1 Mental Illness and Substance Abuse Eric Goldberg D.O.
2 Objectives Item 1 Define and understand Co-Occurring Disorder (COD) Item 2 Item 3 Item 4 Define substance abuse, substance dependence and, Substance induced disorders Identify patients who are at risk for co-occurring disorder (dual diagnosis) Understand treatment guidelines for co-occurring disorders
3 Co-occurring Disorders Co-occurring disorder (COD) refers to a person who has a mental illness as well as a substance- related disorder that is co-occurring (COCE, 2006.) Many times dual diagnosis and co-occurring disorders are used interchangeably.
4 Substance abuse, Substance dependence and Substance induced disorders
5 Substance abuse Substance abuse, substance dependence and substance induced disorders According to the DSM-IV-TR substance abuse is a maladaptive pattern of substance use manifested by recurrent and significant adverse consequences related to the repeated use of substances The individual may have : Legal difficulties Social and interpersonal problems Place self in dangerous situations Failure to fulfill responsibilities at home, work or school. (COCE, 2006)
6 Substance dependence According to the APA, (2000) substance dependence is a cluster of cognitive, behavioral and physiological symptoms that indicate the individual continues to use substances despite significant related problems. Consists of the attributes of substance abuse with additional features: Increased tolerance to the drug/substance to attain the desired effect The person may fixate on ways to find the drug/substance
7 Substance-abuse disorders The APA (2000), postulates substance abuse disorder consists of any of these indicators; however, all of these indicators could be present. Substance Intoxication Substance Withdrawal Group of symptoms found within the related substance that is being used or abused which are severe enough to warrant clinical consideration (COCE, 2006)
8 Co-occurring disorders (COD) How can a person who has a COD be distinguished from a person who requires COD services?
9 Co-occurring disorders (COD) How can a person who has a COD be distinguished from a person who requires COD services? According to the COCE (2006), patients who require services includes: Individuals who have an established diagnosis in at least one domain that occurs with signs and symptoms that coincides with another disorder Individuals who have been diagnosed with a substance related issue and mental illness yet have been stable for a considerable period of time but begin to show signs of decompensation in both areas.
10 Co-occurring disorders How can a person who has a COD be distinguished from a person who requires COD services? Individuals who exhibit symptoms that have suicidal ideation (passive or active) which warrants immediate attention Example: A person with passive/active suicidal ideation While under the influence of ETOH, drugs or Other substances.
11 Co-occurring disorders How can a person who has a COD be distinguished from a person who requires COD services? Marty - 56 year c male. He has been abusing ETOH for two years with increasing use during the past 2 months. He presents to the clinic with a depressed mood which has worsened over the past few months. His wife left him 6 months ago due ETOH consumption. He claims he has nothing to live for. He has been searching the internet for painless ways to die. He began giving away sentimental belongings to family members.
12 Co-occurring disorders How can a person who has a COD be distinguished from a person who requires COD services? Zelda -36 year old c female. She had difficulties with depression and anxiety ten years ago. She was treated with a combination of sertraline and buspirone. She was weaned off her medications 7 years ago. She was arrested recently for DUI while under the influence of xanax. She lost her job due to the legal difficulties. She had been using her friend s Xanax as well as buying them off the street for the past 5 months. She needs them to calm her nerves.
14 Co-occurring disorders Remission According to the COCE (2006) remission is defined as the absence of distress or impairment due to a substance use or mental disorder. Mary - 43 year old Hispanic female who struggled with recurrent depression and alcohol dependence. She had three depressive episodes and was treated with fluoxetine but has not taken it in it two years. Her moods have been stable. She exhibits no depressive symptoms and has been sober for six yrs.
15 Co-occurring disorders Remission-Treatment Treatment: Continue to monitor patient regularly for depressive mood with each office visit Inquire about social support to assess possible need of counseling for life stressors. Inquire about daily approach to maintaining abstinence
16 Co-occurring Disorders Recovery Recovery is: Person driven Holistic Supported by peers and allies though relationships and social networks Culturally based and influenced Addresses trauma Involves individual, family and community strengths and responsibility Based on respect Recovery emerges from hope and occurs through many different pathways
17 Co-occurring Disorders Recovery Laura - 33 year old c female. Her drug of choice (DOC) is cocaine. She has seven years of sobriety after attending a drug and alcohol treatment center. She attends CA meetings several times a week. She is actively involved with her program, has a sponsor, and sponsors others. She sees a therapist regularly and works full time. She feels balanced and enjoys life.
18 Co-occurring disorders Recovery Treatment: Continue to monitor patient and monitor recovery, depression/anxiety symptoms and substance abuse issues. Encourage and support patient on continuation of recovery efforts and attendance of support groups. Coordinate with therapist as needed.
19 Co-occurring disorders Relapse
20 Co-Occurring Disorder Relapse 49 year old male with 22 year history of methamphetamine dependence. He has had multiple periods of abstinence and relapse. He continues to struggle with depression/anxiety over the years. He has attended four different day programs. He recently had a stay in a 90 day program. He began hearing voices. Referred to psychiatrist. He has been sober 75 days and then the voices started. No history of AVH in the absence of substances. Continue to see him no meds. Attend regular NA /AA meetings Encourage him to get a sponsor.
21 Co-occurring disorders Relapse Starts seeing his female friend Wants to help her Knows it is bad for him She wants him to take her to go buy meth/crack He goes to pick her up He wants to take her to a meeting She demands that he drive her the corner of Oracle and Grant He starts heading that way He then thinks better of it He starts driving towards a meeting
22 Co-occurring disorders Relapse She starts getting angry that he is not taking her to get Crack She starts to struggle in the car He starts driving erratically He gets pulled over Confesses to the officer what is going on He gets stern warning as nothing was found in the car HE RELAPSED.
