Clinical Textbook of Addictive Disorders 3rd ed - R. Frances, S. Miller, A. Mack (Guilford, 2005) WW

12. Co-Occurring Substance Use Disorders and Other Psychiatric Disorders 279not be optimal. However, providing group treatments tailored to patientswith some degree of diagnostic homogeneity (e.g., patients with bipolar disorderand SUDs) can be a difficult strategy to implement if one is unable torecruit a large enough clinical population for these groups. Similarly, evenwithin diagnostically homogeneous groups, considerable heterogeneity in illnessseverity and functioning may still exist. Ries, Sloan, and Miller (1997)have suggested a conceptual approach that divides dually diagnosed patientsinto four major subgroups, according to the severity (i.e., major or minor) ofeach disorder. Although this is a somewhat crude way to classify patients, itmay be helpful in developing an outpatient group treatment program fordually diagnosed patients.An additional consideration is that not all patients are similar in terms ofinsight regarding their SUD, nor are they similarly ready to address it. Thus,patients who are undecided whether or not to address their substance use maydo better in a group focused on resolving that issue, as opposed to a group inwhich all participants are actively engaged in treatment and making lifestylechanges to support sobriety. We know of no studies, however, that have testedthis idea empirically. It is possible, for example, that having a mix of patientseverity levels in one group allows patients the opportunity to learn from thosefurther along in their recovery. This is a central principle of Alcoholics Anonymous(AA), and appears to have strong anecdotal support. Treatments thatfocus on particular dual diagnoses (e.g., bipolar SUD patients) also have notbeen directly compared to more general thematic groups (e.g., dual diagnosisgroups that are more general, encompassing a wide variety of diagnoses). Thus,it remains an empirical question how the known heterogeneity of such patientsshould best be addressed within the realistic constraints of specific clinical settings.Sequential, Parallel, and Integrated Treatment ModelsThere are three major models in which dually diagnosed patients are treated:sequential, parallel, and integrated treatment. Each is discussed below.In sequential treatment, the more acute condition is treated first, followed bythe less acute co-occurring disorder. The same staff may treat both disorders, orthe less acute disorder may be treated after transfer to a different program orfacility. For example, a manic patient with a cocaine use disorder needs moodstabilization before initiating substance abuse treatment. Conversely, a patientwith major depression and alcohol withdrawal delirium is not in a position todiscuss treatment adherence to antidepressant medication. Instead, this issue isbest addressed when the patient is more stable. Although sequential treatmenthas the advantage of providing an increased level of attention to the moreacute disorder, a typical disadvantage of this model is that patients are often