Dual diagnosis: working together

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1 Dual diagnosis: working together Tom Carnwath RCGP conference Birmingham 2007

2 DSM-IV & cocaine Cocaine intoxication Cocaine withdrawal Cocaine-induced sleep disorder Cocaine-induced sexual dysfunction Cocaine-induced anxiety disorder Cocaine-induced mood disorder Cocaine intoxication delirium Cocaine-induced psychotic disorder with delusions Cocaine-induced psychotic disorder with hallucinations Cocaine-related disorder not otherwise specified

3 An early victim Springthorpe JW (1897) Scientific American

4

5 Homicides by mentally ill 14 of 17 had significant substance misuse issues In 9 of 17, alcohol/drug misuse was the major cause of homicide (Ward & Applin 1998)

6 Common factor Common factor M.I. Drugs Secondary substance abuse M.I. Drugs Secondary psychopathology Bidirectional Drugs M.I. M.I. Drugs Models of comorbidity

7 New Haven study Cocaine Opiate E.C.A. Major Dep Major Dep (pre) Bipolar Schizophrenia Phobia ASPD Alcoholism Alcoholism (pre)

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10 Alcohol & depression 80% of alcoholics complain of depression, 30% fulfil criteria for major depressive disorder (Raimo & Schuckit 1998) Suicide risk in alcoholics is times greater than average At presentation, 42 % alcoholic men had depression, only 6% after 4 weeks abstinence (Brown & Schuckit 1998)

11 Prevalence of comorbidity In a district of 500,000 expect c.650 patients with psychosis and substance problems, and about 10,000 drug/alcohol users with mental health problems (Checinski 1996)

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14 Police Probation Prisons Child protection Housing Hospital doctors GPs Nurses Voluntary sector Shrinks Addiction shrinks Social Workers Relatives MAPPA

15 Mainstreaming Substance use usual rather than exceptional amongst people with severe mental health problems High quality care should be delivered within mental health services Substance misuse services will continue to treat majority of substance misuse patients DoH good practice guidance

16 Assigning patients Lead agency Level 1A Level 1B Level 2A Level 2B Level 3A Level 3B Mental health Limited Limited Moderate Moderate Severe Severe Substance use Mild Heavy Mild Heavy Mild Heavy Mental Health Team Substance Misuse Team

17 Service mismatch Substance misuse services targeted esp. at heroin users But heroin does not cause mental illness Alcohol/ stimulant services poorly developed, cannabis & ecstasy even less so Drug Commissioners have little concern for dual diagnosis 1 to 15 consultant ratio

18 And patients can be almost as awkward as staff Spectrum of need These needs vary over time Diagnosis often difficult Patients may prefer wrong service Some not helped much by treatment Many have personality disorder

19 Models of Shared Care 3 Specialist GP 2 Specialist GP 4 Liaison worker GP Central clinic 1

20 Delirium Agitation and restlessness Disorientation Reduced attention and registration Visual, tactile & auditory hallucinations/ misinterpretations Paranoia

21 Personality disorder Markedly disturbed emotions, arousal, impulse control,perceptions, relations Long-standing & enduring Pervasive and broadly maladaptive Appear in adolescence Causes personal distress and occupational and social dysfunction

22 Paranoia People looking at me People talking about me Transient delusions Persistent delusions Morbid jealousy

23 Background problems Sexual abuse Post-traumatic stress Eating disorder Personality Disorder Domestic violence General disadvantage etc.

24 Subacute disorders Sleep disorder Sexual dysfunction Mood disorder Anxiety

25 Treatment stages Engagement including helping social/physical need Understanding relationship between drugs & illness Motivation for change Active treatment Relapse prevention Training manuals available to help with each stage

26 FRAMES Feedback Responsibility Advice Menu Empathy Self-efficacy

27 Prochaska & Di Clemente Relapse management Advice Maintenance Precontemplation Action Contemplation Relapse prevention Motivational interviewing

28 Step 4 Step 3 Step 5 Where would I like to be? What can I do? What obstacles need overcoming? What can I do? What obstacles need overcoming? What can I do? What obstacles need overcoming? Step 1 Step 2 Where am I now? What can I do? What obstacles need overcoming? What can I do? What obstacles need overcoming? Mountain climbing

29 What would be nice Substance misuse workers in CMHTs and assertive outreach teams Substance misuse liaison workers in general hospitals & primary care Access to psychological treatment for substance misuse patients Dedicated time for joint case management Specific co-morbidity training Inpatient facilities for substance misuse

30 Useful points Remember alcohol and drug use are important causes of psychiatric illness. Always ask about alcohol and drug use. Early brief intervention can be effective. Prolonged intense intervention can also be effective. Opiates do not usually cause psychiatric illness.

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