Embed Size (px)
Citation preview
This article was downloaded by: [University of Regina]On: 17 November 2014, At: 20:38Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House,37-41 Mortimer Street, London W1T 3JH, UK
Journal of Dual DiagnosisPublication details, including instructions for authors and subscription information:http://www.tandfonline.com/loi/wjdd20
Dual Diagnosis Among Older Adults: Co-OccurringSubstance Abuse and Psychiatric IllnessStephen J. Bartels MD and MS a b , Frederic C. Blow PhD c d , Aricca D. Van Citters MS e &Laurie M. Brockmann MPH and MSW fa Aging Services Research Group , New Hampshire-Dartmouth Psychiatric Research Centerb Dartmouth Medical School , Lebanon, NHc Department of Veterans Affairs, Health Services Research and Development , SeriousMental Illness Treatment Research and Evaluation Centerd Department of Psychiatry , University of Michigan , Ann Arbor, MIe Aging Services Research Group , New Hampshire-Dartmouth Psychiatric Research Center ,Ann Arbor, NHf Serious Mental Illness Treatment Research and Evaluation Center , Ann Arbor, MIPublished online: 22 Sep 2008.
To cite this article: Stephen J. Bartels MD and MS , Frederic C. Blow PhD , Aricca D. Van Citters MS & Laurie M. BrockmannMPH and MSW (2006) Dual Diagnosis Among Older Adults: Co-Occurring Substance Abuse and Psychiatric Illness, Journal ofDual Diagnosis, 2:3, 9-30
To link to this article: http://dx.doi.org/10.1300/J374v02n03_03
PLEASE SCROLL DOWN FOR ARTICLE
Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) containedin the publications on our platform. However, Taylor & Francis, our agents, and our licensors make norepresentations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of theContent. Any opinions and views expressed in this publication are the opinions and views of the authors, andare not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon andshould be independently verified with primary sources of information. Taylor and Francis shall not be liable forany losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoeveror howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use ofthe Content.
This article may be used for research, teaching, and private study purposes. Any substantial or systematicreproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in anyform to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
REGULAR ARTICLES
Dual Diagnosis Among Older Adults:Co-Occurring Substance Abuse
and Psychiatric Illness
Stephen J. Bartels, MD, MSFrederic C. Blow, PhD
Aricca D. Van Citters, MSLaurie M. Brockmann, MPH, MSW
Stephen J. Bartels is the Director of the Aging Services Research Group at the NewHampshire-Dartmouth Psychiatric Research Center, and Professor of Psychiatry atDartmouth Medical School in Lebanon, NH.
Frederic C. Blow is the Director of the Department of Veterans Affairs, Health Ser-vices Research and Development, Serious Mental Illness Treatment Research andEvaluation Center, and Associate Professor and Research Associate Professor in theDepartment of Psychiatry at the University of Michigan, Ann Arbor, MI.
Aricca D. Van Citters is a Project Coordinator with the Aging Services ResearchGroup at the New Hampshire-Dartmouth Psychiatric Research Center, Lebanon, NH.
Laurie M. Brockmann is a Research Associate with the Serious Mental IllnessTreatment Research and Evaluation Center, Ann Arbor, MI.
Address correspondence to: Stephen J. Bartels, MD, MS, New Hampshire-Dart-mouth Psychiatric Research Center, 2 Whipple Place, Suite 202, Lebanon, NH 03766(E-mail: [email protected]).
Journal of Dual Diagnosis, Vol. 2(3) 2006Available online at http://www.haworthpress.com/web/JDD
© 2006 by The Haworth Press, Inc. All rights reserved.doi:10.1300/J374v02n03_03 9
Dow
nloa
ded
by [
Uni
vers
ity o
f R
egin
a] a
t 20:
38 1
7 N
ovem
ber
2014
ABSTRACT. Objectives: The goal of this article is to provide a com-prehensive critical review of studies reporting the prevalence, character-istics, outcomes, and service utilization associated with comorbid substanceabuse and mental illness in older age.
Methods: We searched the Medline and PsycINFO databases usingcombinations of the keywords ‘Dual diagnosis,’ ‘Elderly,’ and ‘Older.’We included English-language reports presenting quantitative data onthe prevalence and/or any descriptive information about older adultswith dual diagnosis.
Findings: The prevalence of older adults with comorbid substanceabuse and mental disorders varies by population, and ranges from 7% to38% of those with psychiatric illness and from 21% to 66% of those withsubstance abuse. Depression and alcohol use are the most commonlycited co-occurring disorders in older adults. Dual diagnosis in olderadults is associated with increased suicidality and greater inpatient andoutpatient service utilization. Data on treatment are limited. However,recommendations have been adapted from evidence-based treatment ofyounger adults with dual diagnosis, older adults with substance abuse,and older adults with mental health problems.
Conclusions: Dual diagnosis among older adults is a growing publichealth problem. Well-designed prevention, early intervention, and treat-ment studies are needed that specifically address co-occurring disordersin older adult populations. [Article copies available for a fee from The HaworthDocument Delivery Service: 1-800-HAWORTH. E-mail address: <[email protected]> Website: <http://www.HaworthPress.com> © 2006 by TheHaworth Press, Inc. All rights reserved.]
KEYWORDS. Dual diagnosis, co-occurring, mental illness, depres-sion, psychiatric, substance abuse, alcohol, older adult, geriatric
Co-occurring mental health and substance use disorders are associ-ated with increased risk of poor health outcomes, greater service utiliza-tion, medical comorbidity, and mortality. An extensive literature documentsthe high prevalence, impact, and evidence-base for effective treatmentsof co-occurring disorders among younger adults.1,2 In contrast, little at-tention has been directed to characterizing co-occurring disorders andmodels of treatment in the rapidly growing population of older adultswith dual diagnoses. The purpose of this review is to examine the preva-lence of co-occurring disorders in older age, to identify characteristicsof older adults with co-occurring disorders, and to evaluate the impactof these disorders on health status and service utilization. In addition,
10 JOURNAL OF DUAL DIAGNOSIS
Dow
nloa
ded
by [
Uni
vers
ity o
f R
egin
a] a
t 20:
38 1
7 N
ovem
ber
2014
we will summarize treatment recommendations that are adapted fromevidence-based treatment of co-occurring disorders among the adultpopulation.
