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1. Relapse prevention in the dual diagnosed Celena A. Heine PSY 492- Adv General Psychology Argosy University June 25, 2010

2. According to Wieder, Lutz, & Boyle (2005), over twenty years of research and observations has led to several apparent truths about those individuals with a dual diagnosis. For one, they are considered a heterogeneous population suffering from substance abuse (drugs, alcohol, or both), and an AXIS I disorder (i.e.. affective, and/or anxiety disorders, or schizophrenia), OR an AXIS II disorder (i.e.. personality disorders). Usually, the dual diagnosed fall within one of three different categories: 1) A substance use disorder with a personality disorder , 2) a substance abuse disorder with a repeated trauma in early life, and 3) a substance abuse disorder with a chronic, severe mental illness like schizophrenia, or Bipolar Disorder (Weider, et al. , 2005).

3. Comorbidity Models If there is a family history of both, substance use disorder and mental illness (Drake, Wallach, & McGovern, 2005; Mueser, Drake, & Wallach, 1998; Wieder, Lutz, & Boyle, 2005). Antisocial personality disorder (Mueser, Drake, & Wallach, 1998; Weider, Lutz, & Boyle, 2005). Super sensitivity model, where there is a biological vulnerability of psychiatric disorders which results in an increased sensitivity to drugs & alcohol; leading to a substance use disorder (Mueser, Drake, & Wallach, 1998; Weider, Lutz, & Boyle, 2005) Self-medication model; where an individual, in order to alleviate the painful effects of their mental illness, uses substances (i.e.. painful side effects of psychiatric disorders). (Mueser, Drake, & Wallach, 1998; Weider, Lutz, & Boyle, 2005; Miles, Johnson, Amponsah-Afuwape, Leese, Finch, & Thornicroft, 2003).

4. The ID of valid and reliable diagnoses of psychiatric Comorbidity in substance abusers is problematic The effects of substance abuse can imitate the symptoms of many other mental disorders, making it hard to differentiate between the actual psychiatric symptoms and/or the active symptoms of substance abuse and withdrawal. (Torrensa, Martin-Santos, & Samet, 2006)

5. In earlier forms of the Diagnostic and Statistical Manual for Mental Disorders (DSM), more specifically the DSM-IV, the differentiation of independent disorders from other psychiatric disorders was unclear With the “Psychiatric Research Interview for Substance and Mental disorders” (PRISM), clearer guidelines were established (Torrensa, Martin-Santos, & Samet, 2006). Three categories provided these “clearer guidelines” in diagnosing psychiatric disorders and heavy substance users: “primary” psychiatric disorders; “substance induced” disorders; and “expected effects” of substances. Torrensa and colleagues (2006) concluded that in comparison with patients who have a single disorder, the dually diagnosed individual showed a higher psychopathological severity, more emergency room and hospital admissions, and a higher rate/prevalence for suicide.

6. Greater occurrences of hospital visits and suicidal intentions were found in several other studies as well. For example, Laudet, Magura, Vogel, & Knight (2004) found that individuals with a substance use disorder and co-occurring serious mental illness have greater vulnerability for hospitalizations, greater instances of depression & suicidal ideation, a proneness to violence, and noncompliance with medications and other treatments. This particular group also had a high occurrence of family issues, as well as legal issues, an increased risk for HIV/AIDS infection, and higher costs for healthcare services (Laudet, et al., 2004). Laudet and colleagues (2004) also found that those individuals with a dual diagnosis had less likelihood of remaining abstinent and in recovery than those with just a substance use disorder. Successful interventions for the dual diagnosed should be aimed at reducing negative, psychiatric, symptomology, as well as reducing the costs of healthcare (Laudet, et al., 2004).

7. Negative psychiatric symptomology and the high cost of healthcare are part of society’s problems with Comorbidity. Miles, Johnson, Amponsah-Afuwape, Leese, Finch, & Thornicroft, (2003), also agree that the presence of the dually diagnosed individual is one that is prevalent and associated with an increase in clinical, as well as, societal problems. In a study examining the subgroups defined by their main substances of misuse, it was hypothesized that the users of stimulants such as cocaine and amphetamines would be characterized by especially high rates of hospitalization, violence, and self-harm (Miles et al., 2003). Ratings used to identify 233 individuals with a severe mental illness and co morbid substance use disorder resulted in 78 individuals being classified as alcohol only miss-users, 52 alcohol and cannabis miss-users, 29 cannabis only users, and 55 stimulant users. Although no specific, differences were found between the subgroups and a lifetime history of self-harm, there wasa significant difference in family violence for the stimulant users. The only other factor worthy of note was that alcoholics are prone to be largely over-looked as problematic and the individuals’ who use alcohol tend to be older and Caucasian (Miles et al., 2003).

