Comorbidity

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• Comorbidity
• Paula Cahill
• GP NSW State Comorbidity Coordinator

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Lets do the time warp again!
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Comorbidity

• Comoridity is defined as to co-existence of
  mental health and drug and alcohol disorders
• Not just chronic and severe disorders
• Not just an issue for mental health, but also
  chronic physical health problems

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Comorbidity

• Most prevalent problem drugs
• Tobacco
• Alcohol
• Cannabis
• prescription drugs
• Most common mental health comorbidities
• Mood disorders (depression, anxiety)
• personality disorders,

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Drug related Deaths

• 80 due to tobacco use (16.6 population daily
  smokers)
• 16 caused by excessive use of alcohol
• 4 caused by other drugs
• The following drugs accounted for largest numbers
  of deaths in the 14-29 year old age group
• Tobacco - 5
• Alcohol - 53
• Other drugs - 42

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Comorbidity

• Complex, range of disorders, severity fluctuates
• Disorders may be primary, secondary or
  independent of each other
• Prevalence rates have been estimated in clinical
  populations from between 20 and 75 depending on
  diagnosis

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For the person / family

• Poorer treatment outcomes
• Difficulty accessing treatment
• Increased frequency of relapse, hospitalisation,
  suicide attempts and violence
• Poorer social outcomes legal probs, family and
  financial problems, increased rates of
  incarceration, homelessness and housing
  instability

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For services

• Separate cultures and philosophies of service
  provision
• Separate funding, administration, training, aims,
  locations
• Strict entry criteria that exclude people with
  one or more disorder
• Symptoms of substance use disorder can interfere
  in psychiatric rehab program and visa versa
• Lack of cross sector training and support between
  services
• Difficulties in clinical assessments and
  identifying best practice approaches

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What does this mean for General Practice?

• 85 population will see GP at least once in any
  year
• GPs have greatest opportunity to identify early
  and provide brief interventions, treatment
• youth populations comorbidity most prevalent in
  this group, most likely to see GP
• More people in General practice with comorbid
  mhda problems

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What are the barriers

• Time constraints
• Complexity of presentations
• Skills and confidence
• Difficulty recognizing problems early
• Lack of support service / appropriate
  interventions
• System problems care pathways, ping pong
  treatment
• Interest / attitude

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Where do GPs / Div work?

• All and in linking GPs to other systems
• Universal screening programs, education
  programs
• Selective population based programs
• Indicated early intervention
• Treatment evidence based, referral to
  specialist services
• Maintenance monitoring, relapse risk

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Stages of Change

• Developed by Prochaska Diclemente to explain
  tobacco use
• Just as relevant when developing change programs
  for organisations

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At a Divisional level

• Pre-contemplative practices
• Information strategies
• Contemplative
• Motivational, more active follow-up
• Action
• Strategy mentoring, screening tools, training,
  involve in advocacy
• Maintenance
• Critical feedback, ongoing support, problem
  solving, mentoring

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Opportunities for Divisions

• Comorbidity projects funded
• Education programs General Practitioners
• Practice nurse support
• ATAPS
• Integration
• Mapping services and directories for General
  Practices
• Identifying referral pathways, but making them
  work
• Co-joint education and training opportunities
• Engagement of services and advocacy for General
  Practice lack of support

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Opportunities for Divisions

• Consumer / Carer
• Linking the consumer / carer perspective into
  planning and education
• Providing practices with information for
  consumers / carers eg directories
• Aboriginal health
• Linking aboriginal health workers in with
  training opportunities
• Links between Aboriginal health organisations and
  Divisions General Practices

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Opportunities for Divisions

• Physical health / chronic care
• Brief alcohol intervention and mental health
  screen in diabetes care plans
• Perinatal care alcohol / tobacco / cannabis
  brief interventions as well as mental health
  screen
• Cardiac programs inclusion of mhda info,
  screening and brief interventions
• Non-judgemental approach

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Resources that are available

• Can Do
• Teams of Two case studies
• Managing the Mix resource kit
• Dept Veterans Affairs alcohol brief
  interventions guide / training program
• NSW Health Comorbidity Guidelines
• Specialist Advisory Services
• Your friendly State team Meg, Paula and Ciara