Transcript Integrated Treatment of Co-Occurring Mental Illness (MI

Integrated Treatment of Co-Occurring
Mental Illness (MI) and Substance Use
Disorders (SUD)
Krishna Balachandra, M.D., FRCPC
Concurrent Disorders Program
University of Western Ontario
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Co-Occurring Disorders
(COD)

~50% Serious disorders have SUD

Physicians inadequately trained in SUD

Pts with COD  suboptimal care

Pts with COD at  risk
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Definitions

Mental disorders

Substance abuse ≥ 1 of

Obligations

Hazardous use

Legal

Interpersonal
problems

Substance dependence ≥
3 of
 Tolerance
 Withdrawal
 Amounts/time
 Cut
 Time
 Activities
 Physical/psychological
problems
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Co-Occurring Disorders
Substance
Use
Disorder
Mental Illness
COD
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This Lecture Reviews

Epidemiology

Etiology

Treatment overall

Relevance of integrated treatment
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Epidemiology of COD
17
SUD
AUD
DUD
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Epidemiology of COD
56
Bipolar
3-5 X’s
17
SUD
AUD
DUD
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Epidemiology of COD
83
56
ASPD
5-7 X’s
17
SUD
AUD
DUD
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Etiology of COD
Common Vulnerability

Common genes

Twin study of AUD + Depression

ASPD

Common physiology in both

HPA axis

Hippocampus/frontal cortex

Cannabinoid, dopamine receptors
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Etiology of COD
SUD as Response to MI
Mental Illness

 Symptoms

 Social skills

 Medication side effects
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Substance
Use
Disorder
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Etiology of COD
MI as Response to SUD
Substance
Use
Disorder
Mental Illness

Cannabis use  ↑ rates of psychosis

Meta-analysis supports ↑ risk

Possible genetic mechanism
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We Have Reviewed

Epidemiology 

Etiology 

Treatment overall

Relevance of integrated treatment
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Treatment Strategies
Advantages
Disadvantages
Sequential Rx
+
+++++
Parallel Rx
++
++++
Integrated Rx
+++
++
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Integrated Treatment

Simultaneous treatment

Consistency of location and providers

Advantages

Disadvantages
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Integrated Rx: Clinical Case

27 M, Bipolar, Alc dep

++ ER visits

No show appts

Frustrated docs

Legal charges

Homeless
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Principles of Integrated Rx

“No wrong door”

Shared decision making

Comprehensiveness

Assertiveness
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Principles of Integrated Rx

 Negative consequences

Time unlimited

Multiple therapies

Cultural sensitivity
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Principles of Integrated Rx

Motivation based treatment

Engagement

Persuasion

Active treatment

Maintenance/Relapse prevention
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Integrated Treatment
Engagement

Goal: Establish working relationship

Outreach

Practical assistance


E.g. housing
Crisis intervention
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Integrated Treatment
Engagement

Support + assistance to social network

Stabilize medical/psychiatric illness

Address legal issues

Family visits

Close monitoring
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Integrated Treatment
Persuasion

Goal:  awareness of problem

Individual + family education

Groups to discuss pros/cons of using

Non substance social skills
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Integrated Treatment
Persuasion

Structured activity

E.g. supported employment

Social + rec activities

“Damp” housing

Psychiatric stabilization
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Integrated Rx: Clinical Case

27 M, Bipolar, Alc dep

 ER visits

Keeps appts

Happier docs

Legal assistance

Housing

Alcohol use continues
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Integrated Treatment
Active Rx

Goal:  substance use

Strategies to substance use

Social skills


E.g. refusal skills
Self help groups

E.g. “Double Trouble”
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Integrated Treatment
Active Rx

Individual psychotherapy

Substitute activities

Meds

 Substance use (e.g. disulfiram, naltrexone)

“Dry” housing

Stress/coping skills
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Integrated Treatment
Maintenance/Relapse Prevention

Goal: maintain and extend recovery

Social skills


E.g. interpersonal relationships
Problem solving

E.g. new ways to cope
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Integrated Treatment
Maintenance/Relapse Prevention

Lifestyle improvement

E.g. smoking cessation

Independent housing

Role modeling

E.g. leading groups
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Hank’s 12 step program
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Efficacy of Integrated Rx

 Retention


55% Integrated Rx > 35% usual Rx
 Substance use

40% Abstinence post Rx vs 2% baseline

60% Negative urine integrated Rx > 25% usual Rx
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Efficacy of Integrated Rx

 Financial stress

40% Employed vs 5% baseline

60% Housing vs 50% baseline

70% $ For basic needs > 45% usual Rx

6000 $/pt Criminal justice cost savings
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Efficacy of Integrated Rx

 Hospitalization


7% Post-integrated Rx vs 30% pre Rx
 Rates of arrest

13% Post-integrated Rx vs 30% pre Rx
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We Have Reviewed

Epidemiology 

Etiology 

Treatment overall 

Relevance of integrated treatment 
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