178 B7: Managing and treating ADHD

Attention-deficit/hyperactivity disorder (ADHD)

ADHD and AOD use frequently co-occur, and there is evidence to suggest that the presence of ADHD
is a primary risk factor for the development of AOD use disorders [872, 873]. Research suggests that
untreated ADHD is associated with a more problematic course of AOD use disorder, with clients less likely
to gain benefits from treatment, adhere to treatment, and achieve and maintain abstinence [874–876].
ADHD is also associated with an earlier age of first substance use, higher rates of poly-substance use,
greater substance dependence, and increased risk of relapse [873, 877–879]. However, evidence suggests
that responding early to ADHD through the provision of appropriate evidence-based treatments can
prevent the development of AOD use disorders among adolescents, and reduce the risk of AOD relapse
among adults [877, 880].

Difficulties can be faced when assessing and screening for the presence of co-occurring ADHD, as
symptoms can be masked or even resemble those of intoxication or withdrawal (see Chapter A4) [878,
881, 882]. Although some experts recommend an abstinence period of one month or more to assist with
diagnosis [102, 883, 884], this strategy is not supported by the broader evidence base, or the majority of
experts [883, 885–887].

To assist with clinical decision making, it may be useful to involve family members or friends, who can
provide further information and clarification regarding the presence of attention problems, impulsivity,
and restlessness over the person’s lifetime [884].

Clinical presentation
ADHD represents a persistent pattern of developmentally inappropriate levels of inattention,
hyperactivity, and/or impulsivity [10, 11]. Although estimates vary, research conducted in the last decade
indicates that, on average, 55% of children and adolescents diagnosed with ADHD in childhood will
continue to have the disorder in adulthood [888]. Attentional difficulties in particular are more likely
to persist into adulthood, whilst impulsivity and hyperactivity tend to diminish over time [889]. Adult
symptoms are expressed differently to the way in which they are expressed in childhood, and may
include [10, 11]:

• Difficulties paying close attention to detail.

• Difficulties maintaining focus.

• Easily distracted.

• Difficulties completing tasks or projects.

• Disorganisation.

• Procrastination.

• Lack of motivation.

• Difficulties concentrating or studying (which may present as academic underachievement).

• Occupational or workplace difficulties.

B7: Managing and treating ADHD 179

• Forgetfulness, including the frequent loss of possessions.

• Restlessness.

• Difficulties with time management.

• Difficulties sleeping, and/or fatigue.

• Irritability, frustration, or anger.

• Problems forming and maintaining relationships.

• Difficulty obtaining and/or maintaining stable employment.

• History of imprisonment or frequent contact with police.

Some symptoms which clients may present with, such as problems sleeping, irritability and fatigue, are
not unique to ADHD, but are common to many mental disorders.

Managing ADHD symptoms

Research indicates that people diagnosed with ADHD in adulthood may require additional psychosocial
support to assist them to come to terms with their diagnosis, and reframe their past [890]. The
techniques outlined in Table 39 can help AOD workers manage clients with ADHD symptoms.

Table 39: Dos and don’ts of managing a client with symptoms of ADHD

Do:

Reduce or remove distracting stimuli.

Consider using visual aids to convey information.

Assist the client plan activities and encourage the use of appropriate tools (e.g., smartphone,
activity journal) to organise prompts, reminders, and important information.

Encourage stress-reduction methods, such as progressive muscle relaxation.

Encourage physical exercise.

Involve family members and friends – educating them about the condition and treatment will
provide long-term benefits.

Offer to help the client engage with education courses or training, which can assist with attention
training.
180 B7: Managing and treating ADHD

Table 39: Dos and don’ts of managing a client with symptoms of ADHD (continued)

Don’t:

Get visibly upset or angry with the client.

Confuse the client by conducting unstructured, unfocused sessions.

Overwhelm the client by conducting lengthy meetings or verbal exchanges.

Adapted from Gournay [891], SAMHSA [102], and Zulauf [892].

Treating ADHD
There are several options available for the treatment of ADHD, including psychotherapy,
pharmacotherapy, e-health interventions, physical activity, as well as complementary and alternative
therapies (e.g., dietary supplements). The evidence base surrounding each of these treatments is
discussed below. There is a general consensus that the treatment of co-occurring ADHD and AOD
use should use an integrated multimodal approach, with components of individual and/or group
psychotherapy, psychoeducation, as well as peer and family support, to enhance the effect of treatment
[9, 884, 893–895]. In general, evidence suggests that treatments focusing on either ADHD or AOD use
in isolation are not effective at treating both disorders [896]. However, there is some recent evidence to
suggest that reducing AOD use, or maintaining abstinence following AOD treatment, may improve ADHD
symptoms [897, 898]. Evidence from the broader ADHD literature suggests that an approach combining
psychotherapy and pharmacotherapy may result in better outcomes for ADHD symptoms than either
psychotherapy or pharmacotherapy alone [781, 886, 892, 899–901], however, this approach has yet to be
rigorously evaluated among people with co-occurring ADHD and AOD use.

Psychotherapy
Psychotherapy is recommended as a critical component of a multimodal approach targeted towards
co-occurring ADHD and AOD use [884, 894, 902]. Evidence suggests that CBT is the most effective
psychological approach for ADHD, when delivered in conjunction with pharmacotherapy [781, 884, 892,
903]; however, positive outcomes have also been associated with the use of other approaches, such as
meta-cognitive group therapy [904, 905], structured skills training [906, 907], virtual remediation therapy
[908], and cognitive remediation, both as therapist-led programs [909] and self-directed interventions
[910].

Common therapeutic elements include psychoeducation, a focus on problem solving and planning,
strategies to improve attention, impulsivity management, and cognitive restructuring [893, 903].
Evidence suggests that a structured format of repetitive skills practising and reinforcement of coping
strategies for core ADHD symptoms are key components for the effective treatment of ADHD [911, 912].
However, these interventions have yet to be evaluated among people with co-occurring AOD use. DBT-
based skills training may be a promising treatment for co-occurring ADHD and AOD use. In a small
B7: Managing and treating ADHD 181

feasibility study conducted among Swedish men in compulsory care for severe AOD use disorders, self-
reported ADHD symptoms, general wellbeing, and externalising behaviours improved after six weeks of
manualised, structured skills training groups [913]. While the lack of control group and low treatment
acceptability and feasibility suggest more research is needed, these findings are encouraging.

To date, only one integrated psychotherapeutic approach for co-occurring ADHD and AOD use has been
rigorously evaluated, which compared CBT for AOD use with an integrated CBT program for ADHD and
AOD use [914]. The integrated CBT program consisted of motivational therapy, coping skills training and
relapse prevention for AOD use, planning and problem-solving skills, and dealing with emotions; whereas
the CBT for AOD use focused only on AOD use. While those in the integrated CBT group demonstrated
greater reductions in ADHD symptoms compared to those who received CBT for AOD use alone, there
was no difference between groups in relation to AOD use or other outcomes [914]. While more research is
needed to support conclusive recommendations, these findings are promising.

Lastly, there is preliminary evidence to support the use of behavioural interventions focused on academic
training for adolescents with ADHD and AOD use disorders, but further research is needed [875].

Pharmacotherapy
There are two main types of pharmacotherapies used in the treatment of ADHD: psychostimulants
and non-stimulants. Table 40 lists some of the pharmacological treatments for ADHD. For ADHD
as a single disorder, the first line pharmacotherapies are the psychostimulants lisdexamfetamine
and methylphenidate [885, 915]. Despite robust findings regarding the effectiveness of these
pharmaceuticals among people with ADHD alone, findings among people with co-occurring AOD use
disorders have been less promising. While these medications have been associated with modest
reductions in ADHD symptoms, few studies have found them to demonstrate superiority over placebos
[916, 917]. Nonetheless, psychostimulants, in combination with psychotherapy, are safe, are associated
with reductions in ADHD symptoms, and remain the first line recommendation for the treatment of ADHD
among people with AOD use disorders [884, 916, 917]. Some trials also indicate that more meaningful
reductions in ADHD symptoms among people with AOD use disorders may be achieved with higher
doses of psychostimulants [884, 918]. Irrespective of dose, it is essential that a medical assessment
be conducted prior to the prescription of psychostimulants to ensure that the person does not have
cardiovascular or other conditions that may contraindicate psychostimulant prescription [919].

While there has been some concern regarding the use of psychostimulants among people with AOD use
disorder due to their potential for misuse and diversion [920], it is important to note that this view is
not supported by the evidence. Psychostimulant medications, particularly longer acting formulations
such as lisdexamfetamine or extended-release methylphenidate, have low abuse potential [884, 921].
Nonetheless, it has been suggested that prescribers may wish to consider the use of non-stimulants if
extra-medicinal use of psychostimulants is of great concern [916]. In view of the fact that non-stimulants
are less efficacious than psychostimulants in treating ADHD, and in the absence of evidence of any
misuse of long-acting stimulants in clinical trials, there is a need to balance the potential risk of misuse
and diversion, against the risk of untreated or inadequately treated ADHD [922].

Atomoxetine, a non-stimulant noradrenaline reuptake inhibitor, is recommended for those who

182 B7: Managing and treating ADHD

cannot tolerate, or do not respond to, lisdexamfetamine or methylphenidate [885]. As is the case
with psychostimulants, it appears that atomoxetine may not be as effective among people with AOD
use disorders compared to those with single disorder ADHD, but this body of research is small [916].
Close monitoring for signs of any depressive symptoms during the first few months of atomoxetine
administration is recommended (including agitation, self-harm behaviours, and suicidal ideation) as
there have been some reports of increased risk among children [919]. Preliminary research has also
been conducted on the non-stimulants bupropion (norepinephrine reuptake inhibitor), guanfacine and
clonidine (alpha 2- adrenoceptor agonists); but conclusions regarding their efficacy cannot be made at
this time [884, 916].

Table 40: Pharmacotherapy medications for ADHD

Drug name Brand name Drug type

Methylphenidate Artige, Concerta, Psychostimulant
Ritalin

Dexamphetamine Aspen Psychostimulant

Lisdexamfetamine Vyvanse Psychostimulant

Atomoxetine Strattera Noradrenaline

reuptake inhibitor

Adapted from Zalauf et al. [892], Pérez de los Cobos et al. [886] and the Better Health Channel [923]. For a full list of generic
brands available, see the Therapeutic Goods Administration website (https://www.tga.gov.au).

E-health and telehealth interventions

Emerging e-health programs combine elements from successful CBT treatments for single disorder
ADHD into internet-based interventions. These interventions, aimed at assisting people with ADHD
structure and organise their lives, incorporate aids such as calendars, schedules, timers, reminders,
shopping lists, and cleaning and laundry schedules, all of which are easily accessible on smartphones
[924, 925]. Smartphone features such as text messages, cameras, GPS, and voice memos, may also be
useful.

One RCT has evaluated an internet-based course teaching people with single disorder ADHD to use
smartphone applications to improve their everyday organisational skills [925]. The course, delivered
with therapist support, teaches participants how to effectively use their smartphone applications to
better organise their lives. Compared to a wait-list control, participants randomised to receive the course
illustrated a significantly larger decrease in ADHD symptoms, including inattention and hyperactivity.
One-third of participants (33%) were deemed to have made a clinically significant improvement in
organisation and attention over the study period, as assessed by clinicians. Although this research has
yet to be conducted among people with co-occurring ADHD and AOD use, the findings from this RCT are
promising.
B7: Managing and treating ADHD 183

Physical activity
Although ADHD treatment is primarily focused on psychotherapy and pharmacotherapy, there is
emerging evidence to suggest that physical activity may have beneficial effects similar to those of
psychostimulant medications, and more beneficial effects on some treatment outcomes compared to
psychotherapies such as CBT [926, 927]. Research indicates that exercise interventions (frequent aerobic
exercise in particular) may assist with the management of ADHD symptoms, particularly intrusive
thoughts, worry, and impulsivity [928]. One meta-analysis has suggested that moderate-intensity aerobic
exercise may reduce symptoms of hyperactivity, impulsivity, anxiety, and inattention, and improves
executive functioning among young boys aged 8 to 13 years with ADHD [929]. As such, exercise may be a
useful adjunct to pharmacotherapy and psychotherapy for ADHD; however, this approach has yet to be
rigorously evaluated in adults with co-occurring ADHD and AOD use [928].

Complementary and alternative therapies

Dietary supplements

There has been very little research examining the use of dietary supplements for ADHD. However, two
meta-analyses have concluded that omega-3 supplementation is associated with modest ADHD
symptom improvement for single disorder ADHD in children and adolescents [930, 931]. Moreover,
another study has reported that omega-3 and omega-6 fatty acids have similar benefits to, and may
improve the tolerability of, methylphenidate in single disorder ADHD [932]. In contrast, however, an RCT
examining the role of omega-3 and omega-6 supplementation over 12 weeks in children with ADHD
did not find any significant treatment effects on aggression, impulsiveness, depression, or anxiety
symptoms relative to placebo [933]. Findings from these studies suggest that intervention length may
moderate treatment effects, and that omega-3 and omega-6 supplements may require dosing durations
of up to 6 months before any symptom benefits become evident [933]. While these findings have yet
to be replicated among adults, and among people with co-occurring ADHD and AOD use, they point to
potential avenues of future research.

Mindfulness

Mindfulness interventions for single disorder ADHD have been evaluated in three meta-analyses, which
found reductions in ADHD and depressive symptoms, and improvements in executive functioning
among children, adolescents, and adults, with larger effects for adults than children [934–936]. Some
research suggests that, among adults, mindfulness exerts similar effects to other established treatment
strategies (e.g., structured skills training [906]). However, this research is yet to be conducted among
people with co-occurring ADHD and AOD use.

Summary
For those with co-occurring ADHD and AOD use, reviews of the evidence recommend an integrated,
multimodal approach, with components of individual and/or group psychotherapy, psychoeducation,
as well as peer and family support [9, 884, 893–895]. The use of structured psychotherapies, including
CBT with a focus on goals, with active AOD worker involvement and effective social support, is likely to
184 B7: Managing and treating ADHD

be the most beneficial [884, 892] and, as with the treatment of other co-occurring disorders, treating
both conditions concurrently is more likely to produce a positive treatment outcome than treating either
disorder alone [102, 896, 922]. Box 14 illustrates such a multimodal approach through the continuation of
case study A, after Sam's ADHD was identified.

Box 14: Case study A: Treating co-occurring ADHD and AOD use: Sam’s story continued

Case study A: Sam’s story continued

Based on Sam’s symptoms, the AOD worker thought it would be beneficial for her to see a psychiatrist
who specialised in adult ADHD, and asked Sam if she would be willing to see a psychiatrist who would be
able to assess her further and help develop a treatment plan. The AOD worker told Sam that they would be
happy to keep seeing her and liaise with both her GP and the psychiatrist. Sam thought this was a good
plan and consented to the sharing of information between these services.

The AOD worker helped Sam make an appointment to see the psychiatrist and her GP, and helped Sam
put these appointments into her phone calendar, setting reminders. Sam also organised a follow-up
appointment to see the AOD worker after her appointments with the GP and psychiatrist. With Sam’s
permission, the AOD worker invited Sam’s partner into the consultation room and let them know about
the upcoming appointments so they could remind Sam and help her arrive on time. Sam had agreed
to the AOD worker discussing her condition with her partner, as she understood they would be able
to provide additional information about her condition and be helpful and supportive of her ongoing
treatment.

The psychiatrist who assessed Sam diagnosed her with ADHD, and noted the range of inattention,
hyperactivity and impulsivity symptoms that were present. The psychiatrist also mentioned that the
way Sam responded to her use of Ritalin and methamphetamines, where she did not experience a ‘high’
but instead felt calm and relaxed, was significant. The psychiatrist explained that psychostimulants
are one of the primary treatments for ADHD, which are carefully prescribed and monitored. After Sam’s
GP conducted a thorough medical assessment, the psychiatrist prescribed her with psychostimulant
medication and advised Sam that it was important for her not to use any other substances, because
of the possibility of interactions between drugs. The AOD worker told Sam she would be available for a
phone or Zoom call every day during Sam’s first week taking the psychostimulants, to see how she was
going.

Sam continued with her treatment and recommenced NRT. In addition to regular monitoring and some
minor adjustments to the psychostimulant dosage, Sam attended individual sessions with her AOD
worker, where she was provided with a range of evidence-based interventions to help her with her alcohol,
methamphetamine and cannabis use. These began with psychoeducation and information about the
substances Sam had been using, focusing on the way in which they affected her ADHD and how her ADHD
symptoms impacted on her substance use. The AOD worker also suggested some relaxation exercises for
occasions when she became tense, that Sam began to practice and enjoy.
B7: Managing and treating ADHD 185

Box 14: Case study A: Treating co-occurring ADHD and AOD use: Sam’s story
(continued)

Sam also re-enrolled in a part-time TAFE course, and started working part-time in a fabric shop, which
aligned well with her studies in design. An important component of her treatment plan was helping
Sam organise activities which were part of her everyday life. The AOD worker helped Sam set up a daily
calendar, and use different functions on her smartphone (i.e., setting alarms for important events,
scheduling meetings and appointments). Sam’s partner also helped her keep a schedule and maintain
reminders and appointments in her phone.

Key points:
• Treatment for ADHD and AOD use should be concurrent and multimodal.
• Providing education about the nature of the ADHD, AOD use and their relationship, is
essential – for both the client, friends and family.
• Treatment requires long-term planning and follow-up and more general efforts at
rehabilitation, including further education.
B7: Managing and treating psychosis 187

Psychosis

Clinical presentation
Acute psychosis represents one of the most severe and complex presentations, and one of the most
intrusive when attempting to treat co-occurring AOD use [937]. During an acute episode of psychosis, a
person’s behaviour is likely to be disruptive and/or peculiar. Symptoms of psychosis include [938]:

• Delusions – false beliefs that are held with conviction. They are often bizarre and may involve a
misinterpretation of perceptions or experiences (e.g., thinking that someone is out to get you, that
you have special powers, or that passages from the newspaper have special meaning for you).

• Hallucinations – false perceptions such as seeing, hearing, smelling, sensing, or tasting things that
others cannot.

• Disorganised speech – illogical, disconnected, or incoherent speech.

• Disorganised thought – difficulties in goal direction such that daily life is impaired.

• Catatonic behaviour – decrease in reactivity to environment (e.g., immobility, peculiar posturing,

motiveless resistance to all instructions, absence of speech, flattened affect).

• Rapid or extreme mood swings or behaviour that is unpredictable or erratic (often in response to
delusions or hallucinations; e.g., shouting in response to voices, whispering).

It is important to note that mood swings, agitation, and irritability without the presence of hallucinations
or delusions does not mean that the person is not psychotic. Workers should respond to these clients in
the usual way for such behaviour (described in this chapter), such as providing a calming environment
so their needs can be met [541].

People in AOD settings commonly present with low-level psychotic symptoms, particularly as a result of
cannabis or methamphetamine use. These clients may display a range of low-grade psychotic symptoms
such as [541]:

• Increased agitation, severe sleep disturbance.

• Mood swings.

• A distorted sense of self, others, or the world.

• Suspiciousness, guardedness, fear, or paranoia.

• Odd or overvalued ideas.

• Illusions and/or fleeting, low-level hallucinations.

• Erratic behaviour.

Co-occurring AOD use adds to diagnostic uncertainty in presentations where there are symptoms
of psychosis. For many people who experience psychotic symptoms as a direct effect of intoxication
(auditory or visual hallucinations, paranoia) these experiences will resolve when the drug has left the
body. These experiences may be considered by people who use AOD as a ‘bad trip’. If symptoms persist
188 B7: Managing and treating psychosis

for periods beyond intoxication, however, it is important to consider whether they may be part of an
emerging or underlying psychotic episode. This becomes likely where symptoms are persistent and
distressing for at least one week (see Chapter B3). Although approximately one third of psychotic
disorders are initially diagnosed as substance-induced [939], 25% are later revised to schizophrenia [38,
940]. Substance-induced psychosis may be virtually indistinguishable from an independent psychotic
disorder at initial presentation [941], and longitudinal observation under abstinence conditions may be
necessary to distinguish between them [102, 942]. The identification, management and treatment of
substance-induced disorders are described in more detail later in this chapter. Irrespective of whether a
person’s psychotic symptoms are substance-induced or not, early identification and intervention is key
to optimal outcomes [943–945].

Managing symptoms of psychosis

Table 41 presents some strategies for managing acute psychotic symptoms. Some clients may be
aware that they are unwell and will voluntarily seek help; others may lack insight into their symptoms
and refuse help. If the active-phase psychosis is putting the client or others at risk of harm, it may be
necessary to contact mental health services. It is also true that many people with psychotic illness are
vulnerable to manipulation, including interpersonal violence, financial and sexual exploitation.

It should also be remembered that there is much stigma and discrimination associated with both
psychotic spectrum disorders and AOD use, and some people may attempt to conceal either one or
both of their conditions. Many people with co-occurring psychosis and AOD use are frightened of being
imprisoned, forcibly medicated, or having their children removed [778, 795]. Take the time to engage the
person, developing a respectful, non-judgemental relationship with hope and optimism. Use a direct
approach but be flexible and motivational [795].

Table 41: Dos and don’ts of managing a client with symptoms of psychosis

Do:

Ensure the environment is well lit to prevent perceptual ambiguities.

Ensure discussions take place in settings where privacy, confidentiality, and dignity can be
maintained.

Try to reduce noise, human traffic, or other stimulation within the person’s immediate
environment (e.g., reduce clutter).

Ensure the safety of the client, yourself, and others.

Allow the person as much personal space as possible.

Be aware of your body language – keep your arms by your sides, visible to the client.

Ignore strange or embarrassing behaviour if you can, especially if it is not serious.

Listen attentively and respectfully.

B7: Managing and treating psychosis 189

Table 41: Dos and don’ts of managing a client with symptoms of psychosis (continued)

Do:

Appear confident, even if you are anxious inside – this will increase the client’s confidence in your
ability to manage the situation.

Be empathic. Psychotic experiences are typically frightening and distressing.

Speak clearly and calmly, asking only one question or giving only one direction at a time.

Present material in simple and concrete terms, with examples.

Use a consistently even tone of voice, even if the person becomes aggressive.

Limit eye contact as this can imply a personal challenge and might prompt a hostile, protective
response.

Point out the consequences of the client’s behaviour. Be specific.

Ensure both you and the client can access exits – if there is only one exit, ensure that you are
closest to the exit.

Have emergency alarms/mobile phones and have crisis teams/police on speed dial.

If psychosis is severe, arrange transfer to an emergency department for assessment and

treatment by calling an ambulance on 000.

Don’t:

Get visibly upset or angry with the client.

Confuse and increase the client’s level of stress by having too many workers attempting to
communicate with them.

Argue with the client’s unusual beliefs or agree with or support unusual beliefs – it is better to
simply say ‘I can see you are afraid, how can I help you?’

Use ‘no’ language, as it may provoke hostility and aggression. Statements like ‘I’m sorry, we’re not
allowed to do that, but I can offer you other help, assessment, referral…’ may help to calm the client
whilst retaining communication.

Use overly clinical language without clear explanations.

Crowd the client or make any sudden movements.

Leave dangerous items around that could be used as a weapon or thrown.

Adapted from NSW Department of Health [431], Canadian Guidelines [778], Jenner et al. [541], SAMHSA Guidelines [102], and UK
NICE Guidelines [795].
190 B7: Managing and treating psychosis

Some clients with psychotic disorders may present to treatment when stable on antipsychotic
medication and thus may not be displaying any active symptoms. These clients should be encouraged
to take any medication as prescribed, and supported to maintain an adequate diet, relaxation, and sleep
patterns because stress can trigger some psychotic symptoms [946].

Despite the risk of further psychotic episodes, some people may continue using substances that can
induce psychosis. In such cases, the following strategies may be helpful [541]:

• Talk to the client about ‘reverse tolerance’ (i.e., increased sensitivity to a drug after a period of
abstinence) and the increased chance of future psychotic episodes.

• Try and understand whether there is a pattern between AOD use and psychotic symptoms. Some
people may use AOD to block out distressing symptoms; others may continue to use for the
positive effects of substances despite the knowledge they will also experience the negative effects
such as psychotic symptoms.

• Encourage the client to avoid high doses of drugs and riskier administration methods (e.g.,
injecting in the case of methamphetamine).

• Encourage the client to take regular breaks from using and to avoid using multiple drugs.

• Help the client recognise early warning signs that psychotic symptoms might be returning
(e.g., feeling more anxious, stressed or fearful than usual, hearing things, seeing things, feeling
‘strange’), and encourage them to immediately stop drug use and seek help to reduce the risk of a
full-blown episode.

• Inform the client that the use of AOD can make prescribed medications for psychosis ineffective.

Social stressors can be an added pressure for clients with psychotic conditions and the client may
require assistance with a range of other services including accommodation, finances, legal problems,
childcare, or social support. With the client’s consent, it can be helpful to consult with the person’s family
or carers and provide them with details of other services that can assist in these areas. Family members
and carers may also require reassurance, education, and support. See Chapter B5 for strategies on how
to incorporate other service providers in a coordinated response to clients’ care.

Treating psychotic spectrum disorders

In general, if a person is well maintained on medication for their psychotic disorder, then management
for AOD use should proceed as usual. Although AOD workers may feel daunted at the prospect of treating
this often severe and complex clinical group, it is crucial to remember that treatment and care should
reflect a person’s needs and preferences, whilst taking into account the evidence base.

People with co-occurring psychotic spectrum and AOD use disorders should have the opportunity to
participate and make informed choices about their treatment, in consultation and partnership with their
health care providers [778]. UK and Canadian guidelines on the management of co-occurring psychosis
and AOD use recommend that, when planning treatment, workers take into account the severity of both
disorders, the person’s social and treatment context, and their readiness to change [778].
B7: Managing and treating psychosis 191

There are several options available for the treatment of co-occurring psychotic disorders and AOD
use, including psychotherapy, pharmacotherapy, ECT, e-health interventions, physical activity, and
complementary and alternative therapies. Clinical guidelines in Australia and internationally currently
recommend the use of integrated treatment programs addressing both psychosis and AOD use, and
suggest that a combination of antipsychotic pharmacotherapy with psychosocial interventions focused
on AOD use may produce the best outcomes [444, 778, 779, 942]. The evidence base surrounding each of
these approaches is discussed below.

Psychotherapy
A Cochrane review [947] of RCTs examining psychosocial treatments for co-occurring severe mental
illness (predominantly psychotic spectrum disorders) and AOD use concluded that there is no clear
evidence supporting the use of any one approach to psychological treatment over standard care, with
many studies reporting mixed findings. The authors note, however, that it is difficult to draw any firm
conclusions from the current evidence base due to methodological differences between studies. The only
clear finding was an association between MI and greater reductions in alcohol use relative to standard
care [947].

Barrowclough and colleagues [948] suggest that MI techniques may need to be adapted for clients with
psychotic disorders because disorganised thoughts and speech may make it difficult for AOD workers to
understand what the client is trying to say, and psychotic symptoms (combined with AOD use and heavy
medication regimes) may impair clients’ cognitive abilities. For this reason, it is recommended that
therapists:

• Make use of more frequent and shorter reflections to clarify meaning.

• Use frequent and concise summaries to draw together information.

• Avoid emotionally salient material that is likely to increase thought disorder.

• Provide sufficient time for the client to respond to reflections and summaries.

• Ask simple open questions and avoid multiple choices or complicated language.

While acknowledging the lack of robust evidence, in addition to MI, the Royal Australian and New Zealand
College of Psychiatry (RANZCP) guidelines for the management of schizophrenia and related disorders
nonetheless recommend the use of integrated therapies that combine CBT, lifestyle interventions and
case management for the treatment of co-occurring schizophrenia and AOD use [444].

