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Co-occurring Addiction and Less Severe Mental Disorders

Co-occurring Addiction and Less Severe Mental Disorders. Richard Ries MD rries@u.washington.edu Harborview Medical Center University of Washington Seattle, Wa. DUAL DIAGNOSIS IS:. TWO DIAGNOSES/ DISORDERS TWO SYSTEMS DOUBLE TROUBLE IN THE EYE OF THE BEHOLDER. MENTAL DISORDERS

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Co-occurring Addiction and Less Severe Mental Disorders

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  1. Co-occurring Addiction and Less Severe Mental Disorders Richard Ries MD rries@u.washington.edu Harborview Medical Center University of Washington Seattle, Wa

  2. DUAL DIAGNOSIS IS: • TWO DIAGNOSES/ DISORDERS • TWO SYSTEMS • DOUBLE TROUBLE • IN THE EYE OF THE BEHOLDER

  3. MENTAL DISORDERS Schizophrenia Bi-polar Schizoaffective Major Depression Borderline Personality Post Traumatic Stress Social Phobia others ADDICTION DISORDERS Alcohol Abuse/Depen. Cocaine/ Amphet Opiates Marijuana Polysubstance combinations Prescription drugs Examples of Dual Disorders:

  4. Dual Disorders for Everyone? • If applied to all cases, Term has no meaning • (eg Spider phobia and “Running Addiction”) • Both Mental and Addiction Disorders need to be over threshold • Personality Disorders, other than Borderline not usually counted • Substance Induced Disorders cause diagnostic confusion

  5. CHARACTERISTICS OF THE DUAL DIAGNOSIS CLIENT IN KING COUNTY… Ries ‘89 Severity of Chemical Dependency High LH HH 2 1 4 Severity of Psychiatric Low Condition 3 High HL LL Low

  6. Systems Problems • Different Laws…commitment/confid. • Different funding..audits etc • Different personnel • Different training • Different certification • Different sites • Different Norms

  7. The Four Quadrant Framework for Co-Occurring Disorders High severity A four-quadrant conceptual framework to guide systems integration and resource allocation in treating individuals with co-occurring disorders (NASMHPD,NASADAD, 1998; NY State; Ries, 1993; SAMHSA Report to Congress, 2002) Not intended to be used to classify individuals (SAMHSA, 2002), but  . . .  Less severemental disorder/more severe substanceabuse disorder More severemental disorder/more severe substanceabuse disorder Less severemental disorder/less severe substanceabuse disorder More severemental disorder/less severe substanceabuse disorder Lowseverity High severity

  8. DOUBLE TROUBLE

  9. But what about NON- severely mentally ill co-occurring pts? • Like in Addiction Treatment settings • Like in Criminal Justice settings • Like in Primary Care Settings • Like in ER’s, especially with suicidal pts • The new TIP will bring more focus on these populations

  10. Risk Factor Cocaine use Major Depression Alcohol use Separation or Divorce NIMH/NIDA Increased Odds Of Attempting Suicide 62 times more likely 41 times more likely 8 times more likely 11 times more likely ECA EVALUATION Likelihood of a Suicide Attempt

  11. Double Trouble:RELATIONSHIP OF ALCOHOL & DRUG PROBLEMSTO SEVERE SUICIDALITY (n=12,196) Percent With Severe Suicide Rating ALCOHOL OR DRUG PROBLEMS ODDS adjusted for age & gender Walds = 235.41 p < .001 Ries & Russo unpub , 2003

  12. Drug States Withdrawal Acute Protracted Intoxication Chronic Use Symptom Groups Depression Anxiety Psychosis Mania Rounsaville ‘90 Drug Induced Psychopathology

  13. Twelve-Month Prevalence of DSM-IV Independent Mood and Anxiety Disorders Among Respondents with DSM-IV Substance Use Disorders Who Sought Treatment in the Past 12 Months Grant B, JAMA 2004

  14. Twelve-Month Prevalence of DSM-IV Independent Mood and Anxiety Disorders Among Respondents with DSM-IV Substance Use Disorders Who Sought Treatment in the Past 12 Months Grant B, JAMA 2004

