Dual Disorders or Dueling Disorders Dual Diagnosis Today

1. Dual Disorders or Dueling DisordersDual Diagnosis Today Alexis Polles, MD agpolles@comcast.net Perspectives on Mind and Body 34 Milbranch Road, Ste. 60 Hattiesburg, MS 39402 P:601-255-5485 F:601-255-5317

2. Outline • I: From the ground up • Definitions and terminology • Integrated Treatment • II: Making the diagnosis • III: Treatment

3. DUAL DIAGNOSIS IS: • Coming to be thought of as an outdated term • Overlap with SUD and MR or LD terms • Traditionally 2 systems (not 2 diagnoses or even a “diagnosis” at all) • Influenced by the biases, perspectives, experience and training of the evaluator • DIFFICULT!!

4. Substance Abuse and Mental Health Services Administration (SAMHSA) Definition of Co-occurring Disorders: • COD refers to co-occurring substance-related and mental disorders. Clients said to have COD have one or more substance-related disorders as well s one or more mental disorders. • At the individual level, COD exists when at least one disorder of each type can be established independent of the other and is not simply a cluster of symptoms resulting from a single disorder. Definitions and Terms Relating to Co-Occurring Disorders. Tech. no. Overview Paper 1. Substance Abuse and Mental Health Services Administration, n.d. Web. 19 Jan. 2013. <http://www.samhsa.gov/>.

5. Examples of Co0ccurring Conditions (COC): • MENTAL DISORDERS • Schizophrenia/Psychoses • Mood Disorders • Anxiety Disorders • Somatoform Disorders • Factitious Disorders • Dissociative Disorders • Sexual Disorders • Eating Disorders • Sleep Disorders • Impulse-control Disorders • Adjustment Disorders • Personality Disorders • Disorders usually first diagnosed in infancy, childhood, or adolescence • ADDICTION DISORDERS • Alcohol Abuse/Depen. • Cocaine/ Amphet./Stimulants • Opiates/Opioids • Marijuana • Polysubstance combinations • Prescription drugs • Synthetics • Hallucinogens • Dissociatives

6. Well, How Common Is The Problem? • Estimates of psychiatric co-morbidity among clinical populations in substance abuse treatment settings range from 20-80% • Estimates of substance use co-morbidity among clinical populations in mental health treatment settings range from 10-35%, with the highest for those with Schizophrenia and Bipolar Disorder * Differences in incidence due to: nature of population served (e.g.: homeless vs. middle class), sophistication of psychiatric diagnostic methods used (psychiatrist or DSM checklist) and severity of diagnoses included (major depression vs. dysthymia).

7. Key Epidemiologic Findings Since 2002Current national COD epidemiologic data are derived from 3 major studies: The National Comorbidity Survey and the NCS-Replication (NIMH); The National Survey on Drug Use and Health (SAMHSA); The National Epidemiologic Study on Alcohol and Related Conditions (NIAAA+NIDA) • Substance use disorders are present in more than 9% of the large numbers of individuals sampled. • More than 9% of adults have diagnosable mood disorders, primarily Maj. Dep. • More than 5 million adult U.S. citizens have a serious mental illness (SMI = Persons age 18 +, who currently or at any time during the past year, have had a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet DSM-IV diagnostic criteria , resulting in functional impairment which substantially interferes with or limits one or more major life activities.)

8. Why Is This So Difficult? • Fear in the SUD treatment community of putting addiction on the back burner. • High utilization of time and resources. • Primary approach for MI is medications. • Primary approach for SUD after detox is other therapeutic interventions (pre-Suboxone). • “Denial” by the individual and their family members regarding both. • Fear of placing more and more people in the bind of creating more stigma, more disability. • (According to the 2004 World Health Report, Maj. Dep. Is the leading cause of disability in the US and Canada for ages 15-44.)

