Transcript What is DDx? - Dual Diagnosis

Workshop
What do mental health workers need to know?
June 2006
Dual Diagnosis introduction
for
mental health workers
Gary Croton
Eastern Hume Dual Diagnosis Service
This presentation….
DDx
cohorts
Definitions
Terminology
Making
sense
of it
Relai’/ps
b/t the
disorders
What is DDx?
Why does it matter?
Prevalence
Potential
Policy
Harms
Demand
What is DDx?
Terminology
Definitions
‘Dual
Diagnosis’
‘Co-occurring
Disorders’
definition:
co-occurrence of any Mental Health Disorder
with any Substance Use Disorder
‘Comorbidity’
Other
terms:
‘Concurrent disorders’….. ‘MICA’….. ‘MISA’…. ‘CAMI’…. ‘SAMI’…. ‘MISUD’…..
c.f.
‘dual disability’:
people with both intellectual disability
and mental illness
DDx
cohorts
Combinations of disorders
Great variety in…
Severity of disorders
Treatment needs
DDx
cohorts
Common dual diagnosis presentations
1. To Primary Care / General Practice
Early psychosis with cannabis abuse or dependence
Anxiety with alcohol abuse or dependence
Depression with alcohol abuse or dependence
DDx
cohorts
Common dual diagnosis presentations
2. To an AT&OD treatment agency
Amphetamine abuse with paranoid symptoms
Opiate abuse or dependence with personality disorder
Alcohol dependence with anxiety &/or depression symptoms or disorder
DDx
cohorts
Common dual diagnosis presentations
3. To an Mental Health treatment agency
Personality disorder with episodic polydrug abuse
Mood disorder with stimulant or depressant abuse or dependence
Schizophrenia with alcohol, cannabis or polydrug abuse or dependence
ICD-10 combinations of disorders
DDx
cohorts
MENTAL
DISORDER
- Organic mental
disorders
- Schizophrenia &
delusional disorders
CLINICAL
STATE
- Alcohol
- Acute
intoxication
Disorders of
personality
- Disorders of
Psyc’al develop’nt
-Disorders with
childhood/ adol’nce
onset
- Opioids
- Cannabinoids
- Harmful use
- Mood disorders
- Neurotic disorders
SUBSTANCE
- Dependence
syndrome
- Sedatives or
hypnotics
- Cocaine
- Other stimulants
- Withdrawal
state
- Withdrawal
state with
delirium
- Hallucinogens
- Tobacco
- Volatile solvents
- Multiple drug use
DDx
cohorts
How do I make sense of it?
How do I make sense of it?
DDx
cohorts
Tier 3
Hi MH with or without SUD
Tier 2
Hi SUD with or without MH
Tier 1
Lo MH & or Lo SUD
with or without COD
Tier 3
Tier 2
Tier 1
Specialist mental health
Clinical & PDRSS
Specialist AT&OD
Possibly PMH teams
Primary Care
General Practice
Community Health
Victorian DHS Policy: Dual Diagnosis
Key directions and priorities for service development
March 2006
Relationships
b/t the
disorders
4 models:
1. Common
risk factors:
2. MH causes
SUD
-
MHD ↑ vulnerability to SUD
Self medication
↓ dysphoria
Super sensitivity
3. SUD
causes MH
4. Bidirectional
- Genetic risk factors
- Trauma
- Poor cognitive functioning
- Amphetamine psychosis
- Cannabis psychosis?
- Ongoing interaction
Relationships
b/t the
disorders
More than 1 model may apply at different times
What maintains the comorbidity is the
most relevant to treatment
Why does DDx matter?
Prevalence
Co-occurring disorders are common in the
general population
In treatment populations co-occurring disorders are
the expectation not the exception
Key
messages
Having 1 of the disorders substantially increases
your risk of also developing the other disorder
Prevalence of particular combinations of disorders
varies with different treatment settings
Prevalence
General
Population
General
Practice
AT&OD
treatment
Mental
Health
General
Population
Prevalence
1997 NSMHW
Australian population / any 12-month period
Anxiety Disorder: 9.7%,
Substance Use Disorder: 7.7%
Mood Disorder: 5.8%
1 in 4 with one of the disorders also had one of the other disorders!!
Alcohol dependent:
4.5 x more likely to also have an Affective disorder
4.4 x more likely to also have an Anxiety disorder
Cannabis dependent:
4.3 x more likely to also have an Anxiety disorder
Tobacco users
2.2 x more likely to also have an Affective disorder
2.4 x more likely to also have an Anxiety disorder.
Prevalence
General
Practice
Hickie et al, 2001 study: (n=46,515)
Comorbidity of common mental disorders & alcohol or other
substance misuse in Australian general practice
56%
Prevalence of mental health &/or substance use
amongst persons attending General Practice
Co-occurring mental disorders & substance misuse in
patients attending General Practice
12%
AT&OD
treatment
Prevalence
Weaver et al, 2002 (UK)
55%
2 or more psych. disorders
19%
53%
81%
Psychotic Disorder
Personality Disorder
Alcohol
service
users:
Depression &/or Anxiety Disorder (n = 62)
8%
36%
Psychotic Disorder
Depression or Anxiety Disorder alone
68%
Depression & Anxiety Disorder
37%
Personality Disorder
No MH
disorder
15%
MH
disorder
85%
Drug
Service
users:
(n= 216)
No MH
disorder
25%
MH
75%
disorder
Prevalence
Mental
Health
Vic MH Branch 2002 - 24hr census
Clinical sample:
45% reported alcohol or drug abuse/ dependence
(possible underestimate).