CBT for psychosis is a well-recognised evidence-based treatment for symptoms of psychosis [444].
Several studies have examined the efficacy of CBT on symptoms of psychosis and AOD use [949, 950];
again, evidence regarding the efficacy of CBT in treating co-occurring psychotic disorders and AOD
problems is mixed. Naeem and colleagues [950] found that although CBT led to better outcomes for
symptoms of psychopathology, there were no differences between CBT and treatment as usual groups on
AOD use outcomes. Similarly, Edwards and colleagues [949] found no significant differences between the
CBT and psychoeducation groups for the key outcomes of cannabis use or psychopathology.
192 B7: Managing and treating psychosis

Recent research has identified assertive community outreach as one integrated approach that may
be particularly beneficial for clients with co-occurring psychosis and AOD use. Assertive community
outreach utilises specialised outreach teams to provide integrated and intensive treatment within a
community setting (e.g., the client’s home), and includes mental health treatment, housing support,
and rehabilitation [951]. Several studies examining the effectiveness of assertive community outreach
for people with co-occurring psychosis and AOD use have found improvements in psychotic symptoms
[952, 953], reduced frequency of AOD use [954], improved housing stability [952, 955, 956], fewer hospital
readmissions [952, 957], improved psychological wellbeing [955], and general functioning [956] relative to
baseline and treatment as usual control conditions.

Recent research has also demonstrated that, relative to standard care for psychosis and co-occurring
AOD use, skills-based training and peer supported social activities delivered alongside standard care,
leads to improved outcomes in relation to symptoms of psychosis, AOD use, as well as functional
outcomes [958]. Cognitive remediation therapy has also been found to be beneficial in addressing
cognitive and functional deficits (e.g., relating executive function, attention, memory, social cognition)
among people with psychotic disorders [959] and shows promise as an adjunctive treatment for people
receiving AOD treatment [960]; however, research among people experiencing both conditions is in its
infancy [961].

Contingency management may also be a useful adjunct to other treatments for psychotic spectrum
disorders and AOD use. As discussed in Chapter B6, contingency management involves the use of
reinforcement to encourage particular behaviours (and discourage undesired behaviours). A meta-
analysis examining the effect of contingency management for people with co-occurring psychotic
and AOD use disorders concluded that contingency management improves abstinence from AOD use,
although effects on psychotic symptoms were not examined [962]. These findings are consistent with a
review of earlier research [963].

The popularity of mindfulness-based interventions has increased in recent years. To date, however, no
studies have evaluated mindfulness in the context of co-occurring psychosis and AOD use. Studies
of single disorder psychosis have found mindfulness beneficial in reducing both negative [964, 965]
and positive psychotic symptoms [965]; and mindfulness has been found to reduce the frequency and
amount of AOD use, AOD-related problems [966], cravings [754, 966], and depressive symptoms [754],
relative to control groups (which included treatment as usual, CBT, and support groups), among people
with AOD use disorders as single disorders. Together these findings suggest that mindfulness may be
beneficial for people experiencing both conditions.

Pharmacotherapy
Despite the high rates of AOD use among people with psychosis, most trials of pharmacotherapy for
psychotic spectrum disorders have excluded people with AOD use disorders [779]. International clinical
guidelines typically conclude that there is limited evidence to recommend the use of one antipsychotic
over another among people with co-occurring AOD use disorders [778]; however, growing literature and
corresponding reviews indicate that some antipsychotics show more promise than others. Most of
the research to date has focused on those with a diagnosis of schizophrenia, but some studies have
B7: Managing and treating psychosis 193

included people experiencing first-episode psychosis or diagnosed with other psychotic disorders (e.g.,
schizoaffective disorder, psychosis in the context of bipolar disorder, substance-induced psychosis).

Two main findings can be drawn from the research to date. Firstly, ‘atypical’ second generation
antipsychotics appear to be more effective relative to ‘typical’ first generation antipsychotics (e.g.,
haloperidol), with reference to both psychiatric and AOD-related outcomes [967, 968]. It has been
theorised that the increased AOD use found among those with psychotic disorders relates to dopamine
dysfunction which is better addressed by the newer atypical antipsychotic agents than the older typical
agents [969]. Atypical antipsychotics may also be preferred by clients as they are associated with fewer
extrapyramidal side effects such as involuntary movements [778]. Furthermore, there has been some
suggestion that typical antipsychotics may actually increase AOD use and craving [968]. Table 42 lists the
names of some of the more common antipsychotics.

There is some evidence to suggest that clozapine [779, 942, 968, 970–972], paliperidone [973–976],
and aripiprazole [967, 976–978] are most promising with respect to a variety of outcomes, including
improvements in symptoms of psychosis and/or AOD use. AOD use has not been found to influence the
efficacy of quetiapine, olanzapine, risperidone, or ziprasidone, for people with psychotic disorders [979].
Preliminary evidence suggests that ziprasidone shows similar efficacy relative to other antipsychotics,
though may be more tolerable with fewer side effects [972].

The second main finding that can be drawn from studies to date is that the use of long-acting
injectables (LAI), also refered to as depot medication, appear to produce better treatment outcomes
among people with AOD use disorders relative to oral antipsychotics. Specifically, LAIs are associated
with a lower rate of relapse to psychosis and longer time to relapse [980]. Paliperidone, aripiprazole and
risperidone are specific medications where there is some evidence to suggest that the LAI form may
be more effective (with respect to producing improvements in severity of psychosis and/or AOD use)
relative to their corresponding oral preparation [973, 974, 976, 978, 981, 982]. People receiving monthly
paliperidone LAI have also been shown to demonstrate greater treatment adherence, have lower rates of
inpatient days, outpatient visits, long-term stays, and lower medical costs; relative to people receiving a
range of other oral atypical antipsychotics [973–975]. While both paliperidone LAI and aripiprazole LAI have
been linked with reductions in the severity of psychotic symptoms, aripiprazole has also been found to
produce improvements in AOD cravings and quality of life [976].

There is also some evidence to suggest that some medications may be more effective than others
depending on the type of AOD used. For example, olanzapine, risperidone and haloperidol may be
particularly effective in improving symptoms of psychosis and reducing cannabis use among people
with cannabis use disorder, while haloperidol and olanzapine have been recommended for those with
cocaine use disorders [983]. For those with polydrug use disorder, atypical antipsychotics, in particular,
olanzapine, may be more effective than typical antipsychotics [983]. It should be noted, however, that
head-to-head comparison studies are rare and tend to be conducted over relatively short follow-up
periods. A good approach to management is to tailor the choice of antipsychotic to the individual based
on response, side-effect profile, and means of administration (oral versus LAI).

Regarding amphetamine-induced psychosis specifically, findings have been mixed. A review of

aripiprazole, haloperidol, quetiapine, olanzapine, and risperidone concluded that they were safe and
194 B7: Managing and treating psychosis

effective in reducing both positive and negative symptoms of psychosis, but found no clear evidence
for the superiority of one antipsychotic over another [984]. However, a subsequent review and meta-
analysis of the efficacy of these drugs and paliperidone extended-release concluded that olanzapine
and quetiapine are more efficacious than risperidone; and olanzapine, quetiapine, haloperidol, and
paliperidone extended-release are more efficacious than aripiprazole, at reducing symptoms of
amphetamine-induced psychosis [985].

Table 42: Antipsychotic medications

Newer (atypical) antipsychotics Traditional (typical) antipsychotics

Drug name Brand names Drug name Brand names

Amisulpride Amipride, Amisolan, Solian, Chlorpromazine Largactil

Sulprix

Aripiprazole Abilify, Abyraz, Tevaripiprazole Droperidol Droleptan

Asenapine Saphris Flupentixol Fluanxol

Brexpiprazole Rexulti Haloperidol Serenace

Carbamazepine Tegretol Periciazine Neulactil

Cariprazine Reagila Zuclopenthixol Clopixol

Clozapine Clopine, Clozaril, Versacloz

Olanzapine Olanzacor, Ozin, Pryzex, Zypine,

Zyprexa

Lithium Lithicarb, Quilonum

Lurasidone Latuda

Paliperidone Invega

Quetiapine Delucon, Kaptan, Quetia,

Seroquel, Syquet, Tevatiapine

Risperidone Ozidal, Rispa, Risperdal,

Rispernia, Rixadone

Sodium Epilim, Valprease, Valpro

valproate

Ziprasidone Zeldox, Ziprox

Adapted from the Australian Government Department of Health [986] and the Therapeutic Goods Administration [987]. For a full
list of generic brands available, see the Therapeutic Goods Administration website (https://www.tga.gov.au).
B7: Managing and treating psychosis 195

Electroconvulsive therapy (ECT)

ECT has long been used as an adjunctive treatment for people who do not have an adequate response to
antipsychotics [808]. A Cochrane review that examined the efficacy of ECT among people with treatment-
resistant schizophrenia as a single disorder concluded that, when combined with standard care, ECT
may lead to greater improvements compared with antipsychotics alone; however, the available evidence
was too weak to determine whether ECT is superior or inferior to other controls for the management of
treatment resistant schizophrenia [988].

E-health interventions
Although research pertaining to the use of e-health interventions for psychosis is in the early stages,
findings to date are promising. A review of internet and mobile-based interventions for psychosis
concluded that they appear to be acceptable and feasible and have the potential to improve clinical and
social outcomes [989]. Specifically, the interventions reviewed showed promise in improving positive
psychotic symptoms, hospital admissions, socialisation, social connectedness, depression, and
medication adherence. Interventions included web-based psychoeducation; web-based psychoeducation
plus moderated forums for patients and supporters; integrated web-based therapy, social networking
and peer and expert moderation; web-based CBT; personalised advice based on clinical monitoring; and
text messaging interventions.

Physical activity
To date there is no evidence about the use of exercise for psychotic disorders other than schizophrenia, or
co-occurring psychosis and AOD use disorder, though results of a meta-review suggest physical activity
is a promising adjunctive treatment for people with either schizophrenia or AOD use disorders [990].
Research conducted among people with single disorder schizophrenia has found that physical exercise
may be useful in terms of improving cognitive functioning (e.g., short-term memory), promoting healthy
lifestyles, managing medication side-effects [991–996], as well as reducing symptoms of psychosis [997–
999]. Studies that have examined the efficacy of exercise interventions among people with schizophrenia
have included a range of physical activities, including basketball [1000], aerobic exercise [992, 998, 1001],
cycling [997], and yoga [995, 1002, 1003]. Based on the evidence to date, aerobic activity has the most
support [992, 994, 998, 1004–1009], but there is also some support for resistance training as an adjunct
to other exercise [996, 1001, 1010, 1011]. In particular, endurance programs of at least 12-weeks, 3 sessions
per week, of general aerobic endurance training lasting at least 30 minutes in duration are recommended
[1012].

Complementary and alternative therapies

Research examining complementary therapies for co-occurring psychosis and AOD use is rare. One RCT
has examined the effects of auricular acupuncture as an adjunct to antipsychotics among people with
co-occurring schizophrenia and AOD use [1013]. In this study, auricular acupuncture (which involves
the placement of acupuncture needles in the ears) was given 4-6 times a week, for 20-40 minutes a
session, for up to 20 sessions. Relative to people who received antipsychotics alone, those also receiving
196 B7: Managing and treating psychosis

acupuncture showed improved treatment adherence to antipsychotics after 10 sessions. Relative to

baseline levels, all participants also showed decreases in AOD cravings after 10 sessions, and further
decreases in AOD cravings after 20 sessions. However, there were no differences in psychiatric symptom
severity from baseline for either group and psychotic symptoms were not examined. These findings
require replication to be sure of their effectiveness.

While there has been little research examining complementary and alternative therapies for people with
co-occurring psychosis and AOD use, there have been some promising treatment outcomes for people
with single disorder psychotic disorders for horticultural therapy [1014], music therapy [1015], yoga [1016],
and a gluten-free diet [1017]. It should be noted however, that the majority of participants in these studies
were also receiving antipsychotic medication and as such, the utility of these complementary and
alternative approaches as standalone therapies for people with single disorder psychotic disorders has
not been established.

Summary
In summary, existing research suggests that there is no ‘one size fits all’ approach for treating co-
occurring psychotic spectrum and AOD use disorders [1018], and that combinations of different
therapeutic approaches may be necessary for each individual client. Further, therapist flexibility is
incredibly important in the treatment of this group. Box 15 illustrates the continuation of case study B,
following Amal’s story after his psychotic symptoms appeared to worsen.

Box 15: Case study B: Treating co-occurring psychosis and AOD use: Amal’s story
continued

Case study B: Amal’s story continued

The inpatient detoxification team immediately organised for Amal to have an assessment by the
team psychiatrist, who admitted Amal to the inpatient mental health unit for further assessment and
stabilisation. Amal’s AOD team continued to provide advice and support for his ongoing detoxification
during his inpatient mental health stay. During this time, Amal’s family were asked to meet with the
treating team and provide additional information. Amal’s father told the team that Amal had experienced
previous episodes of hallucinations and delusions; he did not think these had all occurred when Amal
had used methamphetamines but couldn’t be sure. Amal’s mother said that her mother had experienced
‘mental health problems’ and been hospitalised many times when she was younger, but she didn’t know
the exact nature of her condition.

Amal stayed at the mental health unit for a period of time, during which it was established that while
his substance use may have contributed to and exacerbated his symptoms, it was likely that he had an
independent psychotic disorder. He was stabilised on antipsychotics, started receiving psychotherapy
and began working with a case manager who liaised with the outpatient AOD team and made a plan for
his discharge. It was explained to Amal that his methamphetamine use would likely exacerbate or cause
a relapse in his psychotic disorder. As such, an important part of his discharge plan included relapse
B7: Managing and treating psychosis 197

Box 15: Case study B: Treating co-occurring psychosis and AOD use: Amal’s story
(continued)

prevention strategies and the provision of ongoing support from the AOD service. Amal also had a longer-
term goal of wanting to move out of his parents’ house and live independently, which his case manager
worked into his treatment goals.

Key points:
• Chronic illness does not equate to untreatable illness. Psychotherapy may provide
symptom relief and improved quality of life, and all treatment approaches need to be
carefully integrated.
• Involvement of family, carers or friends is often critical to providing a full picture but
also needs to be carefully and sensitively managed.
• Medication adherence needs long-term attention.
• A holistic approach, assessing a person’s accommodation and employment needs in
addition to their mental, physical, and AOD use disorders, is vital.
B7: Managing and treating bipolar disorders 199

Bipolar disorders

Clinical presentation
It can be particularly challenging to treat people with bipolar disorder due to the broad range of emotions
experienced, which can impact on the relationship between the client and the therapist [133]. Depending
on which phase of the disorder a client is in, they may present with either symptoms of depression or
mania/hypomania. If the person is in between episodes, they may appear to be completely well. People
with bipolar disorder predominantly present to services during the depressive phases of the disorder
rather than during periods of elation.

If experiencing a depressive episode, the client may present with low mood; markedly diminished
interest or pleasure in all, or most activities; sleep disturbances; appetite disturbances; irritability;
fatigue; psychomotor agitation or retardation; poor concentration; feelings of guilt, hopelessness,
helplessness and worthlessness; and suicidal thoughts. When experiencing mania/hypomania however,
a client’s mood is persistently elevated, and symptoms of grandiosity, flights of ideas, hyperactivity,
decreased sleep, psychomotor agitation, talkativeness, and distractibility may be present. Mania and
hypomania may lead to a loss of insight, which can place the person at risk, and impact negatively on
medication adherence.

Managing symptoms of bipolar

In general, if the client presents during a depressive episode, management of symptoms should follow
the guidelines for the management of depressive symptoms (see Table 43). As previously mentioned,
low mood is often a trigger for relapse to AOD use and addressing depressive symptoms is an important
component of relapse prevention [1019]. If, however, the client is experiencing a manic episode or
symptoms of psychosis, consultation with a medical practitioner is recommended for the prescription of
appropriate pharmacological interventions.

The techniques outlined in Table 44 may assist in the management of a person experiencing symptoms
of mania or hypomania. Some clients may be aware that they are unwell and will voluntarily seek help;
others may lack insight into their symptoms and refuse, or not perceive the need for, help. In some
instances, a person’s manic symptoms can put both the client and others at risk of harm. In such
circumstances mental health services should be contacted, whether the client wants such a referral to
be made or not.
200 B7: Managing and treating bipolar disorders

Table 43: Dos and don’ts of managing a client with depressive symptoms of bipolar

Do:

Encourage and emphasise successes and positive steps (even just coming in for treatment).

Take everything they say seriously.

Maintain eye contact and sit in a relaxed position – positive body language will help you and the
client feel more comfortable.

Use open-ended questions such as ‘So tell me about...?’ which require more than a ‘yes’ or ‘no’
answer. This is often a good way to start a conversation.

Constantly monitor suicidal thoughts and talk about these thoughts openly and calmly.

Encourage the client to express their feelings.

Be available, supportive, and empathetic.

Offer realistic hope (i.e., that treatment is available and effective).

Encourage regular sleep, exercise and eating patterns.

Keep language clear, specific, and simple.

Assist the client to identify early warning signs that they may become unwell.

Provide contact details of counselling services and offer to make referrals if required (many
depressed people struggle to do this alone).

Encourage participation in healthy, pleasurable, and achievement-based activities (e.g., exercise,

hobbies, work).

Don’t:

Make unrealistic statements or give unrealistic hope, like ‘everything will be fine’.

Invalidate the client’s feelings.

Be harsh, angry, or judgemental. Remain calm and patient.

Lose hope or become frustrated.

Act shocked by what the client may reveal.

Adapted from Scott et al. [1020], Clancy and Terry [448] and Headspace [1021].
B7: Managing and treating bipolar disorders 201

Table 44: Dos and don’ts of managing a client experiencing mania/hypomania

Do:

Ensure the safety of the client, yourself, and others.

Assist the client identify early warning signs that they may become unwell.

Help to reduce triggers that aggravate the person’s symptoms (e.g., reduce stimulation such as
noise, clutter, caffeine, social gatherings).

Speak clearly and calmly, asking only one question or giving only one direction at a time.

Answer questions briefly, quietly, calmly, and honestly.

Use a consistently even tone of voice, even if the person becomes aggressive.

Encourage regular sleep, exercise and eating patterns.

Be cautious about becoming swept up by the person’s elevated mood.

Point out the consequences of the client’s behaviour. Be specific.

If the person is well enough, discuss precautions they can take to prevent risky activities and
negative consequences (e.g., give their credit cards and/or car keys temporarily to a trusted family
member or friend to prevent reckless spending and driving).

If promiscuity or socially inappropriate behaviour is a problem, encourage the person to avoid

situations in which their behaviour may lead to negative consequences.

Encourage the person to postpone acting on a risky idea until their mood is stable.

Ensure both you and the client can access exits – if there is only one exit, ensure that you are
closest to the exit.

Have emergency alarms/mobile phones and have crisis teams/police on speed dial.

If the person is placing themselves at risk, or they are experiencing severe symptoms of psychosis,
arrange transfer to an emergency department for assessment and treatment by calling an
ambulance on 000.
202 B7: Managing and treating bipolar disorders

Table 44: Dos and don’ts of managing a client experiencing mania/hypomania

(continued)

Don’t:

Argue, criticise, or behave in a threatening way towards them. Consider postponing or avoiding
discussion of issues that aggravate the client for the time being. Try to talk about more neutral
topics.

Get visibly upset or angry with the client. Remain calm and patient.

Confuse and increase the client’s level of stress by having too many workers attempting to
communicate with them.

Get drawn into long conversations or arguments with the person as these can be overstimulating
and upsetting. People with elevated moods are vulnerable despite their apparent confidence, and
they tend to take offence easily.

Leave dangerous items around that could be used as a weapon or thrown.

Laugh (or let others laugh) at the person.

Act horrified, worried, or panic.

Treating bipolar disorders

There are several options available for the treatment of bipolar disorders, including psychotherapy,
pharmacotherapy, ECT, e-health and telehealth interventions, as well as complementary and alternative
therapies (e.g., dietary supplements). The evidence base surrounding each of these treatments is
discussed below. Despite a small evidence base regarding the treatment of bipolar disorder in the
context of co-occurring AOD use disorders, most of which has focused on pharmacological treatments,
experts recommend an integrated multidisciplinary approach to treating these conditions [1022, 1023].

Psychotherapy
Research on psychological treatments for co-occurring bipolar disorder and AOD use is minimal and
has largely been limited to small studies of CBT approaches. In line with Australian and international
guidance on the treatment of bipolar disorder [1024–1027], these studies have examined the use of
psychotherapies as adjuncts to pharmacotherapy, not as monotherapies. The intervention that has
received most investigation to date is Integrated Group Therapy (IGT), an integrated, 12- or 20-session
psychosocial group treatment program that focuses on similarities between recovery and relapse
processes in bipolar disorder and AOD use disorder. One pilot non-randomised trial and two small
RCTs have shown more positive findings in relation to AOD use outcomes relative to group counselling
control conditions, but not in relation to mood [1028–1030]. It has been suggested that the consistent
B7: Managing and treating bipolar disorders 203

superiority of IGT over group drug counselling indicates that the efficacy of drug treatment for people with
co-occurring bipolar disorder is enhanced when treatment is provided in the context of mood disorder
treatment, but additional strategies may be needed for mood management [871].

Preliminary studies have also been conducted on several other integrated treatments delivered as
adjuncts to pharmacotherapy, but again, these have been limited to small RCTs with mixed findings.
Schmitz and colleagues [1031] compared an individual integrated CBT treatment for bipolar and
AOD use delivered in combination with medication monitoring to medication monitoring alone. No
significant differences were found in relation to AOD use; findings in relation to mood were mixed but
appeared promising. A further two intensive 6-month long programs that involved clients’ families, the
Integrated Treatment Adherence Program based on ACT for adults [1032] and the Family Focused Treatment for
adolescents [1033], have also undergone preliminary evaluations with promising findings in relation to
symptoms of bipolar disorder, but not in relation to AOD use.

Other integrated interventions that have undergone preliminary evaluation and found to be acceptable,
feasible, and potentially efficacious in reducing either AOD use and/or symptoms of bipolar disorder
include HABIT, a manualised integrated group therapy that combines CBT with mindfulness-based
relapse prevention [1034], and an integrated individual therapy that combines CBT and MI [1035]. Further
research is needed to determine their effectiveness.

Pharmacotherapy
Pharmacotherapy is the first-line approach to treating bipolar disorders as single disorders [1024–1027].
It is therefore not surprising that the vast majority of research regarding the treatment of co-occurring
bipolar and AOD use disorders has focused on pharmacotherapies. Nevertheless, the evidence base
is limited making it difficult to draw firm conclusions. Most studies have been conducted with a
small number of people, lacked comparison groups, and involved the use of a variety of concomitant
medications, making it difficult to clearly attribute effects to the medication examined [1023, 1036].
Multiple medications are often used to treat each specific disorder, such as the use of mood stabilisers
(see Table 45), antipsychotics (see Table 42), and/or antidepressants (see Table 47) for the bipolar
disorder, in conjunction with medication specifically to treat the AOD use disorder (e.g., naltrexone for
alcohol use disorder) [1037], but care should be taken to avoid unnecessary polypharmacy due to the
potential for interaction effects.
204 B7: Managing and treating bipolar disorders

Table 45: Mood stabiliser medications

Drug name Brand names Drug name Brand names

Aripiprazole Abilify, Abyraz, Quetiapine Delucon, Kaptan, Quetia,

Tevaripiprazole Seroquel, Syquet, Tevatiapine

Asenapine Saphris Risperidone Ozidal, Rispa, Risperdal,

Rispernia, Rixadone

Carbamazepine Tegretol Sodium valproate Epilim, Valprease, Valpro

Lamotrigine Lamictal, Lamidus, Ziprasidone Zeldox, Ziprox

Lamitan, Lamotrust,
Logem, Reedos, Torlemo

Lithium Lithicarb, Quilonum

Olanzapine Olanzacor, Ozin, Pryzex,

Zypine, Zyprexa

Paliperidone Ivenga

Adapted from Khoo [1038]. For a full list of generic brands available, see the Therapeutic Goods Administration website
(https://www.tga.gov.au).

Research to date has largely focused on the use of quetiapine among people with co-occurring bipolar
and alcohol use disorders. Although initial open-label uncontrolled trials largely found quetiapine to have
a positive impact on both psychiatric symptoms and AOD use, most RCTs have demonstrated that these
improvements tend to be no greater than those achieved with a placebo [1036]. A similar pattern has
been observed for sodium valproate among people with co-occurring bipolar and alcohol, cocaine and/or
cannabis use disorders; although findings from one RCT suggest that greater reductions in alcohol use
may be obtained by adding sodium valproate to lithium and individual counselling [1039].

Lithium itself has been examined in a small RCT conducted among adolescents which found
significantly greater reductions in AOD use and depressive symptoms among those who received lithium
relative to those who received placebo [1040]. A further study demonstrated that lithium had an impact
on reducing cannabis and cocaine use among people with co-occurring bipolar disorder, but it is difficult
to generalise the findings of this study due to less than one-quarter of the original sample completing
the stabilisation phase and continuing into the main portion of the study [1041].

Lamotrigine has been shown to have mixed results in uncontrolled trials with regard to symptoms of
bipolar, cocaine and alcohol use, but the only RCT conducted to date found no significant differences
in outcomes for those who received lamotrigine compared to those who received a placebo medication
[1036]. Topiramate has also been examined in an RCT and was not found to be superior to placebo
B7: Managing and treating bipolar disorders 205

with respect to reductions in AOD use and mood [1036]. Aripiprazole, olanzapine, and asenapine have
all undergone preliminary testing, and all have been associated with reductions in cravings and
improvements in bipolar symptoms but are yet to be examined in controlled trials [1036]. Over the past
several years, studies have widened their focus to include non-traditional pharmacotherapies, such as
memantine (an NMDA-receptor agonist typically used in the treatment of Alzheimer’s disease) [1042] and
ondansetron (an antiemetic usually used in the treatment of nausea) [1043]. Although this is an area that
is still developing, some promising findings have emerged.

It is also important to bear in mind that people with a co-occurring bipolar disorder may be less likely
to take their medication if they lack insight, do not recognise their manic episodes, or enjoy their manic
episodes. Measures to increase medication adherence may be particularly pertinent (discussed in
Chapter B6). Other strategies to promote medication adherence among clients with co-occurring bipolar
disorder include the Integrated Treatment Adherence Program described earlier in this chapter, which is an
adjunctive psychosocial approach designed to improve treatment adherence [1032].

Electroconvulsive therapy (ECT)

While ECT has been suggested as a second-line treatment option for single disorder bipolar in very severe
cases (e.g., treatment-resistant or acute mania, depression, suicidality) [1026, 1027], to date, few research
studies have assessed the efficacy of ECT in treating co-occurring bipolar and AOD use disorders.

Of the research that has been conducted, one study conducted a retrospective analysis of Swedish
medical records of people with bipolar and depression, both as single disorders and co-occurring with
AOD use, who had previously received ECT [1044]. ECT was found to improve remission rates from baseline
for people with single disorder bipolar, at a similar rate to people with unipolar depression (35% for
bipolar vs. 45% for unipolar depression). However, people with co-occurring mood disorders and AOD use
had lower remission rates compared to people without co-occurring AOD use (26% to 29% vs. 42% to 47%
respectively) [1044].

In a second study conducted among 190 adolescents and young people aged 16 to 25 with depressive,
psychotic and bipolar disorders, a course of five ECT treatments was found to reduce AOD use outcomes,
such as cravings and problematic behaviour associated with substance use, relative to baseline [1045].
Following these treatments, people also demonstrated reductions in the frequency of depressive and
psychotic symptoms, as well as self-harm ideation [1045]. However, it should be borne in mind that
bipolar disorders made up only a very small subsample of this study (14%). While these studies may be
promising, more conclusive evidence for the use of ECT among people with co-occurring bipolar and AOD
use is needed.

E-health and telehealth interventions

There are several online interventions to support the mental health of people with bipolar disorders,
including MoodSwings [1046, 1047], Living With Bipolar [1048], Beating Bipolar [1049], the Bipolar Education
Programme [1050], HealthSteps for Bipolar Disorder [1051], LiveWell [1052], ORBIT [1053], ERPonline [1054], and
OpenSIMPLe [1055]. However, only some of these have been, or are in the early stages of being, evaluated.
Feasibility and preliminary studies of Living With Bipolar [1048], Bipolar Education Programme [1050], and
OpenSIMPLe [1055] are promising.
206 B7: Managing and treating bipolar disorders

One online program, Therapeutic Education System (TES), developed for people with AOD use was recently
evaluated among 95 people, a subsample of whom were experiencing co-occurring bipolar disorder
[1056]. TES comprises 65, 15-minute modules, covering substance use-related topics, such as problem
solving and drug-refusal skill training. Compared to those in the treatment as usual control group, those
enrolled in TES reported greater perceived usefulness of treatment and better emotional regulation,
although the groups did not differ in subsequent enrolment rates in AOD treatment programs, self-
reported cravings, number of drug-related dreams, or satisfaction with treatment. Outcomes related to
bipolar symptoms were not examined.

