Dual Diagnosis

1
Dual Diagnosis

• And the key clinical issues
• Dr Enrico Cementon
• Dependence Day
• Dual Diagnosis and Substance Use
• 21 July, 2007

2
Dual Diagnosis

• Co-occurrence of mental health substance use
  disorder
• Narrowed definition in MH literature of serious
  mental illness substance use disorder

3
Mental illness Substance use

• Comorbidity common
• Complicate treatment of each other
• People with MI experience more severe
  consequences of drug use than general population
• Substance use as common cause of treatment failure

4
Dual diagnosis cohorts
Tier 3 Hi MH with or without SUD
5
Epidemiologic Catchment Area

• Lifetime prevalence rates
• ? disorder any subs use disorder any alcohol Dx
  any drug Dx
• general pop 16.7 13.5 6.1
• schizophrenia 47 33.7 27.5
• any affective dis 32 21.8 19.4
• bipolar dis 56.1 43.6 33.6
• major depression 27.2 16.5 18
• dysthymic dis 31.4 20.9 18.9
• Regier et al (1990)

6
National Survey of Mental Health and Wellbeing

• Australia 1997
• 12-month prevalence study of 10 000 over 18
  y.o.s
• ICD-10 diagnoses

7
NSMHWBAlcohol-use disorders

• 6.5 of total 3 abuse, 3.5 dependence
• 9.4 of men
• 3.7 of women
• 10.6 of 18-34 y.o.s
• (Teeson et al 2000)

8
NSMHWBAlcohol-use disorders

• Comorbidity
• 48 of women
• 34 of men also anxiety, affective or drug-use
  disorder
• 39 also physical disorder
• Treatment-seeking 28 esp. GP (Teeson et
  al 2000)

9
NSMHWBOther drug-use disorders

• 2.2 of total 0.2 abuse, 2 dependence
• 1.3 of women
• 3.2 of men
• 4.9 of 18-34 y.o.s
• Cannabis-use 1.7 Sedative-use 0.4
• Stimulant-use 0.3 Opioid-use 0.2
  (Teeson et al 2000)

10
NSMHWBOther drug-use disorders

• Comorbidity
• 65 of women
• 64 of men also other mental disorder (esp.
  anxiety for women, other drug for men)
• 42 also physical disorder
  (Teeson et al 2000)

11
Demographic Clinical Predictors of Substance
Abuse in Serious Mental Illness

• Variable Correlate with substance abuse
• Gender Male
• Age Young
• Education Low
• Premorbid socio-sexual adjustment Good
• Age first admission Early
• Treatment compliance Poor
• Relapse rate High
• Symptom severity Higher suicidality
• (Mueser et al 1995)

12
2004 National Drug Strategy Household Survey

• Australian Institute of Health Welfare
• Eighth since 1985
• Lifetime 12 month consumption patterns of all
  drugs as well as attitudes
• 30 000 Australians 12 years and older
• Tobacco
• daily smoking to 17.4 (previously 19.5)

13
2004 NDSHS recent drug use
14
2004 NDSHS drugs ever used
15
Historical background

• Overnight administrative separation of Mental
  Health Services Drug Treatment Services
• We can tolerate, but can the patient?

16
Problems with separate systems

• NOT welcome anywhere people who have both a
  serious psychiatric disorder and problematic drug
  or alcohol use
• McDermott Pyett (1993)
• Services differing treatment philosophies
  cultures

17
How MH and AOD services differ

• MHS
• Serious mental illness only
• Assertive case management
• Involuntary treatment
• Emphasis on abstinence

• AOD
• High prevalence disorders mostly
• Personal responsibility
• Voluntary
• Harm reduction philosophy

18
Implications of comorbidity

• Homelessness
• Violence
• Imprisonment
• Early mortality
• e.g. McEvoy (2000)

• Poorer prognosis
• Poor Rx compliance
• Repeated hospitalisation
• Problems with rehabilitation
• Suicide e.g. Drake et al (1996)

19
Assessment

• Raises awareness
• Brief intervention in itself
• Provide education
• Consider future reassessments
• serial screening

20
Assessment diagnosis

• Complex relationships anxiety, mood psychotic
  symptoms substance use
• intoxication-induced or withdrawal-related?
• or independent?
• or self-medication?

