedback for anxiety.

Psychosocial Assessments:

Treatment of dual disorders, like any mental illness, involves a multidisciplinary team comprising of psychiatrists, psychologists, counsellors and social workers in various roles, such as psychotherapists, student counsellors, and case managers. The detailed assessment of dual diagnosis is covered in a separate article and here we will be covering the assessment in brief.

The assessment should broadly include following areas:

1. Establishing clinical diagnosis of substance use disorders and mental illness – Detailed assessment of substance use and mental illness and consequences of the substance use and mental illness.

2. Assessment of motivation to change – Motivation is a dynamic process and we need to assess the person's motivation to stop or decrease substance use during different treatment phases for mental illness. The psychosocial interventions are very effective when conducted during the stable phase of mental illness.

3. Investigations to confirm the presence of substance, assess the degree of physical damage, and confirm the presence of sexually transmitted disease. Though not used routinely, in some cases, neuropsychological tests can be used to assess the cognitive function particularly in cases with medical, psychiatric complications or with co-morbid other substance use.

Psychosocial Interventions:

Psychosocial interventions in dual diagnosis can be broadly divided into general psychosocial interventions (like Motivational Enhancement Therapy, Cognitive Behaviour Therapy etc.,) or specific interventions like Integrated group therapy for bipolar disorder and substance use (IGT) etc., which have been developed keeping in mind the co-occurrence of BPAD and SUDs. In psychotic disorders specific psychosocial therapies like modified Cognitive Behavior Therapies etc., have been developed keeping in mind the co-occurrence of psychosis and SUDs. Most of these interventions take in to account the cognitive deficits and residual symptoms in patients with psychotic disorder even during the periods of remission.

In this article we will be covering specific therapies which have been specially developed keeping in mind the co-occurrence of BPAD and psychosis, and SUD's.

Specific psychosocial therapies for Bipolar disorder and substance use disorders:

Integrated group therapy for bipolar disorder and substance use (IGT)- It was developed as a treatment approach specific to BPAD with addictive disorders. Its unique feature is integration of the therapeutic interventions addressing BPAD and the counselling principles of psychosocial interventions for SUDs. The main goals of the IGT are to promote staying off drugs completely, to increase medication adherence, to educate the patient about “warning signs” or early symptom recognition and prevent relapse, to carry out relapse prevention therapy and enhance mood stability and improve overall functioning including interpersonal relationships¹⁴. Weiss and his group conducted randomized controlled trials (RCTs) of around 20 sessions of IGT vs treatment as usual¹⁵, IGT vs group therapy for substance use¹⁶ and a community friendly brief version of IGT i.e. 12 sessions¹⁷. They found the IGT for BPAD and SUDs to be significantly more effective on both substance use and mental health outcomes. IGT works on a principle of conceptualizing both the disorders as manifestation of a common underlying process called “bipolar substance abuse.” The treatment for this disorder involves abstaining from drugs and substances; adherence to medication; and engaging in a variety of other “recovery behaviors,” such as getting a good night's sleep, recognizing and avoiding situations that present high risk of relapse to either substance use or mood problems, and attending SUD and BPAD self-help groups. Some recovery behaviours and their underlying thought patterns are specific to one disorder or the other (e.g. learning alcohol and drug refusal; taking mood-stabilizing medication as prescribed), but many behaviours (e.g. regular sleep schedule) facilitate recovery from both disorders¹⁴.

Early recovery adherence therapy (ERAT)- It is a counselling approach directed towards the individual who is in an early phase of recovery from an acute episode of BPAD, with a focus to promote abstinence from the substances. It is an amalgamation of principles of motivational interviewing, relapse prevention, and psychoeducational approaches for management of BPAD and substance use.

It was compared to the Twelve step facilitation approach in a randomized pilot study and was found to be effective¹⁸.

Other than these two therapies, developed specifically for BPAD also deserves mention as it is applicable to the setting of dual diagnosis also.

