Integrated Care Model: Interventions and Strategies for Addressing Co-Morbidities in Early Recovery

Alkesh Patel, M.D., M.R.O.Addiction Psychiatrist

Assistant Clinical ProfessorIcahn School of Medicine at Mount Sinai, NYC

1. Review the history of Substance Abuse Disorders in the Psychiatrically Ill.

2. Gain a better understanding for the different psychiatric co-morbidities that co-exist with addictive disorders.

3. The Integrative care model and levels of care.

4. Evidence based intervention strategies both on pharmacological and non-pharmacologic basis when addressing mental illness and substance use disorders(SUDs)

5. Understand neurobiology of cravings and withdrawal syndromes, specificallyrelated to nicotine, alcohol, and opioid use disorders.

6. Develop strategies for using assessment tools to identify comorbidities andtreatment barriers, and propose better ways to measure the effectiveness oftreatment interventions

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Objectives

Substance Use Disorders in the Psychiatrically Ill

Substance Use Disorders (SUDs) occur commonly in the psychiatrically ill

Often under recognized and undertreated

SUDs co-occur with mental illness at higher rates than they occur in the general population without a previously diagnosed mental illness

Economic burden of SUDs costs the US $375 billion annually (Office of National Drug Control Policy, 2001)

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Substance Use Disorders in the Psychiatrically Ill (cont.)

Compared to patients with only a SUD or mental illness alone, patients with co-occurring illness have:

1. Greater severity of illness, worst longitudinal course of illness over time

2. Increased baseline risk for psychiatric and/or addiction illness relapse

3. Higher rates of recidivism; higher levels of psychological distress

4. Poorer psychosocial functioning, worst treatment retention

5. Poor medication compliance

6. Higher rates of violence, suicide, legal problems, medical complications

7. Higher utilization of health care services (ER, and inpatient care)

(Hser et al. 2006; Mueser et al. 1998; Ziedonis 2004)

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Substance Use Disorders in the Psychiatrically Ill (cont.)

History of Defining and Characterizing Co-Occurring Disorders

1960s-1970s Process of deinstitutionalization moving responsibility of treating patients with severe and persistent mental illness (SPMI) from state hospitals towards less restrictive settings

By late 1970’s and early 1980’s, clinicians fist began to characterize patients with both mental illness and SUDs (Drake, et al. 2004)

Initial term dual diagnosis, which was used in mental retardation field tocharacterize patients with mental retardation and co-occurring mental illness

The DSM-III publication in 1980 also helped to legitimize use of multiple diagnosesto describe patients, given that previous versions of DSM did not provide meansto do this.

Terms of co-occurring and dual disorder were later introduced to describe patientswith SUDs and full spectrum of non-SUD Axis I disorders, personality disorders,mental retardation, and medical conditions

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Substance Use Disorders in the Psychiatrically Ill (cont.)

Dual Diagnosis Epidemiology

In the Epidemiologic Catchment Area (ECA) Community Study sponsored by the NIMH (Regier et al. 1990), lifetime prevalence of any SUD in a community sample was 16.7%, whereas 29% of patients with lifetime history of mental illness met criteria for lifetime comorbid SUD.

Of those with history of Drug Use Disorder’s (DUDs), more than half also had lifetime history of mental disorder and had more than four times the risk (odds ratio [OR] = 4.5) of having a mental disorder compared with individuals with no history of DUD (Regier et al. 1990)

Nicotine use disorder is prevalent in the US in 23% of general population (CDC and Prevention 2002) but is 2-4X HIGHER in patients with mental illness and SUDs (Kalman et al. 2005)

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History of Comorbidities

Schizophrenia and SUD

In Epidemiologic Catchment Area (ECA) Study, 47% of patients withschizophrenia had lifetime history of SUD, with 34% having Alcohol Use Disorder(AUD), and 28% having Drug Use Disorder (DUD) (Regier et al. 1990)

Most common substances abused by schizophrenic patients include nicotine(75%-90%), alcohol (25-45%), cocaine (15-50%), and cannabis (31%)

(Buckley 2006; CDC and Prevention 2005)

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History of Comorbidities

Bipolar Disorder and SUD

According to the ECA study, bipolar spectrum disorders were the Axis I disorders most likely to co-occur with an SUD (excluding nicotine use disorders), with 56% of any bipolar diagnosis being associated with a lifetime SUD (Regier et al. 1990)