PREVALENCE AND IMPACT OF MENTAL ILLNESSAMONG OLDER ADULTS
Approximately one-fifth of older adults in the general populationhave a psychiatric disorder. The most common psychiatric conditionsamong older adults are anxiety and depression. In addition, a smallerproportion of patients are affected by schizophrenia, bipolar disorder,and other mental illnesses.3 The prevalence of mental illness in lateradulthood is even greater in medical care settings. For example, approx-imately one-third of older primary care patients have a psychiatric diag-nosis (mostly consisting of depression and anxiety disorders),4 and 65%to 91% of nursing home patients have a mental disorder (primarily de-pression and dementia).5,6 The magnitude of these problems is pro-jected to increase with the aging “baby boom” cohort.7 Moreover,mental illnesses are associated with significant health burden, deteriora-tion of quality of life, health care utilization, and health care expendi-tures, especially in older patients.8
PREVALENCE AND IMPACT OF SUBSTANCE ABUSEAMONG OLDER ADULTS
Community-based assessments estimate the prevalence of problemdrinking among older adults to range from 1 percent to 15 percent.9-11
Estimates of the prevalence of alcohol dependence among older adultsrange from 1.6% to 4%,12-14 although prevalence rates vary widelyacross studies and are reported to be as high as 17% among older men.15
Estimates of alcohol problems are much higher in clinical populations,because problem drinkers are more likely to seek services in health caresettings. For example, 10.6% to 15% of older primary care patients en-gage in at-risk or problem drinking.19,20 Rates of alcohol use disordersare particularly high among veterans. From 29-49% of older veterans innursing homes meet criteria for a lifetime diagnosis of alcohol abuse ordependence, 10-18% report active dependence symptoms in the pastyear,21,22 and approximately 8.6% of veterans in geriatric mental healthoutpatient clinics meet alcohol dependence criteria.23 Finally, a recent
Bartels et al. 11
Dow
nloa
ded
by [
Uni
vers
ity o
f R
egin
a] a
t 20:
38 1
7 N
ovem
ber
2014
study indicates that about 1% of older Americans use psychoactivedrugs for non-medical purposes and the rate of this misuse is roughlydoubled among older Americans who drink alcohol or smoke ciga-rettes.24
Substance use disorders have a significant impact on the health andfunctioning of older persons.25 These disorders are associated with in-creased morbidity and mortality from alcohol-induced diseases and in-creased risk for falls, motor vehicle accidents, cardiovascular and liverdiseases, suicide, sleeping problems, and adverse interactions betweenprescribed and over-the-counter medications.25-29 Moreover, substanceabuse is highly associated with co-occurring psychiatric disorders. Ahistory of heavy alcohol use for five years or more at any time duringthe lifespan is associated with a significant increase in the risk for devel-oping cognitive impairment or psychiatric illness, especially depres-sion.30,31
PREVALENCE OF CO-OCCURRING PSYCHIATRICAND SUBSTANCE USE DISORDERS IN OLDER ADULTS
A history of substance abuse is associated with increased risk of men-tal illness, and conversely, a history of mental illness is associated witha greater likelihood of having a substance use disorder. High rates ofco-occurring mental health and substance use disorders among olderadults are found in psychiatric clinical populations. For example, 20%of older adults (age 60 +) receiving treatment in a specialty geriatricpsychiatry outpatient clinic were found to have a substance use disor-der, including 11% with benzodiazepine dependence and 9% with alco-hol dependence. The most common psychiatric disorders seen in thisgeriatric psychiatry clinic included depression and dementia.23 Amongpsychiatric outpatients receiving care at Veterans Affairs (VA) facili-ties, the prevalence of co-occurring disorders was 7.3% among thoseage 65 to 74 years and 4.4% among those age 75 years and older.32 Themost common psychiatric disorders included schizophrenia (17%),major depression (14.5%), organic brain syndromes (11.6%), bipolardisorder (7.9%), and PTSD (6.8%).
Even higher rates of comorbid psychiatric and substance use disor-ders have been found among older adults in psychiatric inpatient set-tings. In a study of the prevalence of dual disorders in older psychiatricinpatients (age 60 +), over one third (37.6%) had co-occurring psychiat-ric and substance use disorders, consisting of 71% with alcohol abuse,
12 JOURNAL OF DUAL DIAGNOSIS
Dow
nloa
ded
by [
Uni
vers
ity o
f R
egin
a] a
t 20:
38 1
7 N
ovem
ber
2014
and 29% abusing both alcohol and other substances. The most commonpsychiatric diagnosis in this inpatient study was depression, accountingfor over two-thirds (71%) of the psychiatric co-occurring disorders.33
Similar rates of co-occurring disorders have been reported in other stud-ies of older adults in psychiatric outpatient clinics (15%-20%) and psy-chiatric inpatient settings (21%).34-37
Studies of older adults with substance use disorders also indicate thecommon presence of co-occurring psychiatric illness. Rates of psychi-atric illness in older adults with substance use disorders range from 21%to 66%. For example, approximately 29% of older veterans receivingtreatment for alcohol use disorders have a co-occurring psychiatric dis-order,38 most commonly an affective disorder.31 Nearly half of commu-nity dwelling older adults with a history of alcohol abuse have co-occurring depressive symptoms.39 Among an at-risk population of olderadults receiving in-home services, 9.6% had an alcohol abuse problemand two-thirds of those individuals (6% of the overall sample) had acomorbid psychiatric illness such as depression or dementia.40 Amongolder adults with a recognized substance abuse disorder attending an al-cohol dependence rehabilitation treatment program, 23% had dementiaand 12% had affective disorders.41 Finally, psychiatric comorbidity wasprevalent among older persons (age 65 +) hospitalized for prescriptiondrug dependence, with indications that 32% had a mood disorder and12% had an anxiety disorder.42 The most common categories of drugabuse included sedatives/hypnotics (80%, primarily in the form ofbenzodiazepines), opioid analgesics (49%), nicotine (26%), and stimu-lants (3%).42
Two large studies also support the high prevalence of co-occurringdisorders in older adults. Blow and colleagues examined the presence ofpsychiatric diagnoses in approximately 4,000 alcoholic Veterans Af-fairs patients between age 60 and 69.31 Affective disorders were themost common psychiatric diagnosis found in 21% of these individuals.Approximately 43% of these individuals had major depression. Blazerand Williams conducted an epidemiologic study of 997 community-dwelling older adults. Only 4.5% had a history of alcohol abuse, yet al-most half in this group had a comorbid diagnosis of depression ordysthymia.43
The nature of substance misuse among older adults complicates therelationship between psychiatric illness and substance abuse. Mostolder adults who are experiencing problems related to their alcohol con-sumption do not meet DSM-IV criteria for alcohol abuse or depend-ence.44,45 However, drinking even small amounts of alcohol can increase
Bartels et al. 13
Dow
nloa
ded
by [
Uni
vers
ity o
f R
egin
a] a
t 20:
38 1
7 N
ovem
ber
2014
risks for developing problems in older adults, particularly when cou-pled with the use of specific over-the-counter or prescription medica-tions. The combination of some psychoactive medications with anyalcohol use increases the risk of many unfavorable reactions.45,46 Re-search has indicated how alcohol consumption, as well as at-risk andproblem drinking can aggravate affective disorders, such as depression,among elders. 30, 47-49 Low and moderate levels of drinking among olderadults with psychiatric problems may also influence treatment out-comes for a variety of diagnoses.
