Transcript Maja Makovec

Treatment of Addiction and Co-occurent Mental
Problems: The Power of Interdisciplinary Knowledge
Maja Rus Makovec
University Psychiatric Hospital Ljubljana
Chair of Psychiatry, Medical Faculty Ljubljana
M Rus-Makovec 11 EFTC 2007
How people change their behavior? Can we agree:
– People have their own way how they can learn
(develop, change …): pressure, support, alone, in
group, …; capacity for self-treatment
– Their capacity for change differs in time (“it was not
the right time”)
– People are specific mixture of sources of power and
vulnerabilities, yet there are some universal features
for change
– Addicted people differ: special heterogeneity of legal
drugs addiction
– Equifinality of legal drug (alcohol) addiction: there can
be different pathways to similar condition
M Rus-Makovec 11 EFTC 2007
Bio-psycho-social model of addiction
• State-of-art: do not stop at the level of brain
neurotransmitter biochemistry but to place a person’s
mental dysfunction manifesting itself in their human
suffering and certain behavior into the person’s psychosocial context (Eisenberg, 1999).
• Addicted person: does not want to change or can not
because of biological or other obstacles? Who or what is
responsible for change?
• In western culture learning “per partes” is favoured
(Bateson): different levels of experience are rarely coconstructed – “to fell in love” with one’s own experience
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“What everybody in addiction professional community
should know about co-occurrent mental problems”
• Following co-occurent metal problems with mainly or
partly neurobiological basis can severly damage
addicted persons’ ability for psycho-social change (and
are not only a construct):
– neuro-cognitive impairment of working memory
• restrict abilities to receive, encode and integrate the newly
introduced information
– dual diagnosis of serious mental disorder (as
depression, anxiety, psychosis …)
– trauma experience
– personal development resulting in serious personal or
relational disorder (developmental trauma)
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What to do with information about co-occurent problems?
• To help patients with co-occurent mental problems
efficiently - need for
– More patience
– More time
– More interdisciplinary cooperation
– To have realistic goals of treatment
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Different levels of interactions between drug and other
mental disorder (co-occurent, dual diagnosis, comorbide
state …)
• Drug or end of drug use can induce depression
• Popular theory about drug use as secondary to an
“underlying depressive disorder”
• Two mental problems independently at the same time
• Each mental problem worsen the other
• Addiction can be extremely dramatic per se and without
co-occurrent disorders
• Addiction can be less dramatic in appearance but more
reluctant to change because of co-occurrent disorders
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Major consequences of comorbidity
• At least one-half of the patients in psychiatric and
substance use treatment with comorbid disorder (Regier
et al. 1990, Kessler et al. 1994)
• Higher service utilization …
• More severe symptoms …
• Greater functional disability (Bijl, Ravelli, 2000)
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One of many perspectives on addiction:
• “Altered and and damaged neurochemistry underlies
(their) tragic vulnerability …– the addicts have to struggle
with powerful midbraincircuits (Dackis, Gold, 1998)
• Such perspective counters the notion about “lack of will
power”: surprising, empowering, respect- and hopeintroducing fact is, that so many addicted people
challenge their biology efficiently because of right
motivation and support
• Some addicted people have such an enormous obstacle
of co-occurent mental problems, that they need special
help and special context of treatment to reach their
human capacity for change
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Center for Alcohol Addiction Treatment of University
Psychiatric Hospital Ljubljana
• Started in 1970 with phylosophy of therapeutic
community, now-a-day “addiction psychiatry –
psychotherapy” orientation with some aspects of TC
• 33 slots in inpatient and 30 slots in outpatient treatment
for patients with alcohol and benzodiazepine addiction,
in last year some patients with previous experience of
TC
• After-care: cca 300 visits per month
• Abstinence-based programme: predominantly
psychosocial interventions combining with
pharmacologic agents for dual diagnosis
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• Indications for admission are severe psychosocial or
psychiatric conseqences of addiction or difficulties /
inability to attain abstinency despite previous attempts.
• Population of patients is not preselected.
• Treatment offers (mainly) group psychotherapy and
individual interventions. Heterogenous groups
• The program is encouraging admission of patients with
co-occurrent mental (psychiatric) disorders
• Patients with severe impairment in neuropsychological
functioning ordinary can not follow the program, as well
as acutely suicidal or psychotic patients without longterm stable remission
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• Intensive treatment is conceptualised as:
– 1st part: in-patient setting
– 2nd part: out-patient setting (day-hospital).
• Active participation of important others is stressed as the
essential part of the programme.
