DIAGNOSIS ASSESSMENT AND TREATMENT

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					ASSESSMENT, DIAGNOSIS
   AND TREATMENT
   PLANNING FOR THE
 PATIENT WITH MULTIPLE
       DIAGNOSES
   DUAL DIAGNOSIS

THE CO-EXISTENCE OF A
    MAJOR MENTAL
   DISORDER AND A
  SUBSTANCE ABUSE
      DISORDER
    TRIPLE DIAGNOSIS

HIV (+)

MAJOR MENTAL DISORDER

SUBSTANCE ABUSE
   LIFETIME PREVALENCE
     RATES (ECA, 1990)

NON-SUBSTANCE ABUSE MENTAL
 DISORDERS-22.5%

ALCOHOL ABUSE/DEPENDENCE-13.5%

“OTHER” DRUG ABUSE/DEPENDENCE-
 6.1%
 RATES OF CONCURRENCE
       (ECA, 1990)

MENTAL DISORDER-29% SUBSTANCE
 ABUSE
ALCOHOL ABUSE/DEPENDENCE
 (ALCOHOLISM)-37% MENTAL DISORDER
“OTHER” DRUG ABUSE/DEPENDENCE-
 51% MENTAL DISORDER
   SAN MATEO COUNTY
 MENTAL HEALTH SYSTEM

10,431 UNDUPLICATED CLIENTS,
 JULY 96-JUNE1997
  40% WERE DUALLY DIAGNOSED


4,272 (41%) WERE SERIOUSLY
 MENTALLY ILL
  50% WERE DUALLY DIAGNOSED
  NATIONAL COMORBIDITY
 STUDY (REIGER, et. al., 1990)

55% OF CASES OF ALCOHOL
 DEPENDENCE HAD AT LEAST ONE
 MENTAL DISORDER
69% OF CASES OF DRUG DEPENDENCE
 HAD AT LEAST ONE MENTAL DISORDER
34% OF MENTALLY ILL HAD SUBSTANCE
 ABUSE PROBLEM
 PABLO’S PREVALENCE RATES (SAN
FRANCISCO HOMELESS POPULATION)


MAJOR MENTAL ILLNESS: 60%-80%
 ~EQUALLY DIVIDED BETWEEN SUBSTANCE-
  INDUCED AND PRE-EXISTING MENTAL
  ILLNESS
SUBSTANCE ABUSE: ~99.99%
 NICOTINE=ALCOHOL=MJ
 STIMULANTS (SPEED>COCAINE)
 OPIATES
  INCIDENCE OF MENTAL ILLNESS AND
SUBSTANCE ABUSE AMONG THE HOMELESS


SUBSTANCE ABUSE: ~52%-66%
MENTAL ILLNESS: ~22%
MENTALLY ILL WITH SUBSTANCE ABUSE
 PROBLEM: ~77%
SUBSTANCE ABUSERS WITH MENTAL
 ILLNESS: NO ACCURATE DATA
 AVAILABLE, BUT I SUSPECT ~50%-70%
REASONS FOR CONCURRENCE

MENTAL ILLNESS DOES NOT PREVENT
 SUBSTANCE ABUSE
SUBSTANCE-INDUCED MENTAL ILLNESS
SELF-MEDICATION
SUBSTANCE USE INCEASING SOCIABILITY
SUBSTANCE USE RELIEVING UNPLEASANT
 MEDICATION EFFECTS
  BARRIERS TO PROVIDING
   RATIONAL TREATMENT

IMPEDIMENTS WITHIN THE MENTAL
 HEALTH SYSTEM

IMPEDIMENTS WITHIN THE SUBSTANCE
 ABUSE TREATMENT SYSTEM

THE NEED FOR A NEW APPROACH,
 CREATING A HYBRID SYSTEM
     “MODEL” SYSTEM

CENTRALIZED INTAKE
STANDARDIZED ASSESSMENT PROCESS
 PHYSICAL EXAMINATION
 DISEASE SCREENING
   TB
   HIV
   HEPATITIS
    “MODEL” SYSTEM

