Docstoc

Co-occurring Disorders

Document Sample
Co-occurring Disorders Powered By Docstoc
					Co-occurring Disorders:
   A Brief Introduction

   For San Luis Obispo County
   Behavioral Health Services
        December 8, 2006
       John Lovern, Ph.D.
What We Will Cover Today (1 of 2)
1. What co-occurring disorders are, how prevalent
   they are, and how serious they are
2. How co-occurring disorders have been
   approached in the past and how beneficial the
   different approaches have been.
3. Common problems faced by clients with co-
   occurring disorders—case examples illustrating
   assessment, treatment, and other problems.
What We Will Cover Today (2 of 2)
4. A description of integrated care.
5. Categories of treatment programs.
6. Principles and practice standards
7. Medication issues.
8. Some evidence-based practices.
9. Psychological trauma and co-occurring
   disorders.
10.Comments, questions and answers.
 What are Co-occurring Disorders?
 The term “Co-occurring Disorders” refers to
    substance use (abuse or dependence) and mental
    disorders occurring together in one person.
   Clients said to have co-occurring disorders have
    1. one or more disorders relating to the use of alcohol
       and/or drugs of abuse and
    2. one or more mental disorders.
 At least one disorder of each type must be
    established independently of the other and is not
    simply a cluster of symptoms resulting from one
    disorder (or one type of disorder).
  How Prevalent are Co-occurring
           Disorders?
 Studies in substance abuse settings have found
  that from 50 to 75 percent of clients had some
  type of mental disorder.
 Studies in mental health settings have found that
  between 20 and 50 percent of their clients had
  a co-occurring substance use disorder.
 Experts in this field assert that co-occurring
  disorders should be the expectation, not the
  exception in any behavioral health setting.
                 (Source: SAMHSA’s TIP 42)
    How Serious are Co-occurring
            Disorders?
 Clients with co-occurring disorders require more complex
  and expensive care.
 Clients with co-occurring disorders tend to have more
  problems of all kinds (medical, legal, social,
  interpersonal, homelessness, etc.), and more (and more
  expensive) contacts with agencies and providers (mental
  health, drug & alcohol, law enforcement, courts,
  emergency rooms, social welfare, shelters, etc.).
 Clients with co-occurring disorders tend to “fall through
  the cracks” of the traditional treatment system and
  develop even worse and more expensive problems.
A clients falling between the cracks.
  What Approaches to Treating Co-
occurring Disorders Have Been Tried?
Four general approaches have been tried:
  1. Not at all—referred out to treatment for the other
     problem or refused care entirely.
  2. Serial Treatment—one type of disorder treated at a
     time, in separate settings.
  3. Concurrent or Parallel Treatment—treatment for
     both types of disorder offered at the same time but in
     separate settings and by separate providers.
  4. Integrated Treatment—both types of disorder
     assessed and treated together in specialized settings
     by providers possessing competency in the treatment
     of both types of disorder and integrated treatment.
       How Beneficial Are These
          Approaches? (1 of 5)
 No Treatment At All:
   Denial of treatment is ineffective by definition. It is
    also unethical and could result in legal liability. (Yet I
    have heard reports that it is still taking place in this
    county in 2006.)
 Serial Treatment:
   This approach can be helpful for
      those who are not so impaired by their “secondary” disorder
       that they can wait for it to be treated after their “primary”
       disorder is treated, or
      those whose co-occurring disorders do not interact with one
       another.
      How Beneficial Are These
         Approaches? (2 of 5)
 Serial Treatment, continued:
   Serial Treatment can worsen problems or
    create new ones:
      Confusion due to conflicting treatment
      philosophies held by different providers.
     Confusion due to conflicting treatment
      recommendations or priorities.
     Treatment gaps arising due to communication
      problems between/among providers.
     Practical considerations such as scheduling,
      transportation, etc.
      How Beneficial Are These
         Approaches? (3 of 5)
 Concurrent or Parallel Treatment:
   This approach can be helpful for those who:
      are not seriously impaired by either disorder,
      do not require inpatient or residential care, and
      are cognitively equipped to handle and integrate
       the two treatment experiences.
      How Beneficial Are These
         Approaches? (4 of 5)
 Concurrent/Parallel Treatment,
 continued:
   As with serial treatment, this approach can
    worsen problems or create new ones:
      Confusion due to conflicting treatment
