Mental Health and Substance Use: Concurrent Disorders Capacity and Harm Reduction

Transcription

1 Mental Health and Substance Use: Concurrent Disorders Capacity and Harm Reduction 2012 Ontario Harm Reduction Conference Allison Potts, MSW, RSW Concurrent Disorders System Integration Lead Mental Health and Pinewood Centre Program Lakeridge Health

2 Welcome Who is here? Why does this matter? Who should it matter to?

3 Session Content A Question you came in this room with Quick review of what Concurrent Disorders means and the important fit with Harm Reduction Concurrent Disorders Capacity Building, Harm Reduction and the process of change

4 What are CD? Concurrent Disorders refers to cases where the individual has both a substance use concern and another serious mental health or psychiatric concern (same time or in sequence) Other terms: Dual Diagnosis popular in American literature, but in Canada refers to a Mental Health disorder and a developmental disorder obvious limits are being increasingly recongnized Co-Occurring Disorders commonly accepted term internationally for CD

5 What s Your Number?

6 Access To Treatment Research comparing treatment of patients with a depressive disorder and coexisting substance use issue found that they experience greater complexity of psychosocial needs and clinical presentation than those diagnosed with depression alone and they have fewer admissions and shorter lengths of stay. Brems et al 2006, Journal Of Dual Diagnosis (Research conducted in Alaska Psychiatric Institute). Access to medical care, and clarity regarding diagnoses, HIV status and other health concerns are also impacted by this The difficulty for research to be done on complex samples (aka people with more than one presenting issue) has impacted the availability of data supporting evidence based practices for individuals with CD

7 Common Factors of Mental Illness and Substance Abuse Brain impact Impaired insight Chronic, relapsing conditions Impacts family and significant others Stigmatized Shame and guilt Can be treated

8 Factors Influencing Concurrent Disorders Factors influencing the development of mental health and substance use issues are similar: Genetic, developmental and environmental factors interact and influence outcomes They can mask, mimic, exacerbate, trigger, complicate and possibly be independent of each other

9 So How Can They Interact? MASK: Symptoms of mental illness may be hidden by drug and alcohol use. Example: Someone with a history of trauma may be using oxycontin for relief. The full understanding of PTSD may not be apparent until he/she stops using substances for a significant period of time.

10 So How Can They Interact? MIMIC: Substance use can look like symptoms of a psychiatric disorder. Example: A person with no history of psychiatric symptoms can develop tactile hallucinations after heavy methamphetamine use.

11 So How Can They Interact? EXACERBATE: Symptoms of mental illness may get worse when an individual uses alcohol and drugs. Example: Someone may experience increases in auditory hallucinations during and after use of cannabis as they may react to the hallucinogenic properties of the substance.

12 So How Can They Interact? TRIGGER: Substance use can trigger the emergence of some mental health disorders if a youth is predisposed to mental illness. Example: A youth whose mother has bipolar disorder may have never experienced symptoms of mania until the youth uses Cocaine.

13 So How Can They Interact? COMPLICATE: Substance use can complicate psychiatric symptoms, assessment and treatment. Example: Treating any mental illness is complicated by substance use if there is active cocaine use, how can positive symptoms, such as paranoia be assessed?

14 Evidence Based Practices for CD The most consistent finding across recent studies is that integrated treatment programs are highly effective Ideally, integrated treatment means that the clinician weaves the treatment interventions into one coherent package Several outpatient and residential studies also support the use of Stage-Wise treatments (based on the Transtheoretical Model of Change Prochaska & DiClemente 1984), Engagement Techniques and Motivational Counselling Techniques Drake, R., Mueser, K., Brunette, M., & McHugo, G. 2004

15 Concurrent Disorders are an Expectation, not an Exception This expectation must be incorporated in a welcoming manner into all clinical contact, to promote access to care and accurate identification of the population Dr. K. Minkoff

16 A Four Quadrant Model of Concurrent Disorders HIGH Severity of Substance Use LOW Quadrant 3 CD Capable services delivered to individuals with high severity of substance use issues and low severity of mental illness. Consultation/Collaboration Quadrant 1 CD Capable services delivered to individuals with low severity of both mental illness and substance use. Care is provided throughout the health care system and all points of entry should support recovery and use of consultation. Quadrant 4 Coordinated CD capable and enhanced services are delivered to individuals with high severity of both substance use and mental illness. Integration Quadrant 2 CD Capable services delivered to individuals with high severity of mental illness and low severity of substance use. Consultation/Collaboration LOW Severity of Mental Illness HIGH

17 A System of Silos Historically, individuals with CD have encountered a treatment system that is disjointed and unwelcoming reflecting: Sequential Treatment: Patients frequently experienced a ping pong effect of moving between components of the system that are unconnected and uncoordinated Parallel Treatment: Simultaneous treatment occurring without consultation or collaboration resulting in high potential for conflicting treatment plans, over-servicing while under-providing No Treatment at all: Closed doors due to Stigma associated with substance use issues and mental illness and misperception regarding inter-relatedness of CD

18 Program/Structural Barriers Lack of programming that encompasses both substance use and mental health concerns Exclusion Criteria Focus on abstinence Waitlists, workloads Geography Lack of accessibility to programs Lack of CD Capacity Poor outreach Sorry, wrong door!