Physical activity
A small number of studies with relatively small samples have examined the effect of exercise on bipolar
disorders. Ng and colleagues [1057] conducted a small, retrospective chart review, and found that
depression and anxiety improved among people with bipolar disorder who participated in a voluntary
40-minute, supervised group walking activity whilst in a psychiatric facility, every weekday morning,
compared to non-walkers. However, there was no clinical difference in overall improvement between
walkers and non-walkers [1057]. A small open trial examining the short-term effects of aerobic training
on depression and bipolar disorder found that aerobic training slightly improved symptom severity for
people with bipolar disorder [1058]. Another small RCT examined the effect of a short-term, maximum
endurance exercise program as an accompanying treatment to pharmacotherapy, and found that,
relative to control (gentle stretching and relaxation), depression scores were significantly reduced
among the exercise group [1059]. In a systematic review of the literature, it was similarly concluded that
physical activity is associated with reduced depressive symptoms among people with bipolar, as well as
improved quality of life [1060]. The optimal dose for exercise among people with bipolar has not yet been
determined; however, guidelines for mood disorders from the RANZCP suggest that exercise should be
regular (two to three times per week) and vigorous (requiring sustained effort) to maximise the chance
of deriving health benefits [1027]. Similarly, although the optimal dose and exercise type for people with
bipolar have yet to be determined, aerobic and resistance-based exercises are recommended for people
with mood disorders in general [1027].

Although the aforementioned studies provide evidence to suggest that regular physical activity can
assist in the reduction of depressive symptoms, there is preliminary research pointing to the existence
of possible exacerbation of mania among some people [1060–1062]. Although exercise may be beneficial
in redirecting excess energy for some, others found their manic symptoms were aggravated, potentially
risking a cycle of manic and hypomanic symptoms [1063]. It has been suggested that the exacerbation
of manic symptoms may be due to direct effects on mood, or indirectly on excessive goal-focused
activities, which can be a risk pathway for bipolar disorder [1064, 1065]. However, these preliminary
findings originate from a small qualitative study and require further empirical evidence, with some
participants in the study finding exercise calming [1061]. No research has been conducted to examine the
efficacy of exercise among people with co-occurring bipolar and AOD use; however, given the unknown
and potentially risky relationship with mania, physical activity among people with co-occurring disorders
should be closely monitored.
B7: Managing and treating bipolar disorders 207

Complementary and alternative therapies

Dietary supplements

There have been few reviews that have examined the evidence for the safety and efficacy of dietary
supplements for bipolar disorders. Although research has found some benefit with regards to both
depressive symptoms (e.g., omega-3 and -6 supplementation, icariin, citicoline [1066–1070]), and mania
symptoms (e.g., magnesium supplementation [1071–1073]), many therapies have the potential to induce
mania or interact with pharmacotherapies (e.g., St John’s Wort [1074–1077]); the extent to which needs
further in-depth examination.

Summary
Several psychological and pharmacological approaches for the treatment of co-occurring bipolar disorder
and AOD use appear promising, however, further research is required to establish which therapeutic
approaches are particularly effective for these co-occurring disorders. Box 16 illustrates the continuation
of case study C, following Scott after his initial visit with the AOD worker.

Box 16: Case study C: Treating co-occurring bipolar disorder and AOD use: Scott’s story
continued

Case study C: Scott’s story continued

During the comprehensive assessment with the AOD worker, Scott described other periods where he had
felt elated. His girlfriend said that he would sometimes come home after two weeks at work and start a
new project in a ‘frenzy’, often staying up all night or only coming to bed at 2 or 3am, but rarely finished
any of them before moving on to something new. During these periods, Scott’s girlfriend said he was like
a different person - he was full of energy, talked non-stop, would do all the housework and didn’t seem to
need much sleep. Scott excitedly told the AOD worker that he just started rebuilding a motorbike in his
garage. Scott’s girlfriend expressed her frustration that their house was full of half-completed projects,
with ‘stuff everywhere’.

Recognising a probable bipolar disorder, the AOD worker organised for Scott to see a psychiatrist, who
confirmed this diagnosis. Scott’s AOD worker told him that if he wanted to work on his AOD use, they
would work together with his psychiatrist to manage both conditions together. Scott agreed this was
a good idea and was prescribed a mood stabiliser by his psychiatrist. A concurrent approach to Scott’s
mental health and AOD use began, which involved regular meetings with Scott and the professionals
involved in his mental health care and AOD treatment.

In addition to psychotherapy and medication, the team helped Scott with financial management and
provided him with some strategies to help with his spending. They also discussed Scott’s lifestyle and
in particular, the nature of his fly-in-fly-out employment. The first time this was raised, Scott became
extremely angry. Refusing to believe there was any problem or connection between the long shift work,
numerous consecutive working days, his AOD use and mental health symptoms, he told the treatment
208 B7: Managing and treating bipolar disorders

Box 16: Case study C: Treating co-occurring bipolar disorder and AOD use: Scott’s story
(continued)

team to ‘butt out’ and stormed out of the meeting. Very late that evening, Scott’s girlfriend was contacted
by a friend who had found Scott passed out in a local park – he was naked and his feet were bare and
bloodied. It appeared that he had consumed a large quantity of alcohol and had been wandering around.
His girlfriend picked Scott up and she and the friend took him to emergency, where he was admitted
overnight.

Over the next few days, Scott’s mood had settled, and he started to think more about his life and work,
and the things that were important to him. In the next treatment team meeting, he listened to the
concerns raised, and said he loved his job but could see why the type of work he had been doing may be
contributing to making things worse and would think about it some more. He was grateful that his team
was being patient with him, listening to him think things through without judging him. Scott started
going to the gym again and joined the local soccer team.

Key points:
• In cases of bipolar disorder co-occurring with AOD use, treatments need to be
coordinated and carefully integrated. Strategies to address medication adherence,
particularly over the long-term, are a pertinent aspect of treatment.
• Without addressing the familial and social consequences of longstanding bipolar
disorder, the client’s quality of life will remain much diminished. As such, integrating
the rehabilitative aspects of treatment may have long-term benefits.
• Physical activity and exercise have physical and psychological benefits and may also
help address some of the side effects of medications used to treat bipolar disorder.
210 B7: Managing and treating depression

Depression

Clinical presentation
Depressive symptoms include low mood; markedly diminished interest or pleasure in all or most
activities; sleep disturbances; appetite disturbances; irritability; fatigue; psychomotor agitation or
retardation; poor concentration; feelings of guilt, hopelessness, helplessness and worthlessness; and
suicidal thoughts (refer to Chapter A4).

Managing depressive symptoms

Negative mood is often a trigger for relapse, and therefore addressing depressive symptoms is also
an important part of relapse prevention [1078, 1079]. The techniques outlined in Table 46 may help AOD
workers to manage clients with depressive symptoms. A number of simple strategies based on CBT may
also be useful for clients in managing depressive symptoms, including [482, 1080, 1081]:

• Cognitive restructuring.

• Pleasure and mastery events scheduling.

• Goal setting.

• Problem solving.

These techniques are discussed in greater detail in Appendix BB.

It is important to note that many depressive symptoms (and many anxiety symptoms) will subside
after a period of abstinence and stabilisation [1082–1084]. It is useful to explain to clients that it is quite
normal to feel depressed (or anxious) when entering treatment but that these feelings usually improve
over a period of weeks [1082, 1083, 1085]. During and after this time, constant monitoring of symptoms
will allow the AOD worker to determine if the client requires further treatment for these symptoms.
If the client has a history of depressive episodes in circumstances when they are not intoxicated or
withdrawing, they may have an independent depressive disorder. For these clients, it is unlikely that
their depressive symptoms will resolve completely with abstinence—indeed their symptoms may even
increase. In such cases, clients should be assessed for a depressive disorder and the treatment options
described in this chapter should be considered.

Table 46: Dos and don’ts of managing a client with depressive symptoms

Do:

Encourage and emphasise successes and positive steps (even just coming in for treatment).

Take everything they say seriously.

B7: Managing and treating depression 211

Table 46: Dos and don’ts of managing a client with depressive symptoms (continued)

Do:

Maintain eye contact and sit in a relaxed position—positive body language will help you and the
client feel more comfortable.

Use open-ended questions such as ‘So tell me about...?’ which require more than a ‘yes’ or ‘no’
answer. This is often a good way to start a conversation.

Constantly monitor suicidal thoughts and talk about these thoughts openly and calmly.

Encourage the client to express their feelings.

Be available, supportive and empathetic.

Offer realistic hope (i.e., that treatment is available and effective).

Provide contact details of counselling services and offer to make referrals if required (many
depressed people struggle to do this alone).

Encourage participation in healthy, pleasurable, and achievement-based activities (e.g., exercise,

hobbies, work).

Don’t:

Make unrealistic statements or give unrealistic hope, like ‘everything will be fine’.

Invalidate the client’s feelings.

Be harsh, angry, or judgemental. Remain calm and patient.

Act shocked by what the client may reveal.

Adapted from Scott et al. [1020] and Clancy and Terry [448].

Treating depressive disorders

There are several options available for the treatment of depressive disorders, including psychotherapy,
pharmacotherapy, ECT, e-health, physical activity, as well as complementary and alternative therapies
(e.g., omega-3). The evidence base surrounding each of these treatments is discussed below.
212 B7: Managing and treating depression

Psychotherapy
Research on psychological therapies provides support for the use of integrated psychological treatments
for co-occurring depression and AOD use disorders [228, 665, 1086, 1087]. However, the small number
of studies, methodological limitations (e.g., lack of randomisation to treatment conditions), variation
in study results, and small sample sizes used in these studies highlight the need for larger trials to be
conducted in this area [665, 1088].

The majority of studies to date have examined the use of integrated treatments that adopt a CBT
approach [122, 665, 1089]. Reviews of the literature have shown that integrated CBT approaches yield
superior results for depression and AOD use when compared to no treatment or treatment as usual
comparison groups [1088, 1090], but there is insufficient evidence demonstrating that any one
psychological therapy is more effective than another for these co-occurring conditions [1091].

In a 2019 Cochrane review, Hides and colleagues [1091] identified there was limited evidence to suggest
that integrated CBT (ICBT) results in higher rates of abstinence at 6- to 12-months follow-up compared
to 12-step facilitation therapy. Both approaches appeared to be similarly effective in terms of depressive
symptoms at follow-up, however, reductions appeared more quickly with 12-step facilitation therapy
than ICBT and Hides and colleagues [1091] caution that these findings are based on low-quality
evidence. As a way of enhancing CBT, it has been suggested that CBT be combined with other evidence-
based psychological strategies, such as contingency management (see Chapter B6). The addition of
contingency management to CBT-based approaches has been shown to lead to superior outcomes in
terms of AOD abstinence and depressive symptoms relative to CBT-based approaches alone [1092, 1093].

Another approach showing promise in the treatment of co-occurring AOD use and depression is
behavioural activation (described in Chapter B6). There is empirical evidence illustrating that
behavioural activation is as effective in treating depression as cognitive and behavioural techniques
(with or without antidepressants) and more effective than antidepressant medication alone [693,
694, 1094]. The efficacy of behavioural activation in treating co-occurring AOD use and depression has
been examined in several RCTs across a variety of AOD treatment settings (community-based clinics,
residential treatment, specialist addiction clinics). A systematic review of these trials concluded that,
although the research to date is promising, further research is needed [690].

Lastly, although still in the early stages, there is preliminary support for the use of mindfulness-based
approaches in the treatment of co-occurring depression and AOD use. These approaches include
mindfulness-based relapse prevention [1095, 1096] and mindfulness-based cognitive therapy [1097],
which have been associated with greater reductions in depressive symptoms and AOD craving relative to
treatment as usual for AOD.

Pharmacotherapy
There is consensus amongst experts that pharmacotherapy (i.e., antidepressants; see Table 47) for co-
occurring depression and alcohol use disorders can be effective, provided an individualised approach is
used [1098, 1099]; however, it has been suggested that using pharmacotherapy to treat only depression or
only AOD use is not likely to be sufficient to achieve improvements for both conditions [1100].
B7: Managing and treating depression 213

A number of systematic reviews have examined the effectiveness of antidepressant medication among
people with co-occurring AOD use disorders and depression [1100–1103]. Most studies to date have
focused on alcohol use disorders, but other AOD use disorders examined include cocaine use disorder,
opiate use disorder, and nicotine use disorder [1101].

Systematic reviews and meta-analyses have shown that, while their effect on AOD has been mixed,
the effect of antidepressants on depression among people with AOD use disorders is comparable to
that observed among people with single disorder depression [34, 1100–1102]. There is some evidence to
suggest that their effectiveness may vary depending on the type of AOD use disorder a person presents
with. For example, although studies of co-occurring alcohol dependence and major depression support
the use of antidepressants [1102], most studies of cocaine and opiate dependent clients do not [1101].

The majority of studies to date have examined the use of SSRIs and few have directly compared the
effectiveness of different types of antidepressants among people with AOD use disorders. As such,
there is insufficient evidence to recommend the use of one over another [1102]. Despite a lack of
comparative research, there is some evidence to suggest that particular antidepressants may be more
effective in treating depression among people with AOD use disorders than others. In a systematic
review of pharmacotherapy among people with co-occurring AOD use and depressive disorders (either
major depressive disorder or dysthymia), Stokes and colleagues [1101] found that imipramine (a
tricyclic antidepressant, TCA) improved depressive symptoms among people with co-occurring alcohol
dependence and opiate dependence, however, SSRIs showed no effects on depression. The lack of
effects for SSRIs was observed both when SSRIs were used alone and in combination with other relapse
prevention medications (e.g., naltrexone). Consistent with these findings, the addition of citalopram to
naltrexone and case management has not been shown to confer any added benefit over naltrexone and
case management among people with either independent or substance-induced depression and alcohol
dependence [1104]. Antidepressants that do not come under the umbrella of SSRIs or TCAs have been
found to be effective in single studies, with improvements observed on outcomes such as depression,
alcohol consumption, cravings, and time to relapse [1100].

It has also been suggested that different types of antidepressants seem to be suitable for different
types of substance use disorders [1105]. In particular, people with AOD use disorders tend to respond
better to antidepressants that have a similar direct or side effect profile to their substance use. Hence,
the more sedating antidepressants such as doxepin or paroxetine are more effective among people
who use alcohol, heroin, and sedatives, and the more stimulating antidepressants such as desipramine
and bupropion have greater efficacy among those with depression who use stimulants and nicotine. As
there is insufficient evidence for the use of antidepressants for treating depression among people who
use psychostimulants such as amphetamines and ecstasy [1106, 1107], the use of the more stimulating
antidepressants for these clients provides the best guidance at this time.

As with any medication, the choice of antidepressant used should be made with the client and take into
consideration the safety and tolerability of the medication, and any potential contraindications. SSRIs
and other atypical antidepressants are typically better tolerated, associated with fewer adverse effects,
and are safer in overdose relative to TCAs [1102, 1108, 1109]. For all AOD clients, extreme caution should
be taken when prescribing monoamine oxidase inhibitors (MAOIs). These medications are potentially
214 B7: Managing and treating depression

dangerous because of the dietary and medication restrictions involved [1105, 1106]. Hypertensive crisis
with intracranial bleeding and death can occur if combined with a tyramine-rich diet or contraindicated
medications (including opioid and psychostimulant substances, such as over-the-counter cold and flu
medications) [1110, 1111]. Further MAOIs have a number of possible/theoretical interactions with alcohol
(tyramine in some wines/beers) and other drugs of abuse [1105]. For these reasons, MAOIs should only be
used when other antidepressant medication options have failed.

Esketamine, an NMDA-receptor antagonist recently approved for the treatment of depression by the
Australian Therapeutic Goods Administration, is another pharmacotherapy that may be considered
for people who have not demonstrated an adequate response to at least two other antidepressants
[1112]. Caution should be used however, due to its abuse potential and significant adverse effects (e.g.,
dizziness, nausea, dissociation) [1113–1116]. Relative to placebo, people are more likely to discontinue
esketamine due to the intolerability of these side effects [1116].

Suicide risk should be carefully monitored when a person commences any antidepressant, given
ongoing uncertainty and controversy regarding initiation of antidepressants and increased suicide risk;
in particular, suicide attempts within the first three to four weeks of acute treatment [1117, 1118]. Thus,
although it is suggested that the benefits of antidepressant use outweigh the risks, and appropriate use
actually protects depressed patients from suicide, it is important to maintain appropriate monitoring of
suicidality [1098, 1109].

It is important to note that it can take up to four weeks for an antidepressant to reach therapeutic
levels. Responses to antidepressants are typically noticeable within two to four weeks, with continued
improvement in symptoms for up to 12 weeks [1098]. With these issues in mind, early follow-ups after
initiation of an antidepressant medication are recommended [1098]. If little or no improvement in mood
occurs over the induction time specified by the drug manufacturer, and the medication is being taken
as prescribed (usually a minimum of three weeks), consideration should be given to increasing the dose
within the recommended range. If still little or no improvement is observed, switching or augmenting
with another antidepressant may be considered. It is recommended that there be at least one within-
class switch before considering augmentation or other options, keeping in mind the potential for drug
interactions, and the adverse effects of some antidepressants [1098].

Thase and colleagues [1099] comment on the sometimes over-restrictive attitudes towards
pharmacological treatments for depressive disorders among people with AOD use disorders, where
clients can present in a state of physical and emotional despair that requires immediate intervention.
Considering the safety of most of the newer antidepressants such as SSRIs, such caution as waiting for
a minimum number of weeks of abstinence cannot be justified. This would particularly apply where a
client has a history of depression during periods of abstinence, or where the person has had successful
antidepressant intervention in the past.

Some clients may be reluctant to take SSRIs due to the misconception that they are ‘addictive’. SSRIs are
not habit-forming; however, people may experience a discontinuation syndrome if medication is stopped
abruptly [1109]. Symptoms typically appear within three to four days of stopping and are similar to some
of those experienced during alcohol and opiate withdrawal (e.g., flu-like symptoms, light-headedness,
headache, nausea) [1109]. When discontinuing SSRIs, the dose should be gradually tapered.
B7: Managing and treating depression 215

Table 47: Antidepressant medications

Drug type and name Brand names

Tricyclic antidepressant (TCA):

Amitriptyline Endep, Entrip, Lupin

Clomipramine Anafranil, Placil

Dosulepin (dothiepin) Dothep, Mylan

Doxepin Deptran

Imipramine Tofranil

Nortriptyline Allegron, NotriTABS

Monoamine oxidase inhibitor (MAOI):

Phenelzine Nardil

Tranylcypromine Parnate

Reversible inhibitor of monoamine oxidase A (RIMA):

Moclobemide Amira, Aurorix, Clobemix

Selective serotonin reuptake inhibitor (SSRI):

Citalopram Celapram, Cipramil, Talam

Escitalopram Cilopam, Escicor, Esipram, Lexam, Lexapro, Loxalate

Fluoxetine Fluotex, Lovan, Prozac, Zactin

Fluvoxamine Faverin, Luvox, Movox

Paroxetine Aropax, Extine, Paxtine, Roxtine

Sertraline Eleva, Sertra, Setrona, Zoloft

Serotonin and noradrenaline reuptake inhibitor (SNRI):

Desvenlafaxine Desfax, Desven, Pristiq

Duloxetine Cymbalta, Depreta, Duloxecor, Dytrex, Tixol

Venlafaxine Efexor, Elaxine, Enlafax

216 B7: Managing and treating depression

Table 47: Antidepressant medications (continued)

Drug type and name Brand names

Noradrenaline and specific serotonergic agent (NaSSA):

Mirtazapine Avanza, Axit, Mirtanza, Mirtazon

Tetracyclic antidepressant:

Mianserin Lumin

Noradrenaline reuptake inhibitor (NRI):

Reboxetine Edronax

Melatonergic antidepressant:

Agomelatine Domion, Valdoxan

N-methyl-D-aspartate (NMDA) receptor antagonist:

Esketamine Spravato

Adapted from Australian Government Department of Health [1119]. For a full list of generic brands available, see the Therapeutic
Goods Administration website (https://www.tga.gov.au).

Naltrexone and acamprosate, medications commonly used in the treatment of alcohol use disorders,
have shown moderately positive outcomes in depression as a single disorder [1120]. However, in a 2019
review of trials examining the use of alcohol medications among people with co-occurring alcohol
dependence and depression, naltrexone and acamprosate produced mixed findings. As such, the authors
concluded that their efficacy for alcohol use disorder and depression together remains unclear [1100].
More promising results have been found in relation to the use of disulfiram in this population, which has
been associated with improvements in both depression and alcohol-related outcomes in some studies
[1100, 1103]. While both acamprosate and naltrexone are available on the Pharmaceutical Benefits Scheme
for alcohol dependence, disulfiram is expensive and only available with a private prescription.
B7: Managing and treating depression 217

Recent reviews have noted emerging evidence of the efficacy of anticonvulsants/antiepileptics for
alcohol abstinence in people with co-occurring depression [1100, 1103], and recent trial results have
demonstrated that a single high-dose of buprenorphine may rapidly reduce depression and suicidal
ideation in people with opiate dependence and co-occurring depression [1121, 1122]. These findings
suggest that buprenorphine may prove to be an especially useful pharmacotherapy for this sub-group,
however, further research is needed.

Electroconvulsive therapy (ECT)

The 2019 RANZCP clinical practice guidelines for the treatment of depression note that ECT is a highly
efficacious treatment with a strong evidence base, particularly for patients with severe or psychotic
depression, catatonia, high risk of suicide, or who have not responded to adequate trials of medication
or psychotherapy [808]. However, only one study to date has assessed the efficacy of ECT in treating co-
occurring depression and AOD use disorders [1123]. This study, a retrospective chart review comparing
depressed patients with and without co-occurring AOD use disorders, found that patients with co-
occurring alcohol use disorders experienced similar improvements in their depressive symptoms
following ECT as those with mood disorders alone [1123]; however, patients with both co-occurring alcohol
and drug use disorders experienced smaller improvements post-ECT than those with mood disorders
alone [1123].

E-health interventions
Research examining e-health interventions based mostly on CBT strategies has found evidence for
modest, yet positive effects on depression outcomes [833, 1124], and their use as a low-intensity, initial
treatment for adults experiencing mild symptoms of depression has been recommended by the RANZCP
guidelines [1098]. A small number of e-health interventions specifically designed to treat co-occurring
depression and AOD use have been developed and evaluated in Australia.

The SHADE program, consisting of nine sessions of interactive exercises based on MI and CBT, has
been associated with moderate to large reductions in alcohol consumption and significant reductions
in depression scores over 12-month follow-up [1125, 1126]. More recently, a brief (four-session) early
intervention program called the DEAL Project was developed, targeting young people experiencing
depression with harmful patterns of alcohol use [110]. The program is undertaken entirely online with
no clinician support. In evaluating the intervention, Deady and colleagues [1127] found that individuals
randomised to receive the DEAL Project demonstrated a greater reduction in symptoms of depression and
alcohol use compared to individuals randomised to an attention-control condition. At the time of writing,
both SHADE and the DEAL Project are freely available via the eCliPSE portal http://www.eclipse.org.au.

There are also several Australian-based online programs for depression as a single disorder, including
MindSpot Wellbeing Course, moodgym, myCompass, and This Way Up Depression Course [1128, 1129]. The
majority have been evaluated in clinical trials, and demonstrated small to moderate positive effects on
symptoms of depression [833, 1124, 1130–1132]. The ReachOut website includes a comprehensive list of
apps recommended by clinicians https://au.reachout.com/tools-and-apps.
218 B7: Managing and treating depression

Physical activity
There is increasing evidence to suggest that regular physical exercise has psychological benefits,
with more active people illustrating lower levels of depression than sedentary people [1133–1135]; and,
conversely, more physical inactivity found among people who are depressed [1136]. As mentioned
previously, exercise is relatively low-risk, associated with a wide range of physical health benefits,
and research has demonstrated exercise to be as effective in reducing depressive symptoms as
psychotherapy and antidepressants [272, 1137]. A Cochrane review examining the effect of exercise on
depressive symptoms concluded that physical activity (defined as aerobic, mixed, or resistance) was
moderately more effective than control interventions for treating depression, with exercise equally as
effective as psychotherapy or pharmacotherapy [1138]. The UK NICE Guidelines for mild to moderate
depression recommend 45 minutes to 1 hour duration of structured, supervised physical activity
programs, three times a week over 10 to 14 weeks [1139].

A number of systematic and meta-analytic reviews have examined the effects of physical exercise on
elevated symptoms of depression and/or diagnosed depressive disorders among people with AOD use
disorders. A systematic review by Giménez-Meseguer and colleages [306] found that both physical
fitness and body-mind interventions have positive effects on depression, quality-of-life, and cravings
among people with an alcohol use or other drug use disorder. Similarly, a meta-analysis of 22 studies
examining the use of physical exercise of varied intensity (from light to vigorous, aerobic-based
activities, mind-body practices such as Tai chi, qigong) as a treatment for AOD use disorders found
improvements in abstinence rates, withdrawal symptoms, and depression [305]. However, some reviews
have pointed toward differential effects depending on the type of activity. Specifically, among people
with alcohol use disorders, aerobic exercise or strength training has been found to result in reduced
depressive symptoms but not a reduction in daily alcohol consumption, compared to control conditions
[1140]. Among people with AOD use disorders more broadly, another review found highly mixed outcomes
in relation to depression and AOD use with anaerobic exercise (i.e., high intensity, interval training) [1141].

Yoga

Yoga is a complex mind–body intervention involving spiritual practice, physical activity, breathing
exercises, mindfulness and meditation [1142, 1143]. Although the traditional goal of yoga is to unite body,
mind, and spirit and achieve self-awareness, yoga has become a popular method of maintaining physical
and mental health [1142–1144]. Yoga practice commonly involves postures to improve strength and
flexibility, breathing exercises to focus the mind and assist with relaxation, and meditation to calm the
mind [1144].

Several systematic reviews have been conducted to assess the efficacy of yoga as an intervention for
depression. These studies have found limited to moderate support for short-term improvements in
severity of depression in yoga with meditation-based practice (as opposed to exercise-based practice)
[1145–1148]. Further, yoga has been shown to result in similar remission rates compared to ECT, and
similar short-term improvements in symptoms compared to antidepressant medication [1145]. However,
the current evidence base is hampered by the limited number of RCTs comprising small samples.
B7: Managing and treating depression 219

Reviews of yoga efficacy among people with various standalone AOD use disorders have highlighted
equivalent or superior improvements in AOD use and psychosocial outcomes when compared to
controls (e.g., attention, waitlist, physical exercise). There is also evidence to suggest that it may enhance
the effects of other evidence-based psychological treatments, such as CBT [1149, 1150]. However, only
one study to date has examined the effect of yoga breathing (Sudarshana Kriya Yoga) on depressive
symptoms among people with alcohol dependence [1151]. This study found that the yoga intervention
was associated with reduced depressive symptoms compared to the control group. Although the
effectiveness of yoga as a treatment for people with co-occurring AOD and depressive disorders needs
further investigation, these findings indicate that yoga may be considered as an additional treatment for
clients with co-occurring AOD use and depression.

Complementary and alternative therapies

Omega-3

There has been much research conducted examining the relationship between omega-3 and depressive
disorders, with some limited evidence that omega-3 fatty acids (primarily found in fish and seafood)
have antidepressant effects [1152–1154]. Although there are some indications that omega-3 fatty acids
have a beneficial role in reducing dependence, cravings, and stress among people with AOD use disorders
[1153], findings are inconsistent and most research to date has been conducted on animals [1152, 1154].
Further, the role of omega-3 fatty acids among people with co-occurring AOD use and depression has not
been rigorously examined.

