Critical Issues in the Treatment of CoOccurring Disorders

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Critical Issues in the Treatment of Co-Occurring
Disorders

• Michael V. Pantalon, Ph.D.
• Assistant Professor of Psychiatry
• Yale University School of Medicine
• Supported by the National Institute on Drug Abuse
  grant K23 DA15144 (MVP).

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What are the critical issues?

• Integrated Assessment Rx Services
• primarily concerned with SMI Substance Abuse
• Motivational Factors
• Engagement Adherence
• Pharamcologic Aspects
• The Self-Medication Hypothesis
• Other types of CODs

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Integrated Assessment Treatment Services

• Who do we fail to screen?
• Assessing depression in opiate dependence
• Which came 1st does it always matter?
• Non- sub-syndromal aspects
• demoralization, levels of recreational gambling
• Integrated services gt non-integrated
• But no one combination of Rx superior to any
  other
• Logistically difficult
• Requires highly trained or supervised staff

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Depression Adherence in Cocaine Opioid
Dependence

• In 2 RCTs, agonist-maintained pts with persistent
  depressive sx (BDIgt16 at intake 1 month later)
  were significantly less likely to
• complete treatment (58 vs. 80, plt.05) or
• achieve 3 or more consecutive weeks of abstinence
  from illicit opioids (19 vs. 49, plt0.01) or
  cocaine (38 vs. 59, p0.08).

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Motivational Factors

• Client-centered vs. services delivery focus
• Treatment focus, ordering, emphasis
• Treatment modifications based on motivation are
  ok even empirically validated
• Stage-wise approach harm reduction Double
  Trouble groups
• Motivational assessments
• Motivational interventions
• Motivational Interviewing for co-occurring
  disorders

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Improving Adherence with Motivational Interviewing

• Standard Treatment (ST)MI gt ST for increasing
  o/p treatment adherence in inpt psych DD pts
• Overall, 47 vs. 21 attended 1st o/p appt.
• for dually-diagnosed patients, 42 for STMI
  versus 16 for ST
• Similar results for psychotic affective
  disorders

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Motivation Adherence

• Based on the URICA, Low (vs. High) Readiness to
  change psych DD patients attended a greater
  proportion of
• inpt. CBT groups (54 vs. 39, plt.05) and
• clinic appointments during their first month
  post-discharge (77 vs. 53, plt.05).
• Low Readiness pts were also more likely to have
  perfect attendance in their 1st month
  post-discharge (26 vs. 10, plt.05).
• No sig intx w/treatment condition
• Motivation Disulfiram outcomes

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Predictors of treatment adherence during
motivational interviewing for co-occurring
disorders

• Michael V. Pantalon, Ph.D.
• Declan T. Barry, Ph.D.
• Yale University School of Medicine
• Arthur J. Swanson, Ph.D.
• Albert Einstein Medical College
• Supported by the National Institute on Drug Abuse
  grant K23 DA15144 (MVP).

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Table 2 Predictors of Adherence to the First
Scheduled Appointment Post-Discharge
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Table 2 (contd) Predictors of the First
Scheduled Appointment Post-Discharge
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Table 2 (contd) Predictors of Adherence to the
First Scheduled Appointment Post-Discharge
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Figure 1
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Figure 2
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Engagement Adherence

• Focus on motivational outreach engagement Rx
  on demand
• New line of studies
• Data emerging
• Our initial studies focus on medication adherence

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Pharmacologic Issues

• Co-occurring pharmacologic Rx
• double-duty
• Which came first does it always matter?
• Antidepressants for illicit drug dependence
• Effective meds for single psych may NOT be
  effective for CODs (see table Drake et al.,
  2003)
• Substance Abuse Rx communitys misconceptions re
  meds

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Treatment of depression in methadone maintained
patientsNunes EV, Archives General Psychiatry
55153-160, 1998
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Treatment of depressionEffects on illicit drug
useNunes EV, Archives General Psychiatry
55153-160, 1998
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Self-Medication Hypothesis

• Self-Medication PT I use cocaine to deal with
  my depression
• vs. the Abstinence 1st viewpoint TX All
  cocaine other drug use must end BEFORE any
  depression Rx begins.
• implying that the substance abuse caused the
  psychiatric problems
• Which is it?
• Underlying traits/capabilities vs diagnoses

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The co-occurrence of recreational gambling
substance abuse Do the motivations to gamble
make a difference?

• Michael V. Pantalon, Paul K. Maciejewski, Rani A.
  Desai, Marc N. Potenza
• Supported in part by 1) NIDA grants K23-DA15144
  (MVP), K12-DA00167 (MNP), and K12-DA0366 (MNP)
  2) the National Center for Responsible Gaming 3)
  an unrestricted gift for research from the
  Mohegan Sun casino and 4) Womens Health
  Research at Yale

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Excitement-seeking, Gambling, Impulse Control

• Excitement, gambling, and diminished impulse
  control appear linked, although the relationship
  is incompletely understood.
• Theories have been advanced to explain the
  relationship between excitement- or
  sensation-seeking and gambling.
• Gambling is reinforced by the positive emotional
  sensations, arousal, or excitement which it is
  associated
• The need for excitement/arousal or a high
  susceptibility to boredom will lead to impulsive
  excitement/sensation-seeking
• Gambling and other addictive behaviors share
  common underlying biological mechanism implicated
  in impulsivity, a component of sensation seeking
• Intermediate factors in the relationship between
  excitement- or sensation-seeking and gambling
• Sensation-seeking-induced gambling can lead to
  drug and alcohol abuse in an attempt to relieve
  anxiety or depression following large gambling
  losses, or an attempt to celebrate or further
  enhance the sensation of excitement in the case
  of large wins

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Table 2 Psychosocial Functioning Measures in
Excitement-Seeking and Non-Excitement-Seeking
Recreational Gamblers
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Other Types of CODs

• COD pts in SA Rx cntr vs those in CMHCs
• Opiate Dependence
• chronic medical problems (e.g., Bup in PC)
• SPMI ? Low access to agonist maintenance
• Substance Abuse Pain
• Substance Abuse Anxiety Disorders
• under-diagnosed
• under-treated
• over-reliance on benzos/under-reliance on SSRIs
  CBT (ESTs for anxiety dx-e.g., see JAMA 10/27/04)
• benzo use is controversial

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CONCLUSIONS

• Screen, screen, screen
• Integrate sa psych Rx
• Dont get too caught up in which came 1st
• Assess motivation with Readiness Ruler,On a
  scale of 1-10, how ready are you to? ANSWhy
  not less?
• Utilize brief MI other client-centered
  approaches
• Adherence often much more important than specific
  Rx
• However, select meds carefully when clear COD
  (see Drake et al. guidelines)
• Consider non-traditional CODs
• Consider underlying pt capabilities/traits that
  may explain vulnerability to relapse/sx
  exacerbation across all dx
• Keep in mind staff attitudes
• COD requires Co-Occurring Rx
• Pass the word along