Based on the limited available research data, the prevalence of co-oc-curring disorders is lower in older compared to younger age.32 For ex-ample, nearly one-third (30%) of psychiatric outpatients under age 55receiving care at Veterans Affairs (VA) facilities have a co-occurringsubstance use disorder, while approximately 7% of those aged 65 andolder were characterized as having co-occurring psychiatric and sub-stance use disorders.32 The highest rates of co-occurring substance usedisorders in younger adults are reported among individuals with seriousmental illness. The lifetime prevalence of substance use disorders is ap-proximately 47% among persons with schizophrenia, 32% of personswith affective disorders (56% bipolar disorder, 27% major depression,and 31% dysthymia), and 24% of persons with anxiety disorders (33%OCD, 23% phobias, 36% panic disorder).50 The rate of abuse for otherdrugs is substantially lower in older compared to younger adult psychi-atric outpatients with dual diagnosis. Approximately 65% of youngerdually diagnosed adults abuse drugs other than alcohol, while only 26%of those over 65 abused drugs.32
ALCOHOL-ASSOCIATED COGNITIVE IMPAIRMENT
An overview of co-occurring disorders in older adults would not becomplete without mention of cognitive impairment disorders. How-ever, as reviewed by Oslin and colleagues, the relationship between al-cohol use disorders and cognitive impairment is complex. These disordersspan conditions such as acute intoxication states, transient alcohol-in-duced cognitive impairment, and alcohol-related dementia (ARD).51
Because these disorders are directly caused or induced by heavy alcoholuse (as opposed to co-occurring or “dual” disorders), they are outside ofthe scope and aims of this overview. However, it is important to notethat ARD can be differentiated from other cognitive impairment disor-ders in older adults and is associated with specific characteristics and
14 JOURNAL OF DUAL DIAGNOSIS
Dow
nloa
ded
by [
Uni
vers
ity o
f R
egin
a] a
t 20:
38 1
7 N
ovem
ber
2014
different healthcare outcomes.51,52 Heavy alcohol use is a strong corre-late of ARD (53), and higher levels of alcohol use are associated withlower cognitive performance on standardized tests.54 ARD has been re-ported as the second most common cause of dementia among olderadults in institutional settings.55 Of note, in contrast to Alzheimer’s de-mentia and vascular dementia that are characterized by a general de-cline in cognition and functional status over time, ARD demonstratesstabilization (and in some instances, modest improvement) in cognitionand functional status following periods of abstinence.51 In addition toARD, there is a limited literature on the association of alcohol abuse togreater risk of cognitive impairment in older age. Analyses of theEpidemiologic Catchment Area study found that a lifetime history of al-cohol abuse or dependence was 1.5 times greater in persons with mildand severe cognitive impairment compared to those without cognitiveimpairment.56 In addition, a study by Finlayson and colleagues foundthat almost one fourth of older adults (23%) seeking treatment for alco-hol abuse had dementia associated with alcohol dependence.41 How-ever, data on prevalence, course, and treatment of the co-occurringage-related cognitive impairment disorders (e.g., Alzheimer’s disease)and substance use disorders are lacking.
IMPACT OF DUAL DIAGNOSIS IN OLDER ADULTS
Co-occurring substance use and psychiatric disorders among olderadults are associated with poor health outcomes, higher health care utili-zation, more complications, and higher rates of active suicidal ideationand social dysfunction relative to individuals with either disorder alone.57-60
Co-occurring mental illness and substance abuse leads to increasedtreatment utilization among older adults.61 Older adults with dual diag-nosis of substance abuse and mental illness have higher use of outpa-tient mental health and substance abuse services compared to olderadults with either substance abuse or psychiatric illness alone.32, 38, 62
Similarly, co-occurring disorders are associated with higher rates ofpsychiatric inpatient hospitalizations. In a ten-year study of psychiatrichospitalizations of older veterans (age 55 +), 75% of patients with aco-occurring psychiatric disorder were admitted to a psychiatric inpa-tient unit, compared to 62% among those with an alcohol or drug abuse/dependence alone.38 The results of this study indicated that the long-term demand for mental health services is strongest among older pa-tients with a longer history of co-occurring disorders. Outpatient and in-
Bartels et al. 15
Dow
nloa
ded
by [
Uni
vers
ity o
f R
egin
a] a
t 20:
38 1
7 N
ovem
ber
2014
patient substance abuse services are more frequently used by olderpersons with dual diagnosis, compared to those with mental illnessalone.32 Among adult populations of all ages, use of substance abuseservices increases with the presence of one or more co-occurring mentalhealth disorders.63 Dual diagnosis has also been associated with morefrequent inpatient re-admission and higher costs.64-66
The co-occurrence of alcohol use disorders and depression amongolder adults is associated with higher rates of suicidal ideation and sui-cide attempts in older adults. Although the precise mechanisms are notwell understood, it is likely that greater suicide risk is associated withthe relationship of alcohol abuse to increased depressive symptoms,negatively perceived health status, and lower social support.67 Studiesof older adults in primary care have examined the relationship of at-riskalcohol use with suicidal ideation (defined as seriously considering orattempting to take one’s own life) and death ideation (defined as wish-ing that one were dead). Co-occurring at-risk alcohol use and psychiat-ric disorders are associated with a pronounced increase in suicidal anddeath ideation when these two symptoms are considered together. Ac-tive suicidal ideation was present in 3% of persons with at-risk alcoholuse alone and was present in 12% of older adults with major depressionalone. In contrast, 15% of older adult primary care patients with bothmajor depression and at-risk alcohol use had suicidal ideation.59 Less isknown about the relationship of co-occurring disorders to actual suicideattempts or completed suicides in older adults. However, a report byBlixen and colleagues found that older adults with dual diagnosis are sixtimes more likely to attempt suicide compared to older adults with apsychiatric diagnosis alone (18% vs. 3%, respectively).33
TREATMENT OF CO-OCCURRING SUBSTANCE ABUSEAND MENTAL ILLNESS IN OLDER ADULTS
Despite the significant prevalence and associated complications ofdual disorders in older adults, empirical data on specific interventionsor models of treatment are lacking. However, general principles oftreatment can be derived from the existing treatment literature if age-specific modifications are made. For the purpose of describing theseprinciples, two broad groups of dual disorders are considered: (1) co-occurring substance abuse and mood or anxiety disorders, and (2) co-occurring substance abuse and serious mental illness (i.e., schizophreniaand schizophrenia-spectrum disorders).
16 JOURNAL OF DUAL DIAGNOSIS
Dow
nloa
ded
by [
Uni
vers
ity o
f R
egin
a] a
t 20:
38 1
7 N
ovem
ber
2014
TREATMENT OF CO-OCCURRING SUBSTANCE USEAND MOOD/ANXIETY DISORDERS
The treatment literature on co-occurring substance abuse and depres-sion or anxiety disorders reflects a longstanding clinical debate over therelative merits of sequential versus concurrent treatment. Arguments insupport of a sequential treatment approach (first addressing the sub-stance use disorder, followed by treatment of the psychiatric illness) re-flect the observation that symptoms of substance use disorders mayreplicate the symptoms of depression or anxiety and these symptomscan self-resolve with reduction or elimination of substance use.2 For ex-ample, a reduction in the use of alcohol can improve the symptoms ofanxiety and depression and can decrease psychosocial risk factors asso-ciated with these disorders. Brown and colleagues have shown that thesymptoms of alcohol-induced depression self-resolve in most individu-als within four to six weeks of abstinence.68 Similarly there is a strongrelationship between acute intoxication states and suicidal ideation andattempts.69 Alcohol may adversely interact with medical disorders andprescribed medications in older adults to produce mental status changes,suggesting that reducing or eliminating use of alcohol may be the mostappropriate first step in treatment.16 A sequential approach beginningwith focus on reducing alcohol use is suggested by a recent study byVerheul and colleagues.70 This study of co-occurring mood or anxietydisorders and alcohol abuse found that individuals who achieved reduc-tion or abstinence in alcohol use were over six times more likely to re-cover from their mood or anxiety disorder compared to individuals witha persistent alcohol use disorder.70
On the other hand, the potential merits of a concurrent (rather than se-quential) approach to treatment is suggested by several lines of evi-dence including findings from a recent randomized trial by Oslin andcolleagues of an intervention for alcohol dependent older adults withco-occurring depression.71 In this study, older adults were randomizedto either sertraline (an antidepressant medication) combined with psycho-social support or sertraline combined with psychosocial support plus ad-junctive naltrexone (an opioid antagonist). This study failed to find anyadditional benefit of naltrexone as an adjunctive agent in the treatmentof alcohol dependence. However, the investigators found a strong asso-ciation between reduced depression and lower rates of drinking and re-lapse during treatment. The authors concluded that appropriate andoptimal treatment of co-occurring depression and alcohol dependence
Bartels et al. 17
Dow
nloa
ded
by [
Uni
vers
ity o
f R
egin
a] a
t 20:
38 1
7 N
ovem
ber
2014
should consist of concurrent treatment of both the alcohol dependenceand the depression, as opposed to sequential interventions.
