SAMH Mental Health & Alcohol Conference

1. SAMH Mental Health & Alcohol Conference Transforming the concept of Dual Diagnosis to the concept of Complex Needs Dr Fraser Shaw Consultant Psychiatrist in Addictions, West Dunbartonshire Fraser.Shaw@ggc.scot.nhs.uk

5. What is ‘dual diagnosis’ or ‘comorbidity’? • Two overlapping but discernible subgroups of patients:- • Those with a major substance misuse disorder and • another major psychiatric illness. • Those who use alcohol and/or drugs in ways that • affect course and treatment of their mental illness. • (Guehaly, 1990)

6. Prevalence • Depends on who is asking, how, what, where etc! • OPCS institutional survey, UK (Farrell et al 1998) - 7% of • those with schizophrenia reported ‘ever’ using drugs. • Croydon, UK outpatients (Wright et al 2000) - 33% lifetime, • 10% current prevalence of ‘substance misuse’ in cohort with • regular CMHT contact. • Inner city USA inpatients (Brady et al 1991) 64% lifetime • prevalence of ‘substance abuse’.

7. Prevalence of Dual Diagnosis (The Royal College of Psychiatrists’ Research Unit)

8. Bipolar disorder has the greatest risk of any Axis 1 • disorder for substance misuse comorbidity. • People with schizophrenia three times more likely than • those without to abuse alcohol, six times more likely to • abuse drugs. • Comorbid schizophrenics have higher rates of inpatient • care and intensive crisis support.

9. “Mental disorder and substance misuse sit on separate dimensions each with its own continuum of severity from mild to severe levels.” Banerjee , Clancy and Crome (Eds), (2002) The Royal College of Psychiatrists’ Research Unit

10. ASSESSMENT: SPECTRUM OF CO-MORBIDITY Severity of problematic drug use Severity of mental illness Adapted from DOH Dual Diagnosis Good Practice Guide Available from www.doh.gov.uk/mentalhealth

11. Why is co-morbidity important? Homelessness or unstable housing Interpersonal conflict and family problems Violence Victim of crime History of sexual, physical and/or emotional abuse Suicide and self-harm Poor compliance with medication Treatment recidivism Poor prognosis of mental health problems Increased criminal justice system contact Early mortality Vulnerability: (Drake et al.,1998; Drake et al., 2001; Banerjee et al. (Eds.), 2002)

12. Integrated treatment • Presents fewer hurdles to treatment access for patients with co-morbidity • Better retention in treatment • Potential to reduce substance misuse and attain remission • Improved psychological functioning (Drake et al., 1998, Drake & Mueser, 2000; Mueser et al., 1998).

13. Components of effective integrated treatment approaches • Close monitoring • Case management • Assertive outreach • Comprehensive treatment • Stepped Care • Motivation based intervention • Longitudinal perspective (Drake et al., 1993; Mueser & Drake, 2003)

14. Comorbidity, Dual Diagnosis (blah blah.....) Transform to:- - Complex needs - Recovery Agenda

15. Complex Needs • Mental health problems • Substance misuse problems • Traumatic brain injury/head in jury • Learning disability • Literacy and communication skills • Personality disorder • History of trauma

16. Complex Needs II • Attention deficit hyperactivity disorder • Chronic pain • Sleep disorders • Homelessness • Involvement with criminal justice system

17. Complex Needs III Alcohol use: • In a general UK population, 40% said alcohol made them feel less anxious, 26% said less depressed. • Up to 65% of suicides have been linked to excessive alcohol use. • Specific anxiety disorders and/or depression were found to be related to frequent and/or heavy alcohol misuse in a primary care setting. • Alcohol and/or drug misuse correlated with more frequent hospitalisations for patients with schizophrenia.

18. Complex Needs IV Benzodiazepine use: • Frequent accompaniment to alcohol misuse. • Anterograde amnesia associated with benzodiazepine use will impact processing and retention of interventions. • Effectiveness of CBT-based interventions reduced with benzodiazepine use. • Mounting evidence for persistent cognitive deficits in chronic benzodiazepine use. Other drug use: • Study of methadone maintenance patients found impairment across all cognitive domains. Lifetime diagnosis of alcohol dependence, and number of non-fatal heroin overdoses, were independent predictors.