Understanding Co-Occurring Disorders

Transcription

1 Understanding Co-Occurring Disorders Thursday, May 26 th pm EDT Presented By Tiffany Cooke, MD, MPH, FAPA Assistant Professor, Morehouse School of Medicine For more information go to

2 OVERVIEW Through a Cooperative Agreement with the Substance Abuse and Mental Health Services Administration s (SAMHSA), Center for Substance Abuse Treatment, (CSAT) and Center for Mental Health Services, (CMHS) Morehouse School of Medicine established the Historically Black Colleges and Universities Center for Excellence in Behavioral Health (HBCU-CFE), funded as Grant No. TI

3 The Goals of the HBCU-CFE Promote student behavioral health to positively impact student retention Expand campus service capacity, including the provision of culturally appropriate behavioral health resources Facilitate best practices dissemination and behavioral health workforce development

4 Tiffany Cooke MD, MPH, FAPA, Tiffany Cooke MD, MPH, FAPA, is a board certified psychiatrist and a magna cum laude graduate of Florida A&M University. Dr. Cooke received her medical training at Meharry Medical College. She completed her psychiatric residency at University of Miami/Jackson Memorial Hospital, and earned a master s in public health policy & management while completing a fellowship in community psychiatry at Emory University. Dr. Cooke is currently an Assistant Professor of Clinical Psychiatry with faculty appointments at Morehouse School of Medicine & Emory University School of Medicine. She has a variety of work experience, currently including Grady Health System, Cobb Douglas Community Services Board, and Georgia State University Counseling & Testing Center. Her past work includes DeKalb County Drug Court, McIntosh Tail Community Service Board, Viewpoint Community Service Board, and Tanner Health system. She is also in private practice at Innovations Behavioral Health, LLC providing both patient care and consultation services. She is a public speaker and behavioral health advocate, with a long standing interest in decreasing behavioral health stigma and health disparities, particularly in racial and ethnic minorities. Dr. Cooke has authored publications on various mental health topics.she has also worked in the fields of trauma and HIV/AIDS in Grand Bois Haiti. She is a currently a member of the Ryan White Planning Council Georgia Physicians Psychiatric Association, American Psychiatric Association, American Association of Community Psychiatrists, Black Psychiatrists of America, Black Psychiatrists of Greater Atlanta, and Academy of Psychosomatic Medicine for AIDS Psychiatry.

5 Understanding Co-Occurring Disorders Tiffany Cooke, MD, MPH, FAPA May 26, 2016

6 Objectives Provide at least (1) definition of co-occurring disorders Name at least (2) key considerations when treating cooccurring disorders Name at least (4) screening tools for co-occurring disorders

7 Co-Occurring Disorders Defined Presence of both a mental health & substance use disorder in an individual a.k.a. dual diagnosis

8 HBCU Center for Excellence Overview Through a Cooperative Agreement with the Substance Abuse and Mental Health Services Administration s (SAMHSA), Center for Substance Abuse Treatment, (CSAT) and Center for Mental Health Services, (CMHS) Morehouse School of Medicine established the Historically Black Colleges and Universities Center for Excellence in Behavioral Health (HBCU-CFE), funded as Grant No. TI

9 The Goals of the HBCU-Center for Excellence Promote student behavioral health to positively impact student retention. Expand campus service capacity, including the provision of culturally appropriate behavioral health resources. Facilitate best practices dissemination and behavioral health workforce development.

10 Significance Persons with MH disorders more likely than those without to have SUD s Co-occurrence complicates severity & treatment of each individual disorder One condition can exacerbate the other

11 Significance (cont.) Symptoms often overlap Often only one or the two disorders are treated, sometimes neither Untreated/undertreated disorders homelessness, incarceration, mortality ~45% of Americans seeking SUD have been diagnosed as co-occurring

12 Impact Source: SAMHSA, Behavioral Health Trends in the United States: Results from the 2014 National Survey on Drug Use & Health

13 Co-Occurring Disorders by Age

14 Substance Use Disorders Defined DSM-5 Abuse, dependence replaced with mild: 2-3 sx; moderate 4-5 sx; severe 6+ sx within 12 months Polysubstance dependence obsolete: list each individual disorder

15 Substance Use Disorder Criteria Consuming more alcohol or other substance than originally planned Worrying about stopping or consistently failed efforts to control one s use Spending a large amount of time using drugs/alcohol, or doing whatever is needed to obtain them Use of the substance results in failure to fulfill major role obligations such as at home, work, or school.

