Co occurring Disorders The axis Complexities of Co Occurring

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					          Co-occurring Disorders:
               The “Z-axis”

Complexities of Co-Occurring Conditions Conference
                    June 2004
                  Washington, DC
            Richard Saitz MD, MPH, FACP, FASAM
         Clinical Addiction Research and Education Unit
               Section of General Internal Medicine
    Center to Prevent Alcohol Problems Among Young People
          Boston University and Boston Medical Center
                    Outline
• What we mean by comorbidity
• Conceptual framework
• Risk for co-occurring disorders
• Services not currently coordinated
• MH/SA impact care for chronic medical
  conditions
• Models of care for patients with co-occurring
  disorders
• Research directions
Comorbidity
                     Case #1
• A 40 year old man is transferred from a group
  home to the general medical hospital with diabetic
  ketoacidosis; he stopped taking his antipsychotic.
  He refuses insulin because he believes it will harm
  him. After initial treatment he stabilizes but cannot
  return to his home because he won’t take insulin.
  He is too medically complex for the psychiatric
  hospital and is declined by addictions treatment
  programs. He remains in the medical hospital
  where consultation for MH conditions is available.
                 Case #2
• A 54 year old man with Type 2 diabetes has
  alcohol dependence. He has poor glycemic
  control and severe hypertriglyceridemia.
  His alcohol use limits medication choices;
  he is on maximal doses of oral agents. He
  takes his lipid lowering medication once
  instead of twice a day to avoid drinking and
  taking medication. He declines alcoholism
  treatment.
                    Outline
• What we mean by comorbidity
• Conceptual framework
• Risk for co-occurring disorders
• Services not currently coordinated
• MH/SA impact care for chronic medical
  conditions
• Models of care for patients with co-occurring
  disorders
• Research directions
                                              Service Coordination by Severity
     Alcohol, Tobacco & Other Drug Severity

                                                                                       Integration


                                              Addiction Specialty         Hospital, Prison, ED


                                                                 Collaboration



                                              Primary Health                     Mental Health
                                                                                     Specialty
                                              Consultation

                                                             Mental Illness Severity
Adapted from SAMHSA 2002 Report to Congress on the Prevention and
Treatment of Co-occurring Substance Abuse and Mental Disorders
      Service Coordination by Severity



             Alcohol, Tobacco

              Drug Severity
                                Addiction               Integration




                 & Other
                                Specialty             Hospital, ED




                                Collaboration

                                                  Mental Health
              Primary Health                          Specialty
                  Consultation
                                                Mental Illness Severity
The
“Z-axis”

           Medical Specialty
                    Outline
• What we mean by comorbidity
• Conceptual framework
• Risk for co-occurring disorders
• Services not currently coordinated
• MH/SA impact care for chronic medical
  conditions
• Models of care for patients with co-occurring
  disorders
• Research directions
      Alcohol-related Emergency and
         Hospital Utilization, US
     • Emergency
        – 29 visits/1000 persons each year
        – 8% of all ED visits
     • Hospital
        – 7.4% of acute admissions to short-stay, non-
          Federal general hospitals
        – 1.8 million hospitalizations per year