Interpersonal social rhythms therapy (IPSRT)- A psychosocial therapy developed specifically for patients with BPAD on a premise that stabilizing the circadian rhythms of the patients is effective in preventing relapse to acute mood disturbances. It helps patients gain insight into relationship between mood symptoms and interpersonal changes. It involves structuring daily routines of patients, including sleep cycles and addressing interpersonal problems. There is evidence for its effectiveness in preventing relapse, improving interpersonal functioning and improving satisfaction with life, in addition to effect of medication alone. The stabilization of daily activity schedules and social and interpersonal relationships are bound to have a beneficial effect even on the substance use disorder¹⁹,²⁰.

The various non-pharmacological approaches mentioned above have evidence for effectiveness in either BPAD or SUD respectively, but there is no reason to believe that they will not be effective in the context of co-occurrence of these disorders. A middle path could be the development of integrated therapies which would incorporate the strengths of many of these therapies into one and an eclectic approach to these integrated therapies can be more succinct and problem focused.

Specific psychosocial therapies for Psychotic disorders and substance use disorders

Modified CBT: This is an integrated approach for patients with schizophrenia and substance use disorders. Therapy includes Relapse prevention strategies and Motivational interviewing strategies. CBT is modified to account for the cognitive limitations of psychotic disorders. It focuses on a small number of skills. Initially, the skills specific to problem solving and social skills are taught. Later on, they are informed about craving and triggers for substance use. The unique difficulties pertaining to substance use in patients with psychotic disorders are discussed. Structured small group sessions, taken twice weekly for 6 months, emphasize on social skill and relapse prevention skill building. Improved social skills and abstinence are highly reinforced to enhance self- efficacy of clients. Abstinence is positively reinforced by small amounts of monetary reward for drug free urine test results.²¹,²²

Modified MET: It is a strategy for psychotic patients with low motivation to quit substance use. MET has been developed from the principles of Motivational Interviewing (MI) with added component of utilizing baseline assessment to obtain personalized feedback to further strengthen the motivation to change. Traditional MET is modified to adapt to the unique cognitive challenges and unique reasons of low motivation to quit substance in psychotic patients. One way to modify MET for schizophrenia spectrum disorders can be described as the 5-step “Collaborative, motivational and harm reduction” approach. It includes 1) Developing a working alliance; 2) Helping the patient evaluate the pros and cons of substance use (decisional balance); 3) Formulating individualized goals; 4) Encouraging an environment and lifestyle that are supportive of abstinence and 5) Teaching skills for managing crises.²¹

In other modified MET approaches, depending upon different motivational levels, specific motivational strategies are used. Some approaches acknowledge and emphasize the need to address multiple problems (e.g. use of substances, adherence to medication) and the need for much longer period of engagement and duration of treatment. All modified MET approaches emphasize higher levels of engagement and activity by therapist and behavioural strategies are devised to ensure brief sessions, concrete language, with more repetitions because this subgroup of patients have cognitive impairments, such as low level of alertness. In addition, other unique characteristics of this subgroup of patients, such as lower self-efficacy and need for treatment of concurrent mental illness makes it important to give prolonged period of engagement to handle these issues. Therefore, modified MET is not given as a standalone treatment. Rather, it is integrated with mental health treatments.²³,²⁴

Self Help Groups (Double Trouble in recovery): 12-step recovery principle-based mutual Self Help groups meetings such as Double Trouble in recovery (DTR) are designed specifically for patients with dual diagnosis. It specifically addresses problems of those who have concurrent substance use disorder and psychiatric illness. Problems pertaining to psychiatric illness, such as medication adherence and side effects, psychiatric symptoms remain unaddressed in traditional 12-step meetings and these patients are often stigmatized in traditional settings. However, no outcome data on DTR is yet available²¹