“PATIENT SPECIFIC” MEDICAL CARE
  DETOXIFICATION
  ABSCESS CARE
  HEALTH CARE MAINTENANCE
SUBSTANCE ABUSE SCREENING
PSYCHOSOCIAL SCREENING
PSYCHIATRIC SCREENING
STANDARDIZED ASSESSMENT
       PROCESS

ADDICTION SEVERITY INDEX (ASI)
  DRUG
  ALCOHOL
  MEDICAL
  EMPLOYMENT
  LEGAL
  FAMILY
  PSYCHOLOGICAL
      STANDARDIZED
   ASSESSMENT PROCESS

ASAM (AMERICAN SOCIETY OF
 ADDICTION MEDICINE) TREATMENT
 CRITERIA
 INPATIENT
   MED/PSYCH
   “MINNESOTA” MODEL
 RESIDENTIAL
   THERAPEUTIC COMMUNITIES
   SOCIAL MODEL RECOVERY HOMES
ASAM TREATMENT CRITERIA

OUTPATIENT TREATMENT
 LEVEL 1 (<9 HOURS/WEEK)
 LEVEL 2 (>9HOURS/WEEK)
   DAY TREATMENT
   PARTIAL HOSPITALIZATION
SUBSTANCE ABUSE REVIEW

ADDICTION
DEPENDENCE
TOLERANCE
CROSS TOLERANCE
HALF-LIFE (T1/2)
SUBSTANCE ABUSE REVIEW

ROUTES OF DRUG ADMINISTRATION
 PO
 PR
 INTRANASAL
 IV
 IM
 INHALATION (SMOKING)
   SUBSTANCE ABUSE

PERSISTENT PATTERN OF SUBSTANCE
 USE THAT RESULTS IN SUBSTANCE-
       RELATED PROBLEMS
  MODELS OF SUBSTANCE
         ABUSE

PROHIBITIONIST
SOCIAL
MORAL
PSYCHOLOGICAL
DISEASE
       DISEASE MODEL

ETIOLOGY
SIGNS/SYMPTOMS; NATURAL COURSE
CULTURALLY INTERCHANGEABLE
TREATMENT
       ALCOHOLISM

ETIOLOGY: BIOLOGICAL,
 CULTURAL/BEHAVIORAL,
 PSYCHOLOGICAL
SYMPTOMS: ALCOHOL RELATED
 PROBLEMS; NATURAL COURSE
CULTURALLY INTERCHANGEABLE
TREATMENT: ABSTINENCE
     NATURAL COURSE OF
        ALCOHOLISM
                     ABSTINENCE


PROGRESS               "SOCIAL"          RETURN TO ABSTINENCE
                    ~3DRINKS/DAY
                    ASYMPTOMATIC


PROGRESS                "ABUSE"                RETURN
                     ~8DRINKS/DAY           TO ABSTINENCE
                      PROBLEMS           OR "SOCIAL" DRINKING


           DEPENDENCE             RETURN TO
              (3-5%)         ABSTINENCE, "ABUSE"
                             OR "SOCIAL" DRINKING


  DEATH          "INSTITUTIONALIZATON"
    CNS DEPRESSANTS
 (“MINOR” TRANQUILZERS)
BENZODIAZEPINE/BARBITURATES
  ANTI-ANXIETY
  SEDATIVE-HYPNOTICS
ALCOHOL
“OLDIES BUT GOODIES”
  CHLORAL HYDRATE
  ETHCHLORVYNOL
  MEPROBAMATE
  METHAQUALONE
     CNS STIMULANTS

COCAINE
 SMOKABLE COCAINE: CRACK


METHAMPHETAMINE (SPEED)
 SMOKABLE SPEED: ICE
          OPIATES
NATURAL: OPIUM, MORPHINE, CODEINE
SEMI-SYNTHETIC: HEROIN,
 HYDROMORPHONE (DILAUDID),
 OXYCODONE (PERCODAN)
SYNTHETIC: PROPOXYPHENE (DARVON),
 MEPREIDINE (DEMORAL), DOLOPHINE
 (METHADONE)
     HALLUCINOGENS