21
Assessment diagnosis

• Symptoms during abstinence?
• duration of abstinence controversial
• eg. depressed alcoholic men 42 vs.
  6 (Brown Shuckit 1988)
• Family history of psychiatric disorder?
• Earlier onset?
• Past treatment history

(Myrick Brady 2003)
22
Relationship Between Substance Use Depression

• Depression ? Drug Use
• Self Medication of Depression, Insomnia, Anergy
• Drug Use ? Depression
• Protracted Withdrawal Syndrome
• Polysubstance Use Common
• Intoxication, Withdrawal, Chronic Use
• Drug Using Lifestyle
• Adaptation to Drug Free Lifestyle
• The Two Interact
• E.g. ? risk of suicide

23
Diagnosing Depression In The Substance Abuser

• Depressive Symptoms
• Lowered Mood
• Anhedonia
• Depressive Cognitions
• What Happens in Periods of Sobriety?
• Mood Prior To Onset of Drug Use
• Family History
• Response to Past Treatments

24
Consider Substance Abuse In Depressed Patient
When

• Always
• Treatment Refractory
• Poor Compliance With Treatment
• Significant Anxiety Symptoms
• Significant Somatic Symptoms

25
Substance Use Causing Depression

• Intoxication
• Alcohol
• Withdrawal
• Benzodiazepines, Psychostimulants, Cannabis
  
• Chronic Use
• Alcohol, Benzodiazepines, Cannabis
• Protracted Withdrawal - Any Substance

26
Effects of Giving up Substance Using Lifestyle

• Grief Reaction
• Loss of Usual Coping Mechanism
• Loss of Best Friend (bottle or drug)
• Loss of Area of Competence
• Loss of Meaning in Life
• Loss of Excitement
• Loss of Substance Using Friends
• Inadequate Coping Skills become Obvious
• Confrontation with Effects of Drug Use
• Physical, Psychological, Social

27
Treatment
28
Special challenges in treatment of dual diagnosis

• ? clinical severity
• Comorbid disorders ? chronicity
• 1disorder more severe or adverse life
  situations?
• ? exposure to environmental risks
• ? set of pharmacoRx options
• Abuse potential
• Risk of interactions
• Rx less effective
• Kessler (2004)

29
Best practice guidelines

• Treatment Improvement Protocol (TIP) Series by
  Center for Substance Abuse Treatment (1995 and
  2005 USA)
• Best Practice Concurrent Mental Health
  Substance Use Disorders by Centre for Addiction
  Mental Health (2002 Canada) (see
  www.cds-sca.com)
• The Assessment Management of People with
  Co-existing Substance Use Mental Health
  Disorders by National Centre for Treatment
  Development (1999 New Zealand)

30
Best practice guidelines
31
Models of comorbidity treatment

• 1. Integrated
• 2. Sequential
• 3. Parallel

32
1. Integrated treatment

• Mental health treatments and substance abuse
  treatments are brought together
• same clinicians/support workers, or team of
  clinicians/support workers
• same program
• to ensure a consistent explanation of
  illness/problems and a coherent prescription for
  treatment rather than a contradictory set of
  messages from different providers

33
2. Sequential treatment

• One treatment (either mental health or substance
  abuse) followed by the other treatment
• first deal with one set of problems and then the
  other
• for comorbid anxiety/mood-substance use disorders
• eg. 1 alcoholism ? 2 depression

34
3. Parallel treatment

• concurrent treatment of both the psychiatric
  disorder(s) and substance use disorder(s) by two
  separate agencies, BUT
• different goals eg. abstinence vs. harm min
• different methods eg. confrontation vs.
  client-centredness assertive case management vs.
  personal responsibility
• exclusion of particular groups of comorbidity
• disputes over prime clinical responsibility