Dual Recovery Therapy (DRT): It integrates Relapse Prevention therapy, Motivational enhancement therapy, Principles of 12-step programme for substance use disorder with the Social skills training for psychiatric disorders. These are provided in linked group and individual sessions. Communication skills and Problem-solving skills are taught through role playing technique. The therapist keenly monitors the dynamics of interaction between psychotic illness and substance use disorder and accordingly adjusts the relative treatment emphasis. MET addresses low motivation and the 12-step programme is useful, because it has a common lexicon with which patients are already familiar. Initially, DRT has twice-weekly individual sessions and later on has weekly one individual and one group session. There is a link between individual and group sessions, in a manner that the things discussed during group sessions are reinforced during individual sessions. Subsequently, the focus shifts towards working on dysfunctional relationships with aim of enhancing healthy relationships.²¹,²⁴,²⁵

However, no further quantitative studies were done to substantiate the research evidence for Dual recovery therapy. In a qualitative analysis on dual recovery among people with serious mental illness including schizophrenia and other psychotic disorders, it was concluded that the substance abuse treatment approaches that are flexible and reduce barriers to engagement among people with serious mental illnesses, support learning about the effects of substances on mental health and quality of life, and that adopt a chronic disease model of addiction are likely to be more effective at helping people to quit substances²⁶.

The Substance Abuse Management Module (SAMM): It is based on harm reduction, relapse prevention and social skills training. It relies on teaching only a limited and specific subset of skills for ease of implementation and learning. Specific skills that are crucial for avoiding use of substance and management of illness are taught and practiced e.g. skills to deal with craving and skills required for communicating with therapist. It emphasizes the importance of repeated practice and rehearsal of skills. This model is based on social skills training, which focuses on enhancing problem solving and communication skills to promote abstinence from substance and healthier recovery. It uses role playing modality in group treatment sessions. Here, the therapist helps the group to identify the problem and help to consider ways to address the problem related to promoting abstinence and recovery. The therapist may acquire an active role in these role plays, as a coach to provide positive feedback and helpful criticism for the proceedings of role play.²¹,²⁷

Combination of therapies: Studies have also been done combining therapies like Motivational interviewing plus cognitive behavioral therapy, cognitive behavioral therapy plus contingency management although the overall evidence is still equivocal with regard to effectiveness of these therapies.

Several meta-analyses have been done on psychosocial interventions for people with severe mental illness and substance misuse. They conclude that evidence to support the efficacy of any psychosocial intervention over any other or even treatment as usual (TAU) is insufficient. There were several limitations of the studies taken for meta-analysis. These meta-analyses have consistently reported that available evidence was low or very low, due to large differences across trials which made pooling of the results difficult. The major differences in pooled studies include outcome measures, sample characteristics, type of mental illnesses and substances used, settings, levels of adherence to treatment guidelines, and standard care definitions.²⁸,²⁹,³⁰,³¹ There is a need for good quality RCT's which can address the above limitations to get a better idea about the effectiveness of the Psychosocial interventions in persons with severe mental illness and substance misuse.

Case vignettes-

Bipolar disorder with cannabis use disorder

A 21 year male presented with acute onset behavioural problems. He had not been attending his work since a week and was using cannabis ‘Charas' joints for most of the day. He would talk excessively and get irritable if his father differed from what he was saying or doing. His eyes would often be ‘red’ and he would declare his grandiose plans. He hardly slept for 2-3 hours but never seemed tired. He would listen to songs on his headphones and smoke ‘beedis' in front of his father, unlike his previous self. He had to be brought to the Drug De-addiction Treatment Centre (DDTC) OPD because he had entered into a brawl with his neighbours, who had mocked him regarding his high contacts. He, however, had no doubt regarding his contacts, who would help him in any situation.

