Co-Occurring Substance Use and Mental Health Disorders. Joy Chudzynski, PsyD UCLA Integrated Substance Abuse Programs

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1 Co-Occurring Substance Use and Mental Health Disorders Joy Chudzynski, PsyD UCLA Integrated Substance Abuse Programs

2 Introduction Overview of the evolving field of Co-Occurring Disorders Addiction and Mental Health Disorders Treating COD: Medications Cognitive-Behavioral Skills Motivational Interviewing Skills

3 Intro Exercise Think about a consumer who has experienced both mental health and substance use disorders. How is this consumer unique from other mental health consumers? How does the consumer present? What behaviors does he/she exhibit that are different from a consumer with mental illness only?

4 Co-Occurring Disorders Co-occurring disorders Refers to co-occurring substance use (abuse or dependence) and mental disorders In other words consumers with co-occurring disorders have: one or more disorders relating to the use of alcohol and/or other drugs of abuse and one or more mental disorders

5 Co-Occurring Disorders Diagnosis of COD occurs when: at least one disorder of each type can be established independent of the other and is not simply a cluster of symptoms resulting from the one disorder Clinicians knowledge of both mental health and substance abuse is essential, but challenging to achieve

6 Definitions Substance Use Disorders Alcohol Opiate Amphetamine Sedative/Hypnotic/Analgesic Cocaine THC Mental Health Disorders Depression Anxiety Bipolar Disorder Schizophrenia Personality Disorder

7 Prevalence of COD In 2010, an estimated 45.9 million adults aged 18+ in the United States had AMI in the past year. This represents 20% of all adults in this country In 2010, Illicit drug use in past year was more likely among adults aged 18+ with past year AMI (25.8 percent) than it was among adults who did not have mental illness in the past year (12.1 percent)

8 Prevalence of COD Persons diagnosed with mood or anxiety disorders were about twice as likely to also suffer from at substance disorder Overall rates of abuse & dependence for most drugs tend to be higher among males Women have higher rates of amphetamine dependence and mood & anxiety disorders 75% of offenders in State and local prisons and jails have a mental health & substance abuse diagnosis NIDA RRS, 2008

9 Past Year SUD and Mental Illness SAMHSA, NSDUH 2010

10 Past Year Substance Use and Level of Mental Illness, 2010

11 Past Year Mental Health Care and Treatment for Substance Use Problems among Adults with Co-occurring disorders, 2010

12 COD and Inmates In 2005, more than half of all prison and jail inmates had a mental health disorder These estimates represented 56% of State prisoners, 45% of Federal prisoners, and 64% of jail inmates Bureau of Justice Statistics, 2006

13 COD and Inmates Prisoners with mental health problems were more likely to have: Served 3+ prior incarcerations Met criteria for substance abuse or dependence Used drugs in month prior to arrest Been homeless Report past history of sexual or physical abuse Been in a fight since incarceration Female inmates had higher rates of mental health problems

14 COD and Substance Use Among Inmates An estimated 42% of inmates in State prisons and 49% in local jails were found to have both a mental health problem and substance dependence or abuse Over a third of inmates who had mental health problems had used drugs at the time of the offense Binge drinking was prevalent among inmates who had mental problems

15 COD and Juvenile Justice Nearly two-thirds of incarcerated youth with substance use disorders have at least one other mental health disorder As many as 50% of substance abusing juvenile offenders have ADHD About 30% of incarcerated youth with substance use disorders have a mood or anxiety disorder Those exposed to high levels of traumatic violence might experience symptoms of posttraumatic stress as well as increased rates of substance abuse

16 Prevalence and Other Data Data now show: COD are common in general adult population Increased prevalence of people with COD and programs for people with COD People with COD are more likely to be hospitalized and the rate may be increasing Rates of mental disorders increase as the number of substance use disorders increase If we treat the SUD, we also need to address mental health symptoms

17

18 So, How Do We Treat COD? TIP 42 Guiding Principles and Recommendations

19 Six Guiding Principles (SAMHSA, TIP 42) Employ a recovery perspective Develop a phased approach to treatment Address specific real-life problems early in treatment Plan for cognitive and functional impairments

20 Delivery of Services (SAMHSA, TIP 42) Provide access Complete a full assessment Provide appropriate level of care Achieve integrated treatment - Treatment Planning and Review - Psychopharmacology Provide comprehensive services Ensure continuity of care

21 Vision of Fully Integrated Treatment One program that provides treatment for both disorders Mental and substance use disorders are treated by the same clinicians The clinicians are trained in psychopathology, assessment, and treatment strategies for both disorders

