Subacute Treatment Issues: Matching Patients and Treatment

During subacute treatment, the first decision to be made is whether patients should receive treatment in a psychiatric or addiction setting. In some locations, a third alternative is available: the dual disorders treatment setting. When realistic, both types of treatment should be provided simultaneously; integrated treatment generally is preferable.

Criteria for determining placement include the patient’s treatment needs and potential for loss of control, as well as program features such as intensity, structure, and limitations. There are also considerations specific to mood disorders.

For example, if patients are experiencing mania or psychotic depression with disordered thinking, it must be determined whether the program is capable of handling and treating patients with these problems. While psychotic depression or mania is being managed, patients may then be shifted to an addiction or dual disorder setting. Appropriate matching of patients to facilities is important.

Some patients with dual disorders require rare or minimal psychiatric intervention, such as AOD patients whose bipolar disorder is successfully managed with lithium and regular blood level monitoring. Patients who require a strong recovery-oriented AOD abuse treatment program should also receive treatment for their psychiatric disorder (parallel treatment), with an emphasis on AOD treatment.

In contrast, patients who experience chronic and severe psychiatric disturbances and who episodically use AODs in a markedly destructive fashion will be better treated in a psychiatric program that has staff with expertise in addiction treatment. The optimal match for the patient with two active disorders that require treatment is the integrated facility. The intensity of each disorder dictates the relative intensity of each treatment component required.

Referral to an appropriate facility should be based on practical clinical criteria rather than on diagnosis alone. For example, patients’ ability to understand, interpret, and tolerate the level of care being provided is most important. Some patients can participate in standard 12-step groups. Others will require 12-step groups that are intended for people with dual disorders (Double Trouble groups). Still others will require professionally run therapy groups that include patients with similar problems.

Effective treatment is based on what patients can understand and tolerate, which is not always predicted by diagnosis. Some psychotic patients function well in traditional programs, while others require special settings. An individual plan and a flexible ongoing reassessment of effectiveness are the best ways to ensure fit.

Psychiatric Medications

The judicious use of antidepressant and mood-regulating medication is appropriate for AOD patients with mood disorders. For example, patients who experience debilitating, misery-provoking, and incapacitating depressive symptoms may require antidepressant medication to participate in addiction recovery. (See Chapter 9 for further discussions of psychiatric medications.)

When depressive symptoms interfere with functioning, antidepressant medication can provide symptom relief and allow participation in recovery activities and activities of daily living. Relief from depression and anxiety can be significant motivating factors in recovery. Left untreated, symptoms can keep patients from taking part in recovery activities.

Patients who have difficulty engaging in Alcoholics Anonymous and other support groups and who do not exhibit evidence of a personality disorder may be depressed. Depression may manifest as social withdrawal, reclusiveness, or inability to complete activities of daily living such as going to work. Regularly spending many hours a day in bed or having serious insomnia may be cardinal signs of depression but are often seen among patients with AOD disorders during the first weeks and months of abstinence.

When prescribing antidepressants for people participating in addiction treatment, the acronym MASST is a reminder for clinicians of the areas of AOD recovery that need to be continually assessed. MASST is an acronym that reminds clinicians to assess patients’ treatment needs regarding: 1) Meetings, 2) Abstinence from all psychoactive drugs, 3) Sponsor (or other helping people), 4) Social support systems, and 5) overall Treatment efforts. (See the discussion on the use of 12-step programs in Chapter 6.)

MASST Areas of Recovery

M: Meetings (12-step or other recovery-oriented self-help)

A: Abstinence from all psychoactive drugs

S: Sponsor and other helping people

S: Social support systems

T: Treatment efforts.