The patient was admitted along with his father as an attendant. There was history of an episode of depression 1 year back. He took no treatment for the same and it gradually improved over 4-5 months. He was diagnosed as Bipolar affective disorder with a current episode of Mania with Psychotic symptoms and cannabis and tobacco dependence. His YMRS rating on admission was 35, and he had grade 1 insight in to his mental illness and did not believe that his cannabis use was problematic. He was treated with Valproate titrated upto 1500 mg and Olanzapine 20 mg and given Nicotine TTS 14 mg daily for nicotine craving. In the second week of admission his Young's mania rating scale (YMRS) score was 14 and his irritability and aggression had decreased significantly. He had developed grade 2 insight that his behavior was disturbed, but attributed it to excessive use of cannabis.

His relapse prevention (RP) sessions along with psychoeducation regarding the symptoms of bipolar illness and cannabis use and their interaction were started from 3^rd week onwards when his insight had improved to grade 3 and YMRS score was 10. The patient expressed unwillingness to stop Tobacco use in future and it was not included in RP sessions. Information regarding the harmful effects of Tobacco was given with an open advice that he could seek treatment for tobacco cessation anytime in future, when he was willing for it. High-risk situations for the patient were assessed in terms of external, internal and social factors and their impact discussed. Patient's father was involved in these sessions and explained regarding the warning signs of relapse to either the depressive or manic phase of Bipolar illness or cannabis use as a part of the family focused interventions.

In the 4^th week, the patient was further involved in sessions on coping skills, wherein special focus was given to assertiveness training to refuse peer pressure, which was a major reason for continuing substance use in patient. Lapse management skills were also discussed and patient's cognition, wherein he believed that he would not be able to say no to cannabis was addressed. Stress management was discussed with a focus on managing interpersonal stress and father was also involved in the same. Activity schedule of the patients was charted and followed in the ward, with a view to stabilize his interpersonal and social rhythms.

The patient was discharged in the 5^th week post-admission with a mutually agreed on activity schedule, an occupational plan wherein he would work with his father selling groundnuts and avoid cannabis. He was advised to continue maintenance pharmacotherapy and Nicotine TTS and use tobacco to a minimum. He was advised followed up in the dual diagnosis clinic in OPD where he would first attend a group therapy session which would address both the bipolar illness and substance use in an integrated manner.

Schizophrenia with SUD

A 26 year old male presented with acute onset behavioural disturbances to the DDTC OPD. On further exploration of history, it was found out that he started smoking cigarettes and cannabis filled cigarettes (charas ‘joints’) since 2009 in a pattern characterized by craving, tolerance and withdrawal. He would smoke around 10-15 joints in a day. He failed twice in 11^th standard and then dropped out from school in 2012. Around 2013, reportedly he went to Haridwar and smoked cannabis heavily along with others for about a month following which, he became idle and aloof; his self-care and interaction with family members decreased. He would voice that his neighbours were chasing him and discussing amongst themselves to kill him and take his soul away, with no evidence confirming the same. He became confined to home, fearing that the neighbour would kill him. These symptoms continued despite being abstinent from cannabis for about 9 months, after which he started smoking charas ‘joints' in the previous pattern. He was taken to multiple hospitals and treatment was given (details not available) but he would not adhere to treatment. Symptoms would fluctuate but never improve significantly with treatment. He absconded a third time from home, as he firmly believed that neighbours were conspiring to kill him; was brought back in a disheveled state and was admitted with his attendant. He was diagnosed as cannabis dependence, tobacco dependence and paranoid schizophrenia. Mental state examination revealed Delusion of Persecution and Delusion of reference. His PANSS rating on admission was 52, he had grade 1 insight in to his mental illness and did not believe that his cannabis use was problematic. He was treated with Olanzapine 20 mg, given Nicotine TTS 14 mg daily for nicotine craving and T. N-acetyl Cysteine 600 mg BD for cannabis dependence. He was given injection Haloperidol 5 mg and Promethazine 50 mg for managing his aggression in the first week of admission. Since the adherence to medication was ensured in the ward, the patient responded to the adequate trial of T. Olanzapine (PANSS score after 2 weeks reduced to 38). In the third week of admission, he had only ideas of persecution. In view of earlier non-adherence to treatment and poor insight into illness, plan for Long acting Olanzapine Injection was discussed with family members and he was started on a dose of 300 mg every fortnightly. T. Olanzapine was tapered and stopped a week later.