As in patients with schizophrenia, nicotine use is particularly common in patients with bipolar disorder, with prevalence rates of 55%–70% (Cassidy et al. 2002)

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History of Comorbidities

Major Depressive Disorder and SUD

In addiction treatment settings, about half of patients with SUDs have a lifetime history of MDD (Miller et al. 1996)

In addiction treatment settings, the lifetime prevalence of MDD ranges from 20%-67% in patients with alcohol addiction, from 30%-40% in patients with cocaine addiction, and up to 54% in patients with opioid addiction (Brady et al. 2003)

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History of Comorbidities

Anxiety Disorders and SUD

Data from the ECA study reveals that most anxiety disorders are accompanied by an approximate 2-4x risk for an AUD or DUD (Regier et al. 1990)

Generalized anxiety disorder (GAD) was significantly associated with an elevated risk of alcohol dependence in both men and women compared with the general population

Posttraumatic stress disorder (PTSD) is also particularly associated with an increased risk of SUDs

Of all the anxiety disorders, GAD has the most data from RCTs supporting the efficacy of medication in reducing both anxiety symptoms and substance use

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History of Comorbidities

ADHD and SUD

Evidence ADHD plays a role in development of a SUD?

Approximately 20%-40% of individuals with ADHD have a lifetime history of SUD

Similarly, in patients presenting for treatment for an SUD, 20%-30% have co-occurring ADHD (Schubiner, 2005)

Sobriety is the best time to tease out ADD/ADHD symptoms from those related topost-acute withdrawal or intoxication states from active SUD or other underlyingmood disorders (anxiety, major depression, bipolar disorder)

Although ADHD by itself is a risk factor for developing an SUD in adolescents,conduct disorder appears to predominantly mediate the relationship betweenADHD and SUDs (Biederman et al. 1998; Wilens 2002)

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History of Comorbidities

Eating Disorders and SUD

Eating disorders co-occur with SUDs at elevated rates, with bulimia patients athigher risk compared to those with anorexia nervosa (Levin et al. 2003)

Lifetime prevalence of AUD ranges from 17% in patients with anorexia nervosa,restricting type, to 46% in those with bulimia nervosa (Bulik et al. 2004)

In treatment settings for SUDs, high rates of eating disorders have been found inpatients with alcohol, cocaine, and stimulant use disorders (Levin et al. 2003)

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History of Comorbidities

Personality Disorders and SUD

Numerous studies demonstrate Axis II psychopathology is highly prevalent amongindividuals with SUDs

Antisocial personality disorder is strongly associated with alcohol use disorder

In the ECA study, lifetime prevalence of AUD was 74% among individuals withantisocial personality, compared with 14% in the general population (Regier et al.1990)

No established pharmacotherapeutic algorithm exists to treat patients withpersonality disorders comorbid with SUDs

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Integrated Care Model

Historic Definitions

Serial Model: Patients treated in one setting (substance abuse clinic) for a period oftime, and then in another setting subsequently (mental health clinic)

Parallel Model: Patients with dual disorders simultaneously receive treatment forboth mental illness and substance abuse, but in separate treatment settings

Systems Model: where mental health and substance abuse clinical services areprovided simultaneously in same treatment setting

Most reliable finding from research in past decade is that integrated treatment fromsystems perspective, and across a wide spectrum of psychiatric and SUD diagnosis, isoptimal model, especially when comprehensive services are provided that increaseintensity of treatment (Drake et al. 2004)

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Integrated Care Model

A dedicated coordination of the following treatment services: substance abuse, mentalhealth, and medical care in one setting in order to optimize treatment experience.

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The Integrated Care Model treats the client through thelens “the whole is greater than the sum of its parts.”

Recognizes that every client’s needs are different.

Clinicians work in partnership with each client to developa Individualized Wellness Plan that is based on the client’sstrengths, preferences, and needs.

