Fundamentals of addiction
Management of concurrent mental health and addiction problems
© 2010 CAMH and St. Joseph’s Health Centre, Toronto
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How do I manage concurrent disorders in patients?
The following general principles apply when working with patients who have concurrent substance use and mental health disorders:
- Try to deal with the addiction problem first: When patients with alcohol or other substance dependence exhibit symptoms of mental health problems, such as depression, anxiety or psychosis, assume that the substance is at least part of the problem. Abstinence is the preferred option for most patients with concurrent disorders.
- When in doubt, refer the patient to a psychiatrist: When patients have a past history of primary mental health problems, taking a close history will likely reveal that these disorders underlie their addiction problem. Treatment for a psychiatric disorder may help to facilitate the treatment of an addiction.
What are the goals when treating patients with concurrent disorders?
Patients with concurrent disorders need comprehensive case management and an integrated treatment approach that involves both addiction and mental health treatment.
Phase 1: Getting started
Goals include medical withdrawal management, comprehensive assessment and stabilization of the mental illness. The focus is on engagement and motivation.
Phase 2: Addiction treatment
Goals include counselling, education, group therapy, mutual aid (e.g., Alcoholics Anonymous), family counselling, life skills and behavioural treatments.
Phase 3: Relapse prevention
Goals include mutual aid, addiction aftercare and concurrent mental health case management to provide long-term follow-up and support.
What are the general principles of pharmacotherapy for mental health problems in patients with substance use disorders?
- Patients with milder mood or anxiety disorders who are able to achieve abstinence should be monitored for four to 12 weeks. If the mood or anxiety disorder persists or worsens over this period, consider pharmacotherapy; however, the psychiatric diagnosis may remain unclear until the patient has abstained for three to six months.
- If symptoms are severe or if you strongly suspect that the patient has a primary psychiatric disorder, consider beginning pharmacotherapy earlier than four to 12 weeks.
- If the patient cannot achieve abstinence and you suspect a primary psychiatric disorder, consider pharmacotherapy.
- If possible, avoid benzodiazepines and opioids. Exceptions are:
- Benzodiazepines have no role in the long-term management of primary anxiety disorders in patients with alcohol dependence.
Contents of Fundamentals of Addiction
FAQ: What is addiction?
FAQ: Mental health and addiction
FAQ: Asking about substance use
FAQ: Reporting to the Ontario Ministry of Transportation
FAQ: Methods of managing addiction
Tools and resources