Co-Occurring Disorders

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1 Co-Occurring Disorders PACCT 2011 CAROLYN FRANZEN Learning Objectives List common examples of mental health problems associated with substance abuse disorders Describe risk factors that contribute to the progression of mental health problems associated with substance abuse disorders Identify appropriate screening and assessment tools and evidence-based treatment practices for clients with COD 1

2 Students will be able to demonstrate: Understanding of implementation of evidence-based practices for Co- Occurring Disorders. Practice through role-play screening and assessment techniques to assist identification of COD. Articulate and apply overarching principles used to address the unique treatment challenges and needs of persons with COD. Cultural Competence Define cultural competence and facilitate dialogue on cultural competence as applied to assessment and treatment of clients with COD. Discuss clinical implications of racial and cultural oppression. Discuss mental health service disparities for racial and ethnic minorities and how these needs may be addressed. 2

3 REFERENCES AND RESOURCES Definition Co-occurring disorder: Diagnosis occurs when at least one disorder of each type can be established independent of the other, and not simply a cluster of symptoms resulting from one disorder. 3

4 Co-occurring Disorder DEFINITION CO-OCCURRING DISORDERS: ONE OR MORE MENTAL DISORDERS AS WELL AS ONE OR MORE DISORDERS RELATING TO THE USE OF ALCOHOL AND/OR DRUGS. SAMHSA/CSAT 2006 Terminology Dual Diagnosis Earlier term Is now Co-occurring disorders COD DSM-IV-TR: The concurrent diagnosis of a SUBSTANCE USE DISORDER (SUD) and a PSYCHIATRIC DIAGNOISIS 4

5 Barriers to identifying and treating Low rates of screening, correct diagnosis, and appropriate referral Client denial Client reluctance to talk to provider Clinician attitudes Inadequate training Time constraints Challenges: Client factors Reluctance to discuss lifestyle or emotional issues Tendency to report only somatic symptoms Fear of being labeled I m not a.. alcoholic addict I m not crazy (not all in my head 5

6 Challenges: General system barriers Not enough time of conduct psychosocial assessment Not enough mental health providers Separate location and facilities Specialization leading to separation, isolation, turf issues Negative outcomes of COD Continuing alcohol/drug use Homelessness Disruptive behavior (re)hospitalization incarceration medication non-compliance suicide (higher rate in this group) 6

7 Prevalence of COD Challenges: Diagnostic clarity easy in the DSM, but difficult when you are with the person! Severity of illness Is it abuse or dependence? 7

8 ABUSE VS. DEPENDENCE ABUSE DEPENDENCE DSM-IV Disorders Mood disorders Anxiety disorders Psychotic disorders Personality disorders Substance induced disorders Substance Use Disorders Alcohol and/or drug -abuse -dependence Also use, misuse, unsafe use Is it ok for this client to use? Is abuse moving toward dependence? There is no way to know until after, later, retrospectively understood. Can t say, On a scale of 1 to 10, what is the severity? 8

9 Psychotic disorders: Delusions Hallucinations These clients constitute what is commonly referred to as the serious and persistent mentally ill population Schizophrenia Paranoid type Disorganized type Catatonic type Undifferentiated type Residual type Mood and Anxiety disorders Mood disorder Depression Mania Bipolar disorder Anxiety disorders Social phobia Panic disorders Post traumatic stress disorder (PTSD) 9

10 Stigma Providers Family, friends Community A source of denial A source of guilt Interferes with: admission of problem, seeking help, social functioning Impact of COD Medical and health Psychiatric status Psychological: anger, grief, personal distress Family Social interpersonal relationships and social activities Legal Occupational and academic Economic costs business, society Spiritual guilt, shame, loss of meaning, in life, loss of values 10

11 Etiology: cause or origin Why do substance use disorders and mental health disorders commonly cooccur? Determinants of health: Health care: 10% Genetic: 30% Behavior: 40% Environment: 20%: drugs, stress, trauma 11

12 Reasons why SUDs and MH disorders commonly co-occur Overlapping genetic vulnerabilities Overlapping environmental triggers Involvement of similar brain regions Substance abuse and mental illness are developmental disorders Etiology issues One disorder fosters another disorder One increase the risk for other Medicating negative affect states SUD reveals increased symptoms and severity of MHD Overlapping neurobiological pathways Underlying genetic factors Vulnerability 12