McDonald AJ et al. Arch Intern Med 2004; 164: 531 - 537.
Smothers BA et al. Arch Intern Med 2003; 163: 713 - 719.
       Alcohol-related Diagnoses,
                AAFs<1
Pulmonary and other respiratory tuberculosis           0.25
Malignant neoplasm of lip, oral cavity, and pharynx    0.50
Malignant neoplasm of esophagus                        0.75
Malignant neoplasm of stomach                          0.20
Malignant neoplasm of liver and intrahepatic bile ducts0.15
Malignant neoplasm of larynx                           0.50
Diabetes mellitus                                      0.05
Essential hypertension                                 0.076
Cerebrovascular disease                                0.065
Pneumonia and influenza                                0.05
Diseases of esophagus, stomach, and duodenum           0.10
Cirrhosis of liver without mention of alcohol          0.50
Biliary cirrhosis                                      0.50
Acute pancreatitis                                     0.42
Chronic pancreatitis                                   0.60
        Medical Disorders More Common in
        Patients with Substance Use Disorder,
            Psychotic Disorder, and Both
    •   Diabetes
    •   Hypertension
    •   Heart Disease*
    •   Asthma*
    •   Gastrointestinal Disorders*
    •   Skin Infections*
    •   Malignant Neoplasms
    •   Acute Respiratory Disorders*
*highest risk in those with both
Dickey B et al. Psych Services 2002;53(7):861-7.
       Comorbidity in a Detoxification
                  Sample
     • 470 adults with no primary medical care in
       a short-term residential detoxification unit,
       mean age 36
          – 47% had chronic medical illness
          – 90% had CES-D score >16
          – 70% reported moderate to severe pain at least
            intermittently during 2 years of follow-up
               • Intermittent pain associated with relapse (OR 2.0)
               • Persistent pain associated with relapse (OR 5.2)
DeAlba I et al. Am J Addictions 2004;13:33-45.
Larson MJ et al. CPDD Abstract 2004.
Saitz R et al. HSR 2004;39(3):587-606.
      Med/Psych DX               % of AOD Pts               % of Controls
      Acid-related                      5.5                      2.1
      Arthritis                         3.9                      1.3
      Asthma                            6.8                      2.6
      COPD                              0.7                      0.1
      Headache                          9.2                      3.8
      Hypertension                      7.2                      3.4
      Low back pain                    11.2                      5.8
      Injury/OD                        25.6                     12.1
      Depression                       28.5                      2.7
      Anxiety disorder                 16.9                      2.2
      Major psychosis                   6.6                      0.4
      Liver cirrhosis                   0.7                      0.1
      Hepatitis C                       0.7                      0.2
Mertens JR et al. Arch Intern Med 2003; 163: 2511 - 2517.
                    Outline
• What we mean by comorbidity
• Conceptual framework
• Risk for co-occurring disorders
• Services not currently coordinated
• MH/SA impact care for chronic medical
  conditions
• Models of care for patients with co-occurring
  disorders
• Research directions
    Patients in Addiction Treatment not
    Receiving Medical Care, and Vice Versa

    • Of 5,824 adults entering addiction treatment
      in Massachusetts, 41% had no physician
        – Prior substance abuse treatment or mental
          health treatment were not associated with
          having a physician
    • Of those with a primary care physician,
      45% reported the physician unaware of their
      addiction
Saitz R et al. Substance Abuse 1997;18:187-195.
Saitz R et al. Am J Drug Alcohol Abuse 1997;23:343-354.
    Patients with Severe Mental Illness
      Where are they? Medical Care
                                    Median Outpatient Visits
                                    Psychiatric   Medical
              AUD                       5           10
              No AUD                    9           15
              IDU                       9           18
              No IDU                    7           13
              Cocaine                   6           12
              No cocaine                8           14

Bosworth HB et al. Psych Services 2004 June;55:708-10.
                    Outline
• What we mean by comorbidity
• Conceptual framework
• Risk for co-occurring disorders
• Services not currently coordinated
• MH/SA impact care for chronic medical
  conditions
• Models of care for patients with co-occurring
  disorders
• Research directions
               Quality of Diabetes Care
                                                  % with retina exam

     No mental disorder                                  71

     Psychiatric disorder                                71

     Substance disorder                                  64

     “Dual diagnosis”                                    68

Desai MM et al. Am J Psychiatry 2002;159(9): 1584-90.
               Alcohol Use and Incident
                Diabetic Retinopathy
                   2 Studies                   RR (95% CI)
                   +0.5 drinks/day
                    Younger onset 2.09 (0.04-4.07)
                    Older onset    0.75 (0.40-1.42)

                   >1.9 drinks/day           2.25 (1.15-4.42)




Howard AA et al. Ann Intern Med. 2004;140(3):211–219.
               Catheterization and
              Revascularization after
              Myocardial Infarction
                             CATH        PTCA        CABG
                                 Adjusted Relative Risk
 Mental disorder              0.72         0.75        0.68
   Schizophrenia               0.41         0.55        0.27
  Affective                    0.65         0.51        0.63
   Substance Use               0.78         0.58        0.80
 No mental disorder             1            1           1


