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3 Effective Models for Treatment of Substance Disorders & First-Episode Psychosis

3 Effective Models for Treatment of Substance Disorders & First-Episode Psychosis

Experiencing psychosis for the first time as a young adult is a frightening and confusing experience. The challenge is even greater when substance misuse or a substance use disorder is also present.

13-51 of young people entering treatment for first-episode psychosis have a co-occurring substance use disorder

Research shows that 13-51% of young people entering treatment for first-episode psychosis have a co-occurring substance use disorder. Substance use disorders complicate treatment and lead to poorer outcomes, including:

  • More severe symptoms.
  • Higher rates of relapse and hospitalization.
  • Poorer functioning at work or school.
  • Increased risk of suicide and violence.

The Critical Window of Early Psychosis

  • The time following a first episode of psychosis is a critical period. With early intervention and coordinated treatment, many young people can achieve remission of psychotic symptoms and make a successful recovery.
  • However, those who do not connect to effective care are at risk for worsening symptoms, disability and chronicity.
  • Ongoing substance use makes the already challenging process of treating early psychosis even more difficult.
  • Psychotic symptoms may be worsened or prolonged by the effects of drugs and alcohol. Treatment engagement and medication adherence tend to be lower when a substance use disorder is present.
  • That’s why integrated treatment that addresses both disorders simultaneously is so crucial.

Coordinated Specialty Care: An Integrated Treatment Model

Coordinated Specialty Care (CSC) has emerged as a leading model for treating first-episode psychosis. In CSC, a multidisciplinary team works together to provide comprehensive, individualized treatment to the client and their family. Key components include:

  • Low-dose antipsychotic medications.
  • Cognitive and behavioral psychotherapy.
  • Family education and support.
  • Employment/education services.
  • Case management and care coordination.

Substance use treatment is also integrated into CSC, rather than being addressed separately. Clinicians use evidence-based interventions to help clients reduce or stop substance use as part of their recovery plan. CSC teams take a collaborative, shared decision-making approach that respects the autonomy and expertise of the client and family.

Several research studies have demonstrated the effectiveness of CSC compared to usual treatment. A 2018 meta-analysis found that CSC produced greater improvements in psychotic symptoms, quality of life, and functioning. CSC participants also had lower rates of discontinuing treatment and transitioning to long-term residential care.

3 CSC Models that Integrate Substance Use Treatment

The SAMHSA guide showcases three established CSC models that incorporate substance use treatment:

NAVIGATE

  • NAVIGATE is a comprehensive CSC program developed as part of the NIMH RAISE Early Treatment Program study.
  • Its modular interventions are tailored to the individual’s needs and goals. The Individualized Resiliency Trainer manual includes a module focused specifically on treating substance use.
  • NAVIGATE takes a harm reduction approach, with abstinence and reducing use both presented as valid goals.
  • Motivational interviewing is used to resolve ambivalence and develop discrepancy between substance use and personal goals.
  • Behavioral techniques help clients cope with triggers and develop alternative activities.
  • Peer specialists play a key role in outreach and engagement.
  • Data from the RAISE study showed that NAVIGATE participants experienced greater improvement in symptoms and functioning compared to usual community care.
  • They were also more likely to receive consistent substance use treatment.

Early Assessment and Support Alliance (EASA)

  • EASA is a network of CSC programs across Oregon focused on rapidly identifying and treating psychosis in young people aged 12-25.
  • All clinicians receive training in assessing and treating substance use disorders as part of the core model.
  • Harm reduction is emphasized, with both reduction and abstinence supported as treatment pathways.
  • Clients collaborate with the team to develop individualized treatment plans based on their goals and motivations.
  • Evidence-based practices like supported employment and education are offered to all participants, regardless of their substance use.
  • EASA data shows that the percentage of clients with an alcohol use disorder decreased from 23.8% at intake to 9.2% at discharge.
  • For drug use disorders, rates decreased from 37.8% to 14%.
  • The proportion of clients enrolled in school or employed rose from 31.5% to 50.4%.
Early Assessment and Support Alliance EASA

Early Diagnosis and Preventive Treatment (EDAPT)

  • EDAPT is a CSC model serving clients aged 12-40 in California. It utilizes the Substance Abuse Management Module (SAMM), a group-based intervention providing psychoeducation, problem-solving, coping skills training, and relapse prevention.
  • SAMM presents both harm reduction and abstinence as viable goals.
  • It draws on cognitive-behavioral, dialectical-behavioral, and motivational enhancement strategies to help clients reduce substance use.
  • EDAPT also incorporates family-focused treatment to support recovery.
  • Outcome data demonstrates EDAPT’s impact. Across 12 months of treatment, clients with a substance use disorder at baseline showed significant improvements in psychotic symptoms and psychosocial functioning.
  • The percentage participating in work or school rose from 56% to 60.5%.
Early Diagnosis and Preventive Treatment EDAPT

Implementing Substance Use Treatment in CSC

While more research is needed on the critical components of integrated treatment, these model programs provide a roadmap for implementation. Key lessons include:

  • Adopt a collaborative treatment planning process guided by clients’ goals. 
  • Train all team members in dual diagnosis treatment. 
  • Provide both harm reduction and abstinence-based approaches. 
  • Leverage peer specialists to enhance motivation and engagement. 
  • Offer evidence-based services to all clients regardless of substance use. 
  • Involve families to provide education and social support.

As CSC expands across the US, ensuring that substance use treatment is fully incorporated will be essential. The high co-occurrence of substance use disorders in early psychosis demands a comprehensive approach. With commitment and coordination, CSC programs can break down silos between mental health and addiction services. Young people with early psychosis and their families deserve nothing less than integrated, evidence-based care that supports recovery in all domains.

For treatment providers in Arizona interested in implementing CSC for first-episode psychosis and co-occurring substance use disorders, the SAMHSA guide is an invaluable resource, which is attached below so that you don’t miss any information. By learning from the experiences of established models like NAVIGATE, EASA, and EDAPT, providers can design programs that truly meet the needs of this vulnerable population. The potential impact is transformative – helping young people find a path to recovery and sparing families the anguish of watching a loved one’s future derailed by untreated psychosis and addiction. Bringing effective treatment to scale will require vision, leadership, and a commitment to person-centered, evidence-based care.

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Nirvana Recovery