Long Term Sobriety

Family

Exercise

12-Step Meetings

Coping Skills

Sober Network WorkMedications

Meditation

Nutrition

Levels of Care

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Detoxification

• Medically Supervised Detoxification (protocol)

• Group and Individual therapies with clinical team

• Wellness planning begins in Detox

• 12 Step Meetings (AA, NA)

Residential

• Clinical Care (Individual and group therapies)

• Individualized wellness planning

• Psychiatric consultation and evaluation

• Family therapy• 12 Step Meetings

(AA/NA)• Continuing Care

Extended Care (Including Intensive Outpatient

Treatment)

• Intensive Outpatient • Weekly group and

individual sessions• Urine toxicology

monitoring• 12 Step Meetings

(AA/NA) • Professional skills

workshops• Psychiatric

Consultation and medication management

• Community focused activities

• Continuing Care

Outpatient

• Outpatient setting• Once weekly group

psychotherapy sessions• Individual

psychotherapy sessions per wellness plan

• Urine toxicology monitoring

• 12 Step Meetings (AA/NA)

• Psychiatric Consultation and medication management

Understanding Neurobiology of Alcohol

Ethanol-induced dopamine release within the nucleus accumbens accounts for thereinforcing effects of alcohol

Sedative-hypnotic and anti-anxiety effects of ethanol produced by the activation ofGABAa receptors

Chronic alcohol intake leads to suppression of GABA activity, decrease in GABAa-mediated function, and decreased GABAa receptor sensitivity

Acute ethanol administration inhibits NMDA receptor activity

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Understanding Neurobiology of Alcohol Withdrawal

The up-regulation of NMDA receptors that results from chronic ethanol exposurecontributes to increased neuronal excitability during alcohol withdrawal.

Glutamate elevated in both hippocampus and the striatum during alcohol withdrawal.

Glutamate further activates NMDA receptors to facilitate further release of this aminoacid in a positive feedback loop.

Activation of NMDA receptors by glutamate enhances calcium and sodium flow intoneurons, with a resultant increase in excitatory postsynaptic potentials.

Serotonergic systems, hypothalamic-pituitary adrenal neuroendocrine axis.

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Treatments for Alcohol Use Disorder

Naltrexone - FDA indicated for AUD; used to address protracted abstinence

Acamprosate - FDA 2004; decreases acute post-withdrawal; increases GABAergicactivity; unclear which alcoholics benefit more from it

Disulfiram - FDA approved; irreversibly inhibits aldehyde dehydrogenase, accumulationof acetaldehyde; compliance an issue; explain disulfiram rxn; obtain informed consent;used to address protracted abstinence

Topiramate - (not FDA approved) can address protracted withdrawal at higher doses

Gabapentin - (not FDA approved) can address symptoms of insomnia and anxietyassociated with protracted alcohol withdrawal

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Treatments for Alcohol Use Disorder (cont.)

Naltrexone for Alcohol Use Disorder

FDA approved in 1994 alcohol use disorder; depot naltrexone approved in 2006 foralcohol use disorder; FDA approved in 1984 for opioid use disorder, depotnaltrexone approved in 2010 for opioid use disorder.

Shown to reduce drinking frequency and likelihood of relapse to heavydrinking by competitive antagonism at the mu opioid receptor, blocking therelease of dopamine.

Large meta-analysis including 27 randomized, controlled trials of naltrexonerevealed treatment decreased relapse and lowered the risk of treatmentwithdrawal in alcohol dependence patients by 28%.

Efficacy of naltrexone also supported by Combining Medications & BehavioralInterventions for Alcoholism (COMBINE) trial.

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Withdrawal

Criteria for Alcohol Withdrawal

A. Cessation of (or reduction in) alcohol use that has been heavy and prolonged.

B. Two (or more) of the following, developing within several hours to a few days afterCriterion A:

1) autonomic hyperactivity (e.g., sweating or pulse rate greater than 100)2) increased hand tremor3) insomnia4) nausea or vomiting5) transient visual, tactile, or auditory hallucinations or illusions6) psychomotor agitation7) anxiety8) grand mal seizures

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Withdrawal (cont.)

DSM-IV TR Criteria for Alcohol Withdrawal

C. The symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.

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Neurobiology of Opioids and Opiates

During cycles of chronic heroin addiction,whenever self-administration of a short-actingopiate, such as heroin, does not promptly follow,there is onset of signs and symptoms of opiatewithdrawal, preceded by activation of the HPAaxis, with elevation of levels of ACTH andcortisol.

It has been established that the elevation of HPAaxis hormones precedes, and thus helps drive,the noxious signs and symptoms of opiatewithdrawal.

Opiate withdrawal is excitatory andhypertensive.