In a separate analysis on the effect of alcohol use on depression treat-ment outcomes, Oslin and colleagues found that concurrent treatment ofdepression and a reduction in alcohol use was effective in achievingpositive treatment outcomes.72 In this large study of older persons hos-pitalized for late life depression, outcomes were evaluated three to fourmonths following discharge. Treatment during hospitalization for thevast majority (88%) included concurrent treatment with antidepressantsand abstinence from alcohol. Surprisingly, those with a history of mod-erate and high alcohol consumption (compared to light consumption)had significantly better outcomes. The authors found that the vast ma-jority of those in the moderate and high alcohol consumption group sig-nificantly decreased their alcohol consumption at the same time asreceiving treatment for depression, with approximately 80% of patientsreducing their drinking by over 90%.72
In a different study examining treatment of depression, anxiety, andat risk alcohol use in older primary care patients, outcomes were exam-ined for older adults treated within the primary care setting who receiveintegrated substance abuse and mental health treatment in comparisonto those referred to a specialty mental health clinic.73 A subgroup of par-ticipants in this study had co-occurring at-risk alcohol use and depres-sion or anxiety (n = 147). Of note, dually-diagnosed older adults weresignificantly more likely to engage in the integrated model of treatmentin primary care (4.0 mean treatment visits) compared to the enhancedmodel of referral to specialty mental health clinics (1.8 mean treatmentvisits).73 Both the intervention and control conditions showed improvedsymptoms with respect to alcohol use (as measured by number of drinksper week and the number of binges per month) and also improved withrespect to their overall mental health status (as measured by the mentalcomponent score of the SF-36).74 Unfortunately, it is not possible to de-termine (in the absence of a non-treatment control group) if the positiveoutcomes were due to the treatment, or a non-specific study effect.However, these results suggest that co-occurring at-risk alcohol use anddepression can significantly improve over 6 months among older adultsreceiving mental health and substance abuse services in primary care orspecialty mental health settings.
A final line of evidence supporting the potential benefits of concur-rent treatment may be suggested by the finding that cognitive-behav-ioral treatments are effective for alcohol use disorders and also fordepression and anxiety in older adults. Two randomized control trials
18 JOURNAL OF DUAL DIAGNOSIS
Dow
nloa
ded
by [
Uni
vers
ity o
f R
egin
a] a
t 20:
38 1
7 N
ovem
ber
2014
examining the brief alcohol intervention for at-risk drinking found that50-75% of older adults reduced drinking to moderate levels in the inter-vention. The first study by Fleming and colleagues was conducted in aprimary care setting and consisted of two 10-15 minute physician deliv-ered counseling visits and two follow-up phone calls by clinic staff thatincluded advice and education. At 12-month follow-up, the interventiongroup showed significantly less alcohol use.10 The second study byBlow and colleagues randomized 452 participants to usual care or a sin-gle brief motivational intervention session. This study also showed asignificant reduction in alcohol consumption for those receiving thebrief alcohol intervention at 12 months compared to usual care.75
Age-specific group treatment of alcohol dependence in older adults hassuperior outcomes compared to mainstream treatment in which theolder adult is included in groups with younger patients.76 These results,coupled with an evidence-base supporting the effectiveness of cogni-tive behavioral interventions for depression and anxiety disorders,77
suggest that cognitive-behavioral interventions may have a particularbenefit in co-occurring disorders. Support for this approach is sug-gested by results from a study by Brown and colleagues in younger indi-viduals with depression and alcohol dependence who were treated withan integrated model of 8 sessions of CBT. The results of the study foundthat CBT was associated with reduced mood and anxiety symptoms andgreater rates of abstinence at 6-month follow-up compared to relaxationtherapy.78, 79
In summary, the empirical data on interventions for co-occurring de-pression or anxiety disorders in alcohol use disorders in older adults islimited. To date, the controversy with respect to sequential treatment(first treating the alcohol use disorder followed by treatment of depres-sion or anxiety) versus concurrent treatment (addressing both the sub-stance use disorder and psychiatric condition at the same time) remainsunresolved.34 A comparison study of sequential versus concurrent treat-ment has not been conducted. In the absence of comparison data, find-ings from the currently available research suggest that the most appropriateapproach most likely consists of matching treatment to the clinical situa-tion. For example, onset of depressive or anxiety symptoms that appearto coincide with increased substance use may suggest a substance-in-duced disorder. In this case, a sequential approach that first seeks reduc-tion or abstinence may result in symptom improvement and may improveadherence to specific treatment of the psychiatric disorder if residualsymptoms remain. On the other hand, a prior history of recurrent majordepression or anxiety disorder (especially if these episodes have oc-
Bartels et al. 19
Dow
nloa
ded
by [
Uni
vers
ity o
f R
egin
a] a
t 20:
38 1
7 N
ovem
ber
2014
curred even during periods of abstinence) suggests a concurrent ap-proach of the psychiatric and substance use disorder. It is likely that“dual diagnosis” consisting of depression or anxiety and substance usedisorders in older adults is a heterogeneous entity indicating differentapproaches depending on the clinical presentation. Further research isneeded that provides valid criteria for differentiating the diagnostic sub-types that comprise co-occurring disorders and corresponding treat-ment interventions.
TREATMENT OF CO-OCCURRING SUBSTANCE ABUSEAND SERIOUS MENTAL ILLNESS
An extensive literature addresses optimal approaches to treatment ofyounger adults with co-occurring substance abuse and serious mentalillness (SMI), including disorders such as schizophrenia, schizoaffectivedisorder, bipolar disorder and treatment refractory depression associ-ated with long-term functional impairment. To date, empirical studiesof the integrated dual diagnosis treatment model have focused on youn-ger adults with SMI. This evidence-based treatment model80, 81 seeks toreduce conflicts between providers, eliminate the burden of attendingtwo treatment programs, and reduce financial and other barriers to ac-cess and retention. Integrated models differ from traditional models ofcare in that mental health and substance abuse treatments are deliveredconcurrently by the same team or group of clinicians, as opposed to sep-arate mental health and substance abuse programs that are provided in asequential process.82-84 Integrated and concurrent treatment of sub-stance abuse and mental health disorders are likely to show substantialpromise in improving health outcomes for older adults with dual disor-ders, as they provide comprehensive and concurrent medical, psychiat-ric, and substance abuse treatment and focus on stabilization, education,and self-management of the illnesses.
