Interview with Kenneth Minkoff, MD
Athealth.com: Can you elaborate more on the issue of treatment outcomes?
Dr. Minkoff: One of the things that people usually mean when they talk about outcome from a co-occurring disorder is outcome in terms of the substance use, without attending to the
co-occurring psychiatric illness.
First of all, we need to look at the outcome for both disorders. The outcome for substance use depends a lot on where you start stage-specific or phase-specific interventions or treatment with that person. If you start with a very disorganized,
disengaged, actively psychotic individual, it will take a long time to begin to engage that person in a treatment discussion through intensive, integrated case management interventions. It will take another long time to get this person involved in thinking about whether or not they want
to change their substance use and then, another long time in working incrementally through substance reduction behaviors until this patient can obtain stable abstinence. In fact, it may take several years before about half of those individuals in treatment attain stable abstinence.
The rapidity with which that process occurs depends on a number of variables that have to do with a variety of external contingencies, such as whether or not the patient gets in trouble with the law, or whether the person needs housing services and is willing to engage in sobriety in
order to obtain housing--which is not true for everybody.
On the other hand, a high-functioning business executive with a major depression and alcohol dependence who enters into an addiction treatment program and needs an antidepressant to address the psychiatric issue is likely to
have a better outcome. This person is higher functioning to begin with, has more positive things going, and is easier to treat than someone with a more severe psychiatric disorder.
Athealth.com: How long have the evidence-based best practice guidelines been around for co-occurring substance use and mental health disorders?
Dr. Minkoff: We developed a set of practice guidelines using a national consensus panel as part of the SAMHSA Managed Care Initiative and this report was issued in 1998.
Strictly speaking, this is not evidence-based best practice so much as evidence-derived best practice, recognizing that there is a limitation in available evidence in terms of the certain kinds of interventions and populations that have been studied. The guidelines do not tell us a whole
lot about the application of this model to all of the possible kinds of people with co-occurring disorders, in all different kinds of circumstances, and in all different levels of care. Rather, we took what seemed to be principles of treatment that can be inferred from the available research
and generalized them using an expert consensus panel.
Additionally, within the last year, I have worked to update those guidelines by integrating them into a specific set of service planning guidelines for the State of Arizona. There has been a lot of interest in those recently updated
guidelines.
A notable figure
in the area of evidence-based best practices for this genre of comorbidity is Dr. Robert Drake. He is probably the leading researcher in the development of integrated services for people with co-occurring serious mental illness and substance use disorders, and he piloted the development of the
continuous treatment team model. He is now the editor of a column in the Journal of Psychiatric Services, specifically dedicated to evidence-based best practice. Within the next few months, the Journal will be publishing an article summarizing where we are in terms of evidence-based best practice for the treatment of co-occurring disorders, including what kind of work is going on in applying best practices to systems level interventions.
Athealth.com: What are your thoughts about the psychopharmacological treatment of patients with co-occurring disorders? For example: Are there greater risk factors associated with treating patients with substance use disorders who are actively psychotic?
Dr. Minkoff: First of all, there are guidelines for psychopharmacology included in the practice guidelines that I mentioned earlier. However, evidence-based best practice guidelines for
psychopharmacological interventions and treatment have not been fully developed. There is data that tells us a little bit about the effect of certain specific medications on substance use disorders. Other data is derived more from clinical practice and demonstration projects than from specific
evidence.
Nonetheless, we do know that when people have a known serious mental illness that requires a medication regime of non-addictive medications to stabilize that illness, the treatment regime needs to be initiated and maintained regardless of the status of the co-occurring substance use
disorder. Conversely, if someone has a serious substance dependence problem that requires detoxification or stabilizing interventions for the substance disorder, that person should be detoxed and treated the same as anyone else while clinically preserving the medication regimen when not contraindicated.
For example, if a person needs an alcohol detox or methadone maintenance, the protocols for doing that are generally no different for the person who has co-occurring mental illness and the person who doesn't. In other words, the clinician maintains treatment for the co-occurring mental illness while applying
interventions for the substance use disorder.
It is very risky not to do that. The more we treat people differently because we presume that there is some risk of treating both disorders together, the more likely we are to precipitate poor outcomes.
Page last modified or reviewed on March 8, 2009
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