Transcript Kuutioarviointi kaksoisdiagnoosipotilailla

CUBE assessment with dual
diagnosis patients
Olli Kampman
Adjunct Professor, Univ Tampere,
Medical School, Dept of Psychiatry
Dual diagnosis, DD
• Severe mental disorder (sch, bipolar disorder,
severe depression, comorbidity)
+ at least substance dependency
• Different determinations, lack of constant
terminology
Why new assessment method?
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Need for categorising the DD problem
Epidemiological numbers are varying
Treatment is not currently based on diagnoses
The problem is not recognised or no treatment is
available for DD patients
Difficult to assess outcome
Increasing stigma around the DD problem
A comprehensive problem which is more than a
sum of ingredients
Etc..
Cube assessment method
• Three dimensions: mental disorder, substance
abuse, level of functioning
• Brief and simple assessment
• Gains information for prognosis evaluation
• Recognising risks
(continuous or habitual problem drinking, social
problems, increasing psychic symptoms, poor
functioning)
• Indicator of recovery: follow-up e.g. between 3-6
months
Cube model and SUD intervention
MENTAL DISORDER
CUBE=2-3
AUDIT>10
AUDIT 0-10
CUBE=0-1
OTHER THAN ALCOHOL?
FRAMES
PSYCHOSIS
OTHER
FOLLOW-UP 2 MO
YES: LIKE AUDIT >10
NO: NOT DD
SUD-CLINICS,
PSYCH. CONS.
MOTIVATIONAL INTERVIEW
MHS: HOME VISITS, WARD
CRA, CRAFT
Cube sub-scores
A. Substance abuse: 0/1
B. Mental disorder: 0/1
C. Level of functioning: 0/1
Total risk score 0-3; treatment option
depends on this
Kampman, Lassila SLL 2007:47
Cube (3-dimensional assessment)
Psychotic
disorder
3
Severe
Substance 2
abuse
1
Mild to
moderate
Mental
disorder
2
1
2
0
Good
1
Score
Other
Poor
Primary
intervention
0-1
FRAMES
2-3
Motivational
interview
CRA, CRAFT
Cube sub-scores (0)
A. Substance abuse:
Non-complicated dependency no more than 2 yrs
B. Mental disorder:
Non-psychotic disorder
C. Level of functioning: GAF >50
Screening of substance abuse: AUDIT
Assessment
The severity of substance abuse is assessed, if
AUDIT score at least 11
A. Substance abuse=0
1. Solely alcohol use (or any other single
substance use)
2. Problem within dependency level
(and the use at most 3 days/week)
3. Continuous problem less than 2 yrs
All above criteria must be fulfilled, otherwise
the severity of substance abuse=1
Assessment
B. Mental disorder (last month)
Other than psychotic=0
(depression, anxiety disorder, personality
disorders, co-morbidity)
Psychotic=1
(schizofrenia, bipolar disorder, other)
Assessment
C.Level of functioning (last month)
1.GAF>50=0
2.GAF<50=1
GAF?
Category 50-41:
Serious symptoms (e.g., suicidal ideation, severe
obsessional rituals, frequent shoplifting) OR any serious
impairment in social, occupational, or school functioning
(e.g., no friends, unable to keep a job)
91 - 100 Superior functioning in a wide range of activities, life's problems never seem to get out of hand, is
sought out by others because of his or her many positive qualities. No symptoms.
81 - 90 Absent or minimal symptoms (e.g., mild anxiety before an exam), good functioning in all areas,
interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more
than everyday problems or concerns (e.g., an occasional argument with family members).
71 - 80 If symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g.,
difficulty concentrating after family argument); no more than slight impairment in social, occupational, or
school functioning (e.g., temporarily falling behind in schoolwork).
61 - 70 Some mild symptoms (e.g., depressed mood and mild insomnia) OR some difficulty in social,
occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally
functioning pretty well, has some meaningful interpersonal relationships.
51 - 60 Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR
moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or coworkers).
41 - 50 Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any
serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job).
31 - 40 Some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or
irrelevant) OR major impairment in several areas, such as work or school, family relations, judgment, thinking,
or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up
younger children, is defiant at home, and is failing at school).