Opioid Withdrawal Syndrome

Early to Moderate Symptoms Moderate to Advanced Symptoms

Anorexia Muscle/bone pain

Anxiety, restlessness, irritability, depression, insomnia

Abdominal pain

Craving and intense drug hunger Low grade fever, increase blood pressure

Headache Anorexia

Tachycardia Nausea and vomiting

Rhinorrhea, yawning, lacrimation Hot/cold flashes

Piloerection (gooseflesh) Muscle spasm

Opioid Addiction: Treatment Considerations in Recovery

• Opioid detoxification and withdrawal management (methadone, buprenorphine, clonidine)

• Opioid substitution (methadone, buprenorphine)

• Opioid antagonist treatment (naltrexone)

• Self Help Groups (NA)

• Level of care needs

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Comparison Study of Different Pharmacotherapies for Opioid Addiction

Characteristics Buprenorphine Methadone NaltrexoneMechanism of Action Partial mu opioid agonist, kappa

antagonist; safer in overdose comparedto methadone; (ceiling effect); better sublingual bioavailability

Full mu opioid agonist; racemic mixture, NMDA antagonist property; titration to steady state takes days, monitor for accumulated toxicity;

Naltrexone and its active metabolite 6-β-naltrexol are competitive antagonists at μ- and κ-opioid receptors, and to a lesser extent at δ-opioid receptors

Half-life 37 hours 13-50 hours (24 hr average) The plasma half-life of naltrexone is about 4 h, for 6-β-naltrexol 13 h

Dosing Frequency Daily or 3x weekly Daily Daily or 3x weekly

Abuse Potential High abuse potential High abuse potential No abuse potential

Receptor Activation and Affinity High receptor affinity, but activates receptor as partial agonist (low intrinsic activity)

Lower receptor affinity compared to buprenorphine, but activates receptor more fully

High affinity for receptor, but does NOT activate the receptor

Indication for Opioid Detoxification and Withdrawal Management

Yes Yes No. Use contraindicated in acute opioid withdrawal; can use as maintenance treatment once withdrawal subsides

Office-based Treatment for Opioid Addiction

Yes No Yes

Clinical Indications Opioid addiction/some benefits in pain management

Opioid addiction and pain management Both opioid & alcohol addiction

Clinical Contraindications Avoid in those who abuse alcohol, benzos, or IV buprenorphine abuse hx

History of meth diversion; if not tolerating, consider switch to buprenorphine

Can be first line treatment; or can use if not appropriate candidate for bupr/meth tx

Limitations on Prescribing Need buprenorphine waiver with medical license & DEA

Federal/state/methadone program regulations

Any prescriber can give

Nicotine Addiction

Primary site of action of nicotine is the alpha4B2 nicotinic acetylcholine receptor(nAChR)

Receptor activation on mesolimbic DA neurons leads to DA secretion in the nucleusaccumbens

Document a smoking history (first cigarette, last cigarette, quit attempts, age of firstonset)

Always Educate about Nicotine withdrawal (dysphoria, anxiety, irritability, insomnia,increased appetite, craving)—peak within 24 hrs of cessation

Fagerstrom Test rating scale—allows assessment of nicotine dependency, scores >4positive

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Treatments for Nicotine Addiction

Pharmacological

Nicotine replacement therapies (gum, nicotine patch, etc.): increases venous supply of nicotine

Bupropion: blocks reuptake of DA and NE; high affinity noncompetitive nicotine receptor antagonism

Varenicline: high affinity, acts as partial agonist at alpha4B2 receptors

Clonidine: alpha2 adrenoreceptor agonist

Naltrexone: may also reduce comorbid alcohol usage

Nortriptyline: blocks reuptake of NE and serotonin, treats comorbid depressive disorders

Behavioral Treatments:

Self Help groups, CBT, MET, Acupuncture, biofeedback

Assessment Tools

The use of assessment tools and other measures by the Primary Clinician are useful for:

Development of a positive therapeutic alliance between the clinician and client.

Determining interventions in addressing symptoms and barriers to recovery.

Providing feedback to client and treatment team regarding effectiveness of interventions used.

Some Examples of Assessment tools used are:

PHQ-9 (Depression)

URICA (Stages of change)

GAD-7 (Generalized anxiety disorder 7 item scale)

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Integrated Treatment Approaches

Schizophrenia and SUDPharmacological:

In treating patient with schizophrenia and SUD, second generation antipsychotics(risperidone, olanzapine, quetiapine, aripiprazole) are preferred over firstgeneration medications (haloperidol)

Psychotherapeutic:

Dual Recovery Therapy, Modified Cognitive-Behavioral Therapy, ModifiedMotivational Enhancement Therapy. (Components of relapse prevention,motivational interviewing, social skills training, and encourage involvement in 12step programming).