9. Why Is This So Difficult? Psychiatric Disorders • Health problems • Family/intimacy problems • Isolation • Financial problems • Employment problems • School problems • High risk driving/other accidents • Multiple admissions • Chronic/relapsing • Increased suicide • Has many patterns • Lack of progress=failure • Changing diagnostic criteria Addiction Disorders • Health problems • Family/intimacy problems • Isolation • Financial problems • Employment problems • School problems • High risk driving/other accidents • Multiple admissions • Chronic/relapsing • Increased suicide • Has many patterns • Lack of progress=failure • Changing diagnostic criteria

10. The Four Quadrant Framework for Co-Occurring Disorders Classifies Patients Into 4 Quadrants of Care Based on Symptom Severity, Not Diagnosis This framework is suggested 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) High severity 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

11. And what about Quadrants I and III • As in Addiction Treatment settings • As in Criminal Justice settings, police encounters • As in Primary Care settings such as community health clinics, HIV or Hep C treatment settings, primary care offices • As in ER’s, especially with suicidal pts., ICUs, trauma centers • As in unemployment offices, homeless shelters, schools, workplace settings, faith-based settings • 53% of people with serious psychological distress and a SUD receive no treatment. (2005 National Survey on drug Use and Health)

12. Summary • There is a problem. • It has been documented it for a long time. • More information to figure out • The current state of affairs, especially longer term outcomes. • What to do about it.

13. Current Models for Treatment of Co-occurring Disorders • Treatment System Paradigms • Independent, disconnected • Sequential, disconnected • Parallel, connected • Integrated

14. Treatment of Co-occurring Disorders • Integrated Model • Model with best conceptual rationale • Treatment coordinated best • Challenges • Funding/ payment streams • Staff integration • Threatens existing systems • Short term cost increases (better long term cost outcomes ?)

15. Elements of an Integrated Model • Preliminary assessment of mental health and substance use urgent conditions (Safety First) • Suicidality • Risk to self or others • Withdrawal potential • Medical risks associated with alcohol/drug use

16. Case 1 • 24 year old white male. No prior treatment for SUD or MI reported by mother. Parents noted “strange behavior” for several weeks prior to his disappearance for 2 months. Found by family 3 days before presenting to you, living in another state, with an older man he had met in a Mexican restaurant. Family suspected methamphetamine abuse. PMH: Negative. FH: None known. He was noted to be disheveled with flat affect, sparse verbal interaction with some grunts, and occasional standing in position without moving for prolonged periods. Vitals were normal. 5’7” 160 #. He was oriented but not to place. Urine dip showed THC. • What are your thoughts?

17. Elements of an integrated model • Diagnostic process that produces provisional diagnosis of psychiatric and substance use disorders using: • Substances used (Limitations of but necessity of valid toxicology results.) and when, how much, how often, last time. • Review of signs and symptoms (psychiatric and substance use). Rating scales may be helpful but not better than a really good history. Collateral information. • Personal history timeline of symptom emergence (what started when). • Family history of psychiatric/substance use disorders. • Psychiatric/substance use treatment history. • Look for things that cluster.

18. Think about this! • Unbelievably, he was transferred for psychiatric hospitalization to a large university setting twice. He was initially admitted there after he physically blocked exit from the nurses’ station and was holding body positions for more than an hour (10 days after arrival at your center). He was there for 2 or so days and thought to have a substance abuse problem. He refused antipsychotic medications from you. The second time was 3 to 4 days later after his peers reported him putting garbage in his pockets, not showering or standing in the shower with all his clothes on, and not performing other ADLs. No active hallucinations/delusions were noted, though mutism/catatonia continued. He was admitted again to university and after 3 days returned on no medications. He attended activities but little to no verbal input (17 days after coming in). Told nurse that he wanted to be silent because he “found a new way.” Reported to nurse that he had a psychiatric visit at school 2 years prior for stress. Quit college because he “got tired of the routine.” No relationships for 2+ years, since college. Roommates in treatment think he has schizophrenia.