      philosophies held by different providers.
     Confusion due to conflicting treatment
      recommendations or priorities.
     Treatment gaps arising due to communication
      problems between/among providers.
     Practical considerations such as scheduling,
      transportation, etc.
      How Beneficial Are These
         Approaches? (5 of 5)
 Integrated Treatment:
   A very recent development and not standard or
    typical—yet.
   Essential for clients who are significantly impaired by
    both kinds of disorder.
   Essential for clients whose mental disorder interferes
    with treatment of their substance use disorder.
   Essential for clients whose substance use disorder
    interferes with treatment of their mental disorder.
   Beneficial for all clients with co-occurring disorders
    due to its ability to avoid problems seen with other
    models (provider conflicts, poor provider
    communication, client confusion, scheduling or
    transportation problems, etc.).
  An Important Point About Integrated
  Care: It is a Separate Specialty Area
 Integrated treatment providers should be
  knowledgeable about mental illness and skilled
  in assessing mental problems and providing
  mental health treatment.
 They should also be knowledgeable about
  addictions and skilled in assessing substance
  use problems and providing addiction treatment.
 But these separate knowledge and skill sets are
  not enough. Providers should also be
  knowledgeable about and skilled in integrated
  assessment and treatment of co-occurring
  disorders.
Common Problems that Integrated
  Care is Designed to Address
We will address this topic by using fictional case
examples that illustrate each of the following
three types of problems:
   Assessment Problems.
   Treatment Problems.
   Other Problems.
    Assessment Problems (1 of 4)
 Case Example 1: José presents with restless-
  ness, agitation, anxiety, and tremulousness.
   Mental health providers may tend to suspect an
    anxiety disorder or a manic episode.
   Substance abuse providers may tend to suspect
    amphetamine intoxication or sedative withdrawal.
   Integrated care providers suspect and investigate all
    of these possibilities and are sensitive to the
    additional issues that clients with co-occurring
    disorders may face.
    Assessment Problems (2 of 4)
 Case Example 2: Ellen presents with depressed
  mood, tearfulness, and psychomotor retardation.
   Mental health providers may tend to suspect a mood
    disorder—major depressive episode or dysthymic
    disorder.
   Substance abuse providers may tend to suspect
    amphetamine withdrawal or alcohol or sedative
    intoxication.
   Integrated care providers suspect and investigate all
    of these possibilities and are sensitive to the
    additional issues that clients with co-occurring
    disorders may face.
   Assessment Problems (3 of 4)
 Case Example 3: George presents with
 hallucinations and paranoid ideation.
   Mental health providers may tend to suspect a
    psychotic disorder—i.e., paranoid schizophrenia.
   Substance abuse providers may tend to suspect
    amphetamine psychosis or hallucinogen intoxication.
   Integrated care providers suspect and investigate all
    of these possibilities and are sensitive to the
    additional issues that clients with co-occurring
    disorders may face.
    Assessment Problems (4 of 4)
 Case Example 4: Bob presents with grandiosity,
  excess energy, and serious legal and debt
  problems.
   Mental health providers may tend to suspect bipolar
    disorder (manic phase).
   Substance abuse providers may tend to suspect
    amphetamine intoxication and dependence.
   Integrated care providers suspect and investigate all
    of these possibilities and are sensitive to the
    additional issues that clients with co-occurring
    disorders may face.
     Treatment Problems (1 of 4)
 Case Example 5: María, in treatment for
  addiction but also with unrecognized co-
  occurring major depressive disorder, is labeled
  “resistant” and “unmotivated” by staff.
 Case Example 6: Sam, in treatment for addiction
  but also with co-occurring paranoid
  schizophrenia, has difficulty tolerating group
  sessions, bonding with other members of his
  group, and fitting in at AA meetings.
     Treatment Problems (2 of 4)
 Case Example 7: Heather, in treatment for
  bulimia nervosa, is not doing well because of her
  amphetamine use which providers erroneously
  view as part of her eating disorder instead of as
  independently co-occurring amphetamine
  dependence.
 Case Example 8: Michael, in treatment for
  bipolar disorder, is unable to control his mood
  swings because of his drinking, which providers
  erroneously view as “self-medicating behavior”
  instead of as independently co-occurring alcohol
  dependence.
      Treatment Problems (3 of 4)
 Case Example 9: Mario, who has co-occurring
  bipolar disorder and alcohol dependence, is
  discouraged from taking his medications by
