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Diagnosing and Treating Co-Occurring Substance Abuse Disorders and Mental Illness in Older Adults

This information on co-occurring substance abuse and mental illness is for health and mental health professionals including:

  • psychologists
  • psychiatrists
  • psychotherapists
  • physicians
  • psychiatric nurses
  • clinical social workers

This information is for reference only.  Always consider the needs of individual patients and the resources available.   For additional information, see the depression and anxiety sections of this website.

Risk Factors
Diagnosis
Management

Risk Factors


Risk factors for developing dual disorders

  • Having a mental health disorder; half of all individuals with severe mental health problems are also substance abusers
  • Having a parent who was a substance abuser and/or a parent who suffered from a mood disorder

Negative outcomes associated with having dual disorders

    Health problems such as:

    • Hepatitis B and C
    • HIV
    • Suicide or premature death

    Social problems such as:

    • Family problems
    • Financial difficulties
    • Homelessness
    • Violence and victimization

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Diagnosis


Dual disorders may include a combination of substance abuse (abuse of alcohol or drugs) and any psychiatric disorder including depression, anxiety, bipolar disorder, and schizophrenia.

Diagnostic Instruments

Assessment tools for the diagnosis of dual disorders include:

  • A structured clinical interview
  • The DSM criteria for substance abuse are:
    • a problematic use of a substance for a year or longer and
    • evidence of this problematic use in at least one part of the individual s life e.g., one s family, work, or social life.
  • The DSM criteria for a more serious disorder, substance dependence, are:
    • problematic use of a substance for a year or longer and
    • three or more specific consequences of this problematic use. These consequences include:
      • continued substance abuse in spite of negative consequences in one’s personal or professional life;
      • increased tolerance to the substance;
      • increased use and frequency of use of the substance;
      • withdrawal;
      • wish to use the substance less; and
      • the replacement of usual activities with substance abuse.
  • An assessment for the context of the person’s substance abuse. Questions about when, where, why, and with whom the individual uses substances can point to internal (drinking to relax) and external (drinking to be sociable) triggers for substance abuse. They can also help to identify the individual’s views about positive and negative outcomes of his or her substance use.
  • A comprehensive longitudinal assessment that includes chronological information about the person’s:
    • Functional status
    • Treatment or lack of treatment for mental illness; response to treatment
    • Treatment or lack of treatment for substance abuse; response to treatment
    • Relationship between his or her mental health disorder and substance abuse

      • American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, fourth edition. Washington, DC, 1994.

  • Dartmouth Assessment of Lifestyle Instrument (DALI) (see http://www.dartmouth.edu/~psychrc/alcohol.html).This 18-item questionnaire is geared toward individuals with severe mental illness who are beginning treatment.

For more information, see:
McHugo, GJ, Drake, RE, Burton, HL, & Ackerson, TH (1995). A scale for assessing the stage of substance abuse treatment in persons with severe mental illness. J Nervous and Mental Disease, 183, 762-767.

Mueser, KT, Drake, RE, Clark, RE, et al. (1995). Toolkit for Evaluating Substance Abuse in Persons with Severe Mental Illness. Cambridge, MA: Evaluation Center at HSRI.


More specialized assessments

Depending on the initial assessment, some patients may require further evaluation for:

  • Medical problems
  • Psychological issues
  • Substance abuse

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Management

Management of dual disorders may include drug therapy, psychotherapy, or both.


Medication

Several types of drug therapies are effective in managing dual disorders. When choosing a medication, consider the patient’s age, coexisting medical and psychiatric illnesses, response to medications, and possible drug interactions.

Drugs used to treat dual disorders include:

  • Anti-depressants and anti-anxiety medications(according to the patient’s mental disorder)
  • Naltrexone (Revia)(to reduce the person’s craving for heroin and morphine)
  • Disulfiram (Antabuse)(for patients with alcoholism and severe mental illness)

Psychotherapy

Psychosocial interventions for dual disorders include motivational intervention; cognitive behavioral therapy (CBT); group therapy (such as marital and family therapy); and psychodynamic psychotherapy to address coexisting disorders or stressors. Support, reassurance, and education are important elements of each of these interventions.

