Table Of Content

Managing Depressive Symptoms in Substance Abuse Clients During Early Recovery A Treatment Improvement Protocol TIP 48 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES DeP Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment www.samhsa.gov DEPRESSION Managing Depressive Symptoms in Substance Abuse Clients During Early Recovery Richard N. Rosenthal, M.D. Expert Advisory Board Chair Treatment Improvement Protocol (TIP) Series 48 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment 1 Choke Cherry Road Rockville, MD 20857 Acknowledgments This publication was produced by The CDM Group, Inc. (CDM), and JBS International, Inc. (JBS), under the Knowledge Application Program (KAP) contract number 270-04-7049 with the Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services (DHHS). Christina Currier served as the Center for Substance Abuse Treatment (CSAT) KAP Government Project Officer. Rose M. Urban, M.S.W., J.D., LCSW, LCAS, served as the KAP Project Co-Director. Elizabeth Marsh Cupino formerly served as CDM KAP Managing Co-Director. Sheldon Weinberg, Ph.D., served as KAP Senior Researcher/Applied Psychologist. Other KAP personnel included Susan Kimner, KAP Deputy Project Director /Editorial Director and TIP Editor; Janet Humphrey, M.A., KAP Writer/Editor; Michelle Myers, former Quality Assurance Editor; Amy Conklin, former Quality Assurance Editor; Virgie Paul, Librarian; Jonathan Max Gilbert, M.A., Writer; and Radell Heintze, former KAP Project Coordinator. Disclaimer The views, opinions, and content expressed herein are the views of the consensus panel members and do not necessarily reflect the views, opinions, or policies of CSAT, SAMHSA, or DHHS. No official support of or endorsement by CSAT, SAMHSA, or DHHS for these opinions or for particular instruments, software, or resources is intended or should be inferred. Public Domain Notice All materials appearing in this volume except those taken directly from copyrighted sources are in the public domain and may be reproduced or copied without permission from SAMHSA/CSAT or the authors. Citation of the source is appreciated. However this publication may not be reproduced or distributed for a fee without spe­ cific, written authorization from the Office of Communications, SAMHSA, HHS. Electronic Access and Copies of Publication This publication may be downloaded or ordered at www.samhsa.gov/shin. Or, please call SAMHSA’s Health Information Network at 1-877-SAMHSA-7 (1-877-726-4727) (English or Español). Recommended Citation Center for Substance Abuse Treatment. Managing Depressive Symptoms in Substance Abuse Clients During Early Recovery. Treatment Improvement Protocol (TIP) Series 48. DHHS Publication No. (SMA) 08-4353. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2008. Originating Office Practice Improvement Branch, Division of Services Improvement, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 1 Choke Cherry Road, Rockville, MD 20857. DHHS Publication No. (SMA) 08-4353 Printed 2008 ii Contents Consensus Panel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v Expert Advisory Board. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi What Is a TIP? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix How This TIP Is Organized . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi Part 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Chapter 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Preparing Yourself To Work With Clients With Depressive Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Screening and Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Treatment Planning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Continuing Care and Treatment Termination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Chapter 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Vignette 1—Behavioral Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Vignette 2—Cognitive Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Vignette 3—Interventions With Core Beliefs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Vignette 4—Interventions With Feelings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 Part 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Chapter 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Why SAMHSA Created an Implementation Guide as Part of This TIP . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Consensus Panel Recommendations for Administrators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 Why Address Depressive Symptoms?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 Thinking About Organizational Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 The Role of the Administrator in Introducing and Supporting New Clinical Practices . . . . . . . . . . . . . . . 106 Managing Depressive Symptoms iii Chapter 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Assessment and Planning Before Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Addressing Policies and Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 Addressing Relevant Regulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 Addressing Staff Competence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 Addressing Community Relationships. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 Addressing Financial Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 Addressing Continuity and Fidelity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 Appendix A—Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 Appendix B—Center for Epidemiologic Studies Depression Scale (CES-D) . . . . . . . . . . . . . . . . 135 Appendix C—Fidelity Checklists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 Appendix D—DSM-IV-TR Mood Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 Appendix E—Advisory Meeting Panel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 Appendix F—Field Reviewers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 iv Contents Consensus Panel Chair, Part 1 and Part 2 Consensus Panels Rose M. Urban, M.S.W., J.D., LCSW, LCAS KAP Project Co-Director The CDM Group, Inc. Bethesda, Maryland Part 1 Consensus Panel Members Bruce Carruth, Ph.D. KAP Expert Content Director The CDM Group, Inc. Bethesda, Maryland Jennifer Frey, Ph.D. KAP Expert Content Director The CDM Group, Inc. Bethesda, Maryland Michael Klitzner, Ph.D. KAP Expert Content Director The CDM Group, Inc. Bethesda, Maryland Sheldon R. Weinberg, Ph.D. Senior Research/Applied Psychologist The CDM Group, Inc. Bethesda, Maryland Part 2 Consensus Panel Members Jennifer Frey, Ph.D. KAP Expert Content Director The CDM Group, Inc. Bethesda, Maryland Nancy VanDeMark, Ph.D. Director, Research and Program Evaluation Arapahoe House, Inc. Thornton, Colorado Managing Depressive Symptoms v Expert Advisory Board Richard N. Rosenthal, M.D., Chair Professor of Clinical Psychiatry Columbia University College of Physicians and Surgeons Chairman, Department of Psychiatry St. Luke’s Roosevelt Hospital Center New York, New York Patricia A. Burke, M.S.W., LCSW, BCD, C-CATODSW Private Practice West Baldwin, Maine Dennis C. Daley, LCSW, BCD