St John’s Wort

St John’s Wort is the common name for the plant Hypericum perforatum, the extracts of which are
commonly used to treat depression, sometimes in order to avoid the side-effects involved with
prescription antidepressant medication [1155]. Systematic reviews of studies examining the efficacy of St
John’s Wort found significantly greater reductions in mild to moderate symptoms of depression among
those taking St John’s Wort compared to placebo, and equivalent reductions compared to antidepressant
medications [1156, 1157]. However, the long-term side effects, particularly among pregnant women, are
unknown.

Although there is some evidence of efficacy in mild to moderate depression, as described in Chapter
B6, the use of St John’s Wort has been shown to have significant interactions with a range of other
medications, including SSRIs and related drugs, oral contraceptives, some anticoagulants, and some
cardiac medications [794].

Although the use of St John’s Wort among people with co-occurring AOD and depressive disorders has
not been examined, AOD workers should ask their clients specifically about their use of St John’s Wort
and other complementary medicines, taking note of the potential for interactions between medications.
220 B7: Managing and treating depression

Summary
While these findings indicate that several psychological, pharmacological, and alternative approaches
for the treatment of co-occurring depression and AOD use disorders appear promising, further research is
required to establish which therapeutic approaches are particularly effective. It is suggested that clinical
efforts be focused on the provision of client-centred, evidence-based treatment, taking into account the
client’s needs and preferences, in a collaborative partnership. Box 17 illustrates the continuation of case
study D, following Sheryl after the identification of her co-occurring depressive and AOD use disorder.

Box 17: Case study D: Treating co-occurring depression and AOD use: Sheryl’s story
continued

Case study D: Sheryl’s story continued

When Sheryl’s GP received her blood test results, they showed Sheryl had an underactive thyroid, for
which her GP immediately organised medication. Sheryl’s GP contacted the local addiction medicine
specialist to advise on the most appropriate method of benzodiazepine titration and withdrawal and
organised an appointment for Sheryl. One of Sheryl’s daughters accompanied her to the appointment.
Through the AOD service, Sheryl heard about a group therapy that is run on Tuesday evenings that didn’t
sound too bad, and with the encouragement of her daughter, started attending.

After a few weeks taking thyroxin medication, Sheryl’s energy increased but she continued experiencing
very low mood. Upon telling her GP of her continued periods of depression, they discussed treatment
options including psychological therapy and medications. Sheryl was reluctant to take another
medication and preferred to see a psychologist. She was referred to a clinical psychologist who began
CBT. Sheryl’s GP began organising regular case management meetings between herself, Sheryl, the
addiction medicine specialist, the clinical psychologist and Sheryl’s daughters. It was decided in the
first meeting that given Sheryl’s medical condition her GP was the appropriate person to take on the
role of the primary case manager. At one of these meetings, Sheryl asked to revisit the idea of taking
antidepressants. Although she was making progress, Sheryl was still feeling very low and was having
trouble fully engaging in therapy.

As part of Sheryl’s psychotherapy, Sheryl was encouraged to rediscover things she was genuinely
interested in and re-establish a sense of purpose. Over time, she reconnected with her friends and
enrolled in some online classes through her local community college.

Key points:
• People with co-occurring disorders may not necessarily present in obvious ways. The
need for careful history taking regarding AOD use cannot be overemphasised.
• Underlying medical conditions may resemble or disguise symptoms of mental
disorders, and it is vital to conduct comprehensive medical assessments.
• It is common for symptoms of both AOD and mental health conditions to be
exacerbated by major life events.
244 B7: Managing and treating trauma, PTSD and complex PTSD

Trauma, post traumatic stress disorder (PTSD), and complex

PTSD

Clinical presentation
As described in Chapter A4, trauma is a term that is widely used and may mean different things to
different people. It can include a myriad of extremely threatening or horrific events, or a series of events,
in which a person is exposed to, witnesses, or is confronted with a situation in which they perceive that
their own, or someone else’s, life or safety is at risk [10, 11].

Most people will experience some emotional or behavioural reactions following exposure to a traumatic
event such as anxiety or fear, aggression or anger, depressive or dissociative symptoms. These emotional
and behavioural responses are to be expected and are a completely normal response to an adverse event.
For the majority of people, these emotional and behavioural reactions will subside and/or reduce in
intensity over time without the need for any intervention; for some people however, these reactions may
be prolonged, leading to significant distress, as well as impairment in social, occupational and other
areas of functioning [102, 156, 157]. Symptoms may be especially long-lasting or complex when the trauma
is interpersonal and intentional (e.g., torture, sexual violence), and if the trauma occurred in childhood
[157, 1285].

Approximately one in ten Australians who experience a traumatic event develop PTSD [157] (described in
Chapter A4). Symptoms of PTSD include:

• Recurrent ‘re-experiencing’ of the traumatic event, through unwanted and intrusive memories,
recurrent dreams or nightmares, or ‘flashbacks’.

• Persistent avoidance of memories, thoughts, feelings or external reminders of the event (such as
people, places or activities).

• Persistent negative alterations in cognitions and mood, including guilt and hopelessness; feeling
a distorted sense of blame of self or others; feeling detached from others; a persistent inability to
experience positive emotions; and reduced interest in activities.

• Persistent symptoms of increased physiological arousal and reactivity, including hypervigilance

towards distressing cues, sleep difficulties, exaggerated startle response, irritability, increased
anger, and concentration difficulties.

Some people develop a more complicated form of PTSD referred to as complex PTSD, in which they also
experience pervasive difficulties with emotional regulation, self-concept, and relationship difficulties
across a variety of contexts (described in Chapter A4). Research among people with AOD use disorders
indicates that 85% of those who meet criteria for PTSD experience it in this more complex form [1286].
Although complex PTSD may arise in relation to any trauma, it is typically associated with prolonged or
repeated interpersonal traumas that occur during childhood [158].
B7: Managing and treating trauma, PTSD and complex PTSD 245

Managing trauma-related symptoms

The provision of trauma-informed care in AOD treatment settings is essential and described in more
detail in Chapter B2. Given that substances are often used to self-medicate trauma-related symptoms
[30], it is not surprising that many people report experiencing an increase in trauma-related symptoms
when they reduce or stop using substances [380]. Evidence to date however, indicates that, as with
symptoms of depression and anxiety, on average, PTSD symptoms also decline in the context of well
managed withdrawal [381–383].

As described in Chapter B2, it is important to note that avoidance symptoms, rather than re-
experiencing symptoms, have been associated with the perpetuation of trauma-related symptoms [398,
1287–1291]. It is therefore crucial that if a person does experience an exacerbation of trauma-related
symptoms, that they are not encouraged to avoid or suppress these thoughts or feelings. Telling a person
not to think or talk about what happened may also intensify feelings of guilt and shame. For those who
have experienced abuse, it may closely re-enact their experience of being told to keep quiet about it [136].
This does not mean that clients should be pushed to revisit events or disclose information if they are not
ready to do so. Rather, it means that it is understandable that the person may be upset by these thoughts
and feelings that may arise, and they should be allowed to engage with these feelings in order to help
process the trauma emotionally.

Chapter B3 provides guidance on how to discuss trauma with clients. As mentioned previously, it is
crucial that clients are not forced to discuss any details about past events if they do not wish to. It is
preferable that clients develop good self-care and have skills to regulate their emotions before they
delve deeply into their traumatic experiences or are exposed to the stories of others; however, choice and
control should be left to the client [136]. In-depth discussion of a person’s trauma experiences should
only be conducted by someone who is trained in dealing with trauma responses [135].

Even without knowing the details of a client’s trauma, AOD workers can use the techniques outlined in
Table 52 to help clients manage their symptoms. Encouraging clients for their resilience in the face of
adversity is important even if past adaptations and ways of coping are now causing problems (e.g., AOD
use). Understanding AOD use as an adaptive response reduces the client’s guilt and shame and provides
a framework for developing new skills to better cope with symptoms [384].

Table 52: Dos and don’ts of managing a client with trauma-related symptoms

Do:

Give the client your undivided attention, empathy and unconditional positive regard.

Use relaxation and grounding techniques where necessary.

Display a comfortable attitude if the client chooses to describe their trauma experience.

Normalise the client’s response to the trauma and validate their feelings.
246 B7: Managing and treating trauma, PTSD and complex PTSD

Table 52: Dos and don’ts of managing a client with trauma-related symptoms
(continued)

Recognise the client’s resilience in the face of adversity.

Recognise the client’s courage in talking about what happened.

Let the client know what to expect if they undergo detoxification (e.g., possible changes in trauma-
related symptoms).

Maximise opportunities for client choice and control over treatment processes.

Monitor depressive and suicidal symptoms.

Don’t:

Rush or force the client to reveal information about the trauma.

Engage in an in-depth discussion of the client’s trauma unless you are trained in trauma
responses.

Judge the client in relation to the trauma or how they reacted to the trauma.

Abruptly end the session.

Encourage the client to suppress their thoughts or feelings.

Engage in aggressive or confrontational therapeutic techniques.

Be afraid to seek assistance.

Use overly clinical language without clear explanations.

Adapted from Ouimette and Brown [1292], Elliot et al. [384], SAMHSA [102], Marsh et al. [135], and Mills and Teesson [136].

Brief psychoeducation about common reactions to trauma and symptom management has also been
found to be of benefit to AOD clients who have experienced trauma [1293]. It is important to normalise
clients’ feelings and convey that such symptoms are a typical and natural reaction to an adverse
traumatic event; they are not ‘going crazy’. Letting them know that their reactions are quite normal may
also help to alleviate some of the shame and guilt they have been feeling about not recovering from the
trauma sooner. It is also important that people who have experienced trauma hear that what happened
was not their fault, especially for those who have experienced sexual assault. An information sheet for
clients on common reactions to trauma is provided in the Worksheets section of these Guidelines.
Clients may also find the relaxation techniques described in Appendix CC useful for managing trauma-
related symptoms. Many common procedures and practices may re-trigger trauma reactions. For
example, aggressive or confrontational group techniques can trigger memories of past abuse. Such
B7: Managing and treating trauma, PTSD and complex PTSD 247

techniques are counterproductive; those who have been exposed to abuse in particular may revert to
techniques used to cope during the trauma such as dissociating or shutting down emotionally. Engaging
in these strategies may then lead to the client being labelled as ‘treatment resistant’ and, consequently,
feelings of self-blame. Chapter B2 also provides guidance on other aspects of service provision to
consider in providing a trauma-informed approach to care.

As discussed in Chapter B8, it is also essential that workers attend to their own responses to working
with traumatised clients through self-care. Hearing the details of others’ trauma can be distressing,
and in some cases may lead to vicarious traumatisation or secondary traumatic stress [404, 1294].
By attending to one’s own self-care and engaging in clinical supervision, the likelihood of developing
secondary traumatic stress may be reduced. Chapter B8 provides more detail on strategies for
promoting and enhancing AOD worker self-care and reducing burnout.

Treating PTSD
People with co-occurring PTSD and AOD use can benefit from a variety of treatments. It is important to
emphasise that while there is a strong evidence base for certain treatments, the need for individualising
a treatment plan to suit the particular client is of paramount importance.

Due to the inter-relatedness of PTSD and AOD use, experts recommend that these conditions be treated
in an integrated fashion [102, 141, 739, 1295, 1296]. Some clinicians maintain the view that the AOD use
must be treated first, or that abstinence is necessary before PTSD diagnosis and management can be
attempted. In practice, however, this approach can lead to clients being passed between services with
little coordination of care [1297]. Moreover, clients express a preference for integrated interventions that
treat both disorders concurrently [141, 1298]. Ongoing AOD use may impede therapy, but it is not necessary
to achieve abstinence before the commencement of PTSD treatment [1299]. Improvements can be
obtained even in the presence of continued substance use [1300, 1301].

There are several options available for the treatment of PTSD, including psychotherapy (e.g., past-
and present-focused therapies), pharmacotherapy, e-health interventions, physical activity, and
complementary and alternative therapies (e.g., yoga). The evidence base surrounding each of these
treatments is discussed below.

As complex PTSD is a new diagnosis there is no direct evidence about how to treat it; however, given
the high prevalence of complex PTSD [1286], it is likely that a high proportion of participants in the PTSD
treatment trials described in this section were experiencing PTSD in its complex form. A meta-analysis
that retrospectively assessed PTSD psychotherapy trials to determine if they included patients with
complex PTSD has also found beneficial effects of standard trauma-focused treatments in reducing
PTSD symptoms as well as some symptoms specific to complex PTSD (i.e., negative self-concept,
disturbances in relationships) [1302]. Given that complex PTSD is comprised of a greater number and
diversity of symptoms, its treatment may nonetheless require additional treatments and/or treatment of
a longer duration compared to those with PTSD [1303].
248 B7: Managing and treating trauma, PTSD and complex PTSD

Psychotherapy
A number of psychotherapeutic interventions have been developed for the treatment of co-occurring
PTSD and AOD use, and an increasing number are undergoing evaluation. Although there is some
contention regarding the naming conventions, existing approaches may be divided into two types: i)
past-/trauma-focused therapies; and ii) present-/non-trauma-focused therapies [1304–1306]. The main
distinction is that the former involves the revisiting of trauma memories and their meaning, while the
latter focus on the development of coping skills in the present.

Several reviews have concluded that there is support for individual past-/trauma-focused psychological
interventions that utilise exposure-based approaches, particularly in relation to PTSD outcomes, but
that there is very little evidence to support the use of non-trauma-focused individual or group-based
interventions over treatment as usual for AOD use [739, 1296, 1307, 1308].

It should be noted that there are diverging views as to whether or not psychotherapy for PTSD, and
complex PTSD in particular, should be undertaken using a phase-based approach [1309]. A phase-
based approach proposes that it is necessary for a person to undertake interventions that focus on
stabilisation in the first phase of treatment (i.e., establishing safety, symptom management, improving
emotion regulation and addressing current stressors) prior to moving on to processing the trauma
memory, followed by reintegration (i.e., re-establishing social and cultural connection and addressing
personal quality of life) [1310]. However, the evidence to date suggests that this approach is neither
necessary nor recommended, as it may lead to unnecessary delays or restrictions in access to effective
past-/trauma-focused therapy [1309, 1311, 1312]. Indeed, studies comparing the efficacy of a phased-
based approach relative to past-/trauma-focused treatment have found that recovery may be faster for
those who receive past-/trauma-focused treatment [1311, 1312]. That is not to say that the components
incorporated in phase one are not important, but rather, that they can be integrated throughout the
treatment process alongside the past-/trauma-focused work [1313]. The vast majority of past-/trauma-
focused therapies described in this chapter incorporate phase one components in their programs.

Past-/trauma-focused therapies

Past-/trauma-focused therapies are typically delivered individually and involve various exposure-based
techniques in which the client revisits, and seeks to make meaning of, the traumatic events they have
experienced and their consequences. Of these, prolonged exposure (PE) has received the most empirical
attention. Alongside other past-/trauma-focused therapies, including cognitive processing therapy (CPT),
and EMDR, PE is considered a first-line treatment for PTSD in the absence of AOD use [1303, 1308].

Prolonged exposure (PE)

Similar to exposure for phobias, PE for PTSD involves exposure to the feared object or situation; in this
case, traumatic memories (imaginal exposure) and physical reminders of the trauma (in vivo exposure).
Traditionally, PE for PTSD was considered inappropriate for use with people experiencing AOD use
disorders based on concerns that the emotions experienced may be overwhelming and could lead to
relapse or further deterioration [1314]. However, the evidence suggests that this is not the case; PE does
not lead to an exacerbation of AOD use, cravings, or increase the severity of the AOD use disorder [741,
B7: Managing and treating trauma, PTSD and complex PTSD 249

1314]; in fact, it may be protective against relapse [1315]. Trials examining the efficacy of PE (in its original
form, as well as modified or enhanced versions) delivered alongside treatment-as-usual for AOD use
report positive outcomes including significant reductions in PTSD symptoms [741, 1316, 1317]. Contingency
management has also been shown to be an effective adjunct to PE among people with opioid use
disorders, leading to greater treatment retention and greater reductions in PTSD symptoms [1318]. One
RCT has also examined the efficacy of PE and concurrent naltrexone in treating PTSD and alcohol use
disorders. Exposure therapy was not found to be superior to supportive counselling in reducing PTSD
symptoms; however, it was associated with reduced risk of relapse to alcohol use at 6-month follow-up
[1315].

A number of clinical researchers have investigated the efficacy of integrated exposure-based programs
that address PTSD and AOD use simultaneously. Typically these programs involve psychoeducation
regarding each disorder and their interrelatedness, coping skills training, relapse prevention, and
exposure to traumatic memories and/or reminders; and they are sometimes delivered in combination
with other therapeutic techniques [739]. Support for these programs is growing, with an increasing
number of studies providing evidence for their safety and efficacy, including two Australian trials
[1300, 1301]. Participants in these studies did not demonstrate a worsening of symptoms or high rates
of relapse; on the contrary, they demonstrated improvements in relation to both AOD use and PTSD
outcomes [739, 1296, 1307].

The majority of research in this area has focused on the efficacy of an integrated treatment called
Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE) [442]. Since the first
RCT of this intervention was completed in Australia [1300], a further three have been undertaken in the
United States [772, 1319, 1320]. Collectively, these studies have found that, while decreases in substance
use are comparable to control conditions, with respect to PTSD symptom reduction, COPE outperforms
treatment-as-usual for AOD use, relapse prevention, and a present-/non-trauma focused therapy
(Seeking Safety). A modified version of the COPE program is currently being examined among Australian
adolescents [1321, 1322]. Another integrated exposure-based program for adolescents that has shown
promise in reducing PTSD symptoms, AOD use and risk behaviours is Risk Reduction Through Family Therapy
(RRFT), which combines trauma-focused CBT and multisystemic therapy [1323, 1324].

Cognitive processing therapy (CPT)

CPT focuses on challenging and modifying unhelpful trauma-related beliefs (e.g., beliefs surrounding
safety, trust, power, control, esteem, and intimacy) that are having a negative impact on a person’s life
via written exposure and cognitive restructuring. Despite CPT being a first line treatment for PTSD, few
studies have examined its effectiveness for people with co-occurring AOD use disorders. CPT, and CPT
integrated with CBT for substance use, have shown promise among people with AOD use disorders;
however, the predominance of this research has been conducted on veteran samples. Studies comparing
outcomes of CPT for veterans with and without co-occurring AOD use disorders have found no significant
differences between groups [1325, 1326]. Subsequent open label trials of CPT combined with CBT for
substance use have also reported reduced PTSD symptoms, depressive symptoms, and AOD-related
outcomes [1327–1329].
250 B7: Managing and treating trauma, PTSD and complex PTSD

Eye movement desensitisation and reprocessing (EMDR)

In EMDR, a person focuses on the imagery of a trauma, negative thoughts, emotions and body sensations
whilst following guided eye movements led by a therapist. Although EMDR is a first line treatment for
PTSD only a small number of studies have examined its effectiveness for people with co-occurring
AOD use disorders. Two small pilot trials have found that EMDR, alongside treatment-as-usual for AOD
use, produces significantly greater reductions in PTSD symptoms compared to treatment-as-usual for
AOD use alone [1330, 1331]. Although case series have described benefits in relation to AOD use as well
[1332], these trials did not find any between-group differences [1330, 1331]. There is some very preliminary
evidence to suggest that EMDR combined with schema therapy for PTSD and AOD use disorders may be
effective in reducing both PTSD and AOD use [1333]. Two additional studies of EMDR for people with either
PTSD or a history of trauma and co-occurring AOD use are currently underway [1334, 1335].

Present-/non-trauma-focused therapies

Present-/non-trauma-focused therapies are typically integrated CBT-based treatments which focus on

providing clients with coping skills to live in the present without revisiting the traumatic event [1336].
These interventions are typically delivered in individual or group formats. As mentioned previously,
three reviews have concluded that there is little evidence to support the use of present-/non-trauma-
focused individual or group-based interventions relative to providing treatment-as-usual for AOD use
[739, 1296, 1307]. They are, nonetheless, an important treatment option for clients who are not wishing to
undergo past-/trauma-focused therapies. Several present-focused treatments have, and continue to be,
developed [1336–1339], but the program which has undergone the most extensive evaluation is Seeking
Safety [702, 1340].

Seeking Safety focuses on examining the impact of trauma without delving into the trauma narrative
[1341]. The treatment has been conducted in group and individual formats in a variety of settings (e.g.,
outpatient, inpatient, residential, prisons) and populations (e.g., women, veterans, adolescents). RCTs
and meta-analyses have found that, while PTSD and AOD use treatment outcomes for people who receive
Seeking Safety are better than those who receive no treatment, they are comparable to those who receive
alternate treatments such as relapse prevention, treatment-as-usual for AOD use, or health education
[773, 1342–1344].

An emerging alternative present-centred therapy is integrated CBT (ICBT). ICBT addresses PTSD, substance
use, and their interaction through three core components: cognitive restructuring, centring and
breathing retraining, and psychoeducation [1345]. Two RCTs have examined the efficacy of ICBT relative
to usual care and individual addiction counselling. Neither reported significant differences for PTSD
outcomes [667, 1346], but one reported better AOD-related outcomes [667].

Mindfulness-based programs have also shown promise in early pilot studies [1347–1349] and one RCT
which found greater improvements in PTSD symptoms, AOD cravings, and negative affect among those
randomised to receive Mindfulness Oriented Recovery Enhancement relative to Seeking Safety [1177]. Research
examining the efficacy of ACT for PTSD and AOD use is in its early stages, but has been associated with
improvements in PTSD symptoms and alcohol-related outcomes among veterans [687].
B7: Managing and treating trauma, PTSD and complex PTSD 251

Pharmacotherapy
Pharmacotherapies are not a recommended first line treatment for PTSD due to their limited efficacy.
There is also little evidence to suggest that combining psychological and pharmacological interventions
leads to improved outcomes. Nonetheless, Australian and international guidelines for the treatment
of PTSD [1308, 1350] recommend that pharmacotherapies be used as an adjunct to trauma-focused
psychotherapy if the person has not gained benefit from psychological treatment, or if they express a
preference for pharmacotherapy [1308, 1350–1352]. When pharmacotherapies are considered, SSRIs are
the recommended first line option, particularly fluoxetine, paroxetine, and sertraline [1303, 1308], followed
by the SNRI venlafaxine (see Table 47).

Trials of pharmacotherapy for PTSD co-occurring with AOD use disorders have examined the use of
sertraline and paroxetine (SSRI antidepressants), desipramine (TCA), prazosin (alpha1-adrenergic receptor
agonist), aprepitant (neurokinin-1 receptor antagonist), topiramate and zonisamide (anticonvulsants),
N-acetylcysteine (mucolytic agent), naltrexone (opioid antagonist), and disulfiram (alcohol antagonist).

Early work by Brady and colleagues examining the use of sertraline provided initial evidence of safety
and evidence of efficacy among people with less severe alcohol dependence and earlier onset PTSD [1353,
1354]. More recently, Hien and colleagues [780] investigated the use of sertraline in combination with
the psychotherapy Seeking Safety. In this study, Seeking Safety plus sertraline was found to be superior
to Seeking Safety with placebo in reducing PTSD symptoms, though improvements in alcohol use and
dependence were equivalent between groups.

Petrakis and colleagues [1355] conducted an RCT comparing the efficacy of desipramine and paroxetine
with and without adjunctive naltrexone among veterans with PTSD and alcohol dependence. Both groups
of antidepressants produced a significant decrease in PTSD symptoms, with greater reductions in
alcohol use seen among those who received desipramine. Adjunctive use of naltrexone was associated
with greater reductions in cravings but did not provide any advantage over placebo in terms of alcohol
use.

The limited research that has been conducted among people with co-occurring PTSD and AOD use
disorders in relation to prazosin and aprepitant suggests that these agents are no more effective
than placebo in relation to either PTSD or alcohol-related outcomes [1356], whereas topiramate [1357],
zonisamide (as an adjunct to CPT) [1358], and N-acetylcysteine (as an adjunct to CBT for substance
use) [1359] have been associated with greater reductions in PTSD symptom severity and alcohol-
related outcomes relative to placebo [1357]. Naltrexone, disulfiram, and the combination of these two
medications have been associated with greater reductions in alcohol-related outcomes but not PTSD
symptoms, relative to placebo; however, unwanted side effects were more common among people who
received the combination of naltrexone and disulfiram [1315, 1360].

In recent years there has been growing interest in the use of psychedelic substances such as MDMA,
psilocybin, and ketamine to enhance psychotherapy for the treatment of PTSD and AOD use disorders
(alcohol in particular) as single disorders. Despite there being considerable enthusiasm about
the potential of these substances bringing a long-awaited breakthrough in psychiatry, to date the
predominance of research is limited to small, uncontrolled trials [1361–1364]. Further research is needed
to determine clinical efficacy and safety for single, as well as co-occurring conditions.
252 B7: Managing and treating trauma, PTSD and complex PTSD

E-health and telehealth interventions

Currently, there are two e-health programs which have been developed to target co-occurring AOD
use and PTSD among veterans. Thinking Forward is a self-directed online CBT program, comprising 12
interactive modules, developed for people with PTSD engaging in hazardous alcohol use. Findings to date
have been mixed with one RCT reporting an association between Thinking Forward and reductions in heavy
drinking but not PTSD symptoms, and another finding reductions in PTSD symptoms but not alcohol
use [1365, 1366]. Similarly, VetChange, a CBT and MI-based online program for veterans with clinical levels
of PTSD and at-risk alcohol use, has demonstrated significant post-treatment reductions in alcohol
use and PTSD symptoms relative to baseline [1367–1369]. These reductions were more pronounced for
VetChange participants compared to those randomised to a waitlist control [1367]. VetChange has also been
adapted into a mobile app (https://mobile.va.gov/app/vetchange), which is yet to be evaluated.

Although there are few internet programs targeting co-occurring PTSD and AOD use, many evidence-
based interventions exist for PTSD as a single disorder. Two meta-analyses support the benefit of
e-health interventions, finding that they lead to greater improvements in PTSD symptoms compared to
usual care, waitlist, and active controls [1370, 1371]. Improvements were observed regardless of whether
individualised feedback was provided alongside the e-health intervention [1370]. Programs shown to have
moderate treatment effects often incorporated CBT techniques, in the form of psychoeducation, exposure
(e.g., writing about one’s trauma experience), anxiety management, and cognitive restructuring [1350].

Two promising internet programs – PTSD Online and The PTSD Course – have been developed in Australia
and provide psychoeducational resources about AOD use [1195, 1372]. PTSD Online is a 10-week therapist-
assisted program incorporating psychoeducation and CBT-based components. Several uncontrolled
studies have found promising results, including high levels of treatment satisfaction and significant
post-treatment improvements in PTSD symptoms, psychological distress, and quality of life relative to
baseline [1195, 1196, 1373, 1374]. Similarly, The PTSD Course (formerly PTSD Program) is an online intervention
including seven lessons based on elements of psychoeducation, CBT, and exposure therapy. People
accessing the program are able to discuss relevant issues in forums moderated by therapists and
message clinicians. One small RCT found significantly greater reductions in PTSD symptom severity
among people randomised to receive PTSD Course compared to a waitlist control [1372]. People who
accessed PTSD Course also reported high levels of satisfaction with the treatment.