Druss BG et al. JAMA 2000; 283: 506 - 511.
      Influence of Mental Health and
     Addictions on Hepatitis C Therapy
      • 154 patients with HIV, alcohol abuse, hepatitis C
      • 81 (53%) had contraindications to interferon
          –   52 heavy drinking
          –   15 had CD4<100
          –   14 IDU with needle sharing
          –   14 decompensated liver disease
          –   13 recent suicidal ideation
      • 54 (35%) had lesser contraindications to interferon
          –   47 had significant depressive symptoms
          –   8 Had CD4 100-200
          –   7 were drinking alcohol (“moderate amounts”)
          –   7 IDU
Nunes et al. Abstract at CPDD 2004
 Substance use, Depressive symptoms,
         and HIV Outcomes
      • Prospective cohort study of 350 adults with HIV
        and alcohol problems
      • Depressive symptoms and substance use were
        associated with worse adherence
      • Substance use was associated with less HIV viral
        load suppression
      • Substance abuse treatment
           – reduced the odds of ED utilization (AOR 0.5)
           – increased the odds of HAART for HIV (AOR 1.70)
           – not associated with 30-day HAART adherence or HIV
             viral load suppression

Palepu A et al. J Subst Abuse Treat 2003;25:37-42 and Palepu et al. Addiction 2004;99:361-8
           Major Depression in Patients
           with Myocardial Infarction
                                               Six-month Mortality
                                              Adjusted Hazard Ratio
                                                    (95% CI)

      Depression                                     4.29 (3.14-5.44)




Frasure-Smith N et al. JAMA 1993;270(15):1819-1825
   Treating Major Depression in
     Patients with Myocardial
             Infarction
• Randomized, clinical trial
• 2,481 men and women hospitalized with MI and
  depression (75%) or lower perceived social
  support (25%)
• CBT and group therapy for 6 months
• Results:
  – Improvements in depressive symptoms and perceived
    social support
  – No difference in 24% death or recurrent MI
                   Outline
• What we mean by comorbidity
• Conceptual framework
• Risk for co-occurring disorders
• Services not currently coordinated
• MH/SA impact care for chronic medical
  conditions
• Models of care for patients with co-occurring
  disorders
• Research directions
                The “teachable moment”
      • Definition: naturally occurring health events
        thought to motivate individuals to
        spontaneously adopt risk-reducing health
        behaviors
      • Smoking cessation
          – Pregnancy, hospitalization and disease
            diagnosis, high (10-78%)
          – Clinic visits (2-10%) consistently lower

McBride CM et al. Health Educ Res 2003;18(2):156-70
             Integrated Primary Care and
                 Addiction Treatment
      • Overall sample: trend towards higher costs
        and no difference in abstinence
      • Subgroup with substance abuse-related
        medical or psychiatric conditions
           --More likely to be abstinent in integrated care
             group (69% vs. 55%, p=0.006)



Weisner C et al. JAMA 2001;286:1715-23.
               Integrated Medical and
                  Alcoholism Care
    • Randomized trial of a thorough multidisciplinary
      evaluation, and care plan (N=101)
    • Monthly primary care visits to review drinking
      and medical problems
    • Mental health, social services and more intensive
      alcohol treatment on site
    • 2-year results:
        – 30-day abstinence increased from 47% to 74%
        – Mortality decreased from 30% to 19%


Willenbring ML & Olson DH. Arch Intern Med 1999;159:1946-52
Willenbring ML et al. J Stud Alcohol. 1995;56:337-343
                 Potential Impact of
             Buprenorphine Treatment in
                   Primary Care
       • Initial experience with 37 patients (30 max.
         at any one time). Median age 31.
           – 68% had no previous primary medical care
           – 59% had medical comorbidity
           – 43% had Hepatitis C (a quarter of these
             diagnosed at entry)
           – 54% had psychiatric comorbidity (80% with no
             psychiatric care)
           – 86% retained in care 4 months
Alford DP et al. SGIM Abstract 2004.
                 What is Primary Care?
• Integrated and accessible health services provided
  by primary care clinicians (generally MD, NP, PA)
• Addresses the majority of health care needs
• Sustained personal relationship between patient and
  clinician
• Does not consider mental health separately from
  physical health
• Intrinsic to PC are opportunities to promote health
  and prevent disease
 Institute of Medicine. Primary Care: America’s Health in a New Era. National Academy Press,
 Washington, DC. 1996.
        Receipt of Primary Care Improves
               Addiction Severity
                                    *            **
  # Visits/6 m.           ASI Alcohol   ASI Drug
                           (P=0.04)     (P=0.008)
  0                           0.34        0.16