16 Substance Use Disorder Criteria (cont.) Craving the substance (alcohol or drug) Continuing the use of a substance despite health problems caused/worsened by it, in the domain of mental or physical health Continuing the use of a substance despite its negative effects in relationships with others (ex. using even though it leads to fights or despite people s objecting to it) Repeated use of the substance in a dangerous situation (ex: when having to operate heavy machinery, when driving a car)

17 Substance Use Disorder Criteria (cont.) Giving up or reducing activities in a person s life because of the drug/alcohol use Building up a tolerance to the alcohol or drug (needing to use noticeably larger amounts over time to get the desired effect or noticing less of an effect over time after repeated use of the same amount) Experiencing withdrawal symptoms after stopping use. (anxiety, irritability, fatigue, nausea/vomiting, hand tremor or seizure in the case of alcohol)

18 Examples of Substance Use Disorders Alcohol use disorder Cannabis use disorder Phencyclidine use disorder Other hallucinogen use disorder Inhalant use disorder Opioid use disorder Sedative, hypnotic, or anxiolytic use disorder Stimulant Use disorder Tobacco Use Disorder

19 Criteria Mental Health Disorders Varies per disorder Overlapping criterion disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning

20 Examples of Mental Health Disorders Neurodevelopmental Disorders Schizophrenia Spectrum & Other Psychotic Disorders Bipolar & Related Disorders Depressive Disorders Anxiety Disorders Obsessive-Compulsive & Related Disorders Trauma and Stressor Related Disorders Sexual Dysfunctions Personality Disorders Feeding & Eating Disorders

21 Examples of Mental Health Disorders (cont.) Dissociative Disorders Somatic Symptom Related Disorders Elimination Disorders Sleep-Wake Disorders Gender Dysphoria Neurocognitive Disorders Disruptive, Impulse Control, & Conduct Disorders Paraphilic Disorders Other Mental Disorders Medication Induced Movement Disorders Other Adverse Effects of Medication

22 Co-Occurring Disorders in the Collegiate More likely among Students with depression and/or felt suicidal or attempted suicide in the last year : Alcohol use Smoking Marijuana use Binge drinking >150,000 students develop an alcohol-related health problem ~1.5 % of students tried to commit suicide within the past year due to drinking or drug use

23 Co-Occurring in the Collegiate (cont.) Center for the Study of Addictions & Recovery, 2014 study of students in addiction recovery ~72 % in recovery from alcoholism, ~73 % from a drug addiction Also in recovery from : eating disorders 15.6 % ; self harm/injury,10.5 % and compulsive shopping 3.1 % At least 12 & currently engaging in at least one type of behavioral addiction ¾ of college students in CRPs have been treated for a mental health condition,among those 65.7 % treated for the disorder in the past year

24 Perceived Need in Blacks

25 Why the Co-Morbidity? Disorder disorder; Ex: Depression leading to drinking to cope with negative mood Bipolar disorder leading to cocaine use to mimic pleasurable manic state, avoid crash into depression Schizophrenia leading to marijuana use to silence AH

26 Why the Co-Morbidity? (cont.) Kindling The more sensitized neurons become, less needed to disrupt them Leads to more frequent and intense drug use MH disorders similarly tend to become increasingly symptomatic with shorter periods between episodes

27 Why the Co-Morbidity? (cont.) Genetics Families with SUD s more likely to have members with mood d/o and vice versa Genes may cause brain to respond to initial drug exposures in ways that promote chronic use, drugs lead to changes causing MH disorders

28 Diagnostic Difficulty Symptoms of SUD s can mask symptoms of mental illness Symptoms of mental illness can mimic symptoms of SUD s: Depressive sx: MDD, substance intoxication, substance withdrawal Which occurred first? Ex: major depressive disorder and alcohol use disorder OR Substance induced major depressive disorder