There are several smartphone apps designed to treat PTSD as a single disorder. PTSD Coach, developed
by the US Department of Veterans Affairs, is based on CBT and incorporates psychoeducation, self-
assessment, treatment and referral resources, and social support tools, which can together be used as a
stand-alone or supportive app during therapy [1375]. An online version of the app is also available (http://
www.ptsd.va.gov/apps/PTSDCoachOnline). When compared to a waitlist control, Kuhn and colleagues
[1376] found people accessing PTSD Coach reported greater reductions in PTSD symptoms [1376]. Miner and
colleagues [1377], on the other hand, found no difference in post-treatment PTSD symptom scores [1377].
PTSD Coach has also been adapted into PTSD Coach Australia for Australian veterans [1378]. Qualitative
feedback from participants provided promising support for this adaptation [1379].
B7: Managing and treating trauma, PTSD and complex PTSD 253

Physical activity
A number of uncontrolled pilot studies have found aerobic exercise to be associated with improvements
in PTSD symptoms [1380–1384]. Promising findings were also provided by a small controlled trial which
found greater reductions in PTSD symptoms among people randomised to receive exposure therapy with
exercise augmentation compared to those randomised to receive exposure therapy alone [1385]. Another
small controlled trial reported greater reductions among people with PTSD as a single disorder following
12 weeks of aerobic and resistance exercises, compared to people randomised to a wait-list control [1386].
A more rigorous evaluation of the impact of exercise on PTSD symptoms was completed in Australia.
Rosenbaum and colleagues [1387] compared the efficacy of a 12-week exercise program (consisting of
three 30-minute resistance-training sessions per week and a walking program) provided as an adjunct
to inpatient care for PTSD, to inpatient care alone, in an RCT. People randomised to receive the exercise
program demonstrated significantly greater reductions in PTSD symptom severity compared to those
randomised to receive inpatient care alone.

In a more recent RCT, veterans with PTSD as a single disorder participated in 12 weeks of supervised
exercise training, including aerobic, balance, strength, and flexibility exercises, three days a week [1388].
Relative to veterans randomised to a wait-list control, those who received the exercise intervention
reduced their PTSD symptoms by an average of 16% (compared to 7% in the control group), and
also reported greater decreases in negative cognitions, negative mood, depressive symptoms, and
improvements in sleep quality. While further research is needed examining the optimal dose, frequency
and intensity of exercise, these findings provide preliminary support for the use of exercise as an adjunct
to evidence-based PTSD treatments. Research has yet to examine the impact of physical exercise in
people with co-occurring PTSD and AOD use disorders.

Yoga

A review of the literature concluded that yoga appears to have benefits for people with PTSD, particularly
in relation to hyperarousal symptoms [1389]. The predominance of research to date has consisted of
small, uncontrolled pilot studies; however, one RCT provides stronger evidence in support of yoga as
an alternative therapy for PTSD. Van der Kolk and colleagues [1390] compared the efficacy of a 10-week
yoga program to supportive health education (both delivered for one hour per week) among women
with chronic treatment-resistant PTSD. Significantly greater reductions in PTSD symptom severity were
observed among those randomised to undertake yoga compared to the supportive health education
program, with effect sizes comparable to those observed for well-established psychological and
pharmacological interventions. At the end of the program, 52% of those in the yoga group no longer
met criteria for PTSD compared to 21% in the control group. The authors suggest that yoga may improve
the functioning of traumatised people by helping them to tolerate physical and sensory experiences
associated with fear and helplessness and to increase emotional awareness and affect tolerance [1390].
A long-term follow-up of this trial illustrated that the benefits of yoga relative to a control group were no
longer evident 18 months after study completion, though an increased frequency of yoga practise was
associated with reduced PTSD symptoms in both conditions [1391]. These findings are similar to those
from a more recent RCT, which compared a holistic yoga intervention to a wellness lifestyle program
among veterans and civilians with PTSD as a single disorder [1392]. People randomised to the yoga
254 B7: Managing and treating trauma, PTSD and complex PTSD

intervention experienced greater decreases in PTSD symptom severity directly following the intervention
relative to people randomised to the lifestyle program, but these differences were no longer significant
seven months after the study.

Studies examining the efficacy of yoga among people with co-occurring PTSD and AOD use disorders
are lacking; however, there is some evidence to suggest that yoga may be beneficial among people with
these co-occurring disorders. A small Australian RCT comparing a multicomponent yoga breath program
to waitlist control among heavy drinking male veterans found a significantly greater reduction in PTSD
symptoms in the yoga group compared to waitlist control, and a corresponding small, non-significant
reduction in alcohol use [1393]. Another small trial of women with subthreshold and diagnostic levels
of PTSD examined the impact of yoga on AOD use. Reductions in risky AOD use were observed; however,
this study excluded women with AOD use disorders [1394]. One further qualitative study examined yoga
among women in AOD treatment, most of whom reported a history of trauma [1395]. Women included
in this study reported a wide variety of benefits for yoga, including improved mental health, emotional
expression, improved sleep, and increased strength. Further research among people with co-occurring
PTSD and AOD use disorders is needed, as well as research to determine the best style of yoga, and the
optimal frequency and duration of practice.

Complementary and alternative therapies

Music therapy

A single study examined the efficacy of music-therapy as an adjunct to outpatient AOD treatment among
12 people with PTSD and AOD use disorders, where music therapy involved psychoeducation, breathing/
singing exercises, and attentional control training. In this trial, Hakvoort and colleagues [1396] found that
six, one-hour sessions of music therapy reduced PTSD symptoms relative to before treatment. Moreover,
83% of people remained abstinent at the end of treatment, with no reports of relapse or AOD cravings,
although 50% of people dropped out of the study.

Summary
The importance of providing trauma-informed care in the context of AOD treatment is now well
recognised. Due to the inter-relatedness of PTSD and AOD use, an integrated approach to the treatment
of these disorders is recommended. Several psychotherapeutic interventions have been developed for
the treatment of co-occurring PTSD and AOD use. The evidence to date suggests that individual past-/
trauma-focused psychological interventions delivered alongside AOD treatment are more efficacious
than those that are present-/non-trauma focused. It is, however, important that both options be
considered in the context of tailoring a person’s treatment to their individual needs and preferences.
Findings from pharmaceutical trials indicate that pharmacotherapies (SSRIs in particular) may be a
useful adjunctive treatment if sufficient benefit has not been gained from psychological interventions.
E-health interventions, physical exercise, yoga and music therapy also appear to convey benefit; however,
further research is needed to determine efficacy in PTSD populations and people with co-occurring AOD
use disorders in particular. Box 20 illustrates the continuation of case study G, following Julie’s story after
identification of her PTSD disorder was made.
B7: Managing and treating trauma, PTSD and complex PTSD 255

Box 20: Case study G: Treating co-occurring PTSD and AOD use: Julie’s story continued

Case study G: Julie’s story continued

The AOD worker organised for Julie to speak with one of the team’s psychologists. Over a series of
sessions with her treating psychologist, Julie began to talk more about how the traumatic events in her
life had affected her. She reported a mix of re-experiencing, avoidance and hyperarousal symptoms in
relation to both the physical and sexual assaults she had experienced as a child and as an adult and
became visibly upset - at times shaking - when she discussed the events. It also became apparent that
Julie felt a great deal of guilt, shame and self-blame surrounding the events.

Throughout treatment, the psychologist continued to normalise Julie’s symptoms, providing

psychoeducation and self-management techniques, and was able to explore the relationship between
Julie’s trauma-related symptoms and her substance use. Julie was also able to recognise how these
events had played a deciding role in how she viewed herself and others, and her relationships. Although
distressing, over time Julie recognised that addressing these issues would be an important part of
her treatment and worked with her psychologist on deciding on an evidence-based approach that
she felt comfortable with. Julie struggled to reduce her substance use during this time and with the
support of the psychologist, decided to commence opiate substitution therapy to further support her
in reducing her substance use whilst still undertaking sessions with her psychologist. Both Julie and
her psychologist were aware that it may take time, but they would both work together to help her work
through the traumatic events she had experienced to achieve her long-term treatment goals.

Key points:
• Symptoms of PTSD and other mental disorders may only become apparent during
AOD treatment.
• Many clients have experienced multiple traumas and re-victimisation.
• It is recommended that treatments for PTSD and AOD use should be carefully
integrated.
B7: Managing and treating ED 257

Eating disorders (ED)

EDs (i.e., anorexia nervosa, bulimia nervosa, binge eating disorder) and AOD use frequently co-occur
[1397]. The co-occurrence of ED and AOD use disorders is particularly complex and challenging, in terms
of assessment and treatment, associated physical health complications, and the potential negative
cognitive impacts of both disorders [1398]. Assessment can be made even more difficult as the
minimisation or denial of symptoms can form part of some eating disorder presentations; either due to
a lack of self-awareness, shame, or as a result of some EDs being experienced by the person as ‘valuable’
to them and something they must protect [428, 1399]. It is however, important that co-occurring ED
and AOD use is identified; the consequences of ED and AOD use are severe, and can include medical
complications [1400, 1401], additional severe psychiatric conditions [1402–1404], suicidal ideation and
attempts [1405, 1406], and mortality [1407].

It is vital for AOD workers to be able to recognise the clinical and subthreshold signs of ED and have
some knowledge about simple management strategies.

Clinical presentation
EDs are characterised by disturbances in eating behaviours and food intake that impair psychosocial
functioning and/or physical health. These disturbances may involve:

• Food restriction (e.g., limiting the amount of food eaten each day by reducing portion size, going
long periods of time without food [>4 hours at a time], eliminating food types such as fats or
carbohydrates, or not eating at all).

• Compensatory behaviours in reaction to consuming food (e.g., overexercising, vomiting and/or

purging, laxative use).

• Binge eating (i.e., consuming an objectively large amount of food in a short period of time,
accompanied by a sense of feeling out of control).

The majority of physical symptoms associated with ED are related to the effects of starvation, bingeing,
purging, and/or overexercising [1408–1410]. People with ED, particularly bulimia nervosa, may show few
outward signs of their disorder [1411, 1412], and may also hide symptoms of their ED (e.g., by wearing
loose fitting clothing) [428]. Any visible physical signs of the ED may be complicated by AOD use. For
example, AOD use can influence features that are usually associated with the assessment of ED, such
as weight, appetite and food restriction [1412]. Furthermore, people with an ED may experience eating-
related symptoms which are similar to those associated with AOD use, such as cravings and patterns of
compulsive use [10]. Further, for some with ED and AOD conditions, alcohol may serve as the main source
of nutrition. AOD workers should therefore endeavour to maintain a direct, non-judgemental approach
during assessment, and seek to obtain as much additional information as possible (e.g., from family
and/or friends with the client’s consent) [1413]. The level of care required will depend on illness severity,
the presence of any medical complications, dangerousness of behaviours, and any other psychiatric
comorbidities (e.g., depression, anxiety) [1408, 1414]. In more complex presentations of ED, consultation
with additional interdisciplinary professionals may be required, including dieticians, exercise therapists,
social workers, family therapists, and psychiatrists [1408].
258 B7: Managing and treating ED

AOD workers should also be aware of the potential interactions between co-occurring ED and AOD use
and consider this interplay when conducting assessments. There may be AOD use related to the ED; for
example, the use of tobacco, stimulants, diet pills, laxatives, diuretics, or caffeine to control weight or
suppress appetite [1400]. As such, assessment should include a focus on the use of AOD as a weight loss
mechanism, as well as the role it may have in emotion regulation [1415].

Symptoms of ED

Anorexia nervosa
The most profound clinical feature of anorexia nervosa is extreme caloric restriction to induce weight
loss. People can have anorexia nervosa even when at normal weights; it is the restriction and the weight
loss rather than actual body weight that are the key features. Anorexia nervosa can be conceptualised as
a disorder of control and denial where low body weight is mistakenly perceived to be normal or excessive
and is central to a person’s self-worth [11]. In many instances, the rigid control of food intake and weight
can be best thought of as an attempt to cope with, cause or prevent a life event or mood (e.g., prevent
puberty, reduce anxiety, deter abuse) [423]. Although not all physical symptoms will be noticeable, AOD
workers should be aware of the potential for medical complications, many of which may improve or be
reversed with early intervention [1409]. Physical signs a person may present with may include [1409, 1414,
1416]:

• Bradycardia (slowed heart rate).

• Low blood pressure.

• Abdominal pain, discomfort and/or constipation.

• Peripheral oedema (swelling of lower legs or hands).

• Bruising and/or broken blood vessels.

• Loss of menstruation (in females), and low testosterone levels (in males).

• Fatigue.

• Lethargy or hyperactivity.

• Cold sensitivity or intolerance.

• Loss or thinning of hair.

• Acne.

• Xerosis (dry skin).

• Lanugo hair on the body (fine hairs on the back, face, arms).

• Dehydration.

Other complications may include neurological abnormalities, changes in cardiac structure (e.g.,
ventricular atrophy), decreased bone density or osteoporosis, hypoglycaemia or diabetes, liver enzyme
abnormalities, and elevated cortisol levels.
B7: Managing and treating ED 259

A thorough assessment of anorexia nervosa needs to include a comprehensive physical exam in order
to identify any potential medical complications or other abnormalities that require immediate medical
attention [1414, 1417].

Bulimia nervosa
Bulimia nervosa is characterised by a cycle of binge eating and purging behaviours. Binge eating involves
a discrete time period where a person feels a loss of control over their eating, as they consume more or
different food than usual, and do not feel able to stop eating or limit their intake [10, 11, 1408]. Bingeing
is often followed by compensatory behaviours designed to prevent weight gain (e.g., vomiting, use of
laxatives, fasting or excessive exercising). As with anorexia nervosa, a person’s perception of their value
and self-worth is disproportionately influenced by their body weight, size, and shape [10].

The cycle of bingeing and purging is maintained by the belief that control over one’s eating, weight, and
shape will increase a person’s self-worth, and that by restricting and compensating after a binge they are
effectively managing weight. However, restricting food intake leads to binge eating which then results
in compensatory behaviours [1414]. Negative mood states such as sadness, frustration, anger, fear, or
loneliness, can exacerbate this cycle [1418, 1419].

As described in Chapter A4, people with bulimia nervosa may present with symptoms of extreme dietary
restrictions and/or exercise plans without purging behaviours [1408]. Further, people with bulimia
nervosa are often ashamed of their eating behaviours, and attempt to hide or conceal their symptoms
[428, 1420]. Some people even report deliberately selecting certain compensatory behaviours, such as
vaping, because they are easy to conceal [1421]. As such, bulimia nervosa can be an isolating disorder
[1414]. As with anorexia nervosa, the outward symptoms can be difficult to observe, particularly as people
with bulimia nervosa may not display the same dramatic loss in weight. Physical signs a person may
present with may include [1410, 1414, 1422]:

• Fatigue.

• Bloating and constipation.

• Gastric acid reflux, which can lead to difficulty swallowing or indigestion.

• Abdominal pain and distension.

• Calloused knuckles.

• Hoarse voice.

• Delayed digestion.

• Electrolyte abnormalities, such as hypokalaemia (low potassium).

• Muscle spasms.

• Heart palpitations.

• Nausea.

• Poor kidney function.

260 B7: Managing and treating ED

• Dental erosion.

• Enlarged glands.

• Poor colon function.

Binge eating disorder

Binge eating disorder is characterised by recurrent episodes of binge eating which occur without
compensatory weight control methods. As with bulimia nervosa, an episode of binge eating occurs within
a discrete time period during which a person feels a loss of control over their eating, where they consume
more or different food than usual, and do not feel able to stop eating or limit their food intake [10, 11, 1408].
As described in Chapter A4, binge eating disorder differs from bulimia nervosa as episodes of binge
eating are not regularly followed by compensatory behaviours to prevent weight gain (e.g., strenuous
exercise, self-induced vomiting, misuse of laxatives). Care should be taken not to confuse binge eating
disorder (a psychiatric condition) with obesity (a medical condition), even though they may physically
resemble each other and can co-occur. Symptoms include [1414]:

• Obesity.

• Hyperlipidaemia (elevated lipids in the blood).

• Type 2 diabetes.

Common to anorexia nervosa, bulimia nervosa, and binge eating disorder is a dysfunctional and
distressing system of evaluating a person’s self-worth which, rather than being based on personal
qualities and achievements across various domains (e.g., academic accomplishments, athletic ability,
work achievements, values, relationship qualities), is focused on weight, size, shape, and appearance
[159, 160, 1423]. People with bulimia nervosa and binge eating disorder are distressed by the loss of
control over their eating, and the perception of overeating, and are at increased risk of additional
psychiatric comorbidities [1408]. In bulimia nervosa, binge eating is thought to come about from severely
restricting food intake as well as a mechanism for emotion regulation, but those with binge eating
disorder do not illustrate the same intake restrictions between episodes of binge eating [1414].

Managing ED
Despite the differences between ED in terms of clinical characteristics and observable symptoms, there
are common strategies that AOD workers can utilise to manage these disorders. The general principles
of managing and treating ED should include the establishment of a trusting, collaborative, therapeutic
relationship, taking care to avoid any potential power struggles [1424, 1425]. The techniques outlined in
Table 53 may help AOD workers to manage clients with ED symptoms.
B7: Managing and treating ED 261

Table 53: Dos and don’ts of managing a client with symptoms of eating disorders

Do:

Encourage and emphasise successes and positive steps (even just coming in for treatment).

Take everything the client says seriously.

Approach the client in a calm, confident and receptive way.

Be direct and clear in your approach.

Use open-ended questions such as ‘So tell me about...?’ which require more than a ‘yes’ or ‘no’
answer. This is often a good way to start a conversation.

Constantly monitor suicidal thoughts and talk about these thoughts openly and calmly.

Encourage the client to express their feelings.

Focus on feelings and relationships, not on weight and food.

Be available, supportive, and empathetic.

Encourage participation in healthy, pleasurable, and achievement-based activities (e.g., exercise,

hobbies, or work).

Encourage, but do not force, healthy eating patterns.

Assist the client to set realistic goals.

Involve family or friends in management or treatment strategies.

Be patient in order to allow the client to feel comfortable to disclose information.

Explain the purpose of interventions.

Don’t:

Act shocked by what the client may reveal.

Be harsh, angry, or judgemental. Remain calm and patient.

Use statements that label, blame or shame the client.

Invalidate the client’s feelings.

Make comments (either positive or negative) about body weight, appearance, or food – these will
only reinforce their obsession.

Express any size prejudice or reinforce the desire to be thin.

262 B7: Managing and treating ED

Table 53: Dos and don’ts of managing a client with symptoms of eating disorders
(continued)

Engage in power struggles about eating.

Criticise the client’s eating habits.

Trick or force the person to eat.

Get frustrated or impatient.

Adapted from NSW Department of Health [431], Clancy and Terry [448], and World Health Organisation; Collaborating Centre for
Evidence in Mental Health Policy [1410].

Treating ED
EDs are complex psychiatric illnesses that impair psychological, social, and physical functioning.
It has been argued that the treatment of co-occurring ED and AOD use should be provided using an
integrated approach to minimise the potential for deterioration in one disorder when symptoms of the
other improve [726, 1415, 1426]. Regardless of the eventual treatment plan, the assessment of ED should
involve a multidisciplinary team of health and mental health workers, and include a thorough physical
exam (with blood and urine tests) to identify complications that may need immediate attention and/or
hospitalisation for medical stabilisation [1414, 1415, 1427, 1428].

There are several options available for the treatment of ED alone, including psychotherapy,
pharmacotherapy, e-health and telehealth interventions, physical activity-based interventions, as well
as complementary and alternative therapies. The evidence base surrounding each of these treatments
is briefly discussed below, with regards to each ED. A detailed summary of the evidence relating to each
disorder is also provided in a systematic review undertaken by the Australian National Eating Disorders
Collaboration [1429].

There is limited evidence about the treatment of co-occurring ED and AOD use disorders specifically,
due to the exclusion of people with AOD use disorders from the majority of ED treatment trials [1430].
The preliminary evidence that does exist, however, suggests that structured programs incorporating
elements of established psychotherapies such as CBT, family-based treatment (FBT), and DBT, including
individual psychotherapy sessions, family therapy, group therapy, and nutritional planning, may
effectively reduce symptoms of ED among people with co-occurring AOD use in ED treatment programs
[1404, 1431, 1432]. There is also some evidence to suggest that treating a person’s AOD use disorder may
lead to improvements in ED symptoms [1430].

Treating anorexia nervosa

The treatment of anorexia nervosa should begin with a comprehensive assessment, evaluating a
person’s nutritional, medical and psychological needs [1424]. This process should be ongoing throughout
treatment, as clinical needs and priorities of the client may change [870]. Clinical practice guidelines
on the treatment of ED from the RANZCP [870, 1424, 1433] recommend that the initial assessment of
anorexia nervosa incorporate the following information:
B7: Managing and treating ED 263

• Collection of a thorough history (including dietary restrictions, weight loss, disturbances in body
image, fears about weight gain, bingeing, purging, excessive exercise, use of medications or AOD to
lose weight or suppress appetite).

• Investigate medical complications and assess level of risk (physical exam to assess BMI, heart
rate, blood pressure, temperature, metabolic tests, kidney function).

• Co-occurring psychiatric conditions.

• Cognitive changes due to starvation (e.g., slowed thought processing, difficulty concentrating).

• Possible contributing factors (e.g., family history of ED, developmental difficulties, dieting, or other
weight loss causes).

It is suggested that these assessment factors be incorporated into a case formulation (discussed
in Chapter B3), with treatment priorities based on a thorough risk assessment. Clinical guidelines
recommend that treatment priorities follow client engagement (including psychoeducation, with
family involvement, and MI), medical stabilisation, reversal of the cognitive effects of starvation, and
psychological treatment [870, 1427]. Where possible and practicable, it is recommended that people with
anorexia nervosa requiring admission be treated at specialist ED units, or by professionals specialising
in ED.

Psychotherapy

To date, there are no evidence-based psychotherapies for treating co-occurring anorexia nervosa and
AOD use specifically. Australian and international clinical practice guidelines for single disorder ED
recommend the inclusion of psychotherapy as an essential component of treatment for anorexia nervosa
[870, 1434]; however, it is recommended that, where indicated, more intense psychological therapies be
initiated only after medical stabilisation and the cognitive effects of starvation have improved [870].

The effectiveness of existing psychotherapies is moderate at best, which may be due, in part, to high
rates of treatment dropout and poor treatment retention [1429, 1435]. Regardless of the approach used,
strategies to engage the client and maintain the therapeutic relationship throughout treatment may be
beneficial to address high rates of treatment dropout. The interventions with the most theoretical and
empirical support include family-based therapy (i.e., Maudsley family therapy), particularly among young
people; CBT and CBT-enhanced (CBT-E). Other treatments with some evidence of low to moderate effect
include focal psychodynamic therapy; interpersonal psychotherapy (IPT); cognitive analytic therapy;
specialist supportive clinical management (SSCM); the Maudsley model of anorexia nervosa treatment
for adults (MANTRA), MI, and psychodynamic approaches [870, 1429, 1435]. Table 54 provides a brief
description of these approaches.

Research comparing different approaches has been limited and findings mixed (e.g., [1436–1443]);
as such, there is no clear guidance for clinicians to suggest that one therapeutic approach is better
than the other [1435, 1436, 1444]. In general, for children and adolescents with single disorder EDs, the
best evidence is for Maudsley FBT and, for adults, the best evidence is for CBT or psychotherapy of a
longer duration. As such, Australian clinical guidelines suggest that specialist-led manualised-based
approaches (e.g., CBT approaches) that have the strongest evidence-base should be first line options, but
do not stipulate any specific therapies as a first line treatment option [870].
264 B7: Managing and treating ED

Table 54: Brief description of psychotherapy approaches to ED

Cognitive behavioural therapy – enhanced (CBT-E)

CBT-E is an extension of CBT focused on educating clients about being underweight, starvation and the
initiation and maintenance of regular eating patterns. Included in the therapy are components that focus
on self-efficacy and self-monitoring, which are thought to be crucial to the treatment [1440]. CBT-E also
addresses other features that often co-occur with eating disorders, including low self-esteem, clinical
perfectionism, mood intolerances, and interpersonal difficulties [1423, 1445].

Integrative cognitive-affective therapy (ICAT)

ICAT is focused on the relationship between emotions and bulimic symptoms as well as adaptive eating
[1446]. The relationship between symptoms and factors that maintain bulimic behaviours are addressed
in four phases of treatment: treatment ambivalence and emotions; adaptive coping strategies; problem
areas believed to maintain bulimic symptoms; healthy lifestyle and relapse prevention.

Focal dynamic therapy

Focal dynamic therapy focuses on therapeutic alliance, pro-anorectic behaviour, self-esteem, behaviours
viewed as acceptable, associations between interpersonal relationships and eating, and the transfer back
to everyday life [1440].

Cognitive interpersonal therapy (MANTRA)

MANTRA (Maudsley model of Anorexia Nervosa Treatment for Adults) is a social-cognitive interpersonal
treatment that draws on MI, cognitive remediation, and the involvement of family and carers. It focuses
on addressing intrapersonal and interpersonal processes that are thought to be fundamental to the
maintenance of the disorder [1429].

Family-based treatment (FBT/Maudsley therapy)

FBT, first developed at the Maudsley Hospital in London, is a treatment program for anorexia nervosa in
young people. In Maudsley Therapy, the family is actively involved in treatment, which is primarily focused
on weight gain, and families are encouraged to take control over refeeding. Later stages of treatment
involve handing back control over eating to the young person, and addressing other issues [1429].

Specialist supportive clinical management (SSCM)

SSCM combines features of clinical management and supportive psychotherapy including education,
care, support, fostering of a therapeutic relationship, praise, reassurance, and advice. A central feature
of SSCM is a focus on the abnormal nutritional status and dietary patterns typical of anorexia nervosa.
Clients are provided with information on a range of strategies to promote normalisation of eating and
restoration of weight [1429].
B7: Managing and treating ED 265

Table 54: Brief description of psychotherapy approaches to ED (continued)

Interpersonal psychotherapy (IPT)

IPT targets interpersonal issues which are believed to contribute to the development and maintenance of
ED. Four interpersonal problem areas are addressed: grief, relationship difficulties and deficits, and role
transitions [1429].

Adapted from Peckmezian et al. [1429]. Note this is not an exhaustive list of all psychotherapies available for the treatment of ED.
For a more comprehensive overview of approaches, see the Peckmezian and colleagues [1429] Evidence Review.

Pharmacotherapy

To date, there are no evidence-based pharmacotherapies for treating co-occurring anorexia nervosa
and AOD use. Guidelines suggest that pharmacotherapy alone should not be the primary treatment
for single disorder anorexia nervosa, and there is little consistency between guidelines with regard to
recommendations relating to specific medications [870, 1428, 1434].

Although atypical antipsychotics and SSRIs (olanzapine and fluoxetine in particular) have been used
in clinical settings, research indicates that there is no conclusive evidence of any effect on the primary
psychological features of anorexia nervosa or weight gain, but they may assist in treating other
psychological symptoms (e.g., depression) that may co-occur with anorexia nervosa [1414, 1429, 1447, 1448].
Nonetheless, it has been suggested that olanzapine is currently the best pharmacotherapy available
for anorexia nervosa, particularly for those who cannot access other intensive treatments [1449, 1450]. A
comprehensive review of pharmacotherapy for single disorder anorexia nervosa found that olanzapine
increased weight gain and improved depression, anxiety, aggression and obsessive-compulsiveness
[1451]; however, the evidence remains weak and there is the possibility of adverse side effects [870].

Treating bulimia nervosa

As with the approach to treating anorexia nervosa, the Australian clinical practice guidelines for single
disorder ED recommend that treatment for bulimia nervosa begins with a comprehensive assessment
which includes [870]:

• Enquiry into behaviours; especially binge eating (i.e., uncontrolled episodes of overeating excessive
amounts of food), weight control behaviours that may compensate for binge eating (e.g., self-
induced vomiting, laxative/diuretic use, restricting food intake, overexercising, use of AOD to
control weight).

• Cognitions of weight/shape overvaluation, and preoccupations with body image and/or eating.

The increased risk of medical complications, particularly hypokalaemia, cardiac issues, obesity, Type 2
diabetes, and hypertension, makes physical assessment among those with suspected bulimia nervosa
essential [1424]. As with the physical assessment of those with anorexia nervosa, this assessment
should include weight, height, pulse rate, blood pressure and BMI. Additional tests should be undertaken
266 B7: Managing and treating ED

to assess for hypokalaemia and dehydration (associated with purging behaviours), cardiac function
(e.g., electrocardiogram), glucose levels, and kidney function, as indicated [870, 1424]. If psychological
treatment is being provided by a clinician without medical training, the Australian clinical practice
guidelines for single disorder ED recommend the inclusion of a GP to assist with assessment and
ongoing care [870].

Psychotherapy

There is very little evidence about the concurrent treatment of AOD use and bulimia nervosa. There is,
however, some evidence to suggest that treating a person’s AOD use disorder may lead to improvements
in bulimia nervosa [1430, 1452].