Effective treatment for dual disorders of substance abuse and SMI in-corporates several components. Treatment programs should be compre-hensive, including assertive outreach and case management; providestage-wise, motivational interventions for substance abuse (en-gagement, persuasion, active treatment, and relapse prevention);should integrate services; reduce negative consequences; have a long-termperspective (time-unlimited services); and have the availability of amultidisciplinary team and multiple psychotherapeutic modalities.85
Continuous treatment teams have several advantages in treating dual
20 JOURNAL OF DUAL DIAGNOSIS
Dow
nloa
ded
by [
Uni
vers
ity o
f R
egin
a] a
t 20:
38 1
7 N
ovem
ber
2014
disorders. First, mental health and substance abuse services are admin-istered by the same team, thus eliminating the need for organizationaland administrative lapses in care. Second, both disorders are treated as“primary” and are treated concurrently, thus clinical problems of treat-ing one disorder before the other are eliminated. Third, conflicts be-tween mental health providers and substance abuse providers are lessenedas both have the need to work collaboratively and present the client witha consistent approach, philosophy, and set of recommendations. Due tothe long-term nature of substance abuse disorders and mental disorders,programs and services should span a time period of at least two years.86
The effectiveness of integrated dual diagnosis treatment for adultoutpatients with mental illness and substance abuse problems is sup-ported by several controlled studies.85,87 Programs that provide com-prehensive, motivation-based, long-term integrated treatment result insignificantly better substance abuse outcomes than standard, non-inte-grated programs.80, 88-93 Integrated treatment programs have resulted inimproved outcomes in the domains of substance abuse, psychiatricsymptoms, housing, hospitalization, arrests, functional status, and qual-ity of life.83 Finally, remission rates of substance use disorders follow-ing long-term integrated dual diagnosis treatment have ranged from41% to 61% among adult populations.83 Integrated dual diagnosis treat-ment is now a manualized treatment model with standardized imple-mentation materials and associated fidelity measures that is currentlybeing promoted as one of six evidence-based practices in a national im-plementation initiative.94 Although this model has not been evaluated inolder adults with co-occurring substance use disorders and SMI, out-comes have been comparable in younger and middle aged persons, sug-gesting that the principles of integrated, concurrent, and comprehensivetreatment provide benefits across age groups.
AGE-APPROPRIATE TREATMENT PRINCIPLES
Age-associated changes in physiology and lifestyle underscore thenecessity for providing treatment recommendations that are tailored toolder adults. Compared to younger adults, older adults have differentialresponses to psychotherapeutic interventions according to level of cog-nitive impairment, as well as age-associated differences in pharmaco-logical response and sensitivity to medication side effects.95 Olderadults should be evaluated for medical risk factors, should receiveage-appropriate screening and assessment tools, and should receive
Bartels et al. 21
Dow
nloa
ded
by [
Uni
vers
ity o
f R
egin
a] a
t 20:
38 1
7 N
ovem
ber
2014
treatments that are tailored toward the combination of evidence-basedgeriatric substance abuse treatment and evidence-based geriatric mentalhealth treatment.
Aging is associated with increased risk for medical comorbidity andphysiological changes that affect the absorption and tolerance for alco-hol and medications. As such, older persons should be assessed formedical comorbidity and the use of multiple medications. Medicationinteractions are also common given that older adults, on average, re-ceive two to six prescribed medications and one to three over-the-coun-ter medications.96 Moreover, physiological changes increase the sensitivityto adverse effects and decrease the body’s ability to metabolize alcoholand other drugs.97
Evidence suggests that older adults with alcohol use disorders do notconsistently receive recommended clinical assessments. In a study of as-sessment practices by routine clinicians, only one-fifth of older adults re-ferred to psychiatric services who have secondary disorders due toalcohol received a full battery of assessments suggested by clinical guide-lines. Clinicians obtained a collateral history for only 28% of patients, ob-tained a physical examination for 50% of patients, evaluated the numberof drinks per day for only 43% of patients, and referred only 10% to alco-hol services.98 Several factors have served as barriers to the assessment ofalcohol use disorders among older adults. These factors include the lackof awareness, reluctance to ask potentially embarrassing questions, soci-etal beliefs, and competing comorbid health conditions.97,99
Lifestyle changes that are associated with advancing age also indicatethe need for age-appropriate brief screening tools. Identification strate-gies differ for detecting substance abuse in older persons, compared toyounger persons. Typical strategies that rely on addressing levels of toler-ance, dependence and social consequences of substance abuse problemsare often poor markers for older persons. Older persons are less likely todevelop physiological dependence, are more likely to live alone, may beunemployed, and may no longer drive. Hence, strategies to identify olderadults with alcohol use disorders need to use age-appropriate indica-tors.100 These factors also impact the use of standard mental healthscreening instruments. Several screening instruments allow for these life-style changes and have been developed or commonly used to identify thepresence of substance abuse and mental illness among older adults.101
These include the Michigan Alcoholism Screening Test; Geriatric Ver-sion,102 the CAGE,103 and the Geriatric Depression Scale.104
Finally, use of geriatric evidence-based practices and strategies fortreating older adults with substance abuse and mental health problems
22 JOURNAL OF DUAL DIAGNOSIS
Dow
nloa
ded
by [
Uni
vers
ity o
f R
egin
a] a
t 20:
38 1
7 N
ovem
ber
2014
can be tailored to concurrently address the needs of older adults withco-occurring disorders. Evidence-based principles from research on thetreatment of alcohol use disorders in older adults suggests the impor-tance of approaches that meet the following set of characteristics. Ser-vices should be age-specific, non-confrontational, supportive, and multi-modal. In addition, group or individual brief cognitive-behavioral inter-ventions and motivational interventions have been shown to be effec-tive.77 General principles for treating older adults with substance abuseproblems include age-appropriate settings, pace and content, and ap-proaches to psychological, social, and health needs. Geriatric expertiseof providers, linkages with medical care and social supports, and ad-dressing depression, isolation, loss, and loneliness are also appropri-ate.45,105,106 Brief alcohol interventions have received the most wide-spread support for reducing drinking, relative to control groups, and aresupported by an emerging evidence base.10,77,107 Evidence-based treat-ments for depression and anxiety disorders within older adults includeboth psychosocial (cognitive behavioral therapy, problem solving ther-apy, interpersonal therapy) and pharmacological approaches (SSRI ornovel non-SSRI antidepressant medications; avoidance of tricyclic andheterocyclic agents as well as benzodiazepines). In addition, the combi-nation of psychotherapy and anti-depressant treatment is associated withthe lowest rate of relapse.77 A summary of treatment principles for ad-dressing the needs of older adults with dual diagnosis is shown in Table 1.
SUMMARY
In conclusion, co-occurring disorders are common among olderadults and are associated with negative health consequences and height-ened healthcare utilization. Evidence for treatment models of co-occur-ring disorder in older adults is largely imputed from related research.There is a need for rigorous testing of specific treatment models amongthe older adult population. There is also a need for further examinationof assessment and treatment methodologies for prescription medicationmisuse and abuse among older adults with psychiatric illness. The im-pact of at-risk drinking, without meeting the criteria for alcohol abuse ordependence, on the treatment of other mental disorders is also in need ofcareful study. Finally, once identified, dissemination and implementa-tion of evidence-based practices is needed to guide the prevention andearly intervention of substance abuse and mental health disorders inolder adults.
Bartels et al. 23
Dow
nloa
ded
by [
Uni
vers
ity o
f R
egin
a] a
t 20:
38 1
7 N
ovem
ber
2014
REFERENCES
1. Kessler RC. The epidemiology of dual diagnosis. Biol Psychiatry 2004;56(10):730-7.
2. Centre for Addiction and Mental Health. Best Practices: Concurrent MentalHealth and Substance Use Disorders. Ottawa, Ontario: Health Canada; 2002.
3. Narrow WE, Rae DS, Robins LN, Regier DA. Revised prevalence estimates ofmental disorders in the United States: Using a clinical significance criterion to reconcile2 surveys’ estimates. Archives of General Psychiatry 2002;59(2):115-123.
4. Lyness JM, Caine ED, King DA, Cox C, Yoedlono Z. Psychiatric disorders inolder primary care patients. Journal of General Internal Medicine 1999;14(4):249-254.
5. Wancata J, Benda N, Hajji M, Lesch OM, Muller C. Prevalence and course ofpsychiatric disorders among nursing home admissions. Social Psychiatry & PsychiatricEpidemiology 1998;33(2):74-9.
