Transcript Module 1: Introduction to Dual Diagnosis

Introduction to Dual Diagnosis
in Assertive Outreach
Objectives
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Define and understand the term “dual
diagnosis”
Be aware of the prevalence rates in
assertive outreach
Be able to list associated consequences
of having combined mental health and
substance use problems.
Policies relevant to dual diagnosis within
AOT
Dual Diagnosis Capabilities
• Role Legitimacy: Recognise and accept
that working with people with dual
diagnosis is a routine part of ones role
Dual Diagnosis Capability 1 level 2
• Acceptance of the Uniqueness of Each
Individual: Be able to accept the person as
a unique individual and respect their
choices and lifestyle. Dual Diagnosis
Capability 3 level 2
Definitions
• The term “dual diagnosis” is generally
applied to people who have two disorders
• Combined mental health and substance
use problems
• More than “dual problems”- likely to have
complex health and social needs
• Wide range of people with varying degrees
of need- need individualised treatment
Serious mental illness
E.g. someone with
bipolar affective disorder
who smokes cannabis
twice per week
E.g. Someone with
schizophrenia
and alcohol dependence
Table 1
Minor substance use
E.G. Someone with anxiety who
snorts cocaine occasionally
Minor mental illness
Severe substance use
E.g. someone with heroin
dependency and depression
“Mainstreaming”
DH (2002) Good Practice Guide:
• Doesn’t advocate a separate specialist service for dual
diagnosis
• Mental health services should take primary responsibility
for those with serious mental health problems (like
schizophrenia) and substance use
• AOT likely to provide care for those with dual diagnosis
as typically hard to engage and chaotic users of services
• Substance use services should take primary
responsibility for those with primary substance problems
and common mental health problems (anxiety,
depression)
• However mental health and substance use services
should work together and support each other
Discussion 1
What have been your experiences of
working with people with dual diagnosis
within AOT?
Think about issues concerning:
– the individual
– the carer
– Yourselves
– the AOT
UK Dual Diagnosis Prevalence
Studies
• Menezes (1996) Inner London MH services 36% (1 year)
• Cantwell (1999) Nottingham first episode psychosis 37% (1 year)
• Weaver (2001) Inner London Community mental health and
substance use services 24% (recent-last 30 days)
• Phillips (2003) Inner London (in-patient setting) 49% (last 6 months)
• Graham (2001) Birmingham (MH and SU services) identified 24%
SMI problems with drugs/alcohol
– More likely to be using at impairment/dependence level
– More likely to be in AOT (26-45% of case-loads depending on location)
– Over representation of African-caribbean in AOT (46%)
• Priebe et al (2003) London AOT 29% misused at least 1 type of
substance(last 6 months)
– 20% misused/dependent on drugs
– 16% misused/ dependent on alcohol
– Most common street drug was cannabis (23%), followed by cocaine
(7.4%)
Consequences of co-morbidity
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Increased likelihood of self-harm and violence
Poor physical health (including HIV, hep B and C)
Frequent relapse and re-hospitalisation
Higher rates compulsory detention
Forensic mental health care and criminal justice system
Higher overall risk of untoward incidents
Difficulty getting access to appropriate aftercare
Poor medication adherence
Family problems
Homelessness
Higher overall service costs
Higher levels of social exclusion
Profile Of Dual Diagnosis in AOT
(London) (Fakoury, et al 2006)
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White*
Single
Young
Unemployed
Homelessness
Poor educational attainment
Living alone
Contacts with criminal justice system
* (Graham et al (2001) found over-representation of people of AfricanCaribbean origin in Birmingham, UK)
Most Commonly used substances
1. Alcohol
2. Cannabis
3. Cocaine
More rarely:
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amphetamines
Opiates
Hallucinogens (LSD, magic Mushrooms)
Solvents and glue
Over the counter meds (anti-histamines)
Abuse of prescribed drugs (benzodiazepines, anti-cholinergics)
*NB geographical location will affect patterns- need to know your local
drugs scene.
Patterns of use
• Use with impairment (DSMIV “abuse”)
rather than dependence
• Poly-substance use common
Diagnostic Criteria for Substance
use Problems (DSM IV)
Substance Use
• Substances that alter level of
consciousness and/or perception
• Levels of use:
– Experimental (occassional- not always safe!)
– Recreational (regular, but within safe limits)
– Bingeing/ dangerous use (high intensity over
short length of time)
– dependence (increased tolerance and
withdrawals if stop)
Misuse of Drugs act 1971
• Class A- heroin, cocaine, ecstasy, LSD, anything
prepared for IV use, cannabis oil
• Class B- amphetamines, oral opiates (DF118)
• Class C- benzodiazepines, cannabis
Classification refers to perceived harm, and
severe penalties for possession trafficking and
supply. A carries highest penalties
Exercise 1
Ask yourself these questions:
• What attitudes do I have about people who
use drugs and people who use alcohol?
• Where did these attitudes come from?
(Parents, school, media, religious beliefs
etc)
• How might these attitudes affect how I
work with people with substance use
problems?
Exercise 2: Why Use?