There are currently several evidence-based treatments available for bulimia nervosa as a single disorder,
including CBT and CBT-E; IPT; FBT; DBT; and integrative cognitive-affective therapy (ICAT); in addition to
multidisciplinary and combined therapies [1453]. Unlike anorexia nervosa, overall, these treatments have
been shown to produce moderate to large reductions in symptomology [1454]. On average, an estimated
30-40% of people treated with these psychotherapies attain binge-purge abstinence, and effects appear
to be maintained over the longer term after treatment has ceased [1453, 1454].

Most psychotherapy research to date has been conducted in relation to CBT [1444]. There is robust
evidence supporting CBT treatment approaches (in particular those that are specific to ED, such as
CBT-E [1453–1455]), with both national and international clinical guidelines recommending the use of CBT
approaches as the first line of treatment [870, 1428, 1429, 1434, 1456]. These typically comprise of 16–20
clinician-led sessions. There is some evidence to suggest that self-guided CBT is effective, but less so
than clinician-led CBT [1453].

Pharmacotherapy

Unlike psychotherapy, the impacts of pharmacological treatments for bulimia nervosa are small to
moderate and have not been found to continue after cessation of medication [1454]. However, studies
that have examined the combined use of pharmacotherapies (mostly SSRIs) and psychotherapies
(mostly CBT), have generally found this combined approach to demonstrate similar effectiveness to
psychotherapy alone, but results are not consistent [1454].

Most treatment guidelines for single disorder bulimia nervosa recommend the use of SSRIs (specifically
fluoxetine) in combination with psychotherapy [1434, 1457]. Although meta-analyses and other reviews
have found that SSRIs appear to be less effective than TCAs and MAOIs (such as those listed in Table 47)
[1454, 1458, 1459], their side effect profile is often more tolerable [1449]. As mentioned previously, extreme
caution should be used when prescribing TCAs and MAOIs.

In addition to antidepressants, Australian guidelines for the treatment of ED recommend the use of the
antiepileptic topiramate when psychological treatment is not available [870]. There is also some evidence
from open label trials of lamotrigine, a mood stabiliser, showing positive outcomes on ED symptoms
when given in conjunction with DBT [1460].
B7: Managing and treating ED 267

Treating binge eating disorder

The Australian clinical practice guidelines for single disorder ED recommend the same comprehensive
assessment for binge eating disorder as described for bulimia nervosa [870].

Psychotherapy

To date, there are no evidence-based psychotherapies for treating co-occurring binge-eating disorder
and AOD use. Similar to bulimia nervosa, the first line of recommended treatment for addressing
single disorder binge eating disorder is CBT [870, 1429, 1461]. CBT has been found to outperform most
comparison therapies and has been found to be more effective than pharmacological interventions for
the treatment of binge eating disorder [1462, 1463]. Other psychological therapies found to be effective in
the treatment of binge eating disorder include IPT, psychodynamic therapy, and DBT [1429, 1464].

Pharmacotherapy

Australian clinical guidelines for the treatment of ED recommend that pharmacotherapy be considered
when psychotherapy is not available, or as an adjunctive treatment to psychotherapy [870]. Although
there are no current evidence-based pharmacotherapies for treating co-occurring binge-eating disorder
and AOD use, there is emerging evidence suggesting that pharmacotherapy may be beneficial for some
people with binge eating disorder as a single disorder [1461, 1465]. RCTs examining the efficacy of SSRIs
(fluoxetine, citalopram, escitalopram, fluvoxamine, and sertraline [1464]), SNRIs (duloxetine [1466]), mood
stabilisers (topiramate [1467]), anticonvulsants (lamotrigine [1468]), antiobesity medications (orlistat
[1464]), and psychostimulants (lisdexamfetamine [1464]), have found reductions in the frequency of binge
eating episodes, BMI decreases, and overall clinical improvement.

Five RCTs to date have evaluated lisdexamfetamine for single disorder binge eating disorder, with
findings demonstrating strong evidence in support of its safety and efficacy [1469–1473]. These studies
found that compared to placebo, lisdexamfetamine was associated with significant improvements in
binge-eating symptoms, reduced frequency of binge-eating episodes, and reduced body weight [1474].
The anticonvulsants topiramate and lamotrigine have also been evaluated for efficacy and safety for
single disorder binge eating disorder in several RCTs [1467, 1468, 1475, 1476]. Although topiramate has been
associated with adverse side effects (e.g., participants dropping out of trials with headache, paresthesias
or pins and needles sensations), these studies found that, compared to placebo, topiramate was
associated with significantly greater reductions in binge frequency, BMI, and weight loss. The antiobesity
medication Orlistat has been examined for efficacy in four RCTs to date [1463, 1477–1479]. These trials
found that, although weight loss was enhanced with Orlistat, the frequency of binge eating was not
reduced.

There is also some evidence to support the use of pharmacotherapies which target AOD use, such as
baclofen, acamprosate, and bupropion, for the treatment of binge-eating disorder as a single disorder
[1480, 1481]. Two narrative reviews concluded that, while baclofen reduces the frequency of binge-eating
episodes [1480, 1481], depressive symptoms may increase [1481] relative to baseline. In these reviews,
268 B7: Managing and treating ED

bupropion also reduced the frequency of binge-eating episodes relative to baseline, and improved
weight goals relative to both a placebo and sertraline, although the findings for binge-eating episodes
were somewhat mixed [1480, 1481]. In one RCT, acamprosate also reduced the frequency of binge-eating
episodes, as well as related factors such as food cravings and compulsive eating, relative to before
treatment, but not relative to placebo [1482].

E-health and telehealth interventions

Although there are no e-health or telehealth interventions for co-occurring ED and AOD use disorders,
there has been some research conducted into the use of e-health interventions for single disorder ED.
Systematic reviews of internet-based interventions for single disorder ED have found that ED symptoms,
including bingeing and purging episodes, reduced significantly with the use of an internet-based therapy
[1483, 1484]. In contrast, however, several studies reported poorer outcome, or no difference, for e-health
interventions relative to waitlist and treatment-as-usual control groups [1485]. Notably, though, some
studies that did not report significant findings are likely limited by methodological factors, such as
small sample sizes.

There is no clear evidence as to which e-health intervention has the most empirical support for single
disorder ED, although self-help CBT has been highlighted as an effective, accessible, time and cost
effective alternative to clinician delivered CBT [1455, 1485, 1486]. The majority of studies have focused on
internet-based CBT, with the online components ranging from e-mail-based therapy, adjunctive internet-
based guidance, to online CBT. One review found that internet-based therapies that were bolstered
by face-to-face contact via assessment and clinician support were associated with higher rates of
therapeutic adherence and lower attrition from internet-based treatment [1484].

Guided self-help and self-help CBT for single disorder ED in particular have been shown to be effective in
reducing the frequency of bingeing and purging, and improving ED psychopathology, but less effective
than face-to-face psychotherapy in achieving abstinence [1453, 1455, 1483, 1486–1488]. These findings
provide some support for the use of guided e-health interventions in the treatment of ED as an adjunct to
other treatments [1487]. Unguided self-help initiatives do not appear to be effective at treating ED [1483,
1487].

A systematic review of smartphone applications for ED identified up to 20 interventions currently

available for ED treatment [1487], with varying levels of empirically supported content. These apps mostly
provide educational content, but some incorporate additional features such as self-assessment tools
and referral infrastructure. In another systematic review, smartphone applications improved abstinence
rates from bingeing and purging behaviours from baseline [1483]. Moreover, the increasing popularity and
widespread use of smartphone applications suggests they could be an effective medium for delivering
treatment once their clinical utility is established [1487]. However, most experts agree that the evidence
for smartphone applications as treatment for ED is limited, as these applications are not necessarily
founded on evidence-based principles [1487, 1489].

Physical activity
The role of exercise as adjunctive therapy for people with ED is controversial, despite the fact that
physical activity can play an important role in co-occurring ED and AOD use, in terms of treatment,
B7: Managing and treating ED 269

recovery, and relapse prevention [990]. The benefits associated with exercise in ED include the promotion
of physical activity and healthy weight control, as well as the potential prevention and/or restoration
of medical conditions such as reduced bone mass, cardiovascular disease, and diabetes [1490, 1491].
However, as excessive exercise can also be an illness feature in ED, and further exercise may interfere
with weight gain or reinforce the psychological/pathological symptoms of ED, it is not uncommon for
ED treatment providers to limit the amount of physical activity, allowing little or no exercise [1492]. There
is also the potential that physical activity may lead to compulsive ‘overexercising’ [1493]. As such, some
current international guidelines discourage offering clients with EDs physical therapies [1428], despite
evidence to suggest its effectiveness. Other guidelines recommend its use under the supervision of a
skilled exercise professional with ED experience [1434, 1494, 1495].

Although physical activity has not been evaluated among people with co-occurring ED and AOD use,
two reviews have examined exercise in people with single disorder ED and found moderate physical
activity to be associated with reduced ED cognitions (e.g., food preoccupation), frequency of bingeing and
purging episodes, and ED psychopathology [990, 1496]. One small pilot study examined a graded exercise
program based on ideal body weight and percentage body fat, with exercises ranging from stretching,
to strengthening and low-impact cardiovascular exercise three times per week for three months [1497].
The exercise group demonstrated improvements in weight gain as well as quality of life, which were
substantially greater than the inactive control group, whose quality of life decreased over the study
period.

Another study examined the effectiveness of an exercise program on weight gain among women with
anorexia nervosa, bulimia nervosa, and binge eating disorder in an inpatient treatment facility and
found that 60 minutes of supervised exercise conducted four times per week was associated with 40%
more weight gain than the inactive control group [1498]. The exercises included stretching, yoga, Pilates,
strength training, balance, exercise balls, aerobic exercise (e.g., walking or skipping), recreational games,
or other enjoyable activities [1498]. It is suggested that moderate physical activity facilitates weight gain
by improving emotional wellbeing, increasing appetite, and reducing body-image and appearance-related
distress [1492].

Although preliminary evidence supports the positive impact of exercise for people with ED, it remains
unclear as to how clinicians should approach physical activity among underweight people, or people who
may be normal weight but have been treated for compulsive exercise in the past [1492]. One systematic
review identified 11 therapeutic elements that appear to be essential to the success of exercise
interventions within ED treatment, including the use of positive reinforcement, beginning with mild
intensity exercise, using a graded program, including psychoeducation, including nutritional advice, and
debriefing following exercise sessions [1494].

Despite promising research, the evidence suggests that caution should be taken when recommending
exercise for people with ED, particularly anorexia nervosa, as the presence of behaviours which are
indicative of problematic exercise may negatively impact on the long-term course of illness [1492, 1499],
and thus, hinder potential positive outcomes.
270 B7: Managing and treating ED

Complementary and alternative therapies

Research into complementary and alternative therapies for co-occurring ED and AOD use disorders has
examined yoga, acupuncture, therapeutic massage, hypnosis, herbal medicine, light therapy, spiritual
healing, and art therapy [1500]. Despite the breadth of research, no intervention has been identified
as an effective, evidence-based treatment for co-occurring ED and AOD use. While the research in
this area continues to develop, there are promising preliminary findings relating to the use of yoga
[1501], acupuncture [1502], hypnosis [1503–1505], relaxation [1506], brain stimulation [1507], bright light
phototherapy [1506], and therapeutic massage [1502, 1508].

Summary
Despite much research, there is little evidence upon which to provide clear guidance on the treatment of
co-occurring ED and AOD use disorders. Research from single disorder ED suggests that comprehensive
assessments conducted by a multidisciplinary team should be followed by psychotherapy as the first
line of treatment, with strongest evidence in support of CBT-based approaches [1400]. Although there is
some evidence that pharmacotherapy may be a useful adjunct to the treatment of single disorder ED
(particularly binge eating disorder), the evidence is not conclusive and Australian clinical guidelines do
not recommend its use in the absence of psychotherapy [870]. Box 21 illustrates the continuation of Kai’s
case study, following their story after their ED was identified.

Box 21: Case study H: Treating co-occurring ED and AOD use: Kai’s story continued

Case study H: Kai’s story continued

The AOD worker consulted with an ED specialist, who arranged with Kai and their mother to attend
an assessment. Kai was moderately underweight (with a BMI of 16) and the specialist arranged for a
complete physical assessment, including heart rate, blood pressure, temperature, metabolic tests,
assessments for any cognitive changes, and contributing factors. Kai’s family were encouraged to
maintain involvement with their ongoing treatment, and the specialist devised a plan with Kai that
included their family’s involvement, with a focus on medical stabilisation, psychoeducation with MI,
reversal of the cognitive effects of starvation, and psychological treatment.

Kai continued working with the AOD service who provided ongoing support in relation to their goal of
reducing their use of alcohol and non-prescribed opioids, but Kai said they were not ready to give up
smoking. The AOD worker made a note of this and planned to explore it further using MI in a future
appointment. During one follow-up appointment, the AOD worker asked Kai to take a urine test. Kai
refused and left the appointment. Assuming Kai had used non-prescribed opioids between appointments
and did not want them to show up in a urine test, Kai’s AOD worker called Kai and told them that it was
normal to experience lapses and they would work through the process together. The AOD worker asked
Kai to please come back so they could discuss Kai’s reasons for leaving, and also so she could give Kai
some additional relapse prevention strategies. Kai agreed to come back.
B7: Managing and treating ED 271

Box 21: Case study H: Treating co-occurring ED and AOD use: Kai’s story (continued)

During their next appointment, Kai told the AOD worker that they were sexually assaulted in a public
toilet when they were 14, and since that time had experienced a lot of difficulty going into any public
toilets, even when accompanied. The AOD worker asked Kai whether their food restriction also started
around this time and thinking about it, Kai thought it may have. Kai said they had not used any opioids.
The AOD worker organised a case management meeting with everyone involved in Kai’s care to reassess
Kai’s treatment plan. The ED specialist was able to start addressing the underlying trauma which was
recognised as a contributing factor to the ED. Kai also agreed to an inpatient stay at a specialised ED
facility to stabilise their weight gain and was provided with ongoing support from their AOD worker, who
was also involved in discharge planning and relapse prevention.

Key points:
• It can be difficult to identify ED in people with AOD use disorders.
• Once identified, it is vital that a person experiencing ED receives a comprehensive
physical assessment by a medical professional. The primary focus is on stabilising
the client’s physical health and restoring cognitive function, and then psychotherapy
can begin.
• The AOD worker should maintain client engagement, even if a referral to an ED
specialist is made.
B7: Managing and treating personality disorders 273

Personality disorders
As described in Chapter A4, personality disorders are highly stigmatised conditions, even within mental
health and healthcare more broadly. As such, it is crucial that any communication regarding clients
with potential personality disorders – whether that communication involves the client directly or is with
healthcare providers on behalf of the client – remains respectful, non-judgemental, compassionate, and
client-centred.

Clinical presentation
People with personality disorders display patterns of thinking, behaving and emotional expression
that lead to frequent and enduring problems across multiple areas of a person’s life and, in particular,
problems forming long-term, meaningful, and rewarding relationships with others. Symptoms can
include:

• Behaviour that may be considered manipulative or deceitful.

• Impulsivity.

• Difficulties in relating to others.

• Unstable relationships.

• Difficulty showing remorse for their behaviour or empathy for other people.

• Suspiciousness.

• Difficulty accepting responsibility or accommodating others.

• Emotional instability and hypersensitivity.

• Pervasive and persistent irritation, anger, or aggression.

• Being overly self-involved.

• Excessive dependence on others.

It is important to remember however, that symptoms of personality disorders such as difficulties with
emotion-regulation, self-control, and impulsivity, are often present to varying degrees in many clients
and do not necessarily indicate a personality disorder.

Managing symptoms of personality disorders

Strategies for managing the symptoms of personality disorders are outlined in Table 55. The development
of coping skills (e.g., breathing retraining, meditation, cognitive restructuring described in Appendix
BB and Appendix CC) to regulate emotions is considered fundamental in the treatment of co-occurring
personality and AOD use disorders [102]. Coping strategies have been found to mediate the relationship
between personality disorder and AOD use [1509] and deficits in emotion regulation are considered core
to maintaining symptoms of BPD [1510].
274 B7: Managing and treating personality disorders

AOD workers may find it difficult to manage symptoms of personality disorders which are some of
the most challenging conditions to treat [1511, 1512]. Establishing a positive therapeutic relationship is
essential, but often difficult due to the inherent relational difficulties that are experienced by people
with these conditions. These difficulties often arise from insecure attachment during childhood and
frequently surface in the context of a therapeutic relationship [121]. Other challenges include strong
countertransference reactions including anger, frustration or indifference; as well as often needing to
manage the heightened risk that is presented with chronic suicidal thinking and AOD use [121, 162]. Some
personality characteristics, impulsivity in particular, place clients at extremely high risk for suicide, and
require increased levels of monitoring the risk of suicide and self-harm.

Engagement and rapport building form an intensely important part of treatment and clients with
personality disorders may require more time and attention than other clients [121]. Clients with
personality disorders may have trouble developing positive therapeutic relationships due to a history of
poor relationships with AOD and other health professionals, a bias towards suspiciousness or paranoid
interpretation of relationships, or a chaotic lifestyle, making appointment scheduling and engaging in
structured work more difficult [948]. Structure and firm boundaries are very important components of
the therapeutic process when managing clients with symptoms of personality disorders.

Progress may also be slow and uneven as many people with personality disorders have trouble
integrating change-oriented feedback [102]. Donald and colleagues [121] note the importance of striking
the right balance between validation (i.e., empathetic acceptance of the client and their difficulties),
which has typically been lacking from this client group’s experiences and is often responded to well, and
change-oriented interventions focused on changing current behaviours (such as developing alternative
coping strategies to replace self-harm or AOD use). It may also be helpful to highlight aspects of the
client’s personality that may be viewed as strengths, and enhance their prospects of achieving the
outcomes they are working towards [162].

Table 55: Dos and don’ts of managing a client with symptoms of personality disorders

Do:

Place strong emphasis on engagement to develop a good client–worker relationship and build
strong rapport.

Set clear boundaries and expectations regarding the client’s role and behaviour. Some clients may
seek to test these boundaries.

Establish and maintain a consistent and reliable approach to clients and reinforce boundaries.

Anticipate difficulties with adhering to treatment plans and remain patient and persistent.

Plan clear and mutual goals and stick to them; give clear and specific instructions.

Help with the current problems the client presents with rather than trying to establish causes or
exploring past problems.
B7: Managing and treating personality disorders 275

Table 55: Dos and don’ts of managing a client with symptoms of personality disorders
(continued)

Assist the client to develop skills to manage negative emotions (e.g., breathing retraining,
progressive muscle relaxation, cognitive restructuring).

Maintain a calm environment, as significant stress may exacerbate symptoms.

Take careful notes and monitor the risk of suicide and self-harm.

Avoid judgement and seek assistance for personal reactions (including frustration, anger, dislike)
and poor attitudes towards the client. Remember that challenging aspects of behaviour often
have survival value in the context of past experiences.

Listen to and evaluate the client’s concerns.

Accept but do not confirm the client’s beliefs.

Don’t:

Reward inappropriate behaviour (such as demanding, aggressive, suicidal, chaotic, or seductive

behaviour).

Display frustration or anger with the client. Remain firm, calm and in control.

Assume a difficult client has a personality disorder; many do not, and many clients with these
disorders are not difficult.

Adapted from NSW Department of Health [431], Project Air [1513], Davison [1514], and Fraser et al. [162].

Treating personality disorders

As discussed in Chapter A2, the most common personality disorders seen in AOD services are BPD and
ASPD and research regarding the treatment of co-occurring personality and AOD disorders has largely
focused on these two conditions [162]. Experts suggest that treating both the personality and AOD
use disorder simultaneously, using a combination of psychotherapy and pharmacotherapy to support
reductions in, or the cessation of, AOD use may be the best approach, although research comparing this
with other approaches is lacking [162, 1515]. Donald and colleagues [121] recommend a staged approach,
in which the early phases of treatment concentrate on the stabilisation of AOD use and self-harming
behaviours using a transdiagnostic approach that focuses on emotion regulation and impulsivity,
followed by interventions that focus on issues relating to identity and the self.

Treatment options available include psychotherapy and pharmacotherapy, which may be supplemented
by other interventions including e-health and telehealth interventions, physical exercise and
complementary and alternative therapies (e.g., omega-3). The evidence base surrounding each of these
treatment options with regards to the treatment of BPD and ASPD is discussed below.
276 B7: Managing and treating personality disorders

Borderline personality disorder (BPD)

Psychotherapy

Psychotherapy is regarded as the most effective treatment for BPD as a single disorder [1516] and is the
recommended first-line of treatment for BPD in Australian and international guidelines [555, 1517–1519]. A
Cochrane review of psychotherapies for BPD concluded that psychotherapy is an effective treatment for
reducing BPD symptom severity, depression, and suicidality in people with BPD, but the vast majority of
studies reviewed excluded people with co-occurring AOD use disorders [1516].

Although a large number of treatments have been developed for BPD, Dialectical Behaviour Therapy (DBT)
and Mentalisation Based Treatment (MBT) are the most researched to date [1516]. DBT is a complex, skills-
based, psychological intervention and has been modified for people with co-occurring BPD and AOD use
disorders (DBT-S). In this model, the symptoms of BPD and AOD use are viewed as attempts to regulate
emotions [162]. Using some of the same principles as CBT, the client is supported with strategies to
promote abstinence and is more likely to remain engaged in treatment. Although research to date
is limited to a small number of studies, DBT-S is the preferred treatment approach to date, having
demonstrated improvements in relation to both BPD symptoms and AOD use [724, 1520].

MBT is an evidence-based treatment for BPD that focuses on mentalising, rather than cognitions or
behaviours [1516, 1521]. Mentalising, or mentalisation, is a general term used to describe how we make
sense of ourselves and the world around us. Although difficulties with mentalisation may be associated
with many mental health conditions, people with BPD in particular may be more limited in their capacity
to mentalise [1521]. In targeting mentalisation, MBT aims to improve some of the core characteristics of
BPD, such as impulsivity, emotional instability, impaired interpersonal functioning, fractured identity,
and chronic emptiness [1522]. Philips and colleagues [1523] conducted a feasibility study comparing the
effectiveness of MBT provided in combination with AOD treatment, to AOD treatment alone among people
with co-occurring BPD and AOD use disorders. No significant differences were found between groups with
regard to changes in BPD symptom severity or substance use, but a trend towards a reduced number of
suicide attempts among those who received MBT was found relative to AOD treatment alone. It should be
noted, however, that therapist adherence to the treatment manual in this study was low.

Another promising treatment is Dynamic Deconstructive Psychotherapy (DDP) [1524, 1525]. DDP is a modified
form of psychodynamic psychotherapy, and was initially developed for particularly challenging cases
of BPD, including those with co-occurring AOD disorders [1525]. In a systematic review of the literature,
Lee and colleagues [724] found three studies had evaluated DDP among those with co-occurring BPD
and AOD use. These studies found that DDP had a significantly greater effect on symptoms of both BPD
and alcohol use disorder compared to treatment as usual (i.e., treatment in the community), which were
maintained over 30 months [1524, 1526, 1527]. DDP also effectively reduces some secondary treatment
outcomes related to personality disorders, such as suicidal behaviour [1515].

Several other treatments have also been developed and undergone preliminary examinations for co-
occurring BPD and AOD use but require further research [1528, 1529]. One treatment that does not appear
to be of benefit in the treatment of co-occurring BPD and AOD use is Dual Focus Schema Therapy (DFST) [704,
1530], a combination of relapse prevention and therapy focused on early maladaptive schemas (such
B7: Managing and treating personality disorders 277

as continuing negative self-beliefs, negative beliefs about others or events), as well as coping styles
[724, 1531]. DFST has only been examined in a single study to date, but appeared to be of limited benefit,
and greater reductions in AOD use were found among those in the control condition (individual drug
counselling) [724].

Pharmacotherapy

Although somewhat dated, current Australian and international guidelines on the management
of BPD suggest pharmacotherapies only be used as an adjunct to psychotherapy [555, 1517–1519].
Pharmacotherapies that support a reduction in, or the cessation of, AOD use (e.g., naltrexone and
disulfiram) in particular may be helpful in facilitating stabilisation that will allow the client to make
further gains in psychotherapy [121, 1532]. Concerns have been raised with regard to the potential for
dangerous interaction effects of medications and AOD use in the context of impulsivity and self-harming
behaviours [1240]. As such, although disulfiram has been found to be safe and effective among people
with BPD and alcohol use disorders [1532], caution is advised due to the potential risk [1515].

No pharmacotherapies have been approved for the treatment of BPD as a single disorder, and there is
little evidence to support their efficacy in the context of BPD as a single disorder, and none in the context
of co-occurring AOD use disorders [162]. Nonetheless, off label prescribing of antidepressants, mood
stabilisers, antipsychotics and anticonvulsants to address primary or secondary symptoms of BPD is
common, with medications often chosen to target specific symptoms such as affect dysregulation or
impulsivity [1240, 1533]. This targeted approach to prescribing has been the subject of considerable
debate and concerns have been raised regarding the use of polypharmacy. There is consensus in the
literature, however, that prescribing should be kept to a minimum [1240] and polypharmacy avoided
whenever possible [1515, 1533, 1534].

E-health and telehealth interventions

Several mobile phone applications have been developed for people with BPD, mostly for use as adjuncts
to DBT. Research examining their acceptability, feasibility and preliminary effectiveness appear
promising, but none have undergone rigorous evaluation. Only one, DBT Coach, has been examined among
people with co-occurring AOD use disorders.

DBT Coach is a mobile phone application designed to improve the generalisation of specific skills taught
in DBT. In a pilot study of the feasibility, acceptability, and effectiveness of DBT Coach among people with
co-occurring BPD and AOD use disorders, participants found the application to be helpful and easy to
use, and over the course of the study, there was a decrease in depression, emotion intensity, and urges
to use AOD [1535]. A second study that evaluated DBT Coach among people with single disorder BPD also
found reductions in subjective ratings of distress and urges to self-harm, but borderline symptoms and
emotional regulation did not improve [1536].

Other mobile phone applications developed for BPD include EMOTEO, mDiary and Monsenso’s mHealth for
Mental Health module for BPD. EMOTEO targets emotion regulation through engagement with mindfulness
or distraction exercises that are matched to the user’s level of distress. An initial pilot study found that
people using the app reported high levels of satisfaction, and that the application reduced aversive
278 B7: Managing and treating personality disorders

tension over time [1537]. mDiary and Monsenso’s mHealth for Mental Health BPD modules provide the
opportunity for mood, symptom, medication, and skills monitoring, alongside changes in BPD symptoms
[1538, 1539]. Although interviews with people who have used these apps found that users viewed the
app as being user-friendly [1538], and helped in facilitating access to, and helping them implement, DBT
strategies [1539], outcomes related to psychopathology were not assessed.

In addition to apps based on DBT, one e-health program, Priovi, a schema-therapy based intervention
designed as an adjunct to individual psychotherapy, has been evaluated among people with single
disorder BPD [1540]. Compared to baseline, using Priovi over 12 months was found to reduce BPD
symptoms; however, some exercises provoked mild anxiety.

The use of telehealth interventions has yet to be examined among people with co-occurring BPD and
AOD use specifically. However, an evaluation of the use of telehealth among people with BPD as a single
disorder during the recent COVID-19 pandemic suggests that the delivery of treatments such as ACT and
DBT is as effective when conducted over the phone as treatment in person [1541].

Physical activity

Physical exercise may be a useful part of a treatment approach for people with BPD, with research
indicating that obesity among people with BPD increases over time, escalating the risk of obesity-related
chronic medical conditions [1542, 1543]. BPD has been associated with chronic health problems later in
life, such as arteriosclerosis, hypertension, heart disease, CVD, stroke, liver disease and arthritis [1544,
1545]. Although there has been no research examining the effect of physical activity on symptoms of BPD,
one study recommended that initial interventions include improved sleep and scheduled exercise. It
should be noted however, that this recommendation is based on theory, and lacks supportive evidence
[1546]. As such, while it may be prudent for people with BPD to maintain healthy living practices, which
may include physical activity, a healthy diet, and adequate sleep (see Chapter B1), to date there is no
evidence regarding the effect of these practices on symptoms of BPD.

