Introduction
Chapter 1 Overview
The treatment needs of patients who have a psychiatric disorder in combination with an alcohol and other drug (AOD)
use disorder differ significantly from the treatment needs of patients with either an AOD use disorder or a psychiatric disorder by itself. This Treatment Improvement Protocol (TIP) consists of recommendations for the treatment of
patients with dual disorders.
This TIP was developed by a multidisciplinary consensus panel that included addiction counselors, social workers,
psychologists, psychiatrists, other physicians, nurses, and program administrators with active clinical involvement in
the treatment of patients with dual disorders. Consumers also participated on the panel.
This TIP was written principally for addiction treatment staff. However, it contains information and treatment
recommendations that can be used by healthcare providers in a variety of treatment settings. For example, it will be
useful to people who work in primary care clinics, hospitals, and various mental health settings. In addition, there are
recommendations that are targeted to administrators and planners of healthcare services.
A thoughtful attempt has been made to include information that the consensus panel felt was clinically relevant. While
many clinical topics are explored in depth, some are only briefly mentioned, and a few are avoided altogether.
It is not the goal of this TIP to provide an exhaustive description of all of the possible issues that relate to the
treatment of patients with dual disorders. Rather, the primary goal is to provide treatment recommendations that are
practical and useful.
Indeed, the usefulness of this TIP can be enhanced by blending these recommendations with those of another TIP such
as Intensive Outpatient Treatment for Alcohol and Other Drug (AOD) Abuse.By doing so, treatment protocols can be
developed which will meet very specific treatment needs.
Contents

Definitions and Models

Chapter 2 -- Dual Disorders: Concepts and Definitions -- provides descriptions and diagnostic criteria for AOD
abuse and dependence. There is also a description of the possible interactions between AOD use and psychiatric
symptoms and disorders.
Chapter 3 -- Mental Health and Addiction Treatment Systems: Philosophical and Treatment Approach Issue --
describes the similarities, differences, strengths, and weaknesses of the treatment systems used by patients with dual
disorders: the mental health system, the addiction treatment system, and the medical system. Similarly, there is a
description of treatment models most frequently used: sequential treatment of each disorder, parallel treatment of each
disorder, and integrated treatment of both disorders. The chapter includes a discussion of critical treatment issues and
general assessment issues in providing care to patients with dual disorders.
Linkages
Chapter 4 -- Linkages for Mental Health and AOD Treatment -- describes several areas of critical concern for
programs that provide services to patients with dual disorders. There are discussions regarding policy and planning;
funding and reimbursement; data collection and needs assessment; program development; screening, assessment, and
referral; case management; staffing and training; and linkages with social service, health care, and the criminal justice
systems.
This chapter should be particularly useful for administrators and political planners who address the potential
administrative overlaps and gaps that exist between the mental health and addiction treatment systems. The
semi-outline format of the chapter will allow planners of services a rapid checkup of specific areas such as funding
and reimbursement, program development, and case management.

Specific Psychiatric Disorders

While entire books can be written regarding specific psychiatric disorders, this TIP describes the disorders that
account for the majority of psychiatric problems seen in patients with dual disorders. TIP chapters that address
specific psychiatric problems include:

• Chapter 5, Mood Disorders;
  
• Chapter 6, Anxiety Disorders;
  
• Chapter 7, Personality Disorders; and
  
• Chapter 8, Psychotic Disorders.
  

By combining chapters, strategies for treating patients with complex disorders may be developed. For example, by
combining techniques recommended for the treatment of personality and mood disorders, borderline syndrome
treatment strategies can be developed.
Both content and stylistic approaches vary markedly among these chapters, reflecting the differences of consensus
panel members who composed them. Since these differences in stylistic approaches may be useful to the reader, they
have been retained.
Psychopharmacology

Chapter 9 -- Pharmacologic Management -- is a brief overview of the types of medications used in psychiatry and
addiction medicine and for patients with dual disorders. A stepwise treatment model that can minimize medication
abuse risks is discussed, and cautions about drug interactions are reviewed.
Addiction treatment program staff are increasingly encountering patients who require prescribed medications in order
to participate in recovery. For this reason, it is important for clinical staff to have an understanding of the principle
medications used in psychiatry and how they are used. In addition, agencies that hire a consulting psychiatrist may
want to review with the psychiatrist the prescribing issues raised in this chapter.

Bibliography
A bibliography is provided for further study in Appendix A.

Sample cost data for the treatment of dual disorders
A brief overview of sample cost data for the treatment of dual disorders is in Appendix B. It compares three treatment programs on features such as salary ranges and
administrative costs.