  addiction treatment staff, and is told by mental
  health staff that his “real” problem is his mood
  disorder, and that the drinking is secondary.
 Case Example 10: Edmund, who has co-
  occurring major depressive disorder and
  polysubstance dependence, is denied
  medication by his psychiatrist until he returns to
  the mental health clinic having been clean and
  sober for 30 days.
      Treatment Problems (4 of 4)
 Case Example 11: Susan—who is alcohol- and drug-
  dependent, has PTSD (and possibly a dissociative
  disorder) secondary to extreme child sexual abuse, and
  is HIV and HCV positive—cannot participate in PTSD
  treatment because she is rarely sober; cannot participate
  in addiction treatment because of crises precipitated by
  extremely dysphoric intrusive flashbacks that she tries to
  cope with by drinking alcohol, taking drugs, self-
  mutilating, binge-eating, and acting out sexually; does
  not keep appointments for HIV or HCV treatment; is a
  public health risk due to her high-risk behaviors of
  needle-sharing and multiple sexual partners; and is not
  quite suicidal enough or incapable enough of caring for
  herself to be involuntarily hospitalized.
           Other Problems (1 of 2)
 Case Example 11: During residential polydrug detox,
  treatment staff notice that Jim has a serious mental
  disorder. They refer him for mental health treatment, but
  the earliest he can be seen by a psychiatrist is 60 days
  away—long after he will have completed detox.
 Case Example 12: Jane is referred to addiction
  treatment by her mental health provider, but, because
  the receptionist at the addiction treatment program (who
  has not been trained in how to respond to mentally ill
  clients) reacts to her in an insensitive manner, Jane feels
  unwelcome and leaves without making an appointment.
         Other Problems (2 of 2)
 Case Example 13: Mike is referred to addiction
  treatment by mental health providers, but he is
  homeless and without transportation, so he
  never makes it to his appointment.
 Case Example 14: Dan’s mental health provider,
  Ellen, has a strong countertransference reaction
  to Dan because Dan resembles Ellen’s alcoholic
  father.
 What is Integrated Care? (1 of 3)
 The client participates in one program that
  provides treatment for both disorders.
 The client’s mental and substance use disorders
  are treated by the same clinicians.
 The clinicians are trained in psychopathology,
  assessment, and treatment strategies for both
  mental and substance use disorders.
 The clinicians offer substance abuse treatments
  tailored for clients who have severe mental
  disorders.
 What is Integrated Care? (2 of 3)
 The focus is on preventing anxiety rather
  than breaking through denial.
 Emphasis is placed on trust,
  understanding, and learning.
 Treatment is characterized by a slow pace
  and a long-term perspective.
 Providers offer stagewise and motivational
  counseling.
 What is Integrated Care? (3 of 3)
 Supportive clinicians are readily available.
 Twelve-Step groups are available to those
  who choose to participate and can benefit
  from participation.
 Neuroleptics and other pharmacotherapies
  are indicated according to clients’
  psychiatric and other medical needs.
                 (TIP 42, p. 45)
  Categories of COD Programs
 Dual Diagnosis Capable (DDC-CD or DDC-MH).
   DDC-CD Welcomes individuals with chemical dependency (CD)
    whose conditions are stable; makes provision for comorbidity in
    program mission, screening, assessment, treatment planning,
    staff training, etc.
   DDC-MH is similar to the above in a mental health (MH)
    treatment setting.
 DDE=Dual Diagnosis Enhanced (DDE-CD or DDE-MH).
   DDE-CD is a CD program that is enhanced to accommodate
    individuals with subacute symptomatology or moderate disability;
    enhanced MH staffing and programming, etc.
   DDE-MH is similar to the above in a MH setting.
      COD Program Models
 Continuous Integrated Case Management.
 Continuous Recovery Support.
 Emergency Triage/Crisis Intervention.
 Crisis Stabilization Beds.
 Psychiatric Inpatient Unit or Partial Hospital.
 Detoxification Programs.
 Psychiatric Day Treatment.
 Addiction Intensive Outpatient (IOP), Partial,
  Residential.
 Psychiatric Housing Programs:
    Abstinence-expected (dry).
    Abstinence-encouraged (damp).
    Consumer-choice (wet).
     Principles and Standards
 Next, we will cover aspects of the Minkoff
 Model for assessment and treatment of
 co-occurring disorders:
   The Nine Principles, and
   The Eight Practice Standards
      The Nine Principles (1 of 4)
1. Dual diagnosis is an expectation, not an
  exception.
2. The population of individuals with co-occurring
  disorders can be organized into four subgroups
  based on high and low severity of each type of
  disorder (see next slide).
3. Treatment success involves formation of
  empathic, hopeful, integrated treatment
  relationships.
    The Nine Principles (2 of 4)
         The Four Quadrants