6. American Geriatrics Society and American Association for Geriatric Psychia-try. The American Geriatrics Society and American Association for Geriatric Psychia-try Recommendations for policies in support of quality mental health care in USnursing homes. Journal of the American Geriatrics Society 2003;51(9):1299-1304.
7. Jeste DV, Alexopoulos GS, Bartels SJ, Cummings JL, Gallo JJ, Gottlieb GL etal. Consensus statement on the upcoming crisis in geriatric mental health: Researchagenda for the next 2 decades. Archives of General Psychiatry 1999;56(9):848-853.
8. USDHHS. Mental Health: A Report of the Surgeon General. Rockville, MD:US Department of Health and Human Services; 1999.
9. Adams WL, Barry KL, Fleming MF. Screening for problem drinking in olderprimary care patients. Jama 1996;276(24):1964-7.
10. Fleming MF, Manwell LB, Barry KL, Adams W, Stauffacher EA. Brief physi-cian advice for alcohol problems in older adults: A randomized community-based trial.Journal of Family Practice 1999;48(5):378-384.
24 JOURNAL OF DUAL DIAGNOSIS
TABLE 1. A Summary of Treatment Principles
1. Age-appropriate substance use, mental health, and medical screening and assessment
2. Integrated services: Substance abuse, mental health and primary health care
3. Assertive outreach
4. Reduction of negative consequences
5. Non-confrontational and motivation-based treatment: Engagement, persuasion, activetreatment, and relapse prevention
6. Multiple modalities tailored to individual needs and capacities: Cognitive-behavioraltherapy, brief motivational interventions, individual counseling, integrated group treatment,education, self-help groups, family interventions, pharmacotherapy
7. Long-term perspective (Don't give up!)
Dow
nloa
ded
by [
Uni
vers
ity o
f R
egin
a] a
t 20:
38 1
7 N
ovem
ber
2014
11. Moore AA, Morton SC, Beck JC, Hays RD, Oishi SM, Partridge JM et al. A newparadigm for alcohol use in older persons. Med Care 1999;37(2):165-79.
12. Black BS, Rabins PV, McGuire MH. Alcohol use disorder is a risk factor formortality among older public housing residents. Int Psychogeriatr 1998;10(3):309-27.
13. Kandel D, Chen K, Warner LA, Kessler RC, Grant B. Prevalence and demo-graphic correlates of symptoms of last year dependence on alcohol, nicotine, marijuanaand cocaine in the U.S. population. Drug Alcohol Depend 1997;44(1):11-29.
14. Office of Applied Studies SAAMHSA. Substance Use among Older Adults: 2002and 2003 Update. In. Rockville, MD: Department of Health and Human Services; 2005.
15. Johnson I. Alcohol problems in old age: A review of recent epidemiological re-search. International Journal of Geriatric Psychiatry 2000;15(7):575-581.
16. Oslin DW. Late-life alcoholism: Issues relevant to the geriatric psychiatrist.American Journal of Geriatric Psychiatry 2004;12(6):571-583.
17. Beresford TP. Alcoholism consultation and general hospital psychiatry. GenHosp Psychiatry 1979;1(4):293-300.
18. Institute of Medicine. Who provides treatment? In: Committee of the Institute ofMedicine, Division of Mental Health and Behavioral Medicine, editors. Broadeningthe Base of Treatment for Alcoholism. Washington DC: National Academy Press;1990. p. 98-141.
19. Callahan CM, Tierney WM. Health services use and mortality among older pri-mary care patients with alcoholism. Journal of the American Geriatrics Society 1995;43(12):1378-83.
20. Barry KL, Blow FC, Walton MA, Chermack ST, Mudd SA, Coyne JC et al. El-der-specific brief alcohol intervention: 3-month outcomes. Alcoholism, Clinical andExperimental Research 1998;22:32A.
21. Joseph CL, Ganzini L, Atkinson R. Screening for alcohol use disorders in thenursing home. Journal of the American Geriatrics Society 1995;43(4):368-373.
22. Oslin DW, Streim JE, Parmelee P, Boyce AA, Katz IR. Alcohol abuse: A sourceof reversible functional disability among residents of a VA nursing home. InternationalJournal of Geriatric Psychiatry 1997;12(8):825-32.
23. Holroyd S, Duryee JJ. Substance use disorders in a geriatric psychiatry outpa-tient clinic: Prevalence and epidemiologic characteristics. J Nerv Ment Dis 1997;185(10):627-32.
24. Zarba A, Storr CL, Wagner FA. Carrying habits into old age: Prescription druguse without medical advice by older American adults. J Am Geriatr Soc 2005;53(1):170-1.
25. Oslin DW. Alcohol use in late life: Disability and comorbidity. Journal of Geri-atric Psychiatry and Neurology 2000;13(3):134-40.
26. Liberto JG, Oslin DW, Ruskin PE. Alcoholism in older persons: A review of theliterature. Hospital and Community Psychiatry 1992;43:975-984.
27. Gambert SR, Katsoyannis KK. Alcohol-related medical disorders of olderheavy drinkers. In: Beresford TP, Gomberg ESL, editors. Alcohol and Aging. NewYork: Oxford University Press; 1995. p. 70-81.
28. Kivela SL, Nissinen A, Ketola A, Punsar S, Puska P, Karvonen M. Alcohol con-sumption and mortality in aging or aged Finnish men. J Clin Epidemiol 1989;42(1):61-8.
Bartels et al. 25
Dow
nloa
ded
by [
Uni
vers
ity o
f R
egin
a] a
t 20:
38 1
7 N
ovem
ber
2014
29. Fleming MF. Identification and treatment of alcohol use disorders in olderadults. In: Gurnack AM, Atkinson R, editors. Treating alcohol and drug abuse in the el-derly. New York, NY: Springer Publishing Co.; 2002. p. 85-108.
30. Saunders PA, Copeland JR, Dewey ME, Davidson IA, McWilliam C, Sharma Vet al. Heavy drinking as a risk factor for depression and dementia in elderly men. Brit-ish Journal of Psychiatry 1991;15:213-216.
31. Blow FC, Cook CA, Booth BM, Falcon SP, Friedman MJ. Age-related psychi-atric comorbidities and level of functioning in alcoholic veterans seeking outpatienttreatment. Hospital and Community Psychiatry 1992;43(10):990-995.
32. Prigerson HG, Desai RA, Rosenheck RA. Older adult patients with both psychi-atric and substance abuse disorders: Prevalence and health service use. PsychiatricQuarterly 2001;72(1).
33. Blixen CE, McDougall GJ, Suen L. Dual diagnosis in elders discharged from apsychiatric hospital. International Journal of Geriatric Psychiatry 1997;12(3):307-313.
34. Devanand DP. Comorbid psychiatric disorders in late life depression. Biologi-cal Psychiatry 2002;52(3):236-242.
35. Speer DC, Bates K. Comorbid mental and substance disorders among older psy-chiatric patients. Journal of the American Geriatrics Society 1992;40:886-890.
36. Whitcup S, Miller F. Unrecognized drug dependence in psychiatrically hospi-talized elderly patients. Journal of the American Geriatrics Society 1987;35:297-301.
37. Schuckit MA. Genetic and clinical implications of alcoholism and affective dis-order. American Journal of Psychiatry 1986;143:140-147.
38. Brennan PL, Nichols KA, Moos RH. Long-term use of VA mental health ser-vices by older patients with substance use disorders. Psychiatric Services 2002;53(7):836-841.
39. Blazer D, Williams C. Epidemiology of dysphoria and depression in an elderlypopulation. American Journal of Psychiatry 1980;137(4):439-444.