CANNABINOLS
LSD
MESCALINE (PEYOTE)
PSILOCYBIN (MUSHROOMS)
ECSTASY (MDMA)
PCP (ANGEL DUST)
MENTAL ILLNESS REVIEW

        MEDICAL MODEL
HISTORY
PHYSICAL EXAMINATION
MENTAL STATUS EXAMINATION
LABORATORY STUDIES, ETC
DIAGNOSIS
     DSM-IV MULTIAXIAL
       ASSESSMENT
AXIS I: MAJOR MENTAL ILLNESS
         SUBSTANCE RELATED DISORDERS
AXIS II: PERSONALITY DISORDERS
          MENTAL RETARDATION
AXIS III: GENERAL MEDICAL PROBLEMS
AXIS IV: PSYCHOSOCIAL/ENVIRONMENTAL
           PROBLEMS
AXIS V: GLOBAL ASSESSMENT OF
          FUNCTIONING
      MENTAL STATUS
       EXAMINATION

APPEARANCE    THOUGHT PROCESS
BEHAVIOR      THOUGHT CONTENT
SENSORIUM     COGNITIVE EXAM
ORIENTATION   SUICIDE
SPEECH        HOMICIDE
AFFECT        JUDGMENT
MOOD          INSIGHT
PSYCHIATRIC DISORDERS

PSYCHOTIC DISORDERS

AFFECTIVE DISORDERS

ANXIETY DISORDERS

HIV (+) CONDITIONS

PERSONALITY DISORDERS
 PSYCHOTIC DISORDERS

SUBSTANCE-INDUCED
DUE TO MEDICAL CONDITION
BRIEF PSYCHOTIC DISORDER
SCHIZOPHRENIFORM DISORDER
SCHIZOPHRENIA
DELUSIONAL DISORDER
NOT OTHERWISE SPECIFIED
 AFFECTIVE DISORDERS
SUBSTANCE-INDUCED
DUE TO MEDICAL CONDITION
MAJOR DEPRESSIVE DISORDER
DYSTHYMIC DISORDER
ADJUSTMENTT DISORDER
BIPOLAR DISORDER
CYCLOTHYMIC DISORDER
SCHIZOAFFECTIVE DISORDER
   ANXIETY DISORDERS
SUBSTANCE-INDUCED
DUE TO MEDICAL CONDITION
POST TRAUMATIC STRESS DISORDER
PANIC DISORDER WITH/WITHOUT
 AGORAPHOBIA
OBSESSIVE COMPULSIVE DISORDER
GENERALIZED ANXIETY DISORDER
ATTENTION-DEFICIT/HYPERACTIVITY
 DISORDER (AD/HD)
     HIV PSYCHIATRIC
       CONDITIONS
PSYCHIATRIC CONDITIONS THAT PRE-
 DATE HIV (+)
PSYCHOLOGICAL RESPONSE TO A
 “TERMINAL” DIAGNOSIS
VIRAL-INDUCED CONDITIONS
  PSYCHOTIC
  AFFECTIVE
  ANXIETY
  DEMENTIA
PERSONALITY DISORDERS

LITTLE OR NO ABILITY FOR EMPATHY
UTILIZE “PRIMITIVE” DEFENSES:
  SPLITTING
  PROJECTION
ANTISOCIAL PERSONALITY DISORDER,
 NOT AMENABLE FOR TREATMENT!
  MUST BE DISTINGUISED FROM ADULT,
   LEARNED, ANTISOCIAL BEHAVIOR
   SUBSTANCE-INDUCED
    MENTAL DISORDERS

INTOXICATION

WITHDRAWAL SYNDROMES

ABSTINENCE SYNDROMES
    ALCOHOL-INDUCED
     MENTAL ILLNESS
IMPULSE CONTROL PROBLEMS:
 VIOLENCE, SUICIDE, UNSAFE SEX, HIGH
  RISK BEHAVIOR
SLEEP DISTURBANCE
ANXIETY
DEPRESSION
PSYCHOSIS
DEMENTIA
  STIMULANT-INDUCED
    MENTAL ILLNESS
IMPULSE CONTROL PROBLEMS:
 VIOLENCE, UNSAFE SEX, HIGH RISK
  BEHAVIOR
MANIA
PANIC DISORDER
DEPRESSION
ANXIETY
PSYCHOSIS
COGNITIVE IMPAIRMENT
     MARIJUANA-INDUCED
      MENTAL ILLNESS