23 Co-occurring disorders What percentage of people with COD receive ANY service within SA/MH setting? A. 25 % B. 66% C. 50% D. 87%
24 Co-occurring disorders Four Quadrant Model Only 50% of people with COD receive any service within SA/MH settings. Most people with untreated COD cannot function optimally in school, at work or within their families or communities. The proper Identification of COD is an important first step in helping that person reach their highest potential
25 Co-occurring Disorders Four Quadrant Model Understanding how to decide to move to the next level and what is appropriate from coordination to consultation, to collaboration to integration All conceptual and may be difficult in reality depending on the setting but think of using this structure as guidance (COCE, 2007)
26 Co-Occurring Disorders Four Quadrant Model 1. Identification and initial management is the minimum level of responsibility. Involves screening for COD and provides brief, structured, targeted advice to patients. Referrals should be made for those with positive screens or serious symptoms (ie suicidal thoughts, trouble making sense). 2. Collaboration is a formal process of sharing responsibility for treating a person with COD. This involves regular and planned communication, sharing progress. Different disorders can be treated by different providers.
27 Co-occurring disorders Four Quadrant Model 3. Integration requires the participation of providers trained in both primary care and SA/MH services to develop a single treatment plan addressing all health conditions. These providers continue their formal interaction and cooperation in the client s ongoing reassessment and treatment. While the nature and type of integration will vary by communities it has been proposed that the SA/MA system take the lead in development of the plan of treatment. (COCE, 2007)
28 Co-occurring disorders Health Care Settings: Primary Care Before people with COD come to the attention of SA/MH providers most have seen a primary care provider Depression/Anxiety symptoms present as somatic complaints (fatigue, headaches, and pain) Substance use disorders usually complicates the management of chronic conditions There is a high association of medical problems and infectious disease with mental illness and substance use.
29 Co-Occurring Disorders Health Care Setting: Primary Care What percentage of patients seen in the primary care setting have a psychiatric disorder? A. 20% B. 25% C. 15% D. 5% E. 100%
30 Co-occurring disorders Health Care Settings: Primary Care People with COD tend to be in poorer physical health than persons without these disorders. 20% of patients seen in the primary care setting have a current psychiatric disorder % of patients seen in primary care setting have a current substance abuse disorder
31 Co-Occurring Disorders Health Care Setting: Primary Care The United States Preventative Services Task Force recommends routine screening for alcohol and drug problems as well as depression Surprisingly, most primary care settings are not currently screening for COD. Primary care providers are in prime position to quickly identify these patients and provide appropriate referral or treatment methods
32 Co-occurring Disorder Three program types I. Addiction/mental health only II. Dual Diagnosis Capable (DDC) III. Dual Diagnosis Enhanced (DDE)
33 Co-occurring disorder I. Addiction or Mental health-only services Programs that cannot accommodate patients (either by choice or lack of resources) who have co-occurring disorders that require ongoing treatment.
34 Co-occurring disorders II. Dual Diagnosis capable (DDC) Programs that address co-occurring mental and substancerelated disorders in their policies and procedures, assessment, treatment planning, program content and discharge planning. Generally program staff are able to address the interaction between mental health and substance related disorders however, the facility is more often than not, primarily geared toward treatment of mental health or substance abuse.
35 Co-occurring disorders III. Dual Diagnosis Enhanced (DDE) Programs that have a higher level of integration of substance abuse and mental health treatment services. Provide unified substance abuse and mental health treatment to clients who are more symptomatic and/or functionally impaired as a result of the co-occurring mental disorder.
36 Co-Occurring Disorders Evidence Based Treatment What can be done in the primary healthcare setting to address co-occurring disorders? COCE (2007) recommends the first step in implementing this recommendation is to identify persons with COD as a routine component of care. Healthcare for general, mental, and substance use problems and illnesses must be delivered with an understanding of the inherent interactions between the mind/brain and rest of the body. (IOM, 2006)
37 Co-Occurring Disorders Evidence Based Treatment The Institute of Medicine (IOM) (2006) reports the quality of health care for mental and substance use conditions needs to be improved.
38 Co-occurring disorders Health Care Settings: Primary Care Who should be screened for co-occurring disorders? Individuals requesting mental health services or chemical dependency should be screened for the possibility of a cooccurring mental illness, UNLESS a co-occurring disorder is already known AND documented. (SAMHSA, 2009)
39 Co-occurring disorders Evidence Based Practice How can Primary Care Physician s screen for COD s? There are many different screening tools, the CAGE-AID is one screening tool that is easy to implement. It takes less than 5 minutes to complete. Reliability 80-90% Sensitivity/specificity %
40 Co-occurring disorders Evidenced Based Practice- CAGE- SCREENING TOOL The CAGE and CAGE-AID Questionnaires 1. Have you ever felt you ought to cut down on your drinking or drug use? 2. Have people annoyed you by criticizing your drinking or drug use? 3. Have you ever felt bad or guilty about your drinking or drug use? 4. Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover? (AHRQ, 2004)
41 Co-Occurring Disorders Evidence Based Practice- CAGE-AID - SCREENING TOOL To screen for substances and alcohol use the phrase drinking or drug use. (which is italicized on the previous slide). COCE recommends using the CAGE AID screening tool which is the same 4 questions as the previous slide with 2 additional questions.
42 Co-occurring disorders Evidence Based Practice CAGE-AID Screening Tool Depression: Over the past two weeks have you felt down, depressed or hopeless? Over the past two weeks have you felt little interest or pleasure in doing things? 1. Have you ever felt you ought to cut down on your drinking or drug use? 2. Have people annoyed you by criticizing your drinking or drug use? 3. Have you ever felt bad or guilty about your drinking or drug use? 4. Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover? (AHRQ, 2004)
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