  15. Comorbidity of Depression and Anxiety Disorders 50% to 65% of panic disorder patients have depression† Panic Disorder 70% of social anxiety disorder patients have depression 49% of social anxiety disorder patients have panic disorder** HIGHLY COMMON… HIGHLY COMORBID Social Anxiety Disorder Depression 67% of OCD patients have depression* 11% of social anxiety disorder patients have OCD** OCD

  16. Diagnostic Criteria for Panic Attack A discreet period of intense fear or discomfort in which 4 or more of the following symptoms developed abruptly and reached a peak within 10 minutes: • Palpitations, pounding heart • Sweating • Trembling or shaking Adapted with permission from American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. 1994.

  17. Dizziness Chills or hot flushes Feelings of unreality Fear of losing control or going crazy Fear of dying Paresthesias Choking feeling Smothering or shortness of breath Chest pain or discomfort Abdominal distress Diagnostic Criteria for Panic Attack Continued

  18. Somatic Symptoms In Panic Disorder Gastro-intestinal Symptoms Chest Pain SOMATIC SYMPTOMS Headache Dizziness Fatigue

  19. Quality of Life in Panic Disorder % Marital Discord (past 2 weeks) Use Of ER (past year) Financial Dependence (welfare or disability) Markowitz et al. Arch Gen Psychiatry. 1989;46:984.

  20. DSM-IV Diagnostic Criteria for PTSD • Exposure to a traumatic event in which the person: • experienced, witnessed, or was confronted by death or serious injury to self or others AND • responded with intense fear, helplessness, or horror American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. 1994.

  21. DSM-IV Diagnostic Criteria for PTSD Continued • Symptoms • appear in 3 symptom clusters: re-experiencing, avoidance/numbing, hyperarousal • last for > 1 month • cause clinically significant distress or impairment in functioning

  22. DSM-IV Diagnostic Criteria for PTSD Re-experiencing • Persistent re-experiencing of  1 of the following: • recurrent distressing recollections of event • recurrent distressing dreams of event • acting or feeling event was recurring • psychological distress at cues resembling event • physiological reactivity to cues resembling event

  23. DSM-IV Diagnostic Criteria for PTSD Avoidance/Numbing • Avoidance of stimuli and numbing of general responsiveness indicated by  3 of the following: • avoid thoughts, feelings, or conversations* • avoid activities, places, or people* • inability to recall part of trauma •  interest in activities • estrangement from others • restricted range of affect • sense of foreshortened future

  24. DSM-IV Diagnostic Criteria for PTSD Hyperarousal • Persistent symptoms of increased arousal  2: • difficulty sleeping • irritability or outbursts of anger • difficulty concentrating • hypervigilance • exaggerated startle response American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. 1994.

  25. Prevalence of Trauma and Probability of PTSD 1 Threat w/ Weapon Physical Attack Molestation Witness Accident Combat Rape 2 1 2

  26. Impaired Quality of Life with PTSD SF-36 Score SF-36 = 36 item short form health survey Lower score = more impairment Malik M et al. J Trauma Stress. 1999;12:387-393.

  27. Common Somatic Complaints Of Social Anxiety Disorder Stuttering Blushing Palpitations Sweating Trembling And Shaking “Butterflies” Beidel. J Clin Psychiatry. 1998;59(suppl 17):27.

  28. Social Anxiety DisorderSPIN Screener • Is being embarrassed or looking stupid among your worst fears? • Does fear of embarrassment cause you to avoid doing things or speaking to others? • Do you avoid activities in which you are the center of attention? Katzelnick et al. Presented at 37th Annual Meeting of the American College of Neuropsychopharmacology; December 14-18, 1998; Los Croabas, Puerto Rico.

  29. Social Anxiety Disorder: Educational and Occupational Impairment 0.0 -5.0 Impairment**(%) -10.0  Wages  CollegeGraduation -15.0  ProfessionalOr Management Positions -20.0 * LSAS score in controls = 25; ** Impairment (%) refers to percentage change in wages and percentage point changes in probabilities of college graduation and having a technical, professional, or managerial job. Katzelnick et al. Presented at 37th Annual Meeting of the American College of Neuropsychopharmacology; December 14-18, 1998; Los Croabas, Puerto Rico.