    Quadrant I               Quadrant II
  Low Severity MI       High Severity MI, Low
 Low Severity SUD            Severity SUD

    Quadrant III            Quadrant IV
Low Severity MI, High   High Severity MI, High
    Severity SUD             Severity SUD
       The Nine Principles (3 of 4)
4. Treatment success is enhanced by maintaining
   integrated treatment relationships providing disease
   management interventions for both disorders
   continuously across multiple treatment episodes,
   balancing case management support with detachment
   and expectation at each point in time.
5. Integrated dual primary diagnosis-specific treatment
   interventions are recommended.
6. Interventions need to be matched not only to diagnosis,
   but also to phase of recovery, stage of treatment, and
   stage of change.
         The Nine Principles (4 of 4)
7. Interventions need to be matched according to level of care and/or
    service intensity requirements, utilizing well-established level of care
    assessment methodologies.
8. There is no single correct dual diagnosis intervention, nor single
    correct program. For each individual, at any point in time, the correct
    intervention must be individualized, according to subgroup,
    diagnosis, stage of treatment or stage of change, phase of recovery,
    need for continuity, extent of disability, availability of external
    contingencies, and level of care assessment.
9. Outcomes of treatment interventions are similarly individualized,
    based upon the above variables and the nature and purpose of the
    intervention. Outcome variables include not only abstinence, but
    also amount and frequency of use, reduction in psychiatric
    symptoms, stage of change, level of functioning, utilization of acute
    care services, and reduction of harm.
 The Eight Practice Standards                                (1 of 3)

1. Welcoming Expectation.
    Expect comorbidity and engage clients in an empathic, hopeful,
     welcoming manner.
2. Access to Assessment.
    Access to services should not require clients to self-define as
     MH or SUD before arrival; eliminate barriers; deny no client
     treatment based on disorders.
3. Access to Continuing Relationships.
    Initiate and maintain empathic, hopeful, continuous treatment
     relationships—even if treatment recommendations are not
     followed.
4. Balance Case Management and Care with Expectation,
   Empowerment, and Empathic Confrontation.
The Eight Practice Standards                      (2 of 3)

5. Integrated Dual Primary Treatment.
   Each disorder receives appropriate diagnosis-specific
    and stage-specific treatment, regardless of the status
    of the comorbid condition.
6. Stage-Wise Treatment:
     Acute Stabilization.
     Motivational Enhancement.
     Active Treatment.
     Relapse Prevention.
     Rehabilitation and Recovery.
 The Eight Practice Standards                       (3 of 3)

7. Early Access to Rehabilitation.
   Clients who request assistance with housing, jobs,
    socialization, and meaningful activity are provided
    access even if they are not initially adherent to MH or
    SUD treatment recommendations.
8. Coordination and Collaboration.
   Consistent collaboration between all treaters, family
    caregivers, and external systems is required.
   Collaboration with families should be considered an
    expectation for all individuals at all stages of change.
Medication Guidelines for CODs
           from Minkoff, et al (1998)


