October 9, 2006

Physicians and integrated treatment: specialization and collaboration

—by Christina M. Delos Reyes, M.D.

(Editor's note: This resource first appeared on pages 10-11 in the Fall 2005 issue of SAMI Matters, the newsletter of the Ohio SAMI Coordinating Center of Excellence, an initiative of the Center for Evidence-Based Practices at Case Western Reserve University [click here].)

Physicians of internal medicine, family medicine, and psychiatry fulfill an important role in screening for, assessing, referring, and providing treatment to people who experience severe mental illness (e.g., schizophrenia, bi-polar, depression) and a co-occurring substance use disorder (i.e., alcohol and other drugs). Prescribing medication and helping patients manage side effects and symptoms of both disorders is one of the primary roles of the physician-but not the only one.

Physicians may help patients with co-occurring disorders improve their quality of life if they actively participate as a member of a multidisciplinary treatment team and utilize other principles of Integrated Dual Disorder Treatment (IDDT), such as motivational interviewing and the stages-of-change approach to treatment (see Resources below).

TREAT BOTH DISORDERS: MANAGE CRAVINGS & OTHER SYMPTOMS

Co-occurring disorders are two distinct yet interacting diseases. Therefore, simultaneous treatment of both helps patients sort out and manage all of their symptoms. In my practice, I prescribe medication (such as naltrexone, acamprosate, buprenorphine) to reduce cravings associated with alcohol and other drugs. I also prescribe medication (such as antidepresents, antipsychotics, and anxiolytics) to minimize severe symptoms of mental illness: this enables patients to engage in therapeutic conversations with me and other service team members about reducing and eliminating their substance use.

INFORM YOUR PRACTICE

Psychiatrists and other physicians tend to be wary of treating persons with severe mental illness who are actively drinking and using other drugs. Yet, co-occurring disorders (comorbidity) is very common, so we owe it to our patients to increase our knowledge and our comfort level in treating both disorders simultaneously. Mary Brunette, M.D., and her colleagues at Dartmouth Medical School published an article in March 2005 about the challenges of treating people with schizophrenia who also have a substance use disorder (SUD). The remainder of this column summarizes some important points.

FACTS ABOUT PEOPLE WITH SCHIZOPHRENIA AND SUD

  • 50 percent lifetime prevalence of substance use disorders (3x the general population rate)
  • 70 to 90 percent dependent upon nicotine (3x the general population rate)
  • Use of alcohol and other drugs may enhance the impaired responsiveness of the brain's reward circuit temporarily; however, substance use dramatically worsens the overall course of the illness

ARE ATYPICAL ANTIPSYCHOTICS PREFERABLE TO TYPICAL ANTIPSYCHOTICS FOR PEOPLE WITH SCHIZOPHRENIA AND SUD?

  • Olanzapine and risperidone have produced mixed results
  • Quetiapine may decrease stimulant craving but not substance use (one study)
  • Atypicals may be more effective than typicals for smoking cessation when used with nicotine patches or buproprion (two studies)
  • Ziprasodone or aripiprazole: no published studies to date

CAN OTHER MEDICATIONS MAKE A POSITIVE IMPACT FOR PEOPLE WITH SCHIZOPHRENIA AND SUDS?

  • Buproprion may assist with smoking cessation (3 studies)
  • Naltrexone may decrease alcohol use (2 preliminary studies)
  • Disulfiram has been used safely and with success

WHAT ELSE CAN I DO TO IMPROVE CARE?

  • Increase careful screening and comprehensive assessment to increase detection and treatment of substance use disorders (see Resources below)
  • Ask your patients about their use of alcohol and other drugs at regular intervals (it might take some time for them to trust you enough to be honest about their use)
  • Pay attention to behaviors that might indicate your patients are using (e.g., missing appointments, financial problems, legal problems/criminal justice involvement)
  • Listen to other service providers and family members: their stories might contain clinical evidence about your patients' substance abuse and mental health symptoms
  • Converse with your patients about their lives to learn how symptoms, medication, and medication side-effects might help or hurt their recovery success

SOURCES

Mary F. Brunette, M.D., Douglas L. Noordsy, M.D., and Alan I. Green, M.D. (2005). A Challenging Mix: Co-Occurring Schizophrenia and Substance Use Disorders. Psychiatric Times, v22, n3.
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IDDT & The Physician: Stage-Wise Services & Medication Management (At-A-Glance Table)
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Christina M. Delos Reyes, M.D., is medical consultant at the Ohio SAMI CCOE. She is board certified in adult psychiatry and addiction psychiatry and ASAM certified (American Society of Addiction Medicine). She maintains a clinical practice in Cleveland and teaches at the Case School of Medicine. Edited by Paul M. Kubek of the Ohio SAMI CCOE.
 
  • Christina M. Delos Reyes, M.D.
  • Physicians and integrated treatment: specialization and collaboration

    Physicians of internal medicine, family medicine, and psychiatry fulfill an important role in screening for, assessing, referring, and providing treatment to people who experience severe mental illness (e.g., schizophrenia, bi-polar, depression) and a co-occurring substance use disorder (i.e., alcohol and other drugs). Prescribing medication and helping patients manage side effects and symptoms of both disorders is one of the primary roles of the physician—but not the only one.

    | learn more |