40. Jinks MJ, Raschko RR. A profile of alcohol and prescription drug abuse in ahigh-risk community-based elderly population. The Annals of Pharmacotherapy 1990;24(10):971-975.
41. Finlayson RE, Hurt RD, Davis LJ, Morse RM. Alcoholism in elderly persons: Astudy of the psychiatric and psychosocial features of 216 inpatients. Mayo Clinic Pro-ceedings 1988;63:761-768.
42. Finlayson RE, Davis LJJ. Prescription drug dependence in the elderly popula-tion: Demographic and clinical features of 100 inpatients. Mayo Clinic Proceedings1994;69:1137-1145.
43. Blazer D, Hughes D, George L. The epidemiology of depression in an elderlycommunity population. The Gerontologist 1987;27(3):281-287.
44. Barry KL, Oslin DW, Blow FC. Alcohol Problems in Older Adults: Preventionand Management. New York, NY: Springer Publishing Co.; 2001.
45. Blow FC. Substance Abuse Among Older Adults. Treatment Improvement Pro-tocol (TIP) Series No. 26. Rockville MD: US Department of Health and Human Ser-vices, Public Health Service, Substance Abuse and Mental Health Services Administration,Center for Substance Abuse Treatment; 1998.
46. Korrapati MR, Vestal RE. Alcohol and medications in the elderly: Complex in-teractions. In: Gomberg E, Beresford T, editors. Alcohol and Aging. New York: OxfordUniversity Press; 1995. p. 42-55.
26 JOURNAL OF DUAL DIAGNOSIS
Dow
nloa
ded
by [
Uni
vers
ity o
f R
egin
a] a
t 20:
38 1
7 N
ovem
ber
2014
47. Atkinson RL. Depression, alcoholism and ageing: A brief review. InternationalJournal of Geriatric Psychiatry 1999;14(905-910).
48. Coyne JC, Schwenk TL. The relationship of distress to mood disturbance in pri-mary care and psychiatric populations. J Consult Clin Psychol 1997;65(1):161-8.
49. Graham K, Schmidt G. Alcohol use and psychosocial well-being among olderadults. J Stud Alcohol 1999;60(3):345-51.
50. Regier DA, Farmer ME, Rae DS, Locke BZ, Keith SJ, Judd LL et al. Comorbidityof mental disorders with alcohol and other drug abuse: Results from the EpidemiologicCatchment Area (ECA) study. Journal of the American Medical Association 1990;264(19):2511-2518.
51. Oslin DW, Cary MS. Alcohol-related dementia: Validation of diagnostic crite-ria. American Journal of Geriatric Psychiatry 2003;11(4):441-7.
52. Oslin D, Atkinson RM, Smith DM, Hendrie H. Alcohol related dementia: Pro-posed clinical criteria. International Journal of Geriatric Psychiatry 1998;13(4): 203-12.
53. Smith DM, Atkinson RM. Alcoholism and dementia. Int J Addict 1995;30(13-14):1843-69.
54. Hendrie HC, Gao S, Hall KS, Hui SL, Unverzagt FW. The relationship betweenalcohol consumption, cognitive performance, and daily functioning in an urban sampleof older black Americans. J Am Geriatr Soc 1996;44(10):1158-65.
55. Carlen PL, McAndrews MP, Weiss RT, Dongier M, Hill JM, Menzano E et al.Alcohol-related dementia in the institutionalized elderly. Alcohol Clin Exp Res 1994;18(6):1330-4.
56. George LK, Landeman R, Blazer DG, Anthony JC. Cognitive impairment. In:Robins LN, Regier DA, editors. Psychiatric Disorders in America. New York: FreePress; 1991. p. 291-327.
57. Conwell Y. Suicide in elderly patients. In: Schneider LS, Reynolds CFI,Lebowitz BD, Frieddhoff AJ, editors. Diagnosis and treatment of depression in latelife. Washington, D.C.: American Psychiatric Press; 1994. p. 397-418.
58. Cook B, Winokur G, Garvey M, Beach V. Depression and previous alcoholismin the elderly. British Journal of Psychiatry 1991;153:72-75.
59. Bartels SJ, Coakley E, Oxman TE, Constantino G, Oslin D, Chen H et al. Sui-cidal and death ideation in older primary care patients with depression, anxiety andat-risk alcohol use. American Journal of Geriatric Psychiatry 2002;10(4):417-427.
60. Oslin DW, O’Brien CP, Katz IR. The disabling nature of comorbid depressionamong older DUI recipients. American Journal on Addictions 1999;8(2):128-135.
61. Moos RH, Brennan PL, Mertens JR. Diagnostic subgroups and predictors ofone-year re-admission among late-middle-aged and older substance abuse patients. JStud Alcohol 1994;55(2):173-83.
62. Brennan PL, Kagay CR, Geppert JJ, Moos RH. Predictors and outcomes of out-patient mental health care: A 4-year prospective study of elderly Medicare patientswith substance use disorders. Med Care 2001;39(1):39-49.
63. Wu LT, Ringwalt CL, Williams CE. Use of substance abuse treatment servicesby persons with mental health and substance use problems. Psychiatr Serv 2003;54(3):363-9.
64. Moos R, Moos B. Stay in residential facilities and mental health care as predic-tors of readmission for patients with substance use disorders. Psychiatric Services1995;46(1):66-72.
Bartels et al. 27
Dow
nloa
ded
by [
Uni
vers
ity o
f R
egin
a] a
t 20:
38 1
7 N
ovem
ber
2014
65. Hoff RA, Rosenheck RA. Long-term patterns of service use and cost among pa-tients with both psychiatric and substance abuse disorders. Med Care 1998;36(6): 835-43.
66. Hoff RA, Rosenheck RA. The cost of treating substance abuse patients with andwithout comorbid psychiatric disorders. Psychiatr Serv 1999;50(10):1309-15.
67. Blow FC, Brockmann LM, Barry KL. Role of alcohol in late-life suicide. Alco-holism-Clinical and Experimental Research 2004;28(5 Suppl):48S-56S.
68. Brown SA, Schuckit MA. Changes in depression among abstinent alcoholics.Journal of Studies on Alcohol 1988;49:412-417.
69. Evans K, Sullivan JM. Treating Addicted Survivors of Trauma. New York: TheGuilford Press; 1995.
70. Verheul R, Kranzler HR, Poling J, Tennen H, Ball S, Rounsaville BJ. Axis I andAxis II disorders in alcoholics and drug addicts: Fact or artifact? J Stud Alcohol2000;61(1):101-10.
71. Oslin D, Liberto JG, O’Brien J, Krois S, Norbeck J. Naltrexone as an adjunctivetreatment for older patients with alcohol dependence. American Journal of GeriatricPsychiatry 1997;5(4):324-332.
72. Oslin DW, Katz IR, Edell WS, Ten Have TR. Effects of alcohol consumption onthe treatment of depression among elderly patients. American Journal of Geriatric Psy-chiatry 2000;8(3):215-220.
73. Bartels SJ, Coakley E, Zubritsky C, Ware JH, Miles KM, Areán PA et al. Im-proving access to geriatric mental health services: A randomized trial comparing treat-ment engagement with integrated versus enhanced referral care for depression, anxiety,and at-risk alcohol use. American Journal of Psychiatry 2004;161(8):1455-1462.
74. Oslin DW, Grantham S, Coakley E, Maxwell J, Levkoff S, Miles K et al. Man-aging at-risk alcohol use in older primary care patients: Results of a randomized trial ofreferral care vs. integrated care. Under review.