19 The Outcome of Silo Work? Compounded feelings of stigma (living with a mental illness, substance use, criminal record, and ) Unclear/Competing understanding or perspectives of the primary problem Lack of coordination in service response and transitions The burden of repeatedly sharing your story and feeling the need to fragment it to meet system criteria

20 Rationale for System Design (and change) CD as an expectation in all settings, not an exception Rule it out rather than Rule it in Striving for a minimum standard of concurrent disorder capability as a mechanism for reducing the poor outcomes and high costs of concurrent disorders Includes the understanding that each program within the system has a different job, but better utilizing these programs and matching services to determine most appropriate interventions

21 Counsellor Barriers to CD Capable Work Lack of confidence regarding discussing substance use and/or mental illness (psychotic symptoms and risk of suicide in particular) How do I ask? And then what do I do? Uncertainty about what to do with the responses Personal bias/experiences Sense that there is system resistance to change Access to screening/assessment tools and referral/consultation supports Lack of knowledge of terminology Interest and agency mandate (real or perceived)

22 Client Barriers to Involvement Concern of being judged under-report Lack of hope Lack of awareness of treatment options Individual may deny or under-recognize the existence of a problem in an attempt to normalize their situation Previous negative experiences in treatment system Peer groups reinforce normalcy of use or problem

23 What Could We Be Doing Better? The role for programs that offer HR distribution and support

24 What is CD Capacity Building? Enhancing and Developing Skills, Influencing Change in Organizational Structures, and a Commitment to Overall Health Improvement Hawe et. al Addressing the Gap between mental health and addictions treatment Building on the strengths of current services and programs Broadening the Base of treatment and increasing existing capacity

25 Components of CD Capacity Building System based structures, procedures, policies and practices (important to have top level buy in ) Resource level redirection of $ Clinician & Team based support, information, resources and commitment Partnerships & Collaboration Development of Leadership

26 System Based Structures, Procedures, Policies And Practices Management adopting CD best practices(and in our case CCISC Model) Recognize the value of CD Capacity building from a team level Support consistent policy and procedures regarding CD (eg.welcoming, Collaborative treatment models, opportunities for inclusion)

27 Resource Level Redirection Of $ In many cases, this work has been based on a no new money premise to begin with spending better not less or more yet Community partnerships sharing resources with other agencies Collaborative proposals for funding

28 Partnerships & Collaboration CD Capacity is built by clinicians from MH and SU services developing pilot projects, cross-training, collaborative case conferences, co-facilitating groups It is also built by learning from and with the individuals accessing services, by hearing the experiences and needs of consumers This is an opportunity re: Harm Reduction

29 Harm Reduction Non-judgmental, non-coercive provision of services Low-threshold program models Getting resources to people who use drugs A continuum approach to harm reduction includes abstinence HR programs have a vital role in support of CD Capacity Building in their communities

30 Harm Reduction and Abstinence: What Community Partners Need to Know Harm reduction and abstinence are highly congruent goals. Harm reduction expands the therapeutic conversation, allowing providers to intervene with active users who may not or are not yet contemplating abstinence. Harm reduction strategies can be used at any phase in the change process. Midwest Harm Reduction Institute

31 Development of Leadership - Opportunities to Build Capacity Regional Leaders sitting at broad system tables to champion CD System Integration Concept of Site Champions and a mechanism for supporting development that can be transferred through leaders Clinical leadership fostered through supervision and team support System Advocacy

32 What can be gained from increased CD Capacity? Reduced Stigma Improved treatment outcomes Improved Screening & Identification Better clinical coordination Providing service to the Whole Person Enhanced professional development for staff Increased job satisfaction HARM REDUCTION

33 Going Forward Linkages Partnerships Stepping out of silos Cross-training Assessing strengths and areas of growth

34 Websites of Interest Pinewood Centre: Minkoff & Cline ZiaPartners Centre for Addiction and Mental Health (CAMH): Mood Disorders Association of Ontario (MDAO): Canadian Mental Health Association: ConnexOntario: Rights and Responsibilities: Mental Health and the Law

35 References Bouis, Stephanie, et.al. An Integrated, Multidimensional Treatment Model for Individuals Living with HIV, Mental Illness, and Substance Abuse, Health and Social Work, 32:4, November 2007: Boyle, P. and Kroon, H. Integrated Dual Disorder Treatment International Journal of Mental Health, 35, 2, Summer 2006: Brems, C. et al. Comparing Depressed Psychiatric Inpatients with and Without Coexisting Substance Use Disorders Journal of Dual Diagnosis, 2 (4), 2006, Drake, R., Meuser, K., Brunette M.,McHugo, G. A Review of Treatments for People with Severe Mental Illnesses and Co-Occurring Substance Use Disorders Psychiatric Rehabilitation Journal, 27-4, Spring 2004, Minkoff, K and Cline, C. Changing the World: The Design and Implementation of Comprehensive Continuous Integrated Systems of Care for Individuals with Co-occurring Disorders. Psychiatric Clinics of North America, 27 (4):727-43, 2004 Sealy, John R. Dual and Triple Diagnoses: Addictions, Mental Illness, and HIV Infection Guidelines for Outpatient Therapists Sexual Addiction & Compulsivity, 6: , Whetten, K. et.al. Improving Health Outcomes Among Individuals with HIV, Mental Illness, and Substance Use Disorders in the Southeast AIDS Care, 2006; 18 (Supplement 1): S18-S26. Panel on Antiretroviral Guidelines for Adult and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. January 29, 2008; Available at Accessed March 25, 2008