35
Traditional management approach in MHS

• Under detection of AOD use disorder
• Excess initial focus on establishing 1º - 2º
  diagnosis ? sequential treatment
• frequently unsuccessful in this population
• misdiagnosis of psychotic disorder
• inappropriate treatment
• to fro between mental health and DA services,
  eventual loss to follow-up

36
Dual Focus Approach

• 1. Severity of presenting symptoms
• Medical
• Psychiatric
• Substance use
• 2. Crisis intervention management
• 3. Stabilisation
• 4. Diagnosis over long-term contact
• 5. Longitudinal, multiple contact treatment
  TIP Series ( 1995)

37
Integrated treatment

• Components
• inpatient care for stabilisation, assessment
  referral/linkage only
• case management based on stage of treatment
• close monitoring
• substance abuse Rx
• education, harm minimisation, motivational
  interviewing, self-help groups
• rehabilitation, housing
• pharmacotherapy

Drake Mueser 2000
38
Treatment phases in dual diagnosis

• Engagement
• Persuasion
• Active treatment
• Relapse prevention
• Osher Kofoed (1989)

39
Treatment phases

• Persuasion
• Difficulties
• Social reasons for use
• Lack of usual social pressures
• Tendency to attribute use to mental illness
• Cognitive difficulties e.g. FTD, depressive
  cognitions, cognitive impairment, negative
  symptoms/avolition
• Impulse control problems
• Motivational Interviewing
• ? Encourage CHANGE
• Role of hospitalisation

40
Pharmacological treatment of dual diagnosis
patients

• Stabilisation of acute medical conditions
• Detoxification
• ? withdrawal Sx
• Prevent serious complications
• DTs, seizures, exacerbation of psychosis, death
• Concurrent psychiatric Rx

41
Pharmacological treatment of dual diagnosis
patients

• Clear treatment goals
• Mutually agreed
• Consider
• Drugs used
• Presenting symptoms
• Severity of withdrawal
• Accompanying medical conditions
• Patients stage of change motivation

42
Research/Treatment outcomes
43
Comorbid Depression Alcoholism

• Dx substance use disorder almost always excluded
  from antidepressant trials
• Modest effect of antidepressant (TCA, SSRI) on
  depression, but probably no effect on alcohol
  intake
• Usually concurrent counselling
  Thase et al (2001)

44
Comorbid Depression Substance dependence

• Meta-analysis of 14 RCTs of antidepressant Rx in
  depression substance dependence
• 5 TCA, 7 SSRI, 2 other
• Pooled effect size 0.38 (antidepressant response
  52.1 vs. 38.1 placebo)
• Dx depression gt1/52 abstinence predicted stronger
  AD response
• Pooled effect size on substance use 0.25
• (Nunes Levin 2004)

45
Comorbid schizophrenia substance dependence

• Most evidence for Clozapine
• Case series for other atypical APs
• Olanzapine
• Risperidone
• Quetiapine cravings management

Le Fauve et al (2004)
46
Other issues in PharmacoRx

• Interactions
• Pharmacokinetic Pharmacodynamic
• Risks
• OD, sedation
• Avoid benzodiazepines
• Consider Rx specific to DA field
• Anticraving Acamprosate, Naltrexone
• Substitutions Methadone, Buprenorphine
• Disulfiram renaissance

47
Harm Reduction orAbstinence?

• HR often more acceptable or realistic
• Compatible approaches on a continuum
• Trial controlled less harmful use strategies
• Raise awareness of harms interactions with
  psychiatric symptoms
• Uncontrolled use ? abstinence option
• Attempt abstinence in
• Acute psychosis, aggression, suicidality

48
Psychosocial interventions

• Psychoeducation
• Self-monitoring e.g. drug use diary
• Motivational interviewing
• Family interventions
• Lifestyle
• Relapse prevention, CBT

49
Conclusions

• Dual diagnosis problems are common
• Maintain high index of suspicion as comorbidity
  is the expectation rather than the exception
• Earliest intervention
• Integrated treatment
• Current best practice
• Special challenges
• E.g. Dual-focus approach, long term perspective
• Developing evidence base

50
My experiences