“Psychopharmacology for people with co-
occurring disorders is best performed in
the context of an ongoing, empathic,
clinical relationship that emphasizes
continuous reevaluation of both diagnosis
and medication, and artful utilization of
medication strategies to promote better
outcome of both disorders.”
    Medication Guidelines (2 of 3)
Maximize outcome of two primary disorders:
   For diagnosed psychiatric illness, the most clinically
    effective psychopharmacologic strategy available,
    regardless of the status of the comorbid substance
    disorder.
   For diagnosed substance disorder, appropriate
    psychopharmacologic strategies may be used as
    ancillary treatments to support a comprehensive
    program of recovery, regardless of the presence of a
    comorbid psychiatric disorder (although taking into
    account the individual’s cognitive capacity and
    disability).
    Medication Guidelines (3 of 3)
Priorities:
  1. Establish medical and psychiatric safety in
     acute situations.
  2. Maintain stabilization of severe and/or
     established psychiatric illness.
  3. Use medication strategies to promote or
     establish sobriety.
  4. Diagnose and treat less serious psychiatric
     disorders that may emerge once sobriety is
     established.
          Diagnosis-Specific
         Recommendations (1 of 2)
 Schizophrenic Disorders:
   Atypical neuroleptics; clozapine may reduce
    substance abuse.
 Bipolar Disorders:
   Second and third generation mood stabilizers
    (valproate, lamotrigine).
   Gabapentin and topiramate may also be useful.
   A significant population will still respond to lithium.
 Depressive Disorders:
   No particular category of antidepressant is specifically
    recommended or contraindicated.
          Diagnosis-Specific
         Recommendations (2 of 2)
 Anxiety Disorders:
   Benzodiazepines for acute situations and detox only.
   For anxiety: clonidine, venlafaxine, SSRIs,
    gabapentin, valproate, topiramate, atypical
    neuroleptics, buspirone.
 Attentional Disorders:
   Bupriprion, SSRIs, Strattera (atomoxatine).
 Addictive Disorders:
   Disulfiram, naltrexone, acamprosate, methadone,
    LAAM, buprenorphine.
    Some Evidence-Based Practices
 Stages of Change/Motivational Interviewing.
 Harm Reduction.
 Mutual Self-Help Programs.
 Consumer-Delivered Services.
 Specialty Courts (Drug Court, Mental Health
  Court, Co-occurring Disorders Court).
 Specialized Services for Homeless Populations.
 Group Treatment.
 Family Treatment.
      Psychological Trauma and
       Co-occurring Disorders
 Many studies link childhood trauma to both
  mental illness and addiction.
 One particularly striking study is called the ACE
  Study (http://www.acestudy.org), in which
  17,000 patients of Kaiser-Permanente were
  assessed for number of different types of
  Adverse Childhood Experiences and
  subsequent medical, mental health, and
  addiction problems.
 Some results of this study appear on the next
  slides.
  Definition of Adverse Childhood
            Experiences
Growing up (prior to age 18) in a household
 with:
      (score 1 point for 1 or more incidents in each category)
   Recurrent physical abuse.
   Recurrent emotional abuse.
   Sexual abuse.
   An alcohol or drug abuser.
   An incarcerated household member.
   Someone who is chronically depressed, suicidal,
    institutionalized or mentally ill.
   Mother being treated violently.
   One or no parents.
   Emotional or physical neglect.
Adverse Childhood Experiences
   and Smoking (Tobacco)
Adverse Childhood Experiences
         and COPD
Adverse Childhood Experiences
        and Addiction
Adverse Childhood Experiences
    and Attempted Suicide
                    Your Needs
 Times are changing, and we can no longer act as if co-
  occurring disorders were rare or insignificant.
 You are going to be in the vanguard of a movement to
  overhaul service delivery in this county.
 You are facing a large task, and you will need to be
  equipped to accomplish it.
 What will your needs be?
     Professional     Educational       Personal
 We will be considering this question in the Needs
  Assessment portion of this program.
Questions/Answers/Comments
 Thank-you for your attention.
 Now, please let me know your thoughts,
 observations, questions, dilemmas, fears,
 suspicions, hopes, etc.

				
DOCUMENT INFO