  30. Psych Bio Labs Meds (anti-depressants, etc.) Psych psychotherapy education groups process groups Social Couples conf. D/C planning housing, etc. CD Labs Meds (withdrawal, craving, etc.) Step work Groups AA Meetings Intervention Sober housing Therapy Plan

  31. Treatment of depression in patients with alcohol or other drug dependence: a meta-analysis.Nunes EV, Levin FR. DATA SYNTHESIS: For the HDS score, the pooled effect size from the random-effects model was 0.38 (95% confidence interval, 0.18-0.58). Heterogeneity of effect on HDS across studies was significant (P <.02), and studies with low placebo response showed larger effects. Moderator analysis suggested that diagnostic methods and concurrent psychosocial interventions influenced outcome. Studies with larger depression effect sizes (>0.5) demonstrated favorable effects of medication on measures of quantity of substance use, but rates of sustained abstinence were low. CONCLUSIONS: Antidepressant medication exerts a modest beneficial effect for patients with combined depressive- and substance-use disorders. It is not a stand-alone treatment, and concurrent therapy directly targeting the addiction is also indicated. More research is needed to understand variations in the strength of the effect, but the data suggest that care be exercised in the diagnosis of depression-either by observing depression to persist during at least a brief period of abstinence or through efforts by clinical history to screen out substance-related depressive symptoms.

  32. Fluoxetine versus placebo in depressed alcoholic cocaine abusers.Cornelius JR, Salloum IM, Thase ME, Haskett RF, Daley DC, Jones-Barlock A, Upsher C, Perel JM. All 51 patients participated in a double-blind, parallel group study of fluoxetine versus placebo in depressed alcoholics. The principal focus of this article is the one-third of the depressed alcoholics who also abused cocaine and how the treatment response of those 17 patients compared with that of the 34 depressed alcoholics who did not abuse cocaine. During the study, no significant difference in treatment outcome was noted between the fluoxetine group (N = 8) and the placebo group (N = 9) for cocaine use, alcohol use, or depressive symptoms. In addition, no significant within-group improvement was noted for any of these outcome variables in either of the two treatment groups. Indeed, across the combined sample of 17 depressed alcoholic cocaine abusers, the mean Beck Depression Inventory (BDI) score worsened slightly from 19 to 21 during the course of the study, and 71 percent of the patients continued to complain of suicidal ideations at the end of the study. The 17 cocaine-abusing depressed alcoholics showed a significantly worse outcome than the 34 non-cocaine abusing depressed alcoholics on the 24-item Hamilton Rating Scale for Depression (HAM-D) and BDI depression scales and on multiple measures of alcohol consumption. These findings suggest that comorbid cocaine abuse acts as a robust predictor of poor outcome for the drinking and the depressive symptoms of depressed alcoholics.

  33. Paroxetine for social anxiety and alcohol use in dual-diagnosed patients.Randall CL, Johnson MR, Thevos AK, Sonne SC, Thomas SE, Willard SL, Brady KT, Davidson JR.Fifteen individuals meeting DSM-IV criteria for both social anxiety disorder and alcohol use disorder were randomized to treatment. Paroxetine (n = 6) or placebo (n = 9) was given in a double-blind format for 8 weeks using a flexible dosing schedule. Dosing began at 20 mg/d and increased to a target dose of 60 mg/d. • There was a significant effect of treatment group on social anxiety symptoms, where patients treated with paroxetine improved more than those treated with placebo on both the Clinical Global Index (CGI) and the Liebowitz Social Anxiety Scale (Ps < or = 0.05). • On alcohol use, there was not a significant effect of treatment on quantity/frequency measures of drinking, but there was for the CGI ratings (50% paroxetine patients versus 11% placebo patients were improvers on drinking, P < or = 0.05). • This pilot study suggests that paroxetine is an effective treatment for social anxiety disorder in individuals with comorbid alcohol problems, and positive treatment effects can be seen in as little as 8 weeks. Further study is warranted to investigate its utility in helping affected individuals reduce alcohol use. Copyright 2001 Wiley-Liss, Inc.