29 Diagnostic Pearls If symptoms seem typical of intoxication and/or withdrawal from a known drug use, esp. with no previous psych history, that is probably all they are. Expect quick sx remission days. People with substance-induced disorders exhibit symptoms that result directly from the lingering physiological effects of the substance of abuse. Their affective difficulties commence within 4 weeks of last exposure to the substance, but are more severe and long-lasting than those normally associated with intoxication or withdrawal. Key: proximity of symptoms to last drug use, time for symptom remission

30 Diagnostic Pearls (cont.) Patients with underlying preexisting disorders may experience symptoms of varying type and intensity at any time during withdrawal or treatment Strong family history of MH d/o makes diagnosis of a primary MH d/o more likely, as do a history showing onset of symptoms prior to SUD, severity of symptoms exceeding that normally seen in intoxication and withdrawal, and sustained mood symptoms following substantial abstinence

31 Screening Tools General: SCL-90* Depression: PHQ-9, BDI*, HAM-D Anxiety: GAD-7, BAI Bipolar disorder: MDQ Alcohol use disorder: CAGE, AUDIT Other substance use disorders: CAGE-AID, DAST

32 Treatment Barriers Individuals with mental illness may self medicate Stigma assoc with MH may hinder tx seeking, and perpetuate self medicating Many professionals and agencies may prefer to focus on one solely the SUD or the MI or miss one of the disorders due to improper screening MH Programs may require sobriety/detox prior to admission SUD programs may require individuals be medication free For persons who self medicate the SUD may be obvious, but they may be unaware that an underlying MH d/o is contributing

33 SBIRT Screening: assess for disorders in healthcare setting Brief Intervention: HCP engages person to understand & risks Referral to Treatment: HCP refers if additional services are needed Based on MI Works for SUDs AND chronic conditions Therefore can be used for MH and co-occurring Source: Indiana SBIRT

34 Treatment Goals Goal: specialized, integrated care Reduced substance use Improved psychiatric symptoms and functioning Decreased hospitalization Increased housing stability Fewer arrests Improved quality of life Minimize suicide risk

35 Treatment Approaches Parallel treatment Working Diagnosis Allow for abstinence form substance and thorough history before definitive Provide support, linkage to care, and appropriate pharmacotherapy if needed Therapy: CBT, psychodynamic, others AA/NA/CA Avoid punitive tone

36 Treatment Resources Georgia: Georgia Crisis Access Line (GCAL): Nationally: SAMHSA :findtreatment.samhsa.gov; HELP Schools behavioral health center

37 Consequences of Untreated/Undertreated Disorders Incarceration Lost housing Homelessness Dysfunctional relationships Worse physical outcomes Increased Mortality Source: Ryan Courtade

38 Future Considerations Collegiate Recovery Programs: (CRPs) Need HBCU representation in network Association of Recovery in Higher Education Policy Implications Affordable Care Act Mental Health Parity & Addiction Equity Act Future policies

39 References American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5 th ed. Arlington, VA: American Psychiatric Association; Center for Behavioral Health Statistics and Quality. (2015). Behavioral health trends in the United States: Results from the 2014 National Survey on Drug Use and Health (HHS Publication No. SMA , NSDUH Series H-50). Retrieved from data/ Mericle AA, Ta VM, Holck P, Arria AM. Prevalence, Patterns, and Correlates of Co-Occurring Substance Use and Mental Disorders in the US: Variations by Race/Ethnicity. Comprehensive Psychiatry. 2012;53(6): doi: /j.comppsych Quello SB, Brady KT, Sonne SC. Mood Disorders and Substance Use Disorder: A Complex Comorbidity. Science & Practice Perspectives. 2005;3(1):13-21.

40 Questions

41 Contact Info Tiffany Cooke, MD, MPH, FAPA Morehouse School of Medicine Department of Psychiatry 720 Westview Drive Atlanta, GA (404)

42 HBCU-Center for Excellence at Morehouse School of Medicine Department of Psychiatry & Behavioral Sciences 720 Westview Dr. SW - Atlanta, GA Office: HBCU (4228)

43 HBCU-Center for Excellence at Morehouse School of Medicine Department of Psychiatry & Behavioral Sciences 720 Westview Dr. SW - Atlanta, GA Office: HBCU (4228) Dr. Eugene Herrington, Co-Project Director HBCU - Center for Excellence eherrington@msm.edu Mrs. Joan Trent, Program Coordinator HBCU - Center for Excellence jtrent@msm.edu