13 Risk Factors Family history Common neurotransmitters Disease interaction Impulse control STRESS DEFINE 13

14 Screening and Assessment ASSESSMENT IS A PROCESS NOT AN EVENT Co-Occurring Disorders Screening Assessment Does not identify the kind of problem or its severity For determining the nature of the problem and to develop treatment strategy 14

15 Structured Assessment Process 1. Engage the client 2. Identify and contact collaterals to gather additional information 3. Screen for and detect COD 4. Determine quadrant and locus of responsibility 5. Determine level of care 6. Determine diagnosis 7. Determine disability and functional impairment 8. Identify strengths and supports 9. Identify cultural and linguistic needs and supports 10. Identify problem domains 11. Determine stage of change 12. Plan treatment SAMHSA Assessment Must be structured Assessment and observation over time Crisis stabilization must occur first Psychiatric symptoms related to SU will remit with abstinence Atypical presentations of symptoms of both mental illness and substance abuse are indicators of COD Bio-psycho-social Mental status evaluation 15

16 Screening Screening considers impact and severity Screening Have you ever had a problem with alcohol or drugs? When was your last drink? Have you ever tried to cut down on your use of alcohol or drugs? 16

17 CAGE screening questions Have you ever felt a need to Cut down on your alcohol/medication/drug use? Do you ever feel Annoyed when someone mentions your use? Do you ever feel Guilty about your alcohol/medication/drug use? Do you ever have an Eye-opener? (use to relieve withdrawal symptoms or to get going) Screening tools for alcohol/drug use CAGE AUDIT 20 Questions MAST SASSI ASI DALI Dartmouth Assessment of Lifestyle DAST Drug Abuse Screening Test SADD Short Alcohol Dependence Data Questionnaire MIDAS Mental Illness Drug & Alcohol Screening 17

18 Mental Health Screening and Assessment Diagnostic Interview Screening and Assessment Screen for safety issues Mental Health Screening PHQ Patient Health Questionnaire Zung/Beck Inventory SCL-90 Symptom Checklist SCID Structured Clinical Interview MHSF-III Mental Health Screening Form BPRS Brief Psychiatric Rating Scale 18

19 Screening Practice MIDAS COD safety screening Suicide Violence Care for self or others Infectious disease Risky behaviors Danger of victimization 19

20 Safety Ask! Monitor closely client who express suicidal intention Ask about thoughts as a routine part of every session with a depressed person Immediately follow up appointments missed MH diagnosis with active alcohol/drug use: Recommend 2 4 weeks of abstinence before establishing a diagnosis. APA, ASAM 20

21 Cultural Competence Cultural competence as applied to assessment and treatment Clinical implications of racial and cultural oppression Addressing mental health service disparities Treatment 21

22 12 Step COD Assessment Process 1. Engage the client 2. Identify & contact collaterals to gather additional info 3. Screen for COD 4. Determine quadrant and locus of responsibility 5. Determine level of care 6. Determine diagnosis 7. Determine disability and functional impairment 8. Identify strengths and supports 9. Identify cultural and linguistic needs and supports 10. Identify problem domains 11. Determine stage of change 12. Plan treatment Treatment Phases Process of Treatment Phase 1: Stabilization and assessment Detox Acute psychiatric symptoms Phase 2: Engagement Motivation enhancement Engagement in treatment Stages of Change Phase 3: Prolonged stabilization Active treatment Symptom free Medication compliance Phase 4: Recovery and rehabilitation Stability and sobriety (long term goal) 22

23 COD treatment Correcting physiological deficiencies Building social support Improving family functioning Prompting and reinforcing positive behavior Increasing client functional abilities Encouraging productive thinking patterns Increasing awareness COD treatment challenges Increase use of the ER Lack of social support High risk of suicide Legal problems Medication compliance issues 23

24 COD treatment models Sequential: participation in one system, then the other (not ideal) Parallel: participation in two systems simultaneously Integrated: participation in a single unified and comprehensive program (ideal) COD therapeutic techniques Motivational Enhancement Stages of change Improving stage Matching therapy to stage of change 24

25 Relapse prevention/maintena nce Precontemplation Action Contemplation Preparation Prochaska s Stages of Chang Change Motivational Enhancement Motivational Interview 25

26 Variable that make a difference in treatment Motivation to change Other services (case management) Social supports Length of treatment ** Relationship with the counselor** = most important variable Review Questions and discussion 26

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