Motivational intervention

Patients may move through motivational intervention, a four-stage treatment plan, at different rates:

  1. Engagement: The clinician creates a relationship of trust with the individual and engages him or her in the treatment process.
  2. Persuasion: The clinician motivates the individual to consider the role of substance abuse in his or her life and to participate in his or her own recovery process.
  3. Active treatment: The clinician teaches the individual the skills necessary to manage dual disorders. These skills may include avoiding substances and learning to socialize without them and managing stress and other feelings without substances.
  4. Prevention of relapse:After the individual has maintained a stable remission for six months or more, the clinician teaches him or her the skills necessary to maintain recovery. These skills may include:
    • Participating in self-help groups
    • Developing social skills (e.g., listening, expressing feelings)
    • Identifying new activities to replace substance abuse
    • Exploring new work opportunities

Cognitive behavioral therapy (CBT) can last up to several months. CBT treatments may include:

  • Finding ways to reduce negative thinking
  • Learning relaxation skills to ease anxiety in social situations
  • Improving interpersonal skills (such as conversation and assertiveness)

Assertive community treatment (ACT) connects older adults with helpful services and treatment programs. These efforts also encourage patients to comply with treatment.

Group therapy may include:

  • Social skills training (teaching the individual to avoid social situations that might encourage substance abuse)
  • Education groups
  • Persuasion and active treatment groups: Persuasion groups are for individuals who are just beginning treatment for their substance abuse problem. In these supportive, long-term groups, participants share with each other the role of substance use in their lives. Many members of these groups go on to seek treatment for substance abuse. Active treatment groups are for individuals who have decided to address their substance abuse. Participants learn to recognize triggers of their substance problem and share coping skills with each other.
  • Single and multiple family interventions and therapy
  • Medication support groups
  • Consumer-run self-help groups (e.g., 12-step programs such as Alcoholics Anonymous and other programs such as Rational Recovery, Dual Recovery Anonymous, and Double Trouble)

Psychodynamic psychotherapy to address coexisting disorders or stressors. This form of therapy is often used in addition to CBT and/or medications.

Combined pharmacotherapy and psychotherapy
Because of the broad range of symptoms among older adults who experience dual disorders, it is not possible to make a general recommendation regarding the efficacy of medication, psychotherapy, or a combination of the two types of therapy.

Suggested Guidelines for Treatment

In the integrated treatment of dual disorders, a single clinician or a team of psychiatrists, substance abuse counselors, case managers, nurses, and others coordinates treatment of both the patient s substance abuse and mental disorder. The clinician should be aware of the wide variety of other medical and psychiatric conditions that mimic dual disorders.

The decision to use one treatment method over another may depend in part on:

  • Other medical or psychiatric illnesses that the patient may have
  • His or her history of substance use

Care for suicidal patients

Refer patients who present safety risks to themselves or others to a hospital emergency department or urgent psychiatric evaluation.

Initial Intervention

The clinician or team of caregivers helps the patient to begin working through the stages of motivational intervention. Additional assistance such as pharmacological treatment and family education and residential services may be required.

Active Treatment

During this phase of treament, the individual, with the support of the integrated treatment team and perhaps group therapy, works toward controlling his or her substance abuse problem. The patient and his or her clinician establish goals (such as overcoming the craving to drink) and find ways to meet them (e.g., by learning to use distraction when cravings arise).

The patient may not notice the effects of either pharmacotherapy or psychotherapy for several weeks after treatment begins.

Lack of a response to medication or repeated relapses may be due to:

  • Non-compliance
  • Inadequate dosing
  • Inadequate duration of therapy
  • The need for psychotherapy as well

Look for improvement in the patient’s:

  • Relationships
  • Ability to live independently
  • Ability to maintain a job or work toward educational goals

Assess the individual regularly until he or she attains stable remission of his or her substance abuse disorder. Patients who relapse may require further pharmacotherapy or psychotherapy.

Relapse Prevention

Once the individual has abstained from substance abuse for six months or more, he or she works toward preventing a relapse. Those who have maintained remission for a year or more and have finished treatment are considered to be in recovery.

Adapted from:

  • Brigham and Women’s Hospital. Depression. A guide to diagnosis and treatment. Boston (MA): Brigham and Women's Hospital; 2001. 9 p. [6 references]
  • Excellus/Identification and Treatment of Major Depression in Primary Care
  • http://www.mentalhealthpractices.org/
  • Co-Occurring Disorders: Integrated Dual Disorders Treatment. U.S. Substance Abuse and Mental Health Services Administration, 2002.