8. risk factors for relapse exacerbation of their mental illness’ symptoms, social pressures within drug-using networks (peer pressure), a lack of meaningful activities and/or social support for recovery, (Drake, Wallach, & McGovern, 2005) independent housing in high-risk neighborhoods, a lack of efficient dual diagnosis and/or substance abuse treatment programs, and a lack of trusting relationships.

9. “protective factors” Further research from Drake and colleagues (2005) revealed that several steps are critical in relapse prevention a list of “protective factors” that they recommend for counselors and clinicians to keep in mind. These factors include: Developing healthy and safe environments that are nurturing of recovery Helping people make the fundamental changes in their lives (i.e.. obtaining abstinent friends and family, finding satisfying employment, connecting or re-connecting spiritually to find a sense of purpose and meaning in life), providing specific and individualized treatments for mental illnesses, substance use disorders, and other co-occurring problems, and “…developing longitudinal research on understanding and preventing relapse that addresses social context as well as biological vulnerabilities and cognitive strategies” (Drake, Wallach, & McGovern, 2005, p1300).

10. reasons why individuals use substances: to increase happiness, energy, & emotions, to relax, in response to peer pressure, to increase pleasure, to decrease anxiety, to “get high,” and to reduce depression (Laudet, Magura, Vogel, & Knight, 2004; Phillips & Johnson, 2001).

11. Self-Medication Hypothesis: A primary reason people use investigations done by Phillips & Johnson (2001). A review of their literature revealed that most substances that are abused in the dually diagnosed population are done so in response to the self-medication hypothesis. In particular, to cope with low moods like depression and bipolar disorder, to lower increased stress and/or tension, as well as, to get rid of overall negative feelings (Phillips & Johnson, 2001). Other reasons for co morbid substance misuse relate more to social contexts than an individual’s psychology. For example, people tend to abuse substances in response to social isolation, boredom, difficulties coping with everyday activities, as well as difficulties with interpersonal relationships, and a lack of meaningful activities in their lives (Phillips & Johnson, 2001).

12. The etiology of co-occurring substance use disorders is not apparent (Laudet et al., 2004; Phillips & Johnson, 2001; Mueser, Drake, & Wallach, 1998). All three sources conclude that although there is a large emphasis on biological and pharmacological factors in the literature on dual diagnosis, but, greater attention to the various psychosocial factors in an individual’s life is also important. These psychosocial issues include: social networks (i.e.. an individual’s “persons, places, & things), one’s expectancies of drug effects, boredom, dysphoria (anxiety or an agitated state), unemployment, and poverty, and are extremely important for further investigation (Laudet et al., 2004; Phillips & Johnson, 2001; Mueser, Drake, & Wallach, 1998).

13. Factors indicating success at maintaining sobriety: The strongest factors indicating success at maintaining sobriety at twelve months were older age, living in a residential treatment facility, rather than out on their own, and acquiring gainful employment As evidenced in a study done by Rollins, O'Neill, Davis, & Devitt, (2005): researched existing clinical records of consumers with a severe mental illness and a co-occurring substance use disorder. Of the 133 consumers who had achieved sobriety, it was found that 91(68%) had maintained their abstinence at the six month mark, and 62 (52%) maintained remission at the one-year mark. (Rollins, O'Neill, Davis, & Devitt, (2005).

14. implications for successful treatment options Need to be tailored to each individual’s unique needs. However, there will always be some similarities in any integrated treatment programs, which will include the following: Motivational Interviewing (MI), cognitive-behavioral therapy (CBT), relapse prevention, contingency management, and case management, and skills/vocational training (Gråwe, Hagen, Espeland, & Mueser, 2007; Horsfall, Cleary, Hunt, & Walter, 2009). According to the research, it does not matter if the programs take an integrated or parallel approach, they should be well staffed by team players, be capable of a multi-disciplinary approach, have a wide range of programs available, provide for long-term follow-up care, and be available for their patients 24/7.