  34. Why aren’t Antidepressants more effective in addictions patients? • Psychiatric outcomes: • Antidepressants only beat placebo by 20% anyway in NON addicts • Study patients also get “addiction rx” • Maybe addiction rx is more anti-dep, anti anx than we think…viz Schuckit 80% -> 20% • This is poorly studied…maybe better with 12 step • Sub Induced criteria are wrong • Addictions outcomes • Meds take focus off sobriety • Meds reinforce sobriety • Just don’t work for this

  35. Concurrent alcoholism and social anxiety disorder: a first step toward developing effective treatments.Randall CL, Thomas S, Thevos AK.The present study investigated whether simultaneous treatment of social phobia and alcoholism, compared with treatment of alcoholism alone, improved alcohol use and social anxiety for clients with dual diagnoses of social anxiety disorder and alcohol dependence. • METHODS: The design was a two-group, randomized clinical trial that used 12 weeks of individual cognitive behavioral therapy for alcoholism only (n = 44) or concurrent treatment for both alcohol and social anxiety problems (n = 49). Outcome data were collected at the end of 12 weeks of treatment and at 3 months after the end of treatment. • RESULTS: Results with intent-to-treat analyses showed that both groups improved on alcohol-related outcomes and social anxiety after treatment. • Counter to the hypothesis, the group treated for both alcohol and social anxiety problems had worse outcomes on three of the four alcohol use indices. • No treatment group effects were observed on social anxiety indices. • CONCLUSIONS: Implications for the staging of treatments for coexisting social phobia and alcoholism are discussed, as well as ways that modality of treatments might impact outcomes.

  36. A cognitive-behavioral treatment for incarcerated women with substance abuse disorder and posttraumatic stress disorder: findings from a pilot study.Zlotnick C, Najavits LM, Rohsenow DJ, Johnson DM.This preliminary study evaluates the initial efficacy of a cognitive-behavioral treatment, Seeking Safety, as an adjunct to treatment-as-usual in an uncontrolled pilot study of incarcerated women with current SUD and comorbid PTSD. • Of the 17 incarcerated women with PTSD and SUD who received Seeking Safety treatment and had outcome data, • results show that nine (53%) no longer met criteria for PTSD at the end of treatment; at a followup 3 months later, seven (46%) still no longer met criteria for PTSD • Additionally, there was a significant decrease in PTSD symptoms from intake to posttreatment, which was maintained at the 3-month followup assessment. • Based on results from a diagnostic interview and results of urinalyses, six (35%) of the women reported the use of illegal substances within 3 months from release from prison. Measures of client satisfaction with treatment were high. Recidivism rate (return to prison) was 33% at a 3-month followup.

  37. Can encouraging substance abuse patients to participate in self-help groups reduce demand for health care? A quasi-experimental studyn=1774, 1 year follow-upHumphreys et al ..2001 Outpt Inpt days Abstinence Visits Rates • 12 Step 13.1 10.5 45.7 • Cog Beh 17 17 36.2 * all p< .001 ** 64% higher cost for CBT

  38. Dual Screening: • the “Dual Cage”…………….easy, but no data • ASAM pt placement………..needs experience, little or no data • ASI psych…………………….short, available, good screening, good data • Beck, Zung, Ham D etc…..easy, good data, may be limited • Brief Symptom Inventory…easy, broad symptom mix • Others……………………………see new Co-occurring TIP in 12-04

  39. “Dual CAGE” QUESTIONS • Cut Down (or stopped) • Because mental symptoms worsened • Because MH doctor or therapist suggested • Annoyed when drug/alc. use discussed • Annoyed, anxious or angry,… fights when using • Admitted to ER or hospital for psych when using or not • ADHD when child • Guilty about use • Guilty, depressed, suicidal when using or not • Ever made a suicide attempt when using or not

  40. CAGE Questions • Eye opener: taken drink or drug in AM to feel better • Taken a drink or drug to blot out symptoms • Taken drink or drug with psych med • Not taken meds because of using drug/alc (forgot, avoid mixing, etc.) • What are 2 or 3 reasons you use alc/drugs? • What are 2 or 3 reasons you might want to stop or cut down?

