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August 2007 - Volume 3, No. 4
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Minding the gap between
addictions and mental health treatmentIntegrating clinical training in concurrent disorders
with the general psychiatry residency
by Adam Quastel, MDCM, FRCPC
Medical Head, Substance Abuse and Mental Illness Program,
St. Michael’s Hospital Mental Health Service, Toronto;
Lecturer, University of Toronto Faculty of Medicine, Department of Psychiatry
The high rate of comorbidity of mental health and substance use disorders has been repeatedly observed in population studies as well as clinical settings.
People with mood disorders are estimated to have more than double the lifetime risk of substance abuse problems than the general population—the rate is greater than six times for those with bipolar disorder. People with schizophrenia are 13 times more likely to use cocaine and up to 70 to 90 per cent are cigarette smokers.
Conversely, up to one-third of opiate addicts are believed to have depressive disorders and concurrent anxiety disorders have been noted to present in about 30 per cent of alcoholics.
Given these high rates of comorbidity, it should come as no surprise when mental health service users present with alcohol and drug problems. Such disclosure should be considered the norm in psychiatric practice and a testament to a clinician’s ability to create a trusting treatment environment. Training new psychiatrists in addictions and concurrent disorders is therefore an integral part of preparation for real life clinical responsibility.(1)
Most current recommendations on managing concurrent disorders suggest that treatment be provided in an integrated fashion(1,2), however this has remained a challenge since there is a historical lack of knowledge and training in addiction disorders amongst physicians.
Education researchers have helped to define and identify this gap throughout the 1990s, and the incentive to increase the capacity of physicians as a group is spirited by encouraging research indicating that knowledge of addiction disorders and simple clinical interventions can have impressive effects.(3)
Bridging the divide between psychiatry and addictions
To a great extent, this gap is a by-product of the historical separation of mental health and addictions treatment. It has affected both treatment realms—while we in mental health care suffer from a lack of knowledge of addictions treatments, the addictions treatment world has not conventionally adapted their interventions for people with concurrent mental health disorders.
Our patients suffer from this historical legacy—particularly people with severe and persistent mental illnesses (and especially schizophrenia) who can find support for addiction disorders in distressingly few settings.
Treatment of concurrent disorders—and, in turn, providing truly comprehensive general psychiatric care—necessitates closing this gap by increasing the capacity of addictions facilities to accommodate people with mental illness while making addictions treatments better understood by clinicians in the mental health field.
However, the barriers to best practices will always be the availability of suitably trained clinicians. The provision of suitable care in psychiatry requires not just access to addictions experts, but generalists comfortable with integrated approaches. The core need is to shift attitudes and expand knowledge by better integrating addictions treatment knowledge and skills into psychiatry training.
Addictions training in general psychiatry
There are various models aimed at integrating treatment practice by bringing together addictions and mental health skills at the clinical level. Mental health or psychiatric services can move forward by identifying core competencies in addictions that can be worked into the everyday operation of clinical programs while utilizing the knowledge of identified addictions experts to increase program capacity.(1,2)
The same ideas apply in psychiatry training—identifying core competencies that are required for proficiency across the board, then specifying the additional specialist training that would confer the status of expert. While the latter expert training has conventionally involved clinic experience in specialized programs, such as medical withdrawal management units, addictions treatment facilities, addictions medicine units, methadone clinics, or concurrent disorders units, training for the former has been less developed.
In the United States, the shortage of addictions psychiatrists was addressed through the 1990s with the growth of addictions psychiatry residencies based largely in specialized addictions and concurrent disorders sites. Despite this success in sub-specialty training there has been little integration of these specialty training programs with general psychiatry training even when the programs
co-exist in the same institution.(4,5)
The identification and development of addictions education as a component of general psychiatry training is thus a developing area requiring attention if future generations of psychiatrists are to effectively manage the load of concurrent disorders pathology in a general psychiatry population.
Be that as it may, model curricula indicating specialty and integrated training needs have been forwarded over the past decade or more.(6) The Canadian Psychiatric Association’s 1996 position paper on addictions training guidelines, for example, outlines a training curriculum spanning didactic teaching, core integrated training, and optional specialty training.(7)
The Toronto model: PGY 1-5
Locally developed guidelines at the University of Toronto’s Department of Psychiatry similarly outline level specific training needs for the PGY 1-5 years.(8)
In this curriculum, the PGY-1 year builds on the core undergraduate training when medical students are introduced to basic addictions knowledge such as identification of withdrawal and intoxication states, common comorbid psychiatric symptomatology, and basic introduction to psychosocial interventions.