75. Blow FC, Walton MA, Barry KL, Chermack ST. The impact of brief motiva-tional interventions for substance abuse with older adults in primary care. In progress.
76. Kofoed LL, Tolson RL, Atkinson RM, Toth RL, Turner JA. Treatment compli-ance of older alcoholics: An elder-specific approach is superior to “mainstreaming.”Journal of Studies on Alcohol 1987;48(1):47-51.
77. Bartels SJ, Dums AR, Oxman TE, Schneider LS, Areán PA, Alexopoulos GS etal. Evidence-based practices in geriatric mental health care. Psychiatric Services2002;53(11):1419-1431.
78. Brown RA, Evans DM, Miller IW, Burgess ES, Mueller TI. Cognitive-behav-ioral treatment for depression in alcoholism. J Consult Clin Psychol 1997;65(5):715-26.
79. Miller NS. Pharmacological management of major comorbid psychiatric disor-ders in drug and alcohol addictions. Psychiatric Annals 1995;10:621-627.
80. Drake RE, Mueser KT, Brunette MF, McHugo GJ. A review of treatments forpeople with severe mental illnesses and co-occurring substance use disorders. PsychiatrRehabil J 2004;27(4):360-74.
81. Torrey WC, Drake RE, Cohen M, Fox LB, Lynde D, Gorman P et al. The chal-lenge of implementing and sustaining integrated dual disorders treatment programs.Community Ment Health J 2002;38(6):507-21.
28 JOURNAL OF DUAL DIAGNOSIS
Dow
nloa
ded
by [
Uni
vers
ity o
f R
egin
a] a
t 20:
38 1
7 N
ovem
ber
2014
82. Mueser KT, Drake RE, Noordsy DL. Integrated mental health and substanceabuse treatment for severe psychiatric disorders. Practical Psychiatry and BehavioralHealth 1998;4(3):129-139.
83. Drake RE, Mercer-McFadden C, Mueser KT, McHugo GJ, Bond GR. A reviewof integrated mental health and substance abuse treatment for patients with dual disor-ders. Schizophrenia Bulletin 1998;24:589-608.
84. Mueser KT, Drake RE. Integrated dual disorder treatment in New Hampshire(USA). In: Graham HL, Copello, A., Birchwood, M.J., & Mueser, K.T., editor. Sub-stance Misuse in Psychosis: Approaches to Treatment and Service Delivery. Chichester,England: John Wiley & Sons, LTD; 2002. p. 93-105.
85. Mueser KT, Noordsy DL, Drake RE, Fox L, editors. Integrated Treatment forDual Disorders: A Guide to Effective Practice. New York: Guilford Press; 2003.
86. Drake RE, Mueser KT, Clark RE, Wallach MA. The course, treatment, and out-come of substance disorder in persons with severe mental illness. American Journal ofOrthopsychiatry 1996;66(1):42-51.
87. Drake RE, Essock SM, Shaner A, Carey KB, Minkoff K, Kola L et al. Imple-menting dual diagnosis services for clients with severe mental illness. Psychiatric Ser-vices 2001;52(4):469-476.
88. Barrowclough C, Haddock G, Tarrier N, Lewis SW, Moring J, O’Brien R et al.Randomized controlled trial of motivational interviewing, cognitive behavior therapy,and family intervention for patients with comorbid schizophrenia and substance usedisorders. American Journal of Psychiatry 2001;158(10):1706-13.
89. Carmichael D, Tackett-Gibson M, O’Dell L, Jayasuria B, Jordan J, Menon R.Texas Dual Diagnosis Project Evaluation Report 1997-1998. College Station, TX:Public Policy Research Institute/Texas A&M University; 1998.
90. Drake RE, Yovetich NA, Bebout RR, Harris M, McHugo GJ. Integrated treat-ment for dually diagnosed homeless adults. The Journal of Nervous and Mental Dis-ease 1997;185(5):298-305.
91. Godley SH, Hoewing-Roberson R, Godley MD. Final MISA Report. Bloomington,IL: Lighthouse Institute; 1994.
92. Drake RE, McHugo GJ, Clark RE, Teague GB, Xie H, Miles K et al. Assertivecommunity treatment for patients with co-occurring severe mental illness and sub-stance use disorder: A clinical trial. American Journal of Orthopsychiatry 1998;68(2):201-15.
93. Jerrell JM, Ridgely MS. Comparative effectiveness of three approaches to serv-ing people with severe mental illness and substance use disorders. The Journal of Ner-vous and Mental Disease 1995;183:566-576.
94. Center for Mental Health Services. Evidence-Based Practices: Shaping MentalHealth Services Toward Recovery. Co-Occurring Disorders: Integrated Dual Disor-ders Treatment; 2005.
95. Banerjee S, Dickinson E. Evidence based health care in old age psychiatry. In-ternational Journal of Psychiatry in Medicine 1997;27(3):283-92.
96. Larsen PD, Martin JL. Polypharmacy and elderly patients. Association of Oper-ating Room Nurses Journal 1999;69(3):619-628.
97. Benshoff JJ, Harrawood LK, Koch DS. Substance abuse and the elderly: Uniqueissues and concerns. Journal of Rehabilitation 2003;69(2):43-48.
Bartels et al. 29
Dow
nloa
ded
by [
Uni
vers
ity o
f R
egin
a] a
t 20:
38 1
7 N
ovem
ber
2014
98. Pennington H, Butler R, Eagger S. The assessment of patients with alcohol dis-orders by an old age psychiatric service. Aging & Mental Health 2000;4(2):182-184.
99. Ondus KA, Hujer ME, Mann AE, Mion LC. Substance abuse and the hospital-ized elderly. Orthop Nurs 1999;18(4):27-34; quiz 35-6.
100. Bartels SJ, Liberto J. Dual Diagnosis in the Elderly. In: Lehman AF, Dixon L,editors. Substance Disorders Among Persons with Chronic Mental Illness. New York:Harwood Academic Publishers; 1995. p. 139-157.
101. Widlitz M, Marin DB. Substance abuse in older adults: An overview. Geriatrics2002;57(12):29-34.
102. Blow F. A geriatric version of the MAST. In: Annual Meeting of the AmericanAssociation of Geriatric Psychiatry; 1993; New Orleans; 1993.
103. Buchsbaum DG, Buchanan RG, Welsh J, Centor RM, Schnoll SH. Screeningfor drinking disorders in the elderly using the CAGE questionnaire. Journal of theAmerican Geriatrics Society 1992;40(7):662-5.
104. Yesavage JA, Brink TL, Rose TL, Lum O, Huang V, Adey MB et al. Develop-ment and validation of a geriatric depression screening scale: A preliminary report.Journal of Psychiatric Research 1983;17(1):37-49.
105. Schonfeld L, Dupree LW. Treatment approaches for older problem drinkers. In-ternational Journal of the Addictions 1995;30(13-14):1819-1842.
106. Gatz M, Fiske A, Fox LS, Kaskie B, Kasl-Godley J, McCallum TJ et al. Empiri-cally validated psychological treatments for older adults. Journal of Mental Health andAging 1998;4(1):9-46.
107. Blow FC, Barry KL. Older patients with at-risk and problem drinking patterns:New developments in brief interventions. Journal of Geriatric Psychiatry & Neurology2000;13(3):115-123.
Received: 06/01/05Revised: 08/23/05
Accepted: 08/30/05
30 JOURNAL OF DUAL DIAGNOSIS
Dow
nloa
ded
by [
Uni
vers
ity o
f R
egin
a] a
t 20:
38 1
7 N
ovem
ber
2014