19. Negative Symptoms of Schizophrenia • Positive symptoms make treatment seem more urgent, and they can often be effectively treated with antipsychotic drugs. But negative symptoms are the main reason patients with schizophrenia cannot live independently, hold jobs, establish personal relationships, and manage everyday social situations. • Blunted affect • Alogia (poverty of speech) • Anhedonia • Associality (lack of desire to form relationships) • Avolition (lack of motivation)

20. Case 2 Prozac Nation • http://movieclips.com/QMxW-prozac-nation-movie-health-hazard/

21. DSM IV Major Depressive Episode A. Five (or more) present during the same 2-week period, represent a change, at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. (1) depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful).(2) markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)(3) significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains.(4) insomnia or hypersomnia nearly every day(5) psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)(6) fatigue or loss of energy nearly every day(7) feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)(8) diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)(9) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide B. Symptoms do not meet criteria for a Mixed Episode.C. Symptoms cause clinically significant distress or impairment in functioning.D. Symptoms are not due to the direct physiological effects of a substance or a medical condition.E. Symptoms are not better accounted for by Bereavement (After the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.)

22. Bipolar II Disorder A. Presence (or history) of one or more Major Depressive Episodes. B. Presence (or history) of at least one Hypomanic Episode. (Duration 4 days) C. There has never been a Manic or a Mixed Episode. • D. The mood symptoms in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified. • E. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Bipolar I Disorder (See the wonderful movie Silver Linings Playbook, out now) • One or more Manic Episodes...or Mixed Episodes... Often individuals have also had one or more Major Depressive Episodes, but this is not required for diagnosis. Episodes of Substance-Induced Mood Disorder or of Mood Disorder Due to a General Medical Condition do not count toward a diagnosis of Bipolar I Disorder • A manic episode is defined in the DSM as a period of seven or more days (or any period if admission to hospital is required) of unusually and continuously effusive and open elated or irritable mood, where the mood is not caused by drugs/medication or a medical illness and (a) is causing obvious difficulties at work or in social relationships and activities, or (b) requires admission to hospital to protect the person or others, or (c) the person is suffering psychosis. • To be classed as a manic episode, while the disturbed mood is present at least three (or four if only irritability is present) of the following must have been consistently prominent: grand or extravagant style, or expanded self-esteem; pressured speech; reduced need of sleep (e.g. three hours may be sufficient); talks more often and feels the urge to talk longer; ideas flit through the mind in quick succession, or thoughts race and preoccupy the person; over indulgence in enjoyable behaviors with high risk of a negative outcome (e.g., extravagant shopping, sexual adventures or improbable commercial schemes).[ • If the person is concurrently depressed, they are said to be having a mixed episode.

23. Elements of an integrated model • Initial treatment plan (Days 1-10) that includes: • Choice of a treatment setting appropriate to initially stabilize medical conditions, psychiatric symptoms and drug/alcohol withdrawal symptoms • Initiation of medications to control urgent psychiatric symptoms (psychotic, severe anxiety, etc.) • Implementation of medication protocol appropriate for treating withdrawal syndrome(s) • Ongoing assessment and monitoring for safety, stabilization and withdrawal

24. Elements of an integrated model • Early stage treatment plan (Days 2-14) that includes: • Selection of treatment setting/housing with adequate supervision • Completion of withdrawal medication • Review of psychiatric medications • Completion of assessment in all domains (psychology, family, educational, legal, vocational, recreational) • Initiation of individual therapy and counseling (extensive use of motivational strategies and other techniques to reduce attrition) • Introduction to behavioral skills group and educational groups, step groups • Introduction to self help programs • Urine testing and breath alcohol testing

25. Elements of an integrated model • Intermediate treatment plan (up to 6 or 8 weeks) that includes: • Housing plan that addresses psychiatric and substance use needs • Plan of ongoing medication for psychiatric and substance use treatment with strategies to enhance compliance • Plan of individual and group therapies and psychoeducation with attention to both psychiatric and substance use needs • Skills training for successful community participation and relapse prevention • Family involvement in treatment processes • Self-help program participation • Process of monitoring treatment participation (attendance and goal attainment) • Urine and breath alcohol testing