22 Vision of Fully Integrated Treatment (continued) Treatment is characterized by a slow pace and a long-term perspective Providers offer motivational counseling 12-Step groups are available to those who choose to participate Pharmacotherapies are utilized according to consumers psychiatric and other medical needs Sensitivity to issues of trauma, culture, gender, and sexual orientation

23 Addiction: A Brain Disease Putting Drug Use into Context with other Mental Disorders

24 Drug Use & Mental Illness Establishing causality or directionality is difficult Drugs of abuse can cause users to experience one or more symptoms of another mental illness Mental illnesses can lead to drug abuse Both drug use disorders and other mental illnesses are caused by overlapping factors Underlying brain deficits Genetic vulnerabilities Early exposure to stress or trauma

25 Typical Progression of Use FAS---Substance use in-uterus No Social Use Experimentation Use Use Abuse Dependence Infant Child Pre- Adolescent adol Mental Health Disorder s onset

26 How are they the same? Alcoholism/Addiction Major Mental Disorders Both heredity and environment play a role Characterized by chronicity and denial Affects the whole family Progresses without treatment Feelings of shame and guilt Inability to control behavior and emotions Often seen as a moral issue Leads to feelings of despair and failure Biological, psychological, social and spiritual components

27 Collision of Symptomology Differential Diagnosis is essential for accurate assessment. Is the presenting problem affected by a medical condition or substance? Is it depression or alcohol, prescription pain killer, heroin use? Is it ADHD or is it methamphetamine, cocaine use? Is it bipolar disorder or cocaine use? Is it schizophrenia or methamphetamine use? Is it PTSD or polysubstance use?

28 A Major Reason People Take a Drug is They Like What It Does to Their Brains

29

30 Initially, A Person Takes A Drug Hoping to Change their Mood, Perception, or Emotional State Translation--- Hoping to Change their Brain

31 Dopamine and the Brain

32 DRUGS Re-Wire our BRAINS

33 Prolonged Drug Use Changes the Brain In Fundamental and Long-Lasting Ways

34 Dopamine Transporter Loss After Heavy Methamphetamine Use Comparison Subject METH Abuser

35 Cognitive and Memory Effects

36 Frequency of Impairment by Neuropsychological Domain 60 Controls MA Users % Impaired Attention/ Psychomotor Speed Learning and Memory Working Memory Fluency Executive Systems Function Inhibition 0

37 Control > MA

38 MA > Control

39 Treatments for Co-Occurring Disorders

40 Treatments Medications Cognitive-Behavioral Therapy Motivational Interviewing

41 What is CBT and how is it used in addiction treatment? CBT is a form of talk therapy that is used to teach, encourage, and support individuals about how to reduce / stop their harmful drug use. CBT provides skills that are valuable in assisting people in gaining initial abstinence from drugs (or in reducing their drug use). CBT also provides skills to help people sustain abstinence (relapse prevention) 41

42 Why is CBT useful? CBT is a counseling-teaching approach wellsuited to the resource capabilities of most clinical programs CBT has been extensively evaluated in rigorous clinical trials and has solid empirical support CBT is structured, goal-oriented, and focused on the immediate problems faced by substance abusers entering treatment who are struggling to control their use 42

43 Important concepts in CBT CBT attempts to help clients: Follow a planned schedule of low-risk activities Recognize drug use (high-risk) situations and avoid these situations Cope more effectively with a range of problems and problematic behaviors associated with using 43

44 Important concepts in CBT As CBT treatment continues into later phases of recovery, more emphasis is given to the cognitive part of CBT. This includes: Teaching clients knowledge about addiction Teaching clients about conditioning, triggers, and craving Teaching clients cognitive skills ( thought stopping and urge surfing ) Focusing on relapse prevention 44

45 Effecting Change through the Use of Motivational Interviewing

46 How can MI be helpful for us in working with our consumers/patients? The successful MI therapist is able to inspire people to want to change Use of MI can help engage and retain consumers in treatment Using MI can help increase participation and involvement in treatment (thereby improving outcomes)

47 Definition of Motivation The probability that a person will enter into, continue, and comply with change-directed behavior

48 A patient-centered directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence.

49 Building Motivation OARS (the microskills) Open-ended questioning Affirming Reflective listening Summarizing The goal is to elicit and reinforce self-motivational statements (Change Talk)

50 Four Principles of Motivational Interviewing 1. Express empathy 2. Develop discrepancy 3. Avoid argumentation 4. Support self-efficacy

51 Change Talk Recognizing the problem Expressing concern Stating intention to change Being optimistic about change

52 Thank you!! Joy Chudzynski, PsyD

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