Complementary and alternative therapies

Although there has been some preliminary research with promising results for the use of omega-3
[1534, 1547], at present there is very little research examining the use of complementary or alternative
approaches in the management or treatment of BPD, either as a single disorder or co-occurring with AOD
use. However, one study found that ear acupuncture provided within the context of a modified 3-month
therapeutic community for AOD use disorders that included comprehensive psychotherapy (including
DBT) was positively associated with successful program completion [1548].

Antisocial personality disorder (ASPD)

There is a dearth of research regarding the psychological and pharmacological treatment of both ASPD
as a single disorder, as well as co-occurring with AOD use. More research has been conducted among
incarcerated populations, which may be reflective of the difficulty accessing and engaging those with
ASPD in treatment within the community [1549]. Further, many studies focus on changes to symptoms
and behaviour of ASPD, rather than changes to personality [1549].
B7: Managing and treating personality disorders 279

Psychotherapy

A Cochrane review of psychotherapies for ASPD was unable to draw firm conclusions from the available
evidence [1550]. Of the 19 studies included in the review, eight were conducted among people with co-
occurring ASPD and AOD use disorders [1551–1558]. No study found significant changes to specific ASPD
behaviours (e.g., offending, aggression, impulsivity); however, several found significant reductions in
AOD use following treatment [1553, 1554, 1556, 1557]. The addition of contingency management and/or
CBT to standard methadone maintenance was found to be superior compared to standard methadone
maintenance alone [1553]. Further, contingency management plus standard methadone maintenance
has been associated with significantly greater counselling session attendance and improvements in
social functioning compared to standard methadone maintenance alone [1555].

A driving whilst intoxicated program plus incarceration has also been shown to produce greater
improvements compared to incarceration alone [1557]. This intervention utilised principles of MI and
Fraser and colleagues [162] suggest that this may be indicative of a benefit of non-confrontational
approaches over confrontational approaches in enhancing outcomes for people with ASPD.

There is some evidence supporting the use of brief psychoeducation interventions and cognitive
remediation among people with co-occurring ASPD and AOD use. Impulsive Lifestyle Counselling is a brief
psychoeducation intervention which aims to foster awareness about behavioural difficulties, increase
personal accountability, and support clients to develop alternative coping strategies [1559]. Several RCTs
have found that, relative to treatment as usual, four sessions of Impulsive Lifestyle Counselling delivered
over four weeks with a booster session delivered 8 weeks later [1559], significantly reduces AOD use,
improves abstinence from AOD use, increases self-rated help for ASPD symptoms at 3 months post-
treatment [1560] and reduces AOD treatment dropout at 10 months post-treatment [1561]. Moreover, self-
rated help for ASPD symptoms has been associated with improvements in abstinence from AOD use and
treatment retention [1560].

Cognitive remediation aims to improve cognitive functioning by targeting factors such as attention
and memory. Four weeks of cognitive remediation provided to people with an AOD use disorder, 25-35%
of whom also had a lifetime diagnosis of ASPD, was associated with improvements in impulsivity, self-
control, quality of life, and AOD use cravings relative to treatment as usual [961].

Pharmacotherapy

Although several studies have examined pharmacological interventions among people with ASPD as a
single disorder, a Cochrane review concluded that the limited evidence available does not provide enough
support for strong recommendations [1562]. These studies have investigated the use of antiepileptics
(carbamazepine, phenytoin, sodium valproate, divalproex sodium and tiagabine); antidepressants
(desipramine, fluoxetine and nortriptyline); dopamine agonists (bromocriptine and amantadine); central
nervous system agonists (methylphenidate); and opioid antagonists (naltrexone).

Despite the limited evidence, there has been some research conducted among people with co-occurring
ASPD and AOD use. A Cochrane review examining pharmacological treatments for ASPD found that two
drugs (nortriptyline and bromocriptine) were associated with improved outcomes compared to placebo
control conditions among those with co-occurring conditions [1562]. Compared to placebo, those with
280 B7: Managing and treating personality disorders

ASPD and AOD use disorder who were taking nortriptyline illustrated a greater reduction in alcohol
use and dependence [1563]. In the same study, the use of bromocriptine was found to reduce anxiety
symptoms for those with depression/anxiety and AOD use disorders [1563]. However, no changes to ASPD
symptoms were observed. An additional study found that people with antisocial traits demonstrated
greater reductions in alcohol use when administered naltrexone relative to people low on antisocial traits
[1564].

Based on the lack of consistent evidence, the UK NICE Guidelines do not recommend treating ASPD, nor
co-occurring ASPD and AOD use disorders, with pharmacological interventions. They also advise against
treating underlying behavioural symptoms with pharmacotherapy [1565].

E-health and telehealth interventions

At the time of writing, there were no e-health or telehealth treatments for ASPD either as a single disorder
or co-occurring with AOD use.

Physical activity

At the time of writing, no research has examined the effects of exercise interventions among people with
co-occurring ASPD and AOD use or ASPD as a single disorder.

Complementary and alternative therapies

At the time of writing, there has been no research to support the use of complementary or alternative
therapies among people with co-occurring ASPD and AOD use. However, limited evidence suggests that
meditation may improve secondary outcomes related to the treatment of ASPD as a single disorder, such
as self-control and empathy [1566].

Summary
In general, there is relatively little research to guide treatment for co-occurring personality disorders and
AOD use disorders. The first line of treatment for those with co-occurring BPD and AOD use should be
psychotherapy, with several interventions having been examined among people with co-occurring BPD
and AOD use. Similarly, psychological interventions should be the first line of treatment for those with co-
occurring ASPD and AOD use, although the available evidence is less well-developed. Without evidentiary
support, pharmacological intervention is not recommended for the treatment of either co-occurring
BPD and AOD use, or ASPD and AOD use, highlighting the need for further well-conducted studies to be
undertaken in this area.

Box 22 illustrates the continuation of case study I, following Mira’s story. As illustrated, it may be
necessary to plan treatment over the long-term and coordinate between multiple services in the delivery
of care to a person with co-occurring personality disorders and AOD use disorders.
B7: Managing and treating personality disorders 281

Box 22: Case study I: Treating co-occurring BPD and AOD use: Mira’s story continued

Case study I: Mira’s story continued

The AOD worker immediately noted Mira’s high risk of overdose and organised for Mira to have naloxone
training, which she had never had previously, as well as several take-home naloxone kits. The AOD worker
also liaised with probation and parole. As part of the new program, Mira underwent comprehensive
medical and psychological assessment, where she was also diagnosed with Hepatitis C. Mira
immediately began direct-acting antiviral treatment.

As Mira’s medical needs were being addressed and she began to physically feel better, she told her AOD
worker that she didn’t want to keep going the way she has been and end up back in prison – she wanted
to change. The AOD worker organised for Mira to be put on the wait list for a local DBT-S program. Mira
initially didn’t attend, but using MI techniques, the AOD worker helped Mira remember why attending was
so important to her, and she started attending her appointments regularly. Mira’s AOD worker continued
to provide support along with strategies on emotion regulation and relapse prevention. While there were
several setbacks, Mira remained committed to her treatment plan.

Key points:
• Both the BPD and AOD use should be addressed concurrently, and the approaches
carefully coordinated.
• The need for multi-agency cooperation and information sharing is important and, in
the case of co-occurring disorders, interventions need to be planned over months
and years rather than weeks.
B7: Managing and treating substance-induced disorders 283

Substance-induced disorders

Clinical presentation
It can be difficult to distinguish substance-induced disorders from independent mental disorders at
initial presentation. As described in Chapter A4, substance-induced disorders are those that occur
as a direct physiological consequence of AOD intoxication or withdrawal, and usually abate following
a period of abstinence [10]. Symptoms of mood, anxiety, psychotic, obsessive-compulsive, sleep, and
neurocognitive disorders, as well as sexual dysfunction and delirium, may all be substance-induced. It
is also possible that people may present to treatment with a combination of substance-induced and
independent mental disorders [1567].

More information about identifying substance-induced disorders is described in Chapter B3. While
distinguishing between substance-induced and independent mental disorders can be difficult, it is
crucial that people experiencing mental health symptoms who are currently using substances, or with
a history of AOD use, are not automatically assumed to have a substance-induced disorder [1568]. Such
assumptions may lead to the person not being provided with appropriate and timely treatment.

Managing substance-induced symptoms

Symptoms of substance-induced disorders tend to reduce over hours to days with a period of abstinence
[171]. With respect to amphetamine-induced psychosis, however, some people report experiencing
symptoms of psychosis for months [170]. Substance-induced symptoms can have a dose-response
relationship with AOD use, such that the heavier a person’s AOD use is, the more intense their symptoms
are likely to be [1569, 1570]. Heavier AOD use is associated with an increased likelihood of progressing to a
substance-independent disorder [1570].

In relation to symptom-management, workers should be guided by the management strategies outlined

in the earlier sections of this chapter for managing symptoms of substance-induced disorders, in
relation to the predominant symptoms experienced by the client. It may also be useful to explain
to clients that substance-induced symptoms will likely subside after a period of abstinence and
stabilisation. Providing clients with simple strategies to manage their emotions and stress may also
be useful, as psychosocial stressors can cause a recurrence of substance-induced symptoms [1571].
Appendix CC describes some relaxation methods which clients may find useful.

Ongoing symptom monitoring and assessment is crucial in the management of a person who is
suspected of having a substance-induced disorder, both during and after discharge, as a significant
proportion of people who receive a diagnosis of a substance-induced disorder are later diagnosed with
independent mental disorders. It is estimated that between 25-32% of clients who receive a diagnosis
of substance-induced major depressive disorder are diagnosed with major depressive disorder one year
later [1078, 1572]. Similarly, a systematic review and meta-analysis examining the transition of substance-
induced psychosis to schizophrenia found that 25% of those with substance-induced psychosis
transitioned to schizophrenia. The risk of transitioning to schizophrenia was highest for cannabis-
induced psychosis (34%), followed by hallucinogens (26%), amphetamines (22%), opioids (12%), sedatives
284 B7: Managing and treating substance-induced disorders

(10%), and alcohol (9%) [38]. Findings suggest that half of all cases who transition to a diagnosis of
schizophrenia do so within two-to-three years [36, 1573]; 80% within five years [1573]. A similar proportion
of people diagnosed with substance-induced psychosis are later diagnosed with bipolar disorder (24%),
50% within four years of their diagnosis of substance-induced psychosis [36].

Treating substance-induced disorders

As symptoms of substance-induced disorders are likely to reduce with abstinence, abstinence is
generally recommended as a treatment approach, with careful monitoring of mental health symptoms
[35]. Workers are referred to previous sections of this chapter for evidence in relation to the treatment
of specific mental disorders; as, in general, evidence for the treatment of substance-induced disorders
beyond abstinence is lacking.

Summary
Symptoms of substance-induced disorders will typically reduce following a period of abstinence. During
this time, it is critical to monitor mental health symptoms and provide ongoing support, being mindful
of the possibility of the substance-induced disorder progressing to an independent mental disorder.
286 B7: Managing and treating other conditions

Confusion, disorientation or delirium

On occasion a client may present with no specific symptoms but is generally confused or disorientated.
The client’s confusion or disorientation may be the result of intoxication, or a physical or mental health
condition. In such cases, the AOD worker should [1574–1576]:

• Provide frequent reality orientation (e.g., explain where the person is, who they are, and what your
role is).

• Provide reassurance.

• Attempt to involve family, friends, or carers.

• Attempt to have the client cared for by familiar healthcare workers, in familiar surroundings.

• Attempt to maintain a regular schedule for the client.

• Explain any procedures the staff are applying (e.g., physical exams, treatment).

• Encourage mobility.

The UK NICE Guidelines for the diagnosis and management of delirium [1576] recommend that, if the
client is considered a risk to themselves, AOD workers should de-escalate the situation using verbal and
non-verbal strategies. If these techniques are ineffective, haloperidol can be administered for up to a
week. If delirium does not resolve, underlying causes, such as possible dementia, should be investigated.

Cognitive impairment
In the process of treatment, it may become clear that the client has impaired or poor functioning in one
or many areas of cognition, such as verbal or non-verbal memory, information processing, problem-
solving, reasoning, attention and concentration, decision-making, planning, sequencing, response
inhibition and emotional regulation. Sometimes these cognitive impairments can result in behaviour
that is mistakenly interpreted as the result of poor motivation or lack of effort, with impairments
in executive functioning and goal-directed behaviour often the most commonly observed cognitive
impairments in AOD settings [389].

Cognitive difficulties often bear no relation to mental illness and are sometimes the result of heavy AOD
use or intoxication, or as a consequence of traumatic/acquired brain injury [1577]. There can, however, be
a tendency for cognitive difficulties to be misattributed or minimised as being exclusively related to AOD
use, leading to lack of further investigation, treatment, and subsequently further harm. While cognitive
impairment is common among clients of AOD services, there are a multitude of medical, social, and
neurodevelopmental factors that may contribute to its development, many of which are undiagnosed
at service entry [1578]. Prescription medications and polypharmacy can also contribute to cognitive
impairment. Appendix I contains information on a screening measure that AOD workers may find useful
in identifying clients who may be at risk of cognitive impairment, and it is recommended that workers
consult with neuropsychologists where appropriate.
286 B7: Managing and treating other conditions

Confusion, disorientation or delirium

On occasion a client may present with no specific symptoms but is generally confused or disorientated.
The client’s confusion or disorientation may be the result of intoxication, or a physical or mental health
condition. In such cases, the AOD worker should [1574–1576]:

• Provide frequent reality orientation (e.g., explain where the person is, who they are, and what your
role is).

• Provide reassurance.

• Attempt to involve family, friends, or carers.

• Attempt to have the client cared for by familiar healthcare workers, in familiar surroundings.

• Attempt to maintain a regular schedule for the client.

• Explain any procedures the staff are applying (e.g., physical exams, treatment).

• Encourage mobility.

The UK NICE Guidelines for the diagnosis and management of delirium [1576] recommend that, if the
client is considered a risk to themselves, AOD workers should de-escalate the situation using verbal and
non-verbal strategies. If these techniques are ineffective, haloperidol can be administered for up to a
week. If delirium does not resolve, underlying causes, such as possible dementia, should be investigated.

Cognitive impairment
In the process of treatment, it may become clear that the client has impaired or poor functioning in one
or many areas of cognition, such as verbal or non-verbal memory, information processing, problem-
solving, reasoning, attention and concentration, decision-making, planning, sequencing, response
inhibition and emotional regulation. Sometimes these cognitive impairments can result in behaviour
that is mistakenly interpreted as the result of poor motivation or lack of effort, with impairments
in executive functioning and goal-directed behaviour often the most commonly observed cognitive
impairments in AOD settings [389].

Cognitive difficulties often bear no relation to mental illness and are sometimes the result of heavy AOD
use or intoxication, or as a consequence of traumatic/acquired brain injury [1577]. There can, however, be
a tendency for cognitive difficulties to be misattributed or minimised as being exclusively related to AOD
use, leading to lack of further investigation, treatment, and subsequently further harm. While cognitive
impairment is common among clients of AOD services, there are a multitude of medical, social, and
neurodevelopmental factors that may contribute to its development, many of which are undiagnosed
at service entry [1578]. Prescription medications and polypharmacy can also contribute to cognitive
impairment. Appendix I contains information on a screening measure that AOD workers may find useful
in identifying clients who may be at risk of cognitive impairment, and it is recommended that workers
consult with neuropsychologists where appropriate.
286 B7: Managing and treating other conditions

Confusion, disorientation or delirium

On occasion a client may present with no specific symptoms but is generally confused or disorientated.
The client’s confusion or disorientation may be the result of intoxication, or a physical or mental health
condition. In such cases, the AOD worker should [1574–1576]:

• Provide frequent reality orientation (e.g., explain where the person is, who they are, and what your
role is).

• Provide reassurance.

• Attempt to involve family, friends, or carers.

• Attempt to have the client cared for by familiar healthcare workers, in familiar surroundings.

• Attempt to maintain a regular schedule for the client.

• Explain any procedures the staff are applying (e.g., physical exams, treatment).

• Encourage mobility.

The UK NICE Guidelines for the diagnosis and management of delirium [1576] recommend that, if the
client is considered a risk to themselves, AOD workers should de-escalate the situation using verbal and
non-verbal strategies. If these techniques are ineffective, haloperidol can be administered for up to a
week. If delirium does not resolve, underlying causes, such as possible dementia, should be investigated.

Cognitive impairment
In the process of treatment, it may become clear that the client has impaired or poor functioning in one
or many areas of cognition, such as verbal or non-verbal memory, information processing, problem-
solving, reasoning, attention and concentration, decision-making, planning, sequencing, response
inhibition and emotional regulation. Sometimes these cognitive impairments can result in behaviour
that is mistakenly interpreted as the result of poor motivation or lack of effort, with impairments
in executive functioning and goal-directed behaviour often the most commonly observed cognitive
impairments in AOD settings [389].

Cognitive difficulties often bear no relation to mental illness and are sometimes the result of heavy AOD
use or intoxication, or as a consequence of traumatic/acquired brain injury [1577]. There can, however, be
a tendency for cognitive difficulties to be misattributed or minimised as being exclusively related to AOD
use, leading to lack of further investigation, treatment, and subsequently further harm. While cognitive
impairment is common among clients of AOD services, there are a multitude of medical, social, and
neurodevelopmental factors that may contribute to its development, many of which are undiagnosed
at service entry [1578]. Prescription medications and polypharmacy can also contribute to cognitive
impairment. Appendix I contains information on a screening measure that AOD workers may find useful
in identifying clients who may be at risk of cognitive impairment, and it is recommended that workers
consult with neuropsychologists where appropriate.
B7: Managing and treating other conditions 287

AOD workers may find the recently released Turning Point guidelines on managing cognitive impairment
in AOD treatment settings useful, which are available from: https://www.turningpoint.org.au/
treatment/clinicians/Managing-Cognitive-Impairment-in-AOD-Treatment-Guidelines

When a client is experiencing some level of cognitive impairment, the effectiveness of therapeutic
approaches can be diminished unless care is taken to adapt the approach to address these difficulties.
Table 56 presents some simple techniques which can be useful in overcoming cognitive impairment
[389].

Table 56: Techniques for managing cognitive impairment

General techniques to address cognitive impairment

• Integrate strategies such as repetition, writing things down, and cues to recall important information,
into counselling.
• Provide structure during sessions, reduce the pace of sessions, and avoid overloading clients with
information.
• Encourage healthy behaviours such as social and leisure activities.
• Encourage or incorporate stress reduction strategies such as mindfulness.
• Support motivation and realistic hope by informing clients that cognitive impairment from AOD use
can improve with AOD reduction and targeted interventions.

Techniques to address attention problems

• Have a clear structure for each session.

• Consider shorter but more frequent sessions.
• Avoid overloading by limiting the content of each session.
• Keep sessions focused on relevant topics.
• Reduce session pace and provide breaks.
• Conduct sessions in a quiet, non-distracting environment.
• Provide written handouts of important information.

Techniques to address learning and memory problems

• Present information to be remembered both verbally and visually (e.g., draw diagrams).
• Repeat and summarise key information.
• Ask client to recall information from previous sessions, and suggest techniques to improve recall
(e.g., writing things down, using memory aids).
• Review key points from previous sessions at the start of each session to compensate for poor
memory.
• Remind client of appointment times and keep appointments at routine times.
B7: Managing and treating other conditions 287

AOD workers may find the recently released Turning Point guidelines on managing cognitive impairment
in AOD treatment settings useful, which are available from: https://www.turningpoint.org.au/
treatment/clinicians/Managing-Cognitive-Impairment-in-AOD-Treatment-Guidelines

When a client is experiencing some level of cognitive impairment, the effectiveness of therapeutic
approaches can be diminished unless care is taken to adapt the approach to address these difficulties.
Table 56 presents some simple techniques which can be useful in overcoming cognitive impairment
[389].

Table 56: Techniques for managing cognitive impairment

General techniques to address cognitive impairment

• Integrate strategies such as repetition, writing things down, and cues to recall important information,
into counselling.
• Provide structure during sessions, reduce the pace of sessions, and avoid overloading clients with
information.
• Encourage healthy behaviours such as social and leisure activities.
• Encourage or incorporate stress reduction strategies such as mindfulness.
• Support motivation and realistic hope by informing clients that cognitive impairment from AOD use
can improve with AOD reduction and targeted interventions.

Techniques to address attention problems

• Have a clear structure for each session.

• Consider shorter but more frequent sessions.
• Avoid overloading by limiting the content of each session.
• Keep sessions focused on relevant topics.
• Reduce session pace and provide breaks.
• Conduct sessions in a quiet, non-distracting environment.
• Provide written handouts of important information.

Techniques to address learning and memory problems

• Present information to be remembered both verbally and visually (e.g., draw diagrams).
• Repeat and summarise key information.
• Ask client to recall information from previous sessions, and suggest techniques to improve recall
(e.g., writing things down, using memory aids).
• Review key points from previous sessions at the start of each session to compensate for poor
memory.
• Remind client of appointment times and keep appointments at routine times.
288 B7: Managing and treating other conditions

Table 56: Techniques for managing cognitive impairment (continued)

Techniques to address difficulties with mental flexibility, problem-solving, planning,

and organising

• Encourage routines and daily planning.

• Explain step-by-step problem solving and how to break goals into smaller, more manageable tasks.
• Discuss and practice responding to high-risk situations.
• For impulsive clients, encourage self-monitoring and use of cue cards with strategies to use.

Adapted from Stone et al. [389].

Preliminary research suggests that psychological interventions focusing on cognitive training, such
as cognitive enhancement and remediation, can improve cognitive functioning among clients in AOD
treatment settings [961, 1579, 1580]. Both cognitive remediation and cognitive enhancement therapies
utilise computerised games and tasks to enhance domains of cognitive functioning (e.g., attention,
memory), but cognitive enhancement therapy additionally targets holistic factors such as social skills
and vocational capabilities to improve overall functioning [1581].

However, training for a specific cognitive impairment may have limited transference to other cognitive
domains [1582]. There is preliminary evidence to suggest that pharmacotherapies such as galantamine
(an acetylcholinesterase inhibitor) and modafinil may be effective in improving working memory among
people with cocaine dependence [1583, 1584].

Grief and loss

There is a multitude of different sources of grief and loss, and clients in AOD settings are often highly
likely to experience these emotions for a variety of reasons. Feelings of grief or loss are often associated
with traumatic experiences. It is also common for AOD clients to have lost partners, family members, or
friends as a result of AOD use. Receiving treatment for AOD issues is likely to cause feelings of loss due
to the heavy role AOD use plays in the client’s life [389, 1585]. Other tangible losses may include the loss
of relationships, employment, finances, identity, spiritual beliefs, and physical health, but a person may
also experience intangible losses such as loss of hope, dignity, identity, self-worth, trust, or values [389,
1586].

Clients experiencing grief may report symptoms similar to those of major depression, such as sadness,
tearfulness, difficulty sleeping, and decreased appetite. However, it is unlikely that clients experiencing
feelings of grief and loss would also experience the cognitive symptoms of depression, such as feelings
of guilt, hopelessness, helplessness and worthlessness [1587]. Also, while some people impacted by
grief and loss may express a desire to be reunited with a lost loved one, they generally do not experience
the persistent suicidal ideation that may be experienced by some people with major depression.
Nevertheless, as discussed in Chapter B4, continued assessment should be undertaken, as well as a
thorough risk assessment for any client who may be at increased risk of suicide, as major depression
may develop following grief reactions.
288 B7: Managing and treating other conditions

Table 56: Techniques for managing cognitive impairment (continued)

Techniques to address difficulties with mental flexibility, problem-solving, planning,

and organising

• Encourage routines and daily planning.

• Explain step-by-step problem solving and how to break goals into smaller, more manageable tasks.
• Discuss and practice responding to high-risk situations.
• For impulsive clients, encourage self-monitoring and use of cue cards with strategies to use.

Adapted from Stone et al. [389].

Preliminary research suggests that psychological interventions focusing on cognitive training, such
as cognitive enhancement and remediation, can improve cognitive functioning among clients in AOD
treatment settings [961, 1579, 1580]. Both cognitive remediation and cognitive enhancement therapies
utilise computerised games and tasks to enhance domains of cognitive functioning (e.g., attention,
memory), but cognitive enhancement therapy additionally targets holistic factors such as social skills
and vocational capabilities to improve overall functioning [1581].

However, training for a specific cognitive impairment may have limited transference to other cognitive
domains [1582]. There is preliminary evidence to suggest that pharmacotherapies such as galantamine
(an acetylcholinesterase inhibitor) and modafinil may be effective in improving working memory among
people with cocaine dependence [1583, 1584].

Grief and loss

There is a multitude of different sources of grief and loss, and clients in AOD settings are often highly
likely to experience these emotions for a variety of reasons. Feelings of grief or loss are often associated
with traumatic experiences. It is also common for AOD clients to have lost partners, family members, or
friends as a result of AOD use. Receiving treatment for AOD issues is likely to cause feelings of loss due
to the heavy role AOD use plays in the client’s life [389, 1585]. Other tangible losses may include the loss
of relationships, employment, finances, identity, spiritual beliefs, and physical health, but a person may
also experience intangible losses such as loss of hope, dignity, identity, self-worth, trust, or values [389,
1586].

Clients experiencing grief may report symptoms similar to those of major depression, such as sadness,
tearfulness, difficulty sleeping, and decreased appetite. However, it is unlikely that clients experiencing
feelings of grief and loss would also experience the cognitive symptoms of depression, such as feelings
of guilt, hopelessness, helplessness and worthlessness [1587]. Also, while some people impacted by
grief and loss may express a desire to be reunited with a lost loved one, they generally do not experience
the persistent suicidal ideation that may be experienced by some people with major depression.
Nevertheless, as discussed in Chapter B4, continued assessment should be undertaken, as well as a
thorough risk assessment for any client who may be at increased risk of suicide, as major depression
may develop following grief reactions.
288 B7: Managing and treating other conditions

Table 56: Techniques for managing cognitive impairment (continued)

Techniques to address difficulties with mental flexibility, problem-solving, planning,

and organising

• Encourage routines and daily planning.

• Explain step-by-step problem solving and how to break goals into smaller, more manageable tasks.
• Discuss and practice responding to high-risk situations.
• For impulsive clients, encourage self-monitoring and use of cue cards with strategies to use.

Adapted from Stone et al. [389].

Preliminary research suggests that psychological interventions focusing on cognitive training, such
as cognitive enhancement and remediation, can improve cognitive functioning among clients in AOD
treatment settings [961, 1579, 1580]. Both cognitive remediation and cognitive enhancement therapies
utilise computerised games and tasks to enhance domains of cognitive functioning (e.g., attention,
memory), but cognitive enhancement therapy additionally targets holistic factors such as social skills
and vocational capabilities to improve overall functioning [1581].

However, training for a specific cognitive impairment may have limited transference to other cognitive
domains [1582]. There is preliminary evidence to suggest that pharmacotherapies such as galantamine
(an acetylcholinesterase inhibitor) and modafinil may be effective in improving working memory among
people with cocaine dependence [1583, 1584].

Grief and loss

There is a multitude of different sources of grief and loss, and clients in AOD settings are often highly
likely to experience these emotions for a variety of reasons. Feelings of grief or loss are often associated
with traumatic experiences. It is also common for AOD clients to have lost partners, family members, or
friends as a result of AOD use. Receiving treatment for AOD issues is likely to cause feelings of loss due
to the heavy role AOD use plays in the client’s life [389, 1585]. Other tangible losses may include the loss
of relationships, employment, finances, identity, spiritual beliefs, and physical health, but a person may
also experience intangible losses such as loss of hope, dignity, identity, self-worth, trust, or values [389,
1586].