21 - 30 Behavior is considerably influenced by delusions or hallucinations OR serious impairment, in
communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation)
OR inability to function in almost all areas (e.g., stays in bed all day, no job, home, or friends)
11 - 20 Some danger of hurting self or others (e.g., suicide attempts without clear expectation of death;
frequently violent; manic excitement) OR occasionally fails to maintain minimal personal hygiene (e.g.,
smears feces) OR gross impairment in communication (e.g., largely incoherent or mute).
1 - 10 Persistent danger of severely hurting self or others (e.g., recurrent violence) OR persistent inability to
maintain minimal personal hygiene OR serious suicidal act with clear expectation of death.
0
1
Assessment and follow-up
date 1
date 2
date 3
date 4
A. Substance abuse
1
1
0
0
B.Mental disorder
0
0
0
0
C. Level of functioning
1
1
1
0
Total
2
2
1
0
Cube (3-dimensional assessment)
Psychotic
disorder
3
Severe
Substance 2
abuse
1
Mild to
moderate
Mental
disorder
2
1
2
0
Good
1
Score
Other
Poor
Primary
intervention
0-1
FRAMES
2-3
Motivational
interview
CRA, CRAFT
Cube model and SUD intervention
MENTAL DISORDER
CUBE=2-3
AUDIT>10
AUDIT 0-10
CUBE=0-1
OTHER THAN ALCOHOL?
FRAMES
PSYCHOSIS
OTHER
FOLLOW-UP 2 MO
YES: LIKE AUDIT >10
NO: NOT DD
SUD-CLINICS,
PSYCH. CONS.
MOTIVATIONAL INTERVIEW
MHS: HOME VISITS, WARD
CRA, CRAFT
Assessment and follow-up
date 1
date 2
date 3
date 4
A. Substance abuse
1
1
0
0
B.Mental disorder
0
0
0
0
C. Level of functioning
1
1
1
0
Total
2
2
1
0
Cube assessment in Lahti area
• Local nursing staff participating in regional DD
education
• Five units in SU and psychiatric services (in- and
outpatient units)
• Inclusion criteria mental disorder + harmful SU,
consecutive patients during spring 2009
• No patient identification, questions to staff
• Aim: testing validity and usefulness of the Cube
assessment
Cube assessment in Lahti area:
results
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Patients, n=85, men 2/3, 42±14 yrs.
55% psych. treatm., 45% SU services
45% multiple SU
Duration of SUD 17±11v.
In 50% dg psychosis (F2), 1/3 mood disorders
Cube score (n): 1 (7)
2 (30)
3 (48)
Time used with assessment: 7±3 min.
Perceived difficulty of assessment (0-100 VAS):
34±13
Cube assessment in Lahti area:
results
• SU duration associated
with Cube score
(group 2 < 3)
• Time used with
assessment related to
Cube score, equally
difficult in gr. 2 and 3
Prevalence of DD in
Ostrobothnia district
• MHS case count in January 2008
• All units in SO
(outpatient care 14 days, hospital 28 days)
• GAF assessment after 6 months according to
information in patient records
• N=1219 (appr. 2/3 of outpatient visits/
hospitalisation periods)
• AUDIT ≥ 8, n=322
Prevalence of DD in
Ostrobothnia
Diagnoses
N (%)
Psychoses (F2 + bipolar + psychotic
depression)
113 (35.1)
Depression (primary dg, non-psychotic)
138 (42.9)
Current or earlier diagnosis of SUD
Any other substance than alcohol use during
last 12 months (self-report)
90 (28.0)
26 (8.3)
Prevalence of DD in
Ostrobothnia
AUDIT-score
N (%)
8-10
95 (29.5%)
11-15
102 (31.7%)
16-20
61 (18.9%)
yli 20
64 (19.9%)
Prevalence of DD in
Ostrobothnia
GAF 50 or below
GAF over 50
N=136 (42.2%)
N=186 (57.8%)
Psychosis
N=79 (58.1%)
Depression
N=43 (31.6%)
Anxiety disorders
N=6 (4.4%)
Psychosis
N=32 (17.2%)
Depression
N=95 (51.1%)
Anxiety disorders
N=25 (13.4%)
Cube: conclusion
• Simplifying complex problem
• Suitable for clinical use
• Differentiates between psychotic and nonpsychotic DD-patients
• Time of assessment increases with more severe
problems, but is still easy
• Duration of SUD problem is closely connected
with the total score