mental health-substance use

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1 mental health-substance use recognition and effective responses from General Practice Gary Croton Eastern Hume Dual Diagnosis Service This talk: 25 minutes The territory 5 minutes What helps? 20 minutes CAMI Little traction terms: MICA MISA SAMI MISUD ICOPSUD 1

2 dual diagnosis comorbidity co-occurring disorders 2

3 co-existing disorders concurrent disorders mental health substance use 3

4 CAMI MICA MISA SAMI MISUD ICOPSUD dual diagnosis comorbidity co-occurring disorders co-existing disorders concurrent disorders mental health substance use any mental health disorder with any substance use disorder Cohorts: 4

5 Cohorts: Personality disorder with polydrug abuse Mood disorder with stimulant or depressant Schizophrenia with alcohol, cannabis or polydrug Amphetamine abuse with paranoid symptoms Opiate dependence with personality disorder Alcohol dependence with anxiety &/or depression symptoms or disorder Early psychosis with cannabis Anxiety with alcohol Depression with alcohol Cohorts: MENTAL DISORDER - Schizophrenia & delusional disorders - Mood disorders - Neurotic disorders Disorders of personality - Disorders of Psyc al develop nt -Disorders with Childhood onset CLINICAL STATE Huge - Organic variety mental in: disorders - Acute - Combinations of disorders intoxication - Severity of disorders - Treatment needs - Harmful use - Dependence syndrome - Withdrawal state - Withdrawal state with delirium SUBSTANCE - Alcohol - Opioids - Cannabinoids - Sedatives or hypnotics - Cocaine - Other stimulants - Hallucinogens - Tobacco - Volatile solvents - Multiple drug use Cohorts: Dependence DSM-IV Criteria for substance dependence: Maladaptive pattern of use leading to clinically significant impairment or distress as manifested by three (3) or more of. (within a 12 month period) Alcohol Cannabis Other (specify) Tolerance Withdrawal Using larger amounts or for longer than intended Desire or unsuccessful efforts to cut down Time spent obtaining/ using/ recovering from substance Social /occupational recreational activities reduced or given up for substance use Use continues despite recurrent problems caused by or exacerbated by use 5

6 Cohorts: Abuse DSM-IV Criteria for substance abuse: Maladaptive pattern of use leading to impairment or distress as manifested by one (1) or more of.. (within a 12 month period) Alcohol Cannabis Other (specify) Use results in a failure to fulfil obligations at work / school / home Recurrent use in hazardous situations Recurrent substance-related legal problems Use continues despite recurrent problems caused by or exacerbated by use Cohorts: spectrum of substance use disorders no use.. use without harm Hazardous / Harmful Use / Abuse Depend ce well.. High Prevalence MH disorders SMI spectrum of mental health disorders Where are the greatest costs & harms? Where does treatment tend to be lower-input & more effective? Where does treatment tend to be higher input & less effective? Where do we tend to focus our limited resources? Why does DDx matter? Prevalence expectation not the exception Harms: Relapse Housing instability & homelessness Unemployment Financial.Physical health disorders.forensic involvement. Carer trauma and 3 loss reasons:.suicide.multiple admissions. treatment resistance. Potential: More effective treatment of target disorders 6

7 What are specialist AOD & MH services doing about DDx? Dual diagnosis capability Routine Sc & Ax Integrated treatment Carer & consumer involvement Rotations No Wrong Door service system goals This talk: 25 minutes The territory 5 minutes What helps? 20 minutes Broad definition of SUDs Barriers for GPs: Abuse / Harmful too busy Use as well as not trained in AOD Dependence Not encouraged Lack counseling materials Allows: use Too difficult no Hazardous / Harmful Use early without use.. intervention / Abuse Lack confidence in Rx harm efficacy Prevention Don t identify harmful Brief use clients Interventions Not my responsibility Disease rather than prevention orientation Depend ce 7

8 Welcoming: Rationale: Stigma No Wrong Door..engagement. engagement. engagement Engagement, engagement, engagement Length of time in Rx & client s perception of engagement fundamental determinants of outcome Empathy, respect, & confidence in treatment Build sense of collaboration with client Non-judgmental attitude (double stigma) Non-confrontational Realistic expectations Detection of co-occurring disorders: Disorders often not evident High index of suspicion Especially when 1 of the disorders is present Sensitive questioning (normalising SU) Routine screening 8

9 Detection of co-occurring disorders: MH disorders: AUDIT ASSIST Tools for screening: MH disorders: K10 PsyCheck Integrated treatment (where possible): Sequential treatment Parallel treatment Integrated treatment Stepped care Stepped care means the flexible matching of treatment intensity with case severity. The least intensive & expensive treatment is initially used & a more intensive or different form of treatment is offered only when the less intensive form has been insufficient. Stages of change: PRE- CONTEMPLATION CONTEMPLATION MAINTENANCE ACTION EXIT (long term success) Lapse / Relapse 9

10 EB Rx s for all presenting disorders: Consider both disorders as primary Integrated treatment where possible BIs for Abuse / Harmful Use Motivational Interviewing for ambivalence Brief Interventions: F 5 to 30 mins of advice /counseling Target: problematic/risky / abuse rather than dependence (getting upstream) Evidence base Components= FRAMES Feedback R A M E S Responsibility Advice Menu of change options (drawn from client) Empathy Self efficacy Motivational interviewing / strategies: MI framework 1. Collaboration 2. Evocation 3. Autonomy 1. Express empathy 2. Develop discrepancy 3. Roll with resistance 4. Support selfefficacy 1. Open questions 2. Affirming 3. Reflections 4. Summarising 10

11 11

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