• After-care recovery is strongly recommended
• If comorbide disorders or/and severe interpersonal
problems are identified during the intensive treatment
period, psychotherapy (individual, couple, family therapy)
or psychiatric care is offered to the patients after
discharge
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• Team need to negotiate how to combine the focus
– on behavioural changes (“rehabilitation”,
normative part of approach) and
– non-directive encouragement for increasing
autonomy of patients, attainment of insight and
cultivation of the patient / therapist relationship
• “Matching comorbid psychiatric severity in substance-related
disorders to treatment program characteristics may be more
advantageous because of the emphasis on individualized and
specific levels of intensity of treatment “(McLellan, 1993)
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Research on effectiveness of addiction treatment
programme
• Patients (n = 622) were included in the study
consecutively after the admission
• Group 1 (n = 347 at the beginning) was supposed to be
followed
– at the beginning
– at the end of intensive treatment programme
– 3, 6, 12 and 24 months after discharge from the intensive
treatment programme
• Group 2 (n = 275 at the beginning) was supposed to be
followed
– at the beginning
– at the end of intensive treatment programme
– 24 months after discharge from the intensive treatment program
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• Independent variables
–
–
–
–
–
–
Demographic variables
Co morbidity
Treatment context (in- & out-patient)
After-care treatment
Social support in treatment
Time stage in treatment process
• Treatment success critheria / dependent variables
– Abstinence (sobriety)
– Self-evaluation of mental health, physical health,
financial status, relations with important others, quality of
life
– Changes in marital status / partnership
– Changes in employment status
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• Abstinence / sobriety rate after intensive treatment discharge
– 3 months (n = 213): 85 % abstinent
– 6 months (n = 177): 84 % abstinent
– 12 months (n = 116): abstinent 86 %
– 24 months (n = 213): abstinent 80 %
• Included in some form of after-care
– 3 months: 60 %
– 6 months: 61 %
– 12 months: 59 %
– 24 months: 58 %
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The most frequent co-occurent diagnoses
• After at least 1 months of sobriety the co-occurrence
syndromes are diagnosed, avoiding those anxiousdepressive symptoms as after-end-of-drinking-cessation
should be diagnosed as comorbide/co-ocurrent category
• Depression 19.8 %
• Anxiety disorders 11 %
• Personal disorders 20.9 %
• Benzodiazepine dependency 19 %
• Nicotine dependency 62.2 %
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Comorbide diagnoses and abstinence – no significant risk
found (2, p)
•
•
The finding is explained by their inclusion in proper modality of after-care
treatment, combining psychotherapy and pharmacotherapy.
The only vulneralibility regarding length of abstinence was found in smokers at 6
months (x = 5.9 (1), p = 0.015): smokers showed greater percent of probability
to relapse than non-smokers at that time of evaluation.
3m
6m
12 m
24 m
Depression
0.35
0.792
0.08
0.767
0.89
0.345
0.50
0.480
Anxiety
0.13
0.714
0.17
0.673
3.0
0.081
1.9
0.163
Personal
disorder
0.84
0.357
0.004
0.951
1.9
0.162
1.1
0.302
M Rus-Makovec 11 EFTC 2007
Accurracy of diagnosis of main comorbide disorders in % - too strict
and especially underdiagnosed anxiety states
• The quality of diagnosing was controlled by Mini
International Neuropsychiatric Interview instrument (MINI)
rutine
MINI
Depression
Disthymia
19.8
21.4
11.4
Anxiety disorder
Panic
Generalised
PTSD
11
6.4
16.4
3.6
M Rus-Makovec 11 EFTC 2007
At the beginning of intense treatment
n = 517
- 0.29
0.000
At the end of intense treatment
n = 427
- 0.25
0.000
3 months aftre discage
n = 204
- 0.39
0.000
6 months after discharge
n = 167
- 0.33
0.000
12 months after discharge
n = 108
- 0.23
0.018
24 months after discharge
- 0.38
0.000
n = 209
M Rus-Makovec 11 EFTC 2007
Correlations (r, p)
between selfevaluations of
psychological health
and n of psychiatric
diagnoses
Problems found in diagnostic procedure
• Dual diagnosis syndromes are hidden behind drug
addiction symptoms
• Vice versa, alcohol addiction (also in the early recovery)
can mimic almost all psychiatric symptomes
• In the beginning of treatment addicted patients can be
more prone to defensive attitude and denial instead to
good therapeutic alliance
• Often neuro-cognitive impairment is under-estimated
• Alcohol / drugs can force numbing or dissociative
reactions after trauma causing cognitive and emotional
distortions of experience
– F.e. patient with trauma experience can also be prone to
manipulation
M Rus-Makovec 11 EFTC 2007
Integrated treatment
• In last years it became apparent that some people can
not process stable recovery without concurrently
addressing co-occurrent states and psychological
trauma dynamics
– before we waited first to stable abstinence before
addressing trauma issue, which sometimes never
come
– secondly, it was learned that concurrent treatment did
not result in more relapses (Carruth, Burke 2006).
M Rus-Makovec 11 EFTC 2007
• Psychiatric context can offer concurrent treatment for
alcohol / drugs addiction and severe co-occurrent mental
symptoms including complex symptoms of psychological
trauma because of their broad base of clinicians,
experienced in addiction, psychiatric and
psychotherapeutic fields
• Need for new paradigm in addiction as well in psychiatric
context?
M Rus-Makovec 11 EFTC 2007
Structure of professional and non-professional cooperation in alcohol
addiction problem in SI
Psychiatry
• Detoxification
• Dual diagnoses
Social
Service
GP
Somatic
hospitals
•“ordinary”
• family
medicine
Clients/patients
directly
Addiction psychiatrist
• mental out-patient clinics
• psychiatric hospital
in-patient treatment
day hospital
Non-institutional help
• AA
• Self-help groups
•…
out-patient treatment
After-care (institutional)
- »clubs« of treated A
- group therapy
- family therapy
M Rus-Makovec 11 EFTC 2007 - individual psychotherapy
Not to miss opportunity
for efficient help …
• … because of the way we construct our knowledge: we
use knowledge that informs us about the territory of our
work – we include and exclude what we are trying to
think about and “know”
• … disciplinarity as a form of knowledge and the dynamics of
oppositionality and competition … (Flaskas 2003)
Meta – knowledge: if we construct our knowledge in
systemic way, then we can get pieces of puzzles about
phenomena of addiction together
M Rus-Makovec 11 EFTC 2007