Clients experiencing grief may report symptoms similar to those of major depression, such as sadness,
tearfulness, difficulty sleeping, and decreased appetite. However, it is unlikely that clients experiencing
feelings of grief and loss would also experience the cognitive symptoms of depression, such as feelings
of guilt, hopelessness, helplessness and worthlessness [1587]. Also, while some people impacted by
grief and loss may express a desire to be reunited with a lost loved one, they generally do not experience
the persistent suicidal ideation that may be experienced by some people with major depression.
Nevertheless, as discussed in Chapter B4, continued assessment should be undertaken, as well as a
thorough risk assessment for any client who may be at increased risk of suicide, as major depression
may develop following grief reactions.
B7: Managing and treating other conditions 289

Symptoms of grief and loss fall into a number of categories including [389, 1585, 1588]:

• Emotional – feelings of shock, numbness, disbelief, loss of control, fear, panic, confusion, anger,
sadness, guilt, desire to blame, or hostility. The person is likely to fluctuate between different
emotional states.

• Psychological – in addition to these emotions, clients may also have a preoccupation with the
deceased, or a sense of the presence of the deceased. Temporary cognitive impairments are also
common (e.g., concentration and memory complaints).

• Physical – gastro-intestinal complaints, decreased sex drive, tension, headaches, sleep/appetite

disturbances, fatigue, lethargy, or depersonalisation/dissociation.

• Behavioural/social – inappropriate behaviour (e.g., laughter), social withdrawal, avoidance of

objects or people related to grief/loss, sighing, restlessness, crying, absentminded behaviour,
obsessive behaviour, or hyperactivity.

The above symptoms are all normal responses to grief that tend to dissipate as a person adjusts to
the loss over time. For some people, however, these symptoms may persist for an extended period and
significantly impair their ability to function. In recognition of this experience, the most recent edition
of the DSM has introduced the new diagnosis of prolonged grief disorder. Prolonged grief disorder is
characterised by an intense longing for the deceased person or a preoccupation with thoughts and
memories of the person alongside other grief-related symptoms that occur most of the day, nearly every
day. Grief-related symptoms experienced as a result of the death include identity disruption (e.g., feeling
as though part of oneself has died); a marked sense of disbelief about the death; avoidance of reminders
that the person is dead; intense emotional pain; difficulty reintegrating into one’s relationships and
activities (e.g., problems engaging with friends, pursuing interests, or planning for the future); emotional
numbness; feeling that life is meaningless; and intense loneliness.

Managing grief and loss

Table 57 presents strategies for managing these symptoms. While symptoms of grief and loss may
resemble each other, clients may not recognise their response as grief if it is unrelated to death [389,
1589]. The main issue in grief management is to normalise the process for the client. That is, encourage
and support the grieving process, and remind the client that this process is natural [389, 1585]. Clients
in AOD settings may struggle resolving their grief, as this process usually requires the ability to tolerate
and express intense emotion [1586]. Everyone deals with grief and loss differently and therefore not all
approaches will work for everyone. It has been suggested that treatment for grief and loss in AOD settings
should target coping skills that can help clients process the emotions triggered by loss by [1586, 1590]: i)
accepting the reality of the loss; ii) processing the pain associated with the loss; iii) adjusting to a world
without the loss, and; iv) finding an enduring connection with the loss while moving on [389, 1588]. An
information sheet for clients on grief and loss reactions is provided in the Worksheets section of these
Guidelines.
B7: Managing and treating other conditions 289

Symptoms of grief and loss fall into a number of categories including [389, 1585, 1588]:

• Emotional – feelings of shock, numbness, disbelief, loss of control, fear, panic, confusion, anger,
sadness, guilt, desire to blame, or hostility. The person is likely to fluctuate between different
emotional states.

• Psychological – in addition to these emotions, clients may also have a preoccupation with the
deceased, or a sense of the presence of the deceased. Temporary cognitive impairments are also
common (e.g., concentration and memory complaints).

• Physical – gastro-intestinal complaints, decreased sex drive, tension, headaches, sleep/appetite

disturbances, fatigue, lethargy, or depersonalisation/dissociation.

• Behavioural/social – inappropriate behaviour (e.g., laughter), social withdrawal, avoidance of

objects or people related to grief/loss, sighing, restlessness, crying, absentminded behaviour,
obsessive behaviour, or hyperactivity.

The above symptoms are all normal responses to grief that tend to dissipate as a person adjusts to
the loss over time. For some people, however, these symptoms may persist for an extended period and
significantly impair their ability to function. In recognition of this experience, the most recent edition
of the DSM has introduced the new diagnosis of prolonged grief disorder. Prolonged grief disorder is
characterised by an intense longing for the deceased person or a preoccupation with thoughts and
memories of the person alongside other grief-related symptoms that occur most of the day, nearly every
day. Grief-related symptoms experienced as a result of the death include identity disruption (e.g., feeling
as though part of oneself has died); a marked sense of disbelief about the death; avoidance of reminders
that the person is dead; intense emotional pain; difficulty reintegrating into one’s relationships and
activities (e.g., problems engaging with friends, pursuing interests, or planning for the future); emotional
numbness; feeling that life is meaningless; and intense loneliness.

Managing grief and loss

Table 57 presents strategies for managing these symptoms. While symptoms of grief and loss may
resemble each other, clients may not recognise their response as grief if it is unrelated to death [389,
1589]. The main issue in grief management is to normalise the process for the client. That is, encourage
and support the grieving process, and remind the client that this process is natural [389, 1585]. Clients
in AOD settings may struggle resolving their grief, as this process usually requires the ability to tolerate
and express intense emotion [1586]. Everyone deals with grief and loss differently and therefore not all
approaches will work for everyone. It has been suggested that treatment for grief and loss in AOD settings
should target coping skills that can help clients process the emotions triggered by loss by [1586, 1590]: i)
accepting the reality of the loss; ii) processing the pain associated with the loss; iii) adjusting to a world
without the loss, and; iv) finding an enduring connection with the loss while moving on [389, 1588]. An
information sheet for clients on grief and loss reactions is provided in the Worksheets section of these
Guidelines.
290 B7: Managing and treating other conditions

Table 57: Dos and don’ts of managing a client with symptoms of grief or loss

Do:

Encourage the acceptance of the reality of the situation (e.g., discuss the loss, encourage client to
attend gravesite), as well as the identification and experience of feelings (positive and negative)
associated with loss.

Normalise the client’s emotional, psychological, physical, and behavioural reactions to the loss.

Help the client find a suitable way to remember, but also reinvest in life.

Continually monitor levels of depression and suicidal thoughts and act accordingly; risk is
increased during periods of grief (e.g., the first 12 months after a death, anniversaries, holidays).

Be aware and understanding of feelings associated with grief, including anger.

Give both practical and emotional support.

Give the client your undivided attention and unconditional positive regard.

Be aware that concentration may be affected, therefore repeat instructions, write down
instructions and so on.

Discuss emotions and behaviours related to the loss, including AOD use.

Encourage healthy avenues for the expression of grief (e.g., physical activity, relaxation, artistic
expression, talking, writing) rather than AOD use.

Encourage the client to seek social support. This may include bereavement services.

Don’t:

Avoid the reality of the situation or the feelings associated with it (e.g., use the name of deceased).

Judge or be surprised at how the client reacts – every person is different.

Time-limit the client when discussing grief, it can be a slow process and the story related to grief
may be retold many times.

Be afraid to seek assistance.

Adapted from Marsh et al. [1585], Stone et al. [389] and Horton et al. [1591].
290 B7: Managing and treating other conditions

Table 57: Dos and don’ts of managing a client with symptoms of grief or loss

Do:

Encourage the acceptance of the reality of the situation (e.g., discuss the loss, encourage client to
attend gravesite), as well as the identification and experience of feelings (positive and negative)
associated with loss.

Normalise the client’s emotional, psychological, physical, and behavioural reactions to the loss.

Help the client find a suitable way to remember, but also reinvest in life.

Continually monitor levels of depression and suicidal thoughts and act accordingly; risk is
increased during periods of grief (e.g., the first 12 months after a death, anniversaries, holidays).

Be aware and understanding of feelings associated with grief, including anger.

Give both practical and emotional support.

Give the client your undivided attention and unconditional positive regard.

Be aware that concentration may be affected, therefore repeat instructions, write down
instructions and so on.

Discuss emotions and behaviours related to the loss, including AOD use.

Encourage healthy avenues for the expression of grief (e.g., physical activity, relaxation, artistic
expression, talking, writing) rather than AOD use.

Encourage the client to seek social support. This may include bereavement services.

Don’t:

Avoid the reality of the situation or the feelings associated with it (e.g., use the name of deceased).

Judge or be surprised at how the client reacts – every person is different.

Time-limit the client when discussing grief, it can be a slow process and the story related to grief
may be retold many times.

Be afraid to seek assistance.

Adapted from Marsh et al. [1585], Stone et al. [389] and Horton et al. [1591].
B7: Managing and treating other conditions 291

Aggressive, angry, or violent behaviour

Problems relating to anger and aggression are not uncommon in AOD services and should be managed
appropriately [1592]. Anger and aggression may occur regardless of whether a person has a co-occurring
mental health condition. In general, episodes of aggression are usually triggered by a particular event,
which may involve circumstances that have led the client to feel threatened or frustrated.

The following signs may indicate that a client could potentially become aggressive or violent [431]:

• Appearance: intoxicated, dishevelled or dirty, bloodstained, bizarre, carrying anything that could
be used as a weapon.

• Physical activity: restless or agitated, pacing, standing up frequently, clenching of jaw or fists,
hostile facial expressions with sustained eye contact, entering ‘off limit’ areas uninvited.

• Mood: angry, irritable, anxious, tense, distressed, difficulty controlling emotions.

• Speech: loud, swearing or threatening, sarcastic, slurred.

• Worker’s reaction: fear, anxiety, unease, frustration, anger.

If a client becomes aggressive, threatening or potentially violent, it is important for AOD workers to
respond in accordance with the policies and procedures specific to their service. It is also important for
AOD workers to have knowledge of how to respond to challenging behaviour, including physical threats
or actual violence, in their work with AOD clients. Table 58 outlines some general strategies for managing
aggressive clients. Beyond immediate responses that are described below, clients who have persistent
issues with anger may benefit from anger management programs that promote the development of
coping skills for anger regulation, problem-solving skills, and promote relaxation [1593, 1594].

Table 58: Dos and don’ts of managing a client who is angry or aggressive

Do:

Stay calm and keep your emotions in check.

Adopt a passive and non-threatening body posture (e.g., hands by your side with empty palms
facing forward, body at a 45-degree angle to the aggressor).

Approach the client from the front.

Move the client to a place without an audience if possible, and try to reduce environmental
stimulation.

Let the client air their feelings and acknowledge them.

Ask open-ended questions to keep a dialogue going.

Be flexible, within reason.

Use the space for self-protection (position yourself close to the exit, don’t crowd the client).
B7: Managing and treating other conditions 291

Aggressive, angry, or violent behaviour

Problems relating to anger and aggression are not uncommon in AOD services and should be managed
appropriately [1592]. Anger and aggression may occur regardless of whether a person has a co-occurring
mental health condition. In general, episodes of aggression are usually triggered by a particular event,
which may involve circumstances that have led the client to feel threatened or frustrated.

The following signs may indicate that a client could potentially become aggressive or violent [431]:

• Appearance: intoxicated, dishevelled or dirty, bloodstained, bizarre, carrying anything that could
be used as a weapon.

• Physical activity: restless or agitated, pacing, standing up frequently, clenching of jaw or fists,
hostile facial expressions with sustained eye contact, entering ‘off limit’ areas uninvited.

• Mood: angry, irritable, anxious, tense, distressed, difficulty controlling emotions.

• Speech: loud, swearing or threatening, sarcastic, slurred.

• Worker’s reaction: fear, anxiety, unease, frustration, anger.

If a client becomes aggressive, threatening or potentially violent, it is important for AOD workers to
respond in accordance with the policies and procedures specific to their service. It is also important for
AOD workers to have knowledge of how to respond to challenging behaviour, including physical threats
or actual violence, in their work with AOD clients. Table 58 outlines some general strategies for managing
aggressive clients. Beyond immediate responses that are described below, clients who have persistent
issues with anger may benefit from anger management programs that promote the development of
coping skills for anger regulation, problem-solving skills, and promote relaxation [1593, 1594].

Table 58: Dos and don’ts of managing a client who is angry or aggressive

Do:

Stay calm and keep your emotions in check.

Adopt a passive and non-threatening body posture (e.g., hands by your side with empty palms
facing forward, body at a 45-degree angle to the aggressor).

Approach the client from the front.

Move the client to a place without an audience if possible, and try to reduce environmental
stimulation.

Let the client air their feelings and acknowledge them.

Ask open-ended questions to keep a dialogue going.

Be flexible, within reason.

Use the space for self-protection (position yourself close to the exit, don’t crowd the client).
292 B7: Managing and treating other conditions

Table 58: Dos and don’ts of managing a client who is angry or aggressive (continued)

Do:

Structure the work environment to ensure safety (e.g., have safety mechanisms in place such as
alarms and remove items that can be used as potential weapons).

Make sure other clients are out of harm’s way.

Don’t:

Challenge or threaten the client by tone of voice, eyes or body language.

Say things that will escalate the aggression.

Yell, even if the client is yelling at you.

Turn your back on the client.

Rush the client.

Argue with the client.

Dismiss delusional thoughts. These thoughts are real for the client.

Stay around if the client doesn’t calm down.

Ignore verbal threats or warnings of violence.

Tolerate violence or aggression.

Try to disarm a person with a weapon or battle it alone.

Adapted from NSW Department of Health [431] and Stone et al. [389].

Phases of aggression
This section has been adapted from information provided by Sunshine Coast Mental Health Service
[1595] and NSW Department of Health [431]. Aggressive episodes may be broken down into more detailed
phases. Gaining an understanding of these phases and some of the symptom-control strategies is
useful in controlling anger and aggression. Figure 18 outlines these phases of aggression.
292 B7: Managing and treating other conditions

Table 58: Dos and don’ts of managing a client who is angry or aggressive (continued)

Do:

Structure the work environment to ensure safety (e.g., have safety mechanisms in place such as
alarms and remove items that can be used as potential weapons).

Make sure other clients are out of harm’s way.

Don’t:

Challenge or threaten the client by tone of voice, eyes or body language.

Say things that will escalate the aggression.

Yell, even if the client is yelling at you.

Turn your back on the client.

Rush the client.

Argue with the client.

Dismiss delusional thoughts. These thoughts are real for the client.

Stay around if the client doesn’t calm down.

Ignore verbal threats or warnings of violence.

Tolerate violence or aggression.

Try to disarm a person with a weapon or battle it alone.

Adapted from NSW Department of Health [431] and Stone et al. [389].

Phases of aggression
This section has been adapted from information provided by Sunshine Coast Mental Health Service
[1595] and NSW Department of Health [431]. Aggressive episodes may be broken down into more detailed
phases. Gaining an understanding of these phases and some of the symptom-control strategies is
useful in controlling anger and aggression. Figure 18 outlines these phases of aggression.
B7: Managing and treating other conditions 293

Phase 1: Triggering event

Phase 1 is the initial triggering event which elicits the aggression. This event can be any number of things
that are perceived by the client as threatening or frustrating. Some useful ways to avoid this primary
phase include:

• Allowing the client personal space of up to six metres if possible.

• Avoiding standing over the client (e.g., if they are sitting, sit as well).

• Maintaining minimal eye contact (direct eye contact is confronting).

• Informing the client of anticipated delays.

• Keeping the environment relaxed, non-stimulating and non-stressful.

• Keeping your own posture and body language non-threatening (e.g., open stance and palms).

• Allowing the client to talk and be empathetic to their concerns.

Figure 18: Phases of aggression

Source: NSW Department of Health [431].

Phase 2: Escalation
Phase 2 is the escalation phase. It is important to recognise and address signs of distress or conflict and
use appropriate techniques to try and de-escalate the situation. Common signs of escalation include
pacing, voice quivering, quick breathing, flushed face, twitching, dilated pupils, tense appearance,
abusive, intimidating and derogatory remarks, and clenched fists.
B7: Managing and treating other conditions 293

Phase 1: Triggering event

Phase 1 is the initial triggering event which elicits the aggression. This event can be any number of things
that are perceived by the client as threatening or frustrating. Some useful ways to avoid this primary
phase include:

• Allowing the client personal space of up to six metres if possible.

• Avoiding standing over the client (e.g., if they are sitting, sit as well).

• Maintaining minimal eye contact (direct eye contact is confronting).

• Informing the client of anticipated delays.

• Keeping the environment relaxed, non-stimulating and non-stressful.

• Keeping your own posture and body language non-threatening (e.g., open stance and palms).

• Allowing the client to talk and be empathetic to their concerns.

Figure 18: Phases of aggression

Source: NSW Department of Health [431].

Phase 2: Escalation
Phase 2 is the escalation phase. It is important to recognise and address signs of distress or conflict and
use appropriate techniques to try and de-escalate the situation. Common signs of escalation include
pacing, voice quivering, quick breathing, flushed face, twitching, dilated pupils, tense appearance,
abusive, intimidating and derogatory remarks, and clenched fists.
294 B7: Managing and treating other conditions

The LASSIE model is a useful tool for communication and de-escalation of the situation in this phase:

L Listen actively: allow the client to run out of steam before you talk.

A Acknowledge the problem/situation: validate the client’s feelings, empathise.

S Separate from others: to ensure the safety of others if escalation occurs.

S Sit down: symbolises readiness to negotiate.

I Indicate possible options: give alternatives to alleviate the situation.

E Encourage the client to try these options: assist the client to follow through.

The following strategies may also be useful in managing escalating aggression:

• Provide a safe environment for the client, yourself, and others.

• The presence of a familiar person may help to calm and reassure the client.

• Do not assume aggressive behaviour is necessarily associated with mental illness.

• Know your own limits and refer/seek help if necessary.

• Be warm, friendly, and non-judgemental; reassure the client.

• Stay focused on the current situation but anticipate problems.

• Carefully monitor the physical and psychological condition of the client.

• If the client’s behaviour escalates, withdraw and seek assistance immediately.

• Try to maintain a quiet, non-stimulating environment for the client (excessive noise or people may
contribute to aggression).

Phase 3: Crisis
Phase 3 is the crisis phase, in which the client reacts with aggressive behaviour. The aggression can
often be released indiscriminately, and it is best for workers to remove themselves and any clients
during this stage unless the service has other policies on dealing with violence, aggression, self-defence
and/or restraint.

Phase 4: Recovery
Phase 4 is the recovery phase in which tension tends to reduce; however, the person is still in a state of
high arousal and, if this phase is not handled properly, aggressive behaviour may reignite. It is important
to be supportive and empathic to the client at this stage, but do not crowd or threaten them. It is
important that workers be given the opportunity to debrief. Any violence should be documented in the
client’s file.
294 B7: Managing and treating other conditions

The LASSIE model is a useful tool for communication and de-escalation of the situation in this phase:

L Listen actively: allow the client to run out of steam before you talk.

A Acknowledge the problem/situation: validate the client’s feelings, empathise.

S Separate from others: to ensure the safety of others if escalation occurs.

S Sit down: symbolises readiness to negotiate.

I Indicate possible options: give alternatives to alleviate the situation.

E Encourage the client to try these options: assist the client to follow through.

The following strategies may also be useful in managing escalating aggression:

• Provide a safe environment for the client, yourself, and others.

• The presence of a familiar person may help to calm and reassure the client.

• Do not assume aggressive behaviour is necessarily associated with mental illness.

• Know your own limits and refer/seek help if necessary.

• Be warm, friendly, and non-judgemental; reassure the client.

• Stay focused on the current situation but anticipate problems.

• Carefully monitor the physical and psychological condition of the client.

• If the client’s behaviour escalates, withdraw and seek assistance immediately.

• Try to maintain a quiet, non-stimulating environment for the client (excessive noise or people may
contribute to aggression).

Phase 3: Crisis
Phase 3 is the crisis phase, in which the client reacts with aggressive behaviour. The aggression can
often be released indiscriminately, and it is best for workers to remove themselves and any clients
during this stage unless the service has other policies on dealing with violence, aggression, self-defence
and/or restraint.

Phase 4: Recovery
Phase 4 is the recovery phase in which tension tends to reduce; however, the person is still in a state of
high arousal and, if this phase is not handled properly, aggressive behaviour may reignite. It is important
to be supportive and empathic to the client at this stage, but do not crowd or threaten them. It is
important that workers be given the opportunity to debrief. Any violence should be documented in the
client’s file.
B7: Managing and treating other conditions 295

Phase 5: Post-crisis depression

Phase 5 is the post-crisis depression stage. Generally, the client feels fatigued and exhausted and may
show feelings of guilt and dejection at having had an outburst. Support may be required from workers
during this stage.

Concluding remarks
Although much of this review of treatments leaves many questions to be answered, there are some
guiding principles that tend to be repeated throughout. It is clear that much more research is needed
before definitive practices that will improve outcomes for both mental health and AOD use disorders can
be prescribed. Despite this, it can be generally concluded that treatments that work for a single disorder
will lead to some improvements in clients with co-occurring conditions, if not in both disorders. Although
integrated treatments appear beneficial for some disorders, further investigation is needed [659, 666–
669, 954].

For most co-occurring conditions, both psychotherapy and pharmacotherapy interventions have been
found to have some benefit. Both of these require some basic knowledge or qualifications on the part of
the AOD worker. In particular, psychosocial interventions tend to be based on motivational and cognitive
behavioural approaches and AOD workers will benefit significantly if trained in these intervention styles.
It is generally acknowledged that manual-based psychological interventions are easy to administer and
are the most effective for CBT-style treatments. It is important to recognise that research demonstrating
the potential of other approaches to treating co-occurring conditions, such as mindfulness, contingency
management, ECT, and e-health interventions, is growing. For pharmacological interventions, an
important role for AOD workers is to inform themselves of the benefits, interactions and possible side
effects of the medications prescribed for their clients. Workers can assist their clients with suggestions
for medication scheduling as well as providing adherence therapy.
B7: Managing and treating other conditions 295

Phase 5: Post-crisis depression

Phase 5 is the post-crisis depression stage. Generally, the client feels fatigued and exhausted and may
show feelings of guilt and dejection at having had an outburst. Support may be required from workers
during this stage.

Concluding remarks
Although much of this review of treatments leaves many questions to be answered, there are some
guiding principles that tend to be repeated throughout. It is clear that much more research is needed
before definitive practices that will improve outcomes for both mental health and AOD use disorders can
be prescribed. Despite this, it can be generally concluded that treatments that work for a single disorder
will lead to some improvements in clients with co-occurring conditions, if not in both disorders. Although
integrated treatments appear beneficial for some disorders, further investigation is needed [659, 666–
669, 954].

For most co-occurring conditions, both psychotherapy and pharmacotherapy interventions have been
found to have some benefit. Both of these require some basic knowledge or qualifications on the part of
the AOD worker. In particular, psychosocial interventions tend to be based on motivational and cognitive
behavioural approaches and AOD workers will benefit significantly if trained in these intervention styles.
It is generally acknowledged that manual-based psychological interventions are easy to administer and
are the most effective for CBT-style treatments. It is important to recognise that research demonstrating
the potential of other approaches to treating co-occurring conditions, such as mindfulness, contingency
management, ECT, and e-health interventions, is growing. For pharmacological interventions, an
important role for AOD workers is to inform themselves of the benefits, interactions and possible side
effects of the medications prescribed for their clients. Workers can assist their clients with suggestions
for medication scheduling as well as providing adherence therapy.
Part C: Specific population groups 325

• EQIIP SOL: an intensive outreach intervention team for homeless people with co-occurring
conditions. A prospective longitudinal study found homeless youth with co-occurring psychosis
and AOD use reported reductions in the severity of psychotic symptoms and the likelihood of
reaching the diagnostic threshold for an AOD disorder following 6 months of EQIIP SOL [956].

Women
Although rates of AOD use and related harms have historically been higher among men compared to
women, the gap between men and women has narrowed in recent years, particularly among young
adults [1806, 1807]. The changing rates of AOD use among women are important to consider, as the
psychological, social, and physical contexts of AOD use and mental health are quite different for women
as opposed to men [1807–1809]. There is increased stigma associated with female AOD use (particularly
among those who are pregnant) which is likely to lead to greater guilt and shame [389, 1801, 1810]. This
stigma may lead some women to delay treatment seeking so that, by the time they enter treatment, their
AOD use is quite severe. Childcare considerations, family responsibilities, fear of the removal of children,
factors related to relationships (e.g., family conflict, support from partner), and financial issues have also
been identified as some of the barriers experienced by women seeking treatment [827, 1810, 1811]. Women
presenting for AOD treatment are also more likely to show greater financial vulnerability compared to
men, including a decreased likelihood of employment despite similar education levels, and an increased
likelihood of being financially dependent on another person [1812].

Among women with problems related to their AOD use, rates of depression, anxiety, and personality
disorders are particularly high [1813, 1814]. Poor self-esteem and self-image, high rates of suicide attempts
and self-harm, psychological distress, loneliness, and co-occurring ED are also particularly common to
women with AOD use issues [1811, 1815–1819]. Women, and younger women in particular, are more likely
to use maladaptive coping mechanisms like AOD use [1820] to cope with negative emotional situations,
manage pain, and cope with trauma [1821–1824].

Women who experience problems with AOD use are more likely than men, or women who do not
experience problems with AOD use, to have experienced neglect or sexual, physical, or emotional abuse
as children, as well as domestic violence [434, 1812, 1813, 1825, 1826]. Relative to men, this abuse is also
more likely to be severe, occur at home, and be instigated by a current or former romantic partner [1827,
1828]. In addition, AOD use can often lead to revictimisation via dangerous or risky situations such as
unsafe sex and sex work [1829]. Because of the high rates of trauma among women, often perpetrated by
men, it is imperative to provide a treatment environment in which women feel safe and secure [389]. The
following strategies may be helpful in creating such an environment [389, 1811]:

• Provide the client with the option of a female AOD worker.

• If attending group therapy, offer a women-only group if possible.

• If attending rehabilitation services, offer information and/or referral to women only AOD services.

• Ensure that treatment is gender-sensitive and addresses gender-specific issues and barriers to
treatment.
326 Part C: Specific population groups

• If appropriate, consider facilitating access to childcare, which can enable female parents and
caregivers to attend treatment.

• Where appropriate, consider family inclusive practice, which incorporates the client’s family and
community relationships.

• Where appropriate, ensure sexual health and safety are incorporated into the treatment plan.

Men
In contrast to women, men may be less forthcoming with information concerning their mental health,
which may affect their help-seeking behaviour. In general, men may be less likely than women to
visit a health professional, have lengthy consultations with health professionals, or seek treatment
before symptoms become advanced [1830–1834]. There are a number of barriers that may prevent men
accessing mental health treatment, including [1810, 1835, 1836]:

• Feeling uncomfortable and/or finding it difficult to discuss problems and feelings.

• Not wanting to appear weak, feeling embarrassed, afraid, or ashamed of their distress.

• Feeling very aware of stigma associated with mental health difficulties and accessing services.

• Not recognising feelings of emotional distress.

• Having a preference to work things out for themselves.

• Not considering their mental health a high priority.

• Believing that no one can help them.

• Previous unsuccessful attempts at seeking help.

• Not being aware of available services, and/or not considering the services ‘male friendly’.

• Having a tendency to manage emotional issues through silence or avoidance.

• Preferring ‘acceptable’ male outlets such as alcohol abuse or aggression to release feelings.

Although men are less likely to seek help, they make up 64% of those entering AOD treatment settings
[432]. Physical, sexual, and emotional abuse are highly prevalent among men accessing AOD treatment
settings, and can be accompanied by feelings of shame, guilt, and powerlessness [389]. There are also
strong associations between AOD use (alcohol in particular) and the perpetration of domestic and other
forms of violence, which is often exacerbated by the ways in which men are socialised, such as to display
aggression and emotional restraint, rather than the use of adaptive coping strategies [389]. Difficulties
regulating emotions in particular are associated with increased AOD use among men [1837] and, where
appropriate, emotion management strategies should be integrated into treatment [389]. Men are also at
considerably higher risk than women of death by overdose [1838] or completed suicide [1839], typically by
more lethal means than women [1840], highlighting the importance of risk assessment (see Chapter B4;
[389, 1817, 1841]).