PGY-1 residents go through a four-week addictions rotation—fulfilling the Royal College addictions education requirements—in which core competencies are introduced through interaction with a variety of specialized addictions training sites. At this level, the focus is on withdrawal management and addictions medicine, including understanding Alcoholics Anonymous and other 12-step programs, as well as introduction to mental health comorbidities including identification and screening for addiction disorders.
In the PGY-2 general psychiatry training year, addictions training is concentrated on working with concurrent disorders as they present in general psychiatry practice—a true-to-life model of the practical application of addictions knowledge in general psychiatry.
This involves preparing residents to conduct, when necessary, a suitable addictions interview as part of the general assessment. Residents are expected to provide a complete, relevant DSM IV diagnosis and management plan for an addictions or concurrent disorders case just as they would for any psychiatry specialty area presenting in a general psychiatry setting. As would be the case for any other subspecialty area, the general psychiatry trainee should be able to implement a care plan and provide clinical care for straightforward or moderately complex cases.
The curriculum suggests an analogous format for the PGY-3 and PGY-4 years when residents rotate through a variety of psychiatry specialty areas. Opportunities for clinical teaching in addictions and concurrent disorders might include substance-related cognitive impairments during a consultation/liaison rotation, working with a substance-dependent patient with schizophrenia during chronic care rotations, or identifying and managing substance use in an adolescent patient during the child psychiatry rotation.
Addictions training can be blended with the psychotherapy training across all postgraduate years by offering structured supervision in motivational enhancement or cognitive behavioural interventions for patients with addiction disorders.
Didactic teaching requirements are also crucial to enhance baseline knowledge and raise the stature of addictions psychiatry within the residency. Finally, in the PGY-5 year when residents focus on specialty areas, the availability of addictions psychiatry training sites makes possible concentrated clinical experiences for the resident interested in subspecialty training or enhancing their skills in concurrent disorders.
In an ideal setting where general psychiatrists and addictions sub-specialists work together to identify and manage mental health and addiction comorbidities, such a model curriculum might naturally be accomplished. In real life settings, competition among psychiatry sub-specialties for space and attention in a crowded curriculum slows the implementation of even the best laid plans.
The interest and skill level of existing faculty will always be the test of a program’s capacity to provide integrated concurrent disorders training. Addictions psychiatry faculty are often placed to provide specialized addictions experiences, but may have no direct connection with general psychiatry training. Conversely, there is no guarantee that supervisors in other specialty domains have interest or experience in managing concurrent disorders.
Enacting change necessitates intervention in a number of realms—advocacy for curriculum change; capacity building for teaching staff; active concurrent disorders clinical practice sites that model integrated practice; and support of residents interested in specialty training. Success in these areas will help train a cohort of future supervisors better equipped to provide integrated treatment for future trainees.
Perhaps one of the least significant training issues is having access to concurrent disorders cases. Patients with comorbid substance use disorders present routinely across all areas of psychiatry. If educational development followed simply on the heels of clinical demand, concurrent disorders and addictions would be well on their way to the mainstream of general psychiatry training.
References
1. Mueser, K.T., Noordsy, D.L., Drake, R.E., Fox, L. Integrated treatment for dual disorders: a guide to effective practice. New York: The Guilford Press, 2003.
2. Minkoff, K. (2001) “Developing standards of care for individuals with co-occurring psychiatric and substance use disorders." Psychiatric Services. 2001; 52(5):597-599.
3. El-Guebaly, N., Toews, J., Lockyer, J., Armstrong, S., Hodgins, D. “Medical education in substance related disorders: components and outcomes." Addiction. 2000; 95(6):949-957.
4. Greenberg, W., Ritvo, J.I., Fazzio, L., Bridgeford, D., Fong, T. “A survey of addiction training programming in psychiatry residencies." Academic Psychiatry. 2002; 26(2):105-109.
5. Galanter, M., Dermatis, H., Calabrese, D. “Residencies in addiction psychiatry: 1990 to 2000, a decade of progress." American Journal of Addiction. 2002; 11:192-199.
6. Halikas, J.A. “Model curriculum for alcohol and drug abuse training and experience during the adult psychiatry residency." American Journal of Addictions. 1992; 1(3):222-229.
7. el-Guebaly, N. and Garneau, Y. Curriculum guidelines for residency training of psychiatrists in substance related disorders. CPA Position Paper. 1996. www.cpa-apc.org/
Publications/Position_Papers/Substance.asp.
8. Ballon, B. Clinical training in addiction psychiatry. Unpublished working document for the University of Toronto Addictions Psychiatry Program. 2005.
© Copyright 2007. Canadian Psychiatry Aujourd'hui. All rights reserved.
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