Special needs of psychotic disorder patients must be taken into account, includingproblem areas of low motivation, poor self efficacy, and cognitive impairment

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Integrated Treatment Approaches (cont.)

Bipolar Disorder and SUDPharmacological:

Limited data is available to guide the optimal pharmacological management of patients withbipolar spectrum disorders comorbid with SUDs.

Indirect evidence suggesting that anticonvulsants (valproic acid or carbamazepine) should beselected over lithium as first-line agent.

Psychotherapeutic:

Cognitive-behavioral approaches have mainly been used specifically for patients with co-occurring bipolar disorder and SUD

Integrated Group Therapy (IGT), developed by Weiss et al. (2000) is a manualized, integratedCBT treatment approach that focuses on the parallel processes of relapse and recovery forboth bipolar disorder and addiction

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Integrated Treatment Approaches (cont.)

Major Depressive Disorder and SUDPharmacological:

Research suggests that antidepressant treatment in individuals with co-occurring depression andSUD is effective in reducing substance abuse when depression outcomes improve, but by themselves,antidepressants appear not to improve substance abuse outcomes (Nunes and Weiss 2009)

Certain meta-analyses found more consistent evidence for the efficacy of tricyclic antidepressants orother mixed-mechanism noradrenergic antidepressants (mirtazapine, venlafaxine) than for theselective serotonin reuptake inhibitors.

Psychotherapeutic:

Motivational interviewing can help with treatment engagement and retention and CBT techniques forreducing depressive symptoms and substance abuse.

A community reinforcement approach (CRA) for SUDs appears effective at decreasing substanceabuse and improving depression outcomes (Carroll 2004).

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Integrated Treatment Approaches (cont.)

Anxiety Disorder and SUD

Pharmacological:

Buspirone versus placebo in individuals with co-occurring GAD and AUD’s

Treatment with an SSRI or other non-addictive medication

Psychotherapeutic:

Individual counseling sessions, acupuncture, yoga and exercise.

Seeking Safety, the integrated approach that has been most empirically studied, is amanualized CBT that was specifically developed to treat individuals with SUDs andhistories of trauma

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Integrated Treatment Approaches (cont.)

ADHD and SUD

Pharmacological:

Effective treatments include use of psychostimulants.

Another approach: Start with non-stimulants.

Avoid over-treatment, be careful not to over-diagnose based on particular substance ofabuse (ADHD and stimulant/cocaine addiction).

Psychotherapeutic:

ADHD review of coping skills, cognitive restructuring, use of organizers / calendars,goal setting/planning, meditation, life coaching, aromatherapy, deep relaxation groups,exercise.

SUD relapse prevention, 12 step facilitation, meditation, acupuncture, exercise.

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Integrated Treatment Approaches (cont.)

Eating Disorder and SUD

In patients with both eating disorders and SUD, there is lack of established data thatsupports use of psychopharmacological medications to effectively address bothdisorders simultaneously.

Psychotherapeutic:

Trauma focused therapy may have better utility for both eating disorders andSUD treatment.

Cognitive behavioral therapy may have demonstrated efficacy for both disordersindividually.

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Integrated Treatment Approaches (cont.)

Personality Disorder and SUD

Pharmacological:

Use of antidepressants, anxiolytics, mood stabilizers, and antipsychotics can helpregulate affect, impulsivity, anger outbursts, or reduce escalated risk ofviolence/assault or reduce risk of suicide in this group of patients.

Psychotherapeutic:

Dialectical behavioral therapy has demonstrated efficacy for improving symptomsrelated to both borderline personality disorder and substance abuse in patients withthis unique comorbidity (Dimeff et al. 2003).

Dual Focus Schema Therapy also can help address symptoms and distress related toboth personality disorders and comorbid SUD (Ball 1998).

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Integrated Treatment Approaches (cont.)

Behavioral Interventions: Yoga

Since the 1970s, several stress-reduction techniques have been studied as possibletreatments for depression and anxiety. On average, about 7.5% of U.S. adults had triedyoga at least once, and that nearly 4% practiced yoga in the previous year.

