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Presentation provided by Annie Trépanier , MD, FRCPC

Concurrent Disorders: An Introduction. Presentation provided by Annie Trépanier , MD, FRCPC Clinical Fellow, Center for Addiction and Mental Health, University of Toronto. Fundamentals: Concurrent Disorders. I have no affiliations with a pharmaceutical or medical device company.

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Presentation provided by Annie Trépanier , MD, FRCPC

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  1. Concurrent Disorders: An Introduction Presentation provided by Annie Trépanier, MD, FRCPC Clinical Fellow, Center for Addiction and Mental Health, University of Toronto

  2. Fundamentals: Concurrent Disorders I have no affiliations with a pharmaceutical or medical device company. I am a (very) recent graduate. Disclosures

  3. Fundamentals: Concurrent Disorders Discuss epidemiological data Review underlying models and risk factors explaining concurrent disorders. Review the assessment process facilitating the evaluation of patients with both mental disorders and addictions. Discuss common presentations of co-occurring disorders. Describe approaches to treatment for patients with concurrent disorders Learning Objectives

  4. Fundamentals: Concurrent Disorders • A condition in which a person has both a mental illness and is experiencing harmful involvement with alcohol, drugs and/or gambling. (Pedersen, Management of Alcohol, Tobacco and other Drug Problems, 2000: 391-418) • Dual diagnosis (DD) has been defined as the comorbidity of at least one substance use disorder (SUD) and one severe mental illness (SMI) • There is a wide variety of combinations of either a mental disorder or SUD. (Adan & Benaiges, Neuropathology of Drug Addictions and Substance Misuse, 2016: 258-268) Definition: Concurrent Disorders

  5. Definition: Concurrent Disorders (Pedersen, Management of Alcohol, Tobacco and other Drug Problems, 2000: 391-418)

  6. Fundamentals: Concurrent Disorders • True concurrent disorders occur in less than 5% of patients presenting a SUD. True or False?

  7. Fundamentals: Concurrent Disorders Concurrent substance use and mental health disorders are common. “The rule rather than the exception”.

  8. Fundamentals: Concurrent Disorders Assessing for CD is a complex task, given that substances use (acute or chronic) can mimic psychiatric symptoms. (Adan & Benaiges, Neuropathology of Drug Addictions and Substance Misuse, 2016: 258-268) Highly heterogeneous set of presentations and combinations. (Pedersen, Management of Alcohol, Tobacco and other Drug Problems, 2000: 391-418)

  9. Epidemiology of Concurrent Disorders

  10. Epidemiologyof Concurrent Disorders (Hedden et al, NSDUH, 2015: 1-37)

  11. Epidemiology of Concurrent Disorder (Hedden et al, NSDUH, 2012: 1-178)

  12. Epidemiology of Concurrent Disorders • (Adan & Benaiges, Neuropathology of Drug Addictions and Substance Misuse, 2016: 258-268)

  13. Epidemiology of Concurrent Disorder (Toftdahl, Nordentoft & Hjorthøj, Soc Psychiatry Psychiatr Epidemiol.2016:129-140)

  14. Epidemiology of Concurrent Disorder

  15. CD = Prevalence of 18.5 % • Highest in tertiary care (28 %) • Personality disorders(34 %) • Outpatient and community settings, CD present with more impairment, more likely to be young, single, male, and of low education. • CD strongly associated with antisocial behaviour, risk of suicide or self-harm. (Rush, Can J Psych, 2008: 810-821 ) Some Canadian Data

  16. Fundamentals: Concurrent Disorders • Early occurrence • Of substance use • Of mental disorder (NIH, Comorbidity: Addiction and Other Mental Illnesses, 2010) • Drug use often initiated during adolescence, associated with impulsivity and wish for independence (Dube et al, Pediatrics, 2003: 564-572) • Genetic Factors • Family history of concurrent disorders • Psychosocial experiences and environmental influences • Unemployment, poverty or unstable income • Lack of social network • Stress related to work or school • Past or ongoing abuse or trauma • Females with higher rates of physical, emotional and sexual abuse (Daigre et al, Psychiatric Research , 2015: 743-749) Risk factors for Concurrent Disorders

  17. Mr. Gent is a 37 year old men from the Caribbean who moved to Canada more than 15 years ago in hope of a better life with some of his family members. He was always ostracised by his family and members of his community because of his sexual orientation. He alluded in the initial interview that he had significant trauma and described vivid PTSD symptoms. Over the years, he has developed a substance use disorder, previously with crack-cocaine and now he has been using crystal meth for 3 years (first 2 weeks of each month). A Case in Brief