  41. Medications • Essential to Treatment of Severely Mentally Ill • Substance Use and Not-Taking Meds are the 2 top reasons for De-Comp • Should be part of court orders • Monitored by Case managers, nurses, doctors • For Dep/Anx, less clear • Personal experience shows maximizing 12 step AND use of meds is best rx

  42. It may not be that the med(s) stopped working, but…… • The patient stopped the med • The patient stopped the med AND used drugs and/or alcohol…... • OR lowered the med and used… • OR used on top of the med…. • OR used twice the dose on one day and nothing the next…. • Stimulants ( cocaine/amphets) are most MSE destructive.

  43. How to use AA as a treatment partner • 1. Know something about AA, its history, presence in your community, structure and content • 2. Helpful Readings: • Brown: A psychological view of the 12 steps • AA: AA for the medical practitioner; and • The AA member and medications • Twelve Step Facilitation Therapy Manual- • Project Match, NIAAA web site • Forman: “One AA Meting doesn’t fit all”

  44. One year ABSTINENCE was predicted by: • AA involvement (OR=2.9), ( n=377) • not having pro-drinking influences in one's network (OR=0.7 • having support for reducing consumption from people met in AA (versus no support; OR=3.4). • In contrast, having support from non-AA members was not a significant predictor of abstinence. • Kaskutas: Addiction 2002

  45. Double Trouble Recovery (DTR) Outcomes • Members of 24 DTR groups (n=240) New York City, 1 year outcomes • Drug/alcohol abstinence = 54% at baseline, increased to 72% at follow-up. • More attendance = better Medication adherence, • Better Medication adherence = less hospitalization • Magura Add Beh 2003, Psych Serv 2002

  46. Dual Dep/Anx RX plan • Differential Dx • 12 step facilitation • Meds if indicated ( and I often use them) • Visits: • Ries 1/week ( 12 step facil and meds) • AA 3x week or 90 in 90 • Meet with sponsor • Meet with family

  47. Low mental illness/High addictions outpt gets • In most MHC’s: • MD visit q 3 months • CM visit q 2 wks…focus on ADL’s • Maybe dual dx group 1-2 hrs/wk • Limited expectations of recovery • Pschotherapy time ~ 0-2 hrs week • In the most Addictions IOP’s • MD visit 1/ 3 months, often 1’ care • CM 1:1 q 2 wks….focus on Sub use, U tox’s • IOP group 3 hrs-3x week • Expectations of Sobriety/progress • Psychotherapy time 3-10 hrs week ( plus more AA)

  48. Report Questions Ability of National Treatment Infrastructure to Deliver Quality Care SOURCE: Adapted by CESAR from the McLellan, A. T., Carise, D., and Kleber, J., “Can the National Addiction Treatment Infrastructure Support the Public’s Demand for Quality Care?” Journal of Substance Abuse Treatment 25(2):117-121, 2003. For more information, contact Dr. A. Thomas McLellan at tmclellan@tresearch.org. 301-405-9770 (voice) 301-403-8342 (fax) CESAR@cesar.umd.edu www.cesar.umd.edu  CESAR FAX is supported by VOIT 1996-1002, awarded by the U.S. Department of Justice through the Governor’s Office of Crime Control and Prevention. CESAR FAX may be copied without permission. Please cite CESAR as the source.

  49. New Issues in Medications for Co-occurring Addiction and Mental Disorders Richard Ries MD

  50. Medication monitoring and motivating • Know who is on what and what for • Know the prescriber if possible • Sit in on med sessions onsite • Talk to off-site doctor or nurse PRE problem!!! • Know something about meds… • ATTC Tech transfer centers summary • New COD TIP ( Dec 04) • NIMH web site, NAMI web site

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