15. In Conclusion: To develop a successful treatment program for relapse prevention It is imperative to answer the questions of what makes an individual use, or misuse substances, as well as, the protective and risk factors involved with those who have a dual diagnosis. At the very least we must understand the various factors better so that more integrated treatment programs can be formulated. Being able to come to terms with why people use drugs and alcohol could very well lead researchers in the right direction of better-integrated relapse prevention.

16. Future Research There has been little research in the area of people obtaining sobriety and/or abstinence, as well as the substance abusers’ stated reason for what they believe leads them to use/abuse substances. This could be an important area for further research, as well as, the interplay between the two disorders (the substance use disorder & the mental illness); to determine the roles it plays in substance abuse. Lastly, almost all the research done on co-occurring substance misuse and mental illness has dealt with only schizophrenia. Research on other mental illnesses like bipolar disorder, antisocial personality disorder, and/or clinical depression and how they play a role in substance abuse is important for future studies. A research question for future study is: How does Bipolar I Disorder affect the treatment of a co-occurring substance use disorder? A separate research project on each of the different disorders in the DSM-IV, and how they affect substance abuse would be very beneficial to the research being done in the field of addictions.

17. References Dixon, L., Haas, G., Wieden, P., Sweeney, J., & Frances, A. (1990). Acute effects of drug abuse in schizophrenic patients: clinical observations and patients' self-reports. Schizophrenia Bulletin, 16(1), 69-79. Retrieved from PsycARTICLES database. Drake, R., Wallach, M., & McGovern, M. (2008). Special section on relapse prevention: future directions in preventing relapse to substance abuse among clients with severe mental illnesses. Psychiatric Service,56(10), 1297-1302. Gråwe, R., Hagen, R., Espeland, B., & Mueser, K. (2007). The better life program: effects of group skills training for persons with severe mental illness and substance use disorders. Journal of Mental Health, 16(5), 625-634. Horsfall, J., Cleary, M., Hunt, G., & Walter, G. (2009). Psychosocial treatments for people with co-occurring severe mental illness and substance use disorders (dual diagnosis): A review of empirical evidence. Harvard Review of Psychiatry, 17(1), 24-34. Keith, S. (2007). Dual diagnosis of substance abuse and schizophrenia: improving compliance with pharmacotherapy. Clinical Schizophrenia & Related Psychoses, 1(3), 259-269. Retrieved from Academic Search Complete database. Laudet, A., Magura, S., Vogel, H., & Knight, E. (2004). Perceived reasons for substance misuse among persons with a psychiatric disorder. American Journal of Orthopsychiatry, 74(3), 365-375.

18. References (cont.) Miles, H., Johnson, S., Amponsah-Afuwape, S., Leese, M., Finch, E., & Thornicroft,G (2003). Characteristics of subgroups of individuals with psychotic illness and A co morbid substance use disorder. Psychiatric Services,54(4), 554-561. doi:10.1176/appi.ps.54.4.554. Mueser, K., Drake, R., & Wallach, M. (1998). Dual diagnosis: A review of etiological theories. Addictive Behaviors, 23(6), 717-734. Retrieved on 5/22 from EBSCO host database. Phillips, P., & Johnson, S. (2001). How does drug and alcohol misuse develop among people with psychotic illness? A literature review. Social Psychiatry & Psychiatric Epidemiology, 36(6), 269. Retrieved on 5/24/10 from Academic Search Complete Database. Pourmand, D., Kavanaugh, D., & Vaughn, K. (2005). Expressed emotion (EE) as a predictor of relapse in patients with co morbid psychoses and substance use disorder. Australian & New Zealand Journal of Psychiatry, 39(6), 473-78. Rollins, A., O’Neill, S., Davis, K., & Devitt, T. (2005). Special section on relapse prevention: Substance abuse relapse and factors associated with relapse in an inner-city sample of patients with dual diagnosis. Psychiatric Services, 56 (10), 1274-1281. Torrensa, M., Martin-Santosa, R., & Samet, S. (2006). Importance of clinical diagnoses for Comorbidity studies in substance use disorders. Neurotoxicity Research, 10(3/4), 253-261. Retrieved on 5/22/10 from Academic Search Complete Database. Wieder, B., Lutz, W., & Boyle, P. (2005). Adapting integrated dual diagnosis treatment for inpatient settings. Journal of Dual Diagnosis,2(1), 101-07.