Psychosocial management: Psychoeducation sessions of patient and family members were taken regarding the symptoms of schizophrenia and cannabis use and their interaction in the context of bidirectional etiological model. i.e. both mental illness and cannabis dependence contribute to aggravating symptoms of each other. Relapse prevention (RP) sessions were started from the third week, when his insight had improved to grade III and PANSS score was 32. The Patient was explained in a format comprehensible to him, regarding various terms/events associated with RP (lapse, abstinence violation effect, relapse), and Marlatt's model of relapse prevention was explained. High-risk situations for the patient were assessed in terms of internal, external and social factors and their impact discussed. Patient's father was involved in these sessions and explained regarding the warning signs of relapse to either cannabis use or to psychotic illness as a part of the family focused interventions. In the fourth week, sessions for coping skills were taken, wherein special focus was given to handling of leisure time and issues of handling anger. Patient was further involved in sessions on handling craving including physical and mental distraction techniques. Keeping in view the limitations of cognitive functions of the patient due to psychotic illness, all the sessions were taken with the core approach of being very precise, repetitive and having sessions of brief duration, so that patient would be able to comprehend and remember the discussion and thus might implement in his real life situations. Activity schedule of the patients was charted and followed in the ward, to keep him engaged in various activities, with the purpose of ensuring that the patient would continue the practice of following a structured routine post-discharge.

The patient was discharged in the fifth week post-admission with a mutually agreed upon activity schedule, focus on healthy lifestyle (low fat diet and regular exercise) and occupational plan, wherein he would work under supervision of his father in their shop and a detailed plan of immediate intervention was provided, in case of lapse. He was advised to continue fortnightly L.A. Olanzapine, Nicotine TTS and T. N-acetyl Cysteine 600 mg BD. He was advised to follow-up in the dual diagnosis clinic in the OPD where he would first attend a group therapy session which would address both the schizophrenia and substance use in an integrated manner.

Indian scenario

Most of the research evidence for psychosocial management of dual disorders comes from western literature. The situation is different in India as there are very few trained professionals to deliver these interventions. There is also a need for conducting good quality studies in India on the management of dual diagnosis.

The recent clinic based guidelines published by Indian Psychiatric Society (IPS) highlight specific issues in the management of patients with dual diagnosis. The IPS CPG on bipolar disorders emphasizes that both the conditions need to be treated concurrently and abstinence as crucial both during the acute episodes and maintenance phase.³² The IPS CPG on depression states that that abstinence is a principle priority in management of patients with dual diagnosis, but if other factors permit, first detoxification should be done and then anti-depressant treatment commenced.³³ The IPS CPG on Schizophrenia mentions that an additional aim of treatment is to achieve abstinence from substances or at least harm reduction. They advocate incorporation of psychosocial approaches such as relapse prevention counselling, cognitive behavioural interventions and motivational interviewing as a part of the treatment plan.³⁴

SUMMARY

Psychosocial management of patients with dual diagnosis is challenging and requires a multipronged approach that involves a multidisciplinary team. The key guiding principles of psychosocial treatment for patients with Dual diagnosis are as follows:

• During the engagement process, focus on developing a supportive therapeutic alliance and emphasize on modified motivational enhancement approaches.

• Integrate evidence based psychosocial treatments for different illness to formulate an individualized management plan.

• Help the patient in acquiring skills for abstinence and recovery using different principles like relapse prevention counseling, therapies using behavioural and cognitive principles etc.,

• Enhance positive support from family members by educating them about the illness (substance use and mental illness) and other networks.

• Short term case management approaches during critical periods with high risk of relapse to promote treatment retention enhances successful outcome.

There is a need for good quality studies for establishing effectiveness of the psychosocial interventions in persons with severe mental illness and substance misuse especially in India setting.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.