• Why do I (did I) smoke cigarettes; drink
caffeinated drinks e.g. coffee, tea, cola; drink
alcohol? Make a list of the reasons why, the
benefits, and if there are any, some of the less
good aspects of these habits.
• why do people with mental health problems use
drugs and alcohol? Make a list of the reasons
that you are aware of from what service users
have told you, or assumptions that you have
made.
Reasons for use
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To feel euphoric or feel nothing
To feel more confident
To work longer hours or enhance performance
To belong to a social group (peer pressure)
To kill time (alleviate boredom)
To alleviate physical pain and other health problems
Because it is a habit
To satisfy cravings and avoid withdrawal symptoms
For weight loss
To experience an altered state of consciousness
To unwind after a stressful day
Alcohol
• Alcohol is a widely used, legal
and socially acceptable drug.
• It is taken orally.
• It is a central nervous system
depressant
• Dangerous drug; accidents
whilst intoxicated, overdose
choking on vomit.
• Alcohol related to 40% of
violent offences;44 per cent for
domestic violence and 53 per
cent for violence committed
against a stranger [British
Crime Survey, 2000].
Alcohol 2
• Safe levels <3 units per day
• Males up to 21 units/week; females up to 14 units/week
• Unit = volume x ABV/1000 (250mls wine
13%ABV/1000=3.25 units
• Physical dependency- ↑tolerance and withdrawals
• Signs of withdrawal: nausea, vomiting, sweating, high
temperature, hypertension, anxiety, sleeplessness,
restlessness, and sometimes hallucinations, epileptic
fits.
• Withdrawals need immediate medical attention and
treatment as can be life-threatening.
• Never advise abrupt cessation of heavy drinking without
treatment!!
Cannabis
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Cannabis is a sedative and hallucinogenic drug produced from the leaves
and buds of the cannabis sativa plant.
Most commonly used illegal drug.
Cannabis is an illegal substance under class B of the misuse of Drugs Act.
dried leaves or black/brown block of resin
Cannabis leaves or resin are smoked (roll-up with tobacco or in a bong)
Signs of Use: reddened eyes, dilated pupils, increased pulse rate,
drowsiness, giggling, and a sweet herbal smell.
Effects: relaxation, increased senses, slowing of thoughts, time seems to
pass more slowly, sometimes mild hallucinogenic effects.
Risks: mouth and lung cancer, exacerbate other lung conditions, increases
likelihood of psychosis, road traffic accidents whilst driving under the
influence.
Cocaine and Crack Cocaine
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Stimulant drugs
Legality- class A drugs
What do they look like: cocaine is a white crystalline powder, and crack is white or
off-white crystalline rocks
How taken: Cocaine may be taken orally, snorted, inhaled, or injected. Crack:
inhaled from a pipe, but sometimes injected.
Effects: Cocaine, in both forms, increases heart rate, breathing, blood pressure,
thoughts and activity levels. It also lifts mood and gives a sense of energy and
wellbeing.
Signs of use: dilated pupils, dry mouth, elevated body temperature, teeth grinding,
agitation, restlessness, excitability, pressure of speech, flight of ideas, weight loss
(appetite suppressant).
Risks: paranoia, confusion, and disorganized patterns of behaviour. The “come
down” period causes fatigue, and depressed mood. Heart attacks, hgh blood
pressure, stroke, and kidney damage
Opiates
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Derived from the opium poppy.
They include heroin, morphine, methadone and codeine.
Central nervous system depressants
Legality: these are class A drugs
What they look like: heroin is a pale brown powder;
also available in pharmaceutically manufactured form
such as tablets, green or blue syrup (methadone) and
glass ampoules (for injection)
How used: mainly smoked or injected, some opiates are
available in tablet and suppository form.
Signs of use: pallor, pinprick pupils “pinned”,
sedation/drowsiness (“gouching out”), signs of injecting
on body
Effects: people feel emotionally numb, warm and
drowsy, with an initial intense rush, especially if injected
intravenously.
Withdrawals: gooseflesh, shivering, profuse sweating,
feeling feverish, aching limbs, yawning, runny eyes,
runny nose, gastrointestinal disturbances such as
stomach cramps, nausea, vomiting and diarrhoea.
Risks: overdose, injecting related problems, BBVs,
accidents
Other Drugs: solvents, ecstasy,
LSD, amphetamines
Other Drugs
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Hallucinogens: LSD, magic mushrooms
– Distort perceptions for several hours
– “psychotic” trip
– Can be terrifying “bad trip”
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Ecstasy
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Stimulant and mildly hallucinogenic
Feelings of empathy, energy
Depression and short term memory problems
Death as a result of kidney failure
Amphetamines
– Effects like cocaine
– Paranoia and aggression
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Solvents and gases
– Sniffed, inhaled
– Intoxication
– Risk of instant death, brain damage, accidents
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Caffeine– “Red Bull”; coffee; cola drinks
– Stimulants, irritability, aggression, paranoia
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OTC- over the counter (cough linctus, anti-histamines etc)
Prescription drugs- benzodiazepines, anti-cholinergics