  1                          0.26         0.15

  >2                         0.30         0.13


Saitz et al. Submitted.
     Care for People with Drug Abuse
              or Dependence
                                           Hospitalization
                                           (AOR, 95% CI)
     HIV
      Regular drug care                   0.85 (0.76-0.96)
      Regular med care                    0.82 (0.74-0.91)
      Both                                0.76 (0.67-0.85)
     Non-HIV
      Regular drug care                   0.71 (0.66-0.76)
      Regular med care                    0.91 (0.86-0.95)
      Both                                0.73 (0.68-0.79)
Laine C et al. JAMA, May 2001; 285: 2355 - 2362.
         Chronic Disease Management
     • 1,801 older adults with depression or dysthymia in
       18 primary care clinics
         – Mean 3 chronic conditions
     • 20 minute educational video, booklet, visit with
       nurse or psychologist case manager in primary
       care, with medical and psychiatric consultation as
       needed
     • Results: Significant reduction in depressive
       symptoms, functional impairment, and arthritis
       pain and functional outcomes (for the 1001 with
       arthritis)
Lin EHB et al. JAMA 2003; 290: 2428 - 2429
Unützer J et al. JAMA 2002; 288: 2836 - 2845
                    Outline
• What we mean by comorbidity
• Conceptual framework
• Risk for co-occurring disorders
• Services not currently coordinated
• MH/SA impact care for chronic medical
  conditions
• Models of care for patients with co-occurring
  disorders
• Research directions
              Research Agenda
• Prevalence of co-occurring MH/SA disorders and
  medical disorders
• Impact of one medical/MH/SA disorder on the
  incidence, severity, quality of care and health
  outcomes of others
• Development and testing of new models of care
  that
   – bring needed care to the patient with “triple diagnosis”
   – can address comorbidity in the face of varied levels of
     severity of comorbidities
• Identify and overcome barriers to implementation
Thank You for Your Attention
Extra Slides
      Alcohol-related diagnoses
              AAFs=1
Alcoholic psychoses
Alcohol dependence syndrome
Nondependent abuse of alcohol
Alcoholic polyneuropathy
Alcoholic cardiomyopathy
Alcoholic gastritis
Alcoholic fatty liver
Acute alcoholic hepatitis
Alcoholic cirrhosis of liver
Alcoholic liver damage, unspecified
Excessive blood level of alcohol
Accidental poisoning by ethyl alcohol, not elsewhere
specified
         Cardiac Catheterization after
            Myocardial Infarction
                               Unadjusted       Adjusted
                             Proportion (%)   Relative Risk

   Mental disorder                  32           0.72
     Schizophrenia                   22           0.41
    Affective                        33           0.65
     Substance Use                   41           0.78
   No mental disorder               44         Reference


Druss BG et al. JAMA 2000; 283: 506 - 511.
          Revascularization after
          Myocardial Infarction
                         PTCA                CABG
                     Unadj. Adj. RR Unadj.    Adj. RR
                      %              %

Mental disorder       12     0.75      8        0.68
  Schizophrenia         9     0.55      4        0.27
 Affective              9     0.51      8        0.63
  Substance Use        12     0.58      11       0.80
No mental disorder    17     Ref      13        Ref
     Preventive Care: Mammography
    • Older women with schizophrenia
        – 62% in past 2 years
    • Age-matched controls
        – 86% in past 2 years




Dickerson FB et al. Psych Services 2002;53:882-4.
              Alcohol Use and Diabetes
      • Incident diabetes
          – 18 prospective cohort studies: U-shaped relationship
      • Glycemic control
          – 6 experimental studies of up to 6 drinks given to 5-20
            subjects with diabetes
               • 3 found decreases in serum glucose
               • 3 found no difference each
      • Diabetes medications
          – In 2 studies, immediate glycemic response to 3-drink
            challenge did not differ
               • 23 subjects taking troglitazone or placebo
               • 50 subjects before and after sulfonylurea

Howard AA et al. Ann Intern Med. 2004;140(3):211–219.