Associate Professor of Psychiatry Western Psychiatric Institute and Clinic University of Pittsburgh Medical Center Pittsburgh, Pennsylvania William Mock, Ph.D., LISW, LICDC, SAP Director The Center for Interpersonal Development Lakewood, Ohio Paul Nagy, LPC, CCAS, CCS Program Director, Duke Addictions Program and Clinical Associate, Duke University Department of Psychiatry and Behavioral Sciences Durham, North Carolina Bette Ann Weinstein, Ph.D., LCSW Private Practice Delray Beach, Florida vi What Is a TIP? Treatment Improvement Protocols (TIPs), developed by the Center for Substance Abuse Treatment (CSAT), part of the Substance Abuse and Mental Health Services Administration (SAMHSA) within the U.S. Department of Health and Human Services (DHHS), are best-practices guidelines for the treatment of sub­ stance use disorders. CSAT draws on the experience and knowledge of clinical, research, and administrative experts to produce the TIPs, which are distributed to facilities and individuals across the country. As alcohol and drug use disorders are increasingly recognized as a major problem, the audience for the TIPs is expanding beyond public and private treatment facilities to include practitioners in mental health, criminal justice, pri­ mary care, and other healthcare and social service settings. The recommendations contained in each TIP are grounded in evidence that includes scientific research findings and the opinion of the TIP consensus panel of experts that a particular practice will produce a specific clinical outcome (measurable change in client status). In making recommendations, consensus panelists engage in a process of “evidence-based thinking” in which they consider scientific research, clinical practice theory, practice principles, and practice guidelines, as well as their own individual clinical experiences. Based on this thinking, they arrive at recommendations for optimal clinical approaches for given clinical situations. Relevant citations (to research outcome reports, theoretic formulations, and practice principles and guidelines) are provided. New TIP Format Beginning with this TIP, 48, CSAT is embarking on a new approach to and format for TIPs. CSAT recognizes that its primary constituency is substance abuse treatment counselors. Working with and enabling the efforts of substance abuse counselors are program administrators and clinical supervisors. Market research conducted on the TIP series over the past several years has indicated these individuals want products that are short, con­ cise, focused on how to perform relevant activities, and targeted to their particular needs. To those ends, this TIP is organized into three parts: • Part 1 for substance abuse counselors focuses on providing appropriate counseling methods and frameworks. • Part 2 for program administrators focuses on providing administrative support to implement adoption of the counseling recommendations made in Part 1. • Part 3 for clinical supervisors, program administrators, and interested counselors is an online literature review that provides an in-depth look at relevant published resources. Part 3 will be updated every 6 months for 5 years. Ideally, a supervisor might assemble a small group of counselors, hand out copies of this TIP (which are free), and begin a series of six or so meetings where the materials in the TIP would be reviewed, discussed, and in other ways used as an educational and training vehicle for the improvement of counseling skills (with the par­ ticulars of how this training would be done determined by the individual supervisor, based upon her or his unique situation, needs, and preferences). Thus, after a relatively short period of time and with few or no addi­ tional resources, this TIP could meet the challenge of fostering improvement in the delivery of substance abuse treatment services. Managing Depressive Symptoms vii Development Process This TIP was produced as a prototype for the new TIP series. Accordingly, the development process for this TIP differs from previous TIPs. The topic for this TIP was selected following an advisory meeting of experts in sub­ stance use disorders (Appendix E). Clinical staff members of the CDM/JBS Joint Venture developed the proto­ type (see p. v). An Expert Advisory Board, consisting of a chair and five panel members, was assembled to review the document (see p. vi). The Board provided guidance for revising the TIP prior to field review. The TIP then was field reviewed by an external group of subject matter experts, who provided suggestions for further refining the document (see Appendix F). TIPs Online TIPs can be accessed via the Internet at www.kap.samhsa.gov. The online Managing Depressive Symptoms: A Review of the Literature, Part 3, which will be updated every 6 months for 5 years, is also available at http://www.kap.samhsa.gov. viii What Is a TIP Foreword The Treatment Improvement Protocol (TIP) series supports SAMHSA’s mission of building resilience and facili­ tating recovery for people with or at risk for mental or substance use disorders by providing best-practices guid­ ance to clinicians, program administrators, and payers to improve the quality and effectiveness of service deliv­ ery and, thereby, promote recovery. TIPs are the result of careful consideration of all relevant clinical and health services research findings, demonstration experience, and implementation requirements. Clinical researchers, clinicians, and program administrators meet to debate and discuss their particular areas of expert­ ise until they reach a consensus on best practices. This panel’s work is then reviewed and critiqued by field reviewers. The talent, dedication, and hard work that TIP panelists and reviewers bring to this highly participatory process have helped bridge the gap between the promise of research and the needs of practicing clinicians and administrators to serve, in the most scientifically sound and effective ways, people who abuse substances. We are grateful to all who have joined with us to contribute to advances in the substance abuse treatment field. Eric B. Broderick, D.D.S., M.P.H. Acting Administrator Substance Abuse and Mental Health Services Administration H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM Director Center for Substance Abuse Treatment Substance Abuse and Mental Health Services Administration Managing Depressive Symptoms ix

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Gilbert, M.A., Writer; and Radell Heintze, former KAP Project Coordinator. Disclaimer necessarily reflect the views, opinions, or policies of CSAT, SAMHSA, or DHHS. Michael Klitzner, Ph.D Master clinician notes and comments that help you understand the client, his or her issues related to.
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Gilbert, M.A., Writer; and Radell Heintze, former KAP Project Coordinator. Disclaimer necessarily reflect the views, opinions, or policies of CSAT, SAMHSA, or DHHS. Michael Klitzner, Ph.D Master clinician notes and comments that help you understand the client, his or her issues related to.

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