26. Elements of an integrated model • Extended treatment plan that includes (up to 6 months): • Housing plan • Ongoing medication for psych and substance use treatment • Plan of individual and group therapies and psychoeducation with attention to both psychiatric and substance use needs • Ongoing participation in relapse prevention groups and appropriate behavioral skills groups and family involvement • Initiation of new skill groups (e.g.; education, vocational, recreational skills) • Self help involvement and ongoing testing • Monitoring attendance and goal attainment

27. Elements of an integrated model • Ongoing plan of visits for review of: • Medication needs • Individual therapies • Support groups for psych and substance use conditions • Self help involvement • Instructions to family to recognize relapse to psych and substance use In short, a chronic care model is used to reduce relapse and if/when relapse (psychiatric or substance use) occurs, treatment intensity can be intensified.

28. Abstinence & Relapse • Goal for COD recovery • Controlled usage ? • Abstinence ? • Ultimately: Developing a personally meaningful life • Contracts to Quit: Clarifies Commitment to Change • Relapse • Return to old drug abuse patterns • This is the rule rather than the exception • Treat them as setbacks or opportunities for learning, instead of failures • Contributing causes include stress, strong emotional states, conflicts with family or friends, social pressures, other addictions ?

29. 12 Step Versus Cognitive Behavioral Treatment (Self-Management and Recovery Training) In Dual Diagnosis (Brooks & Penn, Am J of Alcohol and Drug Abuse, 29 (2), 359-383, 2003. 12 Step • More effective in decreasing alcohol use and increasing social interactions • Worsening of medical problems, health, employment, psychiatric hospitalizations Cognitive Behavioral • More effective in improving overall health and work status N=50 ½ went to 12 step treatment and ½ to SMART. One year observation. Findings drawn from those who finished 3 months of treatment. (Brooks & Penn, 2003)

30. Does participation in self-help groups reduce demand for health care? n=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

31. One year ABSTINENCE was predicted by: • AA involvement ( n=377 men and 277 women) • Not having pro-drinking influences in one's network • Having support for reducing consumption from people met in AA • In contrast, having support from non-AA members was not a significant predictor of abstinence. • Kaskutas: Addiction 2002

32. 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

33. Evidence-based practices regarding self-help J of Sub. Abuse Treatment, Vol 26, Issue 3, Pp. 151-158, April, 2004. • Summary of status of U.S. self-help groups A diverse set of self-help organizations has developed for all substances of significant public health concern (Most research done on AA/NA/DTR) Collectively, these self-help organizations are both appealing and affordable to a broad spectrum of people. Clinical, agency and governmental procedure and policy influence the prevalence, organizational stability, and availability of addiction-related self-help groups • Synthesis of effectiveness research results Longitudinal studies associate AA and NA participation with greater likelihood of abstinence, improved social functioning, and greater self-efficacy. Participation seems more helpful when members engage in other group activities in addiction to attending meetings. Twelve-step self-help groups significantly reduce health care utilization and costs, removing a significant burden from the health care system. Self-help groups are best viewed as a form of continuing care rather than as a substitute for acute treatment services (e.g., detoxification, hospital-based treatment, etc.) Randomized trials with coerced populations suggest that AA combined with professional treatment is superior to AA alone.

34. Definition of Insanity? • Same applies to treatment so---- Those who do not experience an adequate response to treatment should receive timely reassessment and a change in their treatment!

35. Primary References • ASAM Review Course in Addiction Medicine. Chicago: ASAM, 2012. Print. “Co-occurring Addiction and Mental Disorders,” presented by Richard Ries, MD. • "Substance Abuse & Mental Health Services Administration." The Substance Abuse and Mental Health Services Administration. SAMHSA, n.d. Web. 20 Jan. 2013. <http://www.samhsa.gov/>.