  18. Fundamentals: Concurrent Disorders In studies, ACEs known to be related to a myriad of negative health outcomes and behaviors Abuse • Emotional • Physical • Sexual Neglect • Emotional • Physical Household Dysfunctions • Parental • Separation or divorce • Domestic violence • Substance abuse • Crime • Mental illness Adverse Childhood Experiences (ACE) (Dube et al, Pediatrics, 2003: 564-572)

  19. Eachcategoryof ACEswasassociatedwith • 2-4 x increaseillicitdrug use by age 14 • Increasedriskof use as an adult. • >5 ACEs • 7- to 10 x more likely to report druguse problems, addiction to drugs, and IV drug use. (Dube et al, Pediatrics, 2003: 564-572) Adverse Childhood Experiences (ACE)

  20. With drug use • Markedly decrease brain dopamine function. • Dysfunction of pre-frontal regions (Volcow et al, The Journal of Clinical Investigation, 2003: 1444-1451) • Stress modifies brain pathways • Hypothalamus, pituitary and adrenal glands pathway • Involvement of CRF (corticotrophin releasing factor) • In animal models of addiction, CRH increased drug use, resistance to stopping drug use, and drug relapse • Involvement with reward processes (Sinha, Psychopharmacology, 2001: 343-359) Brain Changes

  21. Complexinterplay of different factors. Any diagnosis from either category may cause, potentiate or predispose to the other. Different models developed to explore the complexity of CD. Between the Substance Use and Mental Health Problems

  22. How Do We Understand CD

  23. Fundamentals: Concurrent Disorders 1. Self-medication Model • (Adan & Benaiges, Neuropathology of Drug Addictions and Substance Misuse, 2016: 258-268)

  24. Fundamentals: Concurrent Disorders Substance use to alleviate negative emotional states or secondary effects of medication. Sparse scientific findings, questionable generalizability. 1. Self-Medication Model • (Adan & Benaiges, Neuropathology of Drug Addictions and Substance Misuse, 2016: 258-268)

  25. Fundamentals: Concurrent Disorders 2. Secondary Psychopathology Model

  26. Fundamentals: Concurrent Disorders « Neural diathesis-stress model - a neurobiologicalvulnerabilitycan trigger psychiatricdisordersthroughcomplex interactions betweenenvironmentaleventssuch as substance abuse » 2. Secondary Psychopathology Model • (Adan & Benaiges, Neuropathology of Drug Addictions and Substance Misuse, 2016: 258-268)

  27. Fundamentals: Concurrent Disorders 3. Common Factor Model

  28. Fundamentals: Concurrent Disorders 3. Common Factor Model Biological factors - determining gene parallelism • Some evidence that genes expressing the dopamine receptors (D4 and D2 receptors) associated with addictive behaviors and personality traits as novelty seeking. • Data remains inconsistent. • (Adan & Benaiges, Neuropathology of Drug Addictions and Substance Misuse, 2016: 258-268)

  29. Fundamentals: Concurrent Disorders 4. Bi-directional Models (Adan & Benaiges, Neuropathology of Drug Addictions and Substance Misuse, 2016: 258-268)

  30. Fundamentals: Concurrent Disorders • Inconclusive results. • Likely complementary of each other. • May explain certain concurrent presentations. • Careful individual assessment. Conclusions from the Models (Adan & Benaiges, Neuropathology of Drug Addictions and Substance Misuse, 2016: 258-268)

  31. Fundamentals: Concurrent Disorders • Challenges in assessing for a primary disorder versus secondary to the effect of a substance: • Intoxication • Withdrawal • Substance-induced disorders Assessment (Adan & Benaiges, Neuropathology of Drug Addictions and Substance Misuse, 2016: 258-268)

  32. Primary Mental Disorder versus Substance-InducedDisorder (Adan & Benaiges, Neuropathology of Drug Addictions and Substance Misuse, 2016: 258-268)

  33. He was first seen by a psychiatrist urgently because of his disturbing behaviours in the waiting room (i.e.: he was throwing coins in a specific corner of the room). At the time, he presented a significant thought disorder, appeared very agitated, irritable and most of his words were “mumbled”. A few weeks later, he was seen by me, in a generally much improved state. He is now calm, polite, speaks clearly though with still some delay in response. A Case in Brief

  34. He reports low grade psychotic symptoms for the last 2 to 3 years and hoards computer devices secondary to these symptoms, using up a good amount of his already low income. He was recently diagnosed with HIV, remains untreated (low viral count, normal CD4 according to his case worker). His level of functioning is very low, he benefits from the structure and stimulation from the subsidised living where he lives. He steals secondary to his spending habits, low income and likely lack of appropriate cognitive skills. He was recently arrested for shoplifting food. Poor medication compliance. A Case in Brief