- Cannabis abuse/dependence = 37% of all comorbidity
- Alcohol abuse/dependence = 31%
- Amphetamine abuse/ dependence = 10%.
Severely mentally ill:
Harms
•
•
More frequent relapse and hospitalisation
Greater housing difficulties & homelessness
•
Violence and exploitation
• Forensic involvement:
Wallace, Mullen and Burgess (2004).
- persons with schizophrenia committed 8 x the # of offences as non-schizophrenia
matched control group
- much higher rates of criminal conviction for persons with schizophrenia with
substance abuse than for those without substance abuse problems (68.1% versus
11.7%).
•
•
Physical disorders
Increased treatment costs
•
•
Carer trauma & loss
Blood-borne infections
•
•
Suicide risk
Unemployment / work instability / poverty
Demand
2006 Senate Mental Health Inquiry
submissions & reports
2003 ‘Out of Hospital, Out of Mind’
2 top priorities:
- Implementation of earlier intervention strategies
- Attention to the overlap between mental health & drug &
alcohol abuse
SANE Mental Health Report card 2004
‘There are no coherent national strategies covering key issues
such as dual diagnosis’
2005 ‘Not for service’
Policy
Victorian
MH &
DP&S Branches
Dual Diagnosis:
Key directions and priorities
for service development
Policy:
March 2006
Forum
April 2006
5 mandated service development outcomes:
1. Dual diagnosis is systematically identified
and responded to in a timely evidence-based
manner as core business in
both mental health and d & a services.
2. Staff in mental health and d&a services
are dual diagnosis capable (have the necessary
knowledge and skills to provide
integrated responses to people with dual diagnosis).
Policy
Victorian
MH &
DP&S Branches
Dual Diagnosis:
Key directions and priorities
for service development
5 mandated service development outcomes:
3. Specialist mental health and d&a services
develop partnerships for the provision of
integrated treatment and care.
(No wrong door service system)
4. Client outcomes and service responsiveness to dual diagnosis
clients are monitored and regularly reviewed
5. Consumers and carers are involved in the planning
and evaluation of service responses.
Policy
Commonwealth /
State COAG:
2006/07 budget:
$21.6 mill:
campaign alerting community to
links b/t illicit drug use & mental health.
$73.9 mill :
training/ resources to assist AT&OD workers
to provide effective Rx
National Comorbidity Initiative
Federal
initiatives
ADGP – Managing the mix – primary care initiative
National Youth Mental Health Foundation
Potential
Improving our recognition of and response to cooccurring SUDs will improve the effectiveness of
our treatment of mental health disorders
References
• Andrews, G., Hall, W., Teesson, M., Henderson, S.
(1999). National survey of mental health and wellbeing:
Report 2: The mental health of Australians. Canberra,
Department of Health and Aged Care
• Croton, G. (2005): Australian treatment system’s
recognition of and response to co-occurring mental
health & substance use disorders Senate Mental Health
Inquiry Submission
• Degenhardt, L., Hall, W., Lynskey, M (2001) Alcohol,
cannabis and tobacco use among Australians: a
comparison of their associations with other drug use and
use disorders, affective and anxiety disorders and
psychosis. Addiction 96, 1603-1614.
References
• Groom et al, (2003), ‘Out of Hospital, Out of Mind' Mental
Health Council of Australia
• Hickie, I, Koschera, A, Davenport, T., Naismith, S., Scott,
E. Comorbidity of common mental disorders and alcohol
or other substance misuse in Australian general practice.
Med J Aust. 2001 Jul 16; 175 Suppl: S31-6.
• Mental Health Council of Australia, (2005) Not For
Service: Experiences of Injustice and Despair in Mental
Health Care in Australia, Canberra
• SANE (2004) SANE Mental Health Report 2004
References
• Victorian DHS: Dual Diagnosis: Key directions and
priorities for service development. Draft policy version
March 2006
• Wallace, C., Mullen, P., Burgess, P. (2004). Criminal
offending in Schizophrenia over a 25-year period marked
by deinstitutionalisation and increasing prevalence of
comorbid substance use disorders. Am J Psychiatry
161:4, April 2004.
• Weaver, T., Madden, P., Charles, V. (2003) Comorbidity
of substance misuse and mental illness in community
mental health and substance misuse services.
BJPsychiatry , 183 304-313
• WHO International Statistical Classification of Diseases
and Related Health Problems 10th Revision Version for
2006
Resources / More info
• Dual Diagnosis Australia & NZ /
Co-occurring disorders
roundup www.dualdiagnosis.org.au
• National Comorbidity Initiative
http://www.health.gov.au/internet/wcms/publishing.nsf/Content/healt
h-pubhlth-strateg-comorbidity-index.htm
• Managing the Mix
http://www.adgp.com.au/site/index.cfm?display=4614
• CCISC model / Drs Ken Minkoff & Christie Cline
http://www.kenminkoff.com/index.html
http://www.zialogic.org/
• TIP 42: Substance Abuse Treatment for Persons With Co-Occurring
Disorders
http://store.health.org/catalog/ProductDetails.aspx?ProductID=1697
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