Topics in Addictions and Mental Health: Concurrent Disorders and Community Resources. Christian G. Schütz MD PhD MPH

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1 Topics in Addictions and Mental Health: Concurrent Disorders and Community Resources Christian G. Schütz MD PhD MPH

2 Overview Introduction Epidemiology Treatment Principles and Issues Community Resources Summary

3 What are Concurrent Disorders? Co-occurrence or Comorbidity of mental illness and addiction MICA (mentally ill chemical abusers) PISA (psychiatrically ill substance abusers) SAMI (substance abuse and mental illness) CAMI (chemical abuse and mental illness) Dual Diagnosis, etc

4 What are Concurrent Disorders? Any combination of: mental disorder + substance use disorder = concurrent disorder 4

5 How Common Are They? Epidemiological Catchment Area Study: Alcohol-related disorders 37% have mental illness Other addictions 53% have mental illness Mentally ill population 33% with substance disorder (lifetime prevalence)

6 B. Rush 2010 How Common Are They? Canada

7 Odds of concurrent mental disorder Rush 2010

8 The Four Quadrant Framework for ConcurrentDisorders More severe mental disorder/ more severe substance abuse disorder More severe mental disorder/ less severe substance abuse disorder High severity Ries

9 Overview How Common Are They? 1. British Columbia Homeless Study 2. Trauma 3. Affective Disorder 4. Available treatments 5. Summary Health of the Homeless Study Krausz et al.

10 In the 12 months prior to interview, 76% of the sample fulfilled ICD-10 criteria for a psychiatric disorder other than substance-use disorder. Over half of the group interviewed fulfilled ICD-10 criteria for an affective disorder. Two-thirds fulfilled criteria for an anxiety disorder. 19% fulfilled ICD-10 diagnostic criteria for a moderate or severe affective disorder. In 71% of the group who had a comorbid psychiatric illness, the onset of psychiatric symptomatology was reported to predate the use of heroin. Callaly et al. (2001).

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14 Adapted from

15 Pharmacotherapy for Concurrent Disorders Little evidence beyond treatment of single disorders Concurrent chronic disorders Both must be treated Involves ongoing clinical relationship Continue to re-evaluation diagnosis and medications

16 Buspar Anxiety and opioid use disorder

17 Depression and opioid dependence TCAs (lethality in overdose) MAOI (hypertensive crisis dietary and medication contraindications)

18 Psychosis and opioid use disorder QTc high dose (Chlorpromazine, Haloperidol, Seroquel, Olanzapine, Fluoxetine, cocaine)

19 Counselling & Community Resources Detoxification Centres Outpatient Counselling Services & Day Programs Support Recovery Houses Residential Treatment Centres Self-Help Support Groups Specific Concurrent Disorders Programs

20 Desired Treatment Outcomes: Signs of progress may include: Reduction/abstinence in substance use Reduction/elimination of mental health symptoms Use of adaptive strategies (rather than substances) as an alternative to deal with negative emotions 20

21 VAMI

22 Counselling & Community Resources Specific Concurrent Disorders Programs: Centre for Concurrent Disorders (CCD) Concurrent Disorders Intervention Unit (CDIU) Burnaby Centre for Mental Health & Addictions (BCMHA)

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25 Heartwood Program

26 Very limited evidence at best! Summary

27 Summary Psychosocial setting: Recovery in severe concurrent disorder is necessarily based on a supportive psychosocial structure, e.g. outpatient treatment, day care, ICM, ACT, BCMHA model

28 Summary Psychosocial setting: Recovery in severe concurrent disorder is necessarily based on a supportive psychosocial structure, e.g. outpatient treatment, day care, ICM, ACT, BCMHA model Psychotherapeutic intervention: Cognitive and psycho-educative approaches are considered fundamental, but have so far limited validation in this group. Adaptation of approaches are essential. Motivational Enhancement seems to be effective. CM currently underutilized.

29 Summary Psychosocial setting: Recovery in severe concurrent disorder is necessarily based on a supportive psychosocial structure, e.g. outpatient treatment, day care, ICM, ACT, BCMHA model Psychotherapeutic intervention: Cognitive and psycho-educative approaches are considered fundamental, but have so far limited validation in this group. Adaptation of approaches are essential. Motivational Enhancement seems to be effective. CM currently underutilized. Medication intervention: Limited evidence for mood-stabilizers and antipsychotics in concurrent BP (valproic acid), none for MDD; mixed evidence for SSRI s (citalopram and sertraline) and other antidepressants. NICE: given lack of evidence of the opposite, treat as you would treat single disorders. Consider interaction of side effects.

30 Thank you very much for your attention If you have any further questions:

31 Health Canadian Guidelines: CANMAT: w.canmat.org/articles-mdh/5.%20beaulieu,%20canmat%20comorbidity%20- %20Substances,%20Ann%20Clin%20Psyt% pdf Cochrane Library: US SAMSAH: Practices-EBP-KIT/SMA US APA UK NICE Australian NHMRC

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