DELIRIUM: MEMORY PROBLEMS,
 DIFFICULTY WITH MULTI-STEP TASKING
PSYCHOSIS
PANIC DISORDER
AMOTIVALTIONAL SYNDROME (?)
   SUBSTANCE USE AS AN
ATTEMPT AT SELF-MEDICATION

MAJOR DEPRESSIVE DISORDER
 SPEED
 OPIATES


ANXIETY DISORDERS
 MINOR TRANQUILIZERS
 MJ
 OPIATES
     SELF-MEDICATION
ATTENTION-DEFICIT/HYPERACTIVITY
 DISORDER
  MINOR TRANQUILIZERS
  MJ
  OPIATES
  SPEED*


SCHIZOPHRENIA
  STIMULANTS
  OPIATES
    SELF-MEDICATION

BIPOLAR DISORDER
 MINOR TRANQUILIZERS
 MJ
 OPIATES
 SPEED (FOR DEPRESSIVE CYCLE)
   DIAGNOSTIC STRATEGY
ASSESS HEALTH STATUS
ASSESS DEGREE OF SUBSTANCE USE
ASSESS MENTAL HEALTH STATUS
ATTEMPT TO DETERMINE “CAUSE/EFFECT”
 HIV-INDUCED
 SUBSTANCE-INDUCED
 PRE-EXISTING MENTAL ILLNESS
 ALL OF THE ABOVE*
         TREATMENT
       CONSIDERATIONS

INTERVENTION STRATEGIES
STAGES OF CHANGE EVALUATION
TREATMENT MATCHING
ACHIEVING ABSTINENCE (0-6 MONTHS)
MAINTAINING ABSTINENCE (6-24 MONTHS)
LIFELONG ABSTINENCE
  ACHIEVING ABSTINENCE
DETOXIFY, IF NECESSARY
ASSESS/TREAT PSYCHIATRIC DISORDER, IF
 PRESENT
MOTIVATIONAL INTERVIEWING
SUPPORTIVE PSYCHOTHERAPY*
RELAPSE PREVENTION*
MEDICATION SUPPORT
SOCIAL SUPPORTS
PEER SUPPORT GROUPS (I.E. 12 STEP)
       SUPPORTIVE
     PSYCHOTHERAPY

“ABSTINENCE” PSYCHOTHERAPY
PSYCHO-EDUCATION
MEDICATION COMPLIANCE
AVOIDANCE OF ALL SUBSTANCES
  RELAPSE PREVENTION

RELAPSE IS A PROCESS
IDENTIFIABLE TRIGGERS
PRESDICTABLE SET OF THOUGHTS,
 FEELINGS AND BEHAVIORS
NEED TO IDENTIFY THE RELAPSE
 PROCESS AND INSTITUTE ALTERNATE
 BEHAVIORS
       MAINTAINING
       ABSTINENCE
SUPPORTIVE PSYCHOTHERAPY-
 PSYCHODYNAMICALLY ORIENTED
 PSYCHOTHERAPY (IF CLINICALLY
 INDICATED)
TAPER SUPPORTIVE MEASURES AS
 INDICATED
INCREASE INTENSITY OF TREATMENT AT
 TIMES OF POTENTIAL RELAPSE
 LIFELONG ABSTINENCE

PSYCHODYNAMICALLY ORIENTED
 PSYCHOTHERAPY (IF CLINICALLY
 INDICATED)
INCREASE INTENSITY OF TREATMENT AT
 TIMES OF POTENTIAL RELAPSE
    OPIATE REPLACEMENT
         THERAPY

 METHADONE MAINTENANCE: DRUG
REPLACEMENT THERAPY WITH A LONG
  ACTING, ORALLY ADMINISTERED
 MEDICATION THAT IS REPLACING A
      SHORT ACTING, ILLICIT,
  INTRAVENOUSLY ADMINISTERED
             OPIATE
    HARM REDUCTION

PUBLIC HEALTH EFFORTS THAT ARE
 AIMED AT REDUCING THE INHERENT
 RISKS ASSOCIATED WITH SUBSTANCE
 USE
HARM REDUCTION EXAMPLES:
 DESIGNATED DRIVER PROGRAMS
 NEEDLE EXCHANGE
 METHADONE MAINTENANCE

				
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