Yoga lowers breathing and heart rates, decreases blood pressure (restoringbaroreceptor sensitivity), and increases blood flow to the intestines and reproductiveorgans—the relaxation response

Yoga lowers blood sugar and LDL (“bad”) cholesterol and boosts HDL (“good”)cholesterol. In diabetics, yoga can lower blood sugar by lowering cortisol andadrenaline levels, encouraging weight loss, and improving sensitivity to the effects ofinsulin.

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Integrated Treatment Approaches (cont.)

Behavioral Interventions: Yoga

One randomized controlled study examined the effects of yoga and a breathingprogram in disabled Australian Vietnam veterans diagnosed with severe PTSD. Theveterans were heavy daily drinkers, and all were taking at least one antidepressant.The course included breathing techniques, yoga asanas, education about stressreduction, and guided meditation. Participants were evaluated at the beginning ofthe study using the Clinician Administered PTSD Scale (CAPS), which ranks symptomseverity on an 80-point scale.

Six weeks after the study began, the yoga and breathing group had dropped theirCAPS scores from averages of 57 (moderate to severe symptoms) to 42 (mild tomoderate). These improvements persisted at a six-month follow-up. The controlgroup, consisting of veterans on a waiting list, showed no improvement.

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Behavioral Interventions: Meditation

An eight week study conducted by Harvard researchers at Massachusetts General Hospital (MGH) determined that meditation literally rebuilds the brains grey matter (Lazar, 2011)

For the current study, magnetic resonance (MR) images were taken of the brain structure of 16 study participants two weeks before and after they took part in the eight-week Mindfulness-Based Stress Reduction (MBSR) Program

The analysis of MR images, which focused on areas where meditation-associated differences were seen in earlier studies, found increased gray-matter density in the hippocampus, known to be important for learning and memory, and in structures associated with self-awareness, compassion, and introspection

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Integrated Treatment Approaches (cont.)

Behavioral Interventions: Acupuncture

Acupuncture, the practice of inserting thin solid needles into specific documented points of the body to treat many different disorders, has been practiced in China since 2500 BC

Frequent uses include pain management (e.g. arthritis, back pain, and migraines), neurological conditions, asthma, addiction, nausea related to chemotherapy, weight control, smoking, stroke, gastrointestinal disorders, gynecological and obstetric problems, and stress management

Neurotransmitter systems involving opioids and GABA have been implicated in the modulation of dopamine release by acupuncture

Acupuncture treatment activates GABAB receptors and activates presynaptic  κ-opioid receptors in the nucleus accumbens through dynorphin neurons, resulting in decreased dopamine release (Lin et al., 2012)

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Integrated Treatment Approaches (cont.)

Integrated Treatment Approaches (cont.)

Behavioral Interventions: Adventure Based Therapy Adventure therapy is a cognitive-behavioral-affective approach which utilizes a

humanistic existential base to strategically enact change through direct experience and challenge

Concepts contributing to adventure therapy effectiveness include:1. Increases in self-esteem, attitude and interpersonal relatedness2. Increase in self efficacy and group cohesion3. Improved problem solving4. Decrease in conduct disordered behaviors5. Improves psychosocial related difficulties (effective in treating drug addicted

juvenile youth)6. Facilitates connecting participants with their therapist and treatment issues

(Parker, 1992; Blanchard, 1993)

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Summary Points

Psychiatric Interventions within Integrated Care Model

• General Goals: Acute stabilization, and aim for complete remission of symptomswhenever possible

• Consider stage of motivational engagement when considering medication choiceand appropriate psychotherapeutic interventions

• Treat BOTH disorders (mental illness/SUD) simultaneously if identified

• Treat early in the course of illness, and avoid under-treatment; failure to treat onedisorder negatively affects the longitudinal course of the other

• Treat underlying opioid, alcohol, and nicotine use disorders with anti-cravingmedications. Cravings occur throughout levels of care.

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Summary Points

Psychiatric Interventions within Integrated Care Model

• Always assess for mood symptoms/ADHD in the absence of active SUD

• Understand the DSM-V diagnostic criteria for psychiatric disorders, andinclusion/exclusion criteria when making an accurate diagnosis such as ADHD, Bipolardisorder, Schizophrenia

• Reassure ALL patients that any previous diagnosis made and treatment history will bereviewed for accuracy

• Obtain collateral information from family, friends, case managers when reviewingdiagnostic criteria needed in making an accurate diagnosis

• Increase reliability and validity of diagnoses by considering frequent objectivereassessment of core symptoms, especially assessments done AFTER acutedetoxification

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Closing RemarksQuestions