  35. Fundamentals: Concurrent Disorders • Intoxication or withdrawal from drugs or alcohol can mimic nearly every psychiatric disorder: • Cocaine Intoxication may induce symptoms similar to mania • Cocaine withdrawal may induce/mimic a depressive episode • Alcohol-Induced Mood Disorder Clinical Presentation of Substance Induced Disorder (Pedersen, Management of Alcohol, Tobacco and other Drug Problems, 2000: 391-418)

  36. Fundamentals: Concurrent Disorders • After acute intoxication • During or within 1 month of intoxication • Involved substance is capable of producing the mental disorder (DSM-V, Substance-Related and Addictive Disorders) • Anxiety and or psychosis usually ameliorate within 2 to 3 weeks. (Adan & Benaiges, Neuropathology of Drug Addictions and Substance Misuse, 2016: 258-268) • With heavy and chronic use • > 6 month abstinence for some substance-induced psychiatric sx and cognitive changes to reverse Substance Induced Disorders

  37. Fundamentals: Concurrent Disorders • Intoxication and withdrawal • Mood Disorders • Anxiety Disorders • Neurocognitive Disorder • Psychotic Disorder (DSM-V, Substance-Related and Addictive Disorders) Substance Induced Disorders

  38. Fundamentals: Concurrent Disorders Consequences Associated with Concurrent Disorders (Adan & Benaiges, Neuropathology of Drug Addictions and Substance Misuse, 2016: 258-268)

  39. His substance use, behaviour (especially when intoxicated) and issues with the law has put his lodging at the subsidized housing at risk for eviction. If he loses his apartment, he loses his case worker. He wants help, knows he “becomes this other person when he uses crystal meth” but certain out-patient’s treatment setting cannot take him because of his volatility when he uses or shortly thereafter. A Case in Brief

  40. Fundamentals: Concurrent Disorders • Careful, individualized assessment of needs and clinical presentation • Safety • Severe psychiatric symptoms may necessitate immediate use of medication. (Adan & Benaiges, Neuropathology of Drug Addictions and Substance Misuse, 2016: 258-268) • Suicidal ideation • Dangerous withdrawal Steps to Treatment

  41. Fundamentals: Concurrent Disorders Steps to Treatment • Substance use treatment • Different phases • First Phase (Getting Started) • Second Phase (Learning to Live Drug Free) • Third Phase (Rehabilitation and Relapse Prevention) • Acute intoxication or withdrawal symptoms subsided prior to entering more active therapy program (Pedersen, Management of Alcohol, Tobacco and other Drug Problems, 2000: 391-418) • Engagement • Preparation • Active treatment • Continuing care and support. (Skinner, 2005 Treating Concurrent Disorders)

  42. Fundamentals: Concurrent Disorders Four Quadrant Model

  43. Fundamentals: Concurrent Disorders Integrated Approach • SAMHSA supports an integrated treatment approach to treating co-occurring mental and substance use disorders. • Collaboration across disciplines • Client-centered, patient’s goals • Integrated treatment associated with lower costs and better outcomes : • Reduced substance use • Improved psychiatric symptoms and functioning • Decreased hospitalization • Increased housing stability • Fewer arrests • Improved quality of life (SAMHSA, Behavioral Health Treatments and Services, 2016) Othermodels of treatment • Sequential • Parallel (SAMHSA’sWORKING DEFINITION OF RECOVERY, 2016)

  44. Fundamentals: Concurrent Disorders Treatment Approaches Integrated Approach: Components Otherapproaches SeekingSafety (Najavits, Journal of Traumatic Stress, 2001: 437-456) • Staged interventions • Assertive outreach • Motivational interventions • Counseling • Social support interventions • Long-term perspective • Comprehensiveness • Cultural sensitivity • Competence (Drake et al, Psychiatric Services, 2001: 469-476)

  45. Fundamentals: Concurrent Disorders • Mental health symptoms should be treated concurrently, especially if severe. (Health Canada, Best Pratices, 2002) • Avoid addictive medications if possible (e.g. benzodiazepines, stimulants) • Sertraline + naltrexone or mirtazapine superior in co-occurring depression and EtOH use (Beaulieu et al, Annals of Clinical Psychiatry, 2012: 38-55) • ADHD: treat SUD first than ADHD. Can treat ADHD but high potential for diversion and misuse (Caddra, 2010) Pharmacotherapy

  46. SAMHSA http://www.samhsa.gov/treatment#co-occurring • Health Canada, Best Practices http://www.hc-sc.gc.ca/hc-ps/pubs/adp-apd/bp_disorder-mp_concomitants/index-eng.php • Substance Abuse in Canada: Concurrent Disordershttp://www.ccsa.ca/Resource%20Library/ccsa-011811-2010.pdf Some Useful Links

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