Transcript Co-occurring addiction and mental disorders

Co-occurring Addiction and
Severe
Mental Disorders
Richard Ries MD
Harborview Medical Center
University of Washington
Seattle, Wa
Dr Ries speaks for:
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Lilly, Janssen, Pfizer, Forest, Zeneca,
Bristol Myers, Abbot,
States, counties, NAMI, mental
health centers, addiction agencies,
and others (even in prisons)
DUAL DIAGNOSIS IS:
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TWO DIAGNOSES/ DISORDERS
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TWO SYSTEMS
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DOUBLE TROUBLE
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IN THE EYE OF THE BEHOLDER
Examples of Dual Disorders:
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MENTAL DISORDERS
 Schizophrenia
 Bi-polar
 Schizoaffective
 Major Depression
 Borderline
Personality
 Post Traumatic
Stress
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ADDICTION
DISORDERS
 Alcohol
Abuse/Depen.
 Cocaine/ Amphet
 Opiates
 Marijuana
 Polysubstance
combinations
 Prescription drugs
CHARACTERISTICS OF THE DUAL
DIAGNOSIS CLIENT IN KING COUNTY
Severity of
Chemical Dependency
High
LH
HH
2
Severity of
Psychiatric
Condition
1
4
Low
3
HL
LL
Low
High
Dual Disorders for Everyone?
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If applied to all cases, Term has no
meaning
Both Mental and Addiction Disorders need
to be over threshold
Personality Disorders, other than
Borderline not usually counted
Substance Induced Disorders cause
diagnostic confusion
Drug Induced Psychopathology
Drug States
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Withdrawal
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Acute
Protracted
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Symptom Groups
Intoxication
Chronic Use
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Depression
Anxiety
Psychosis
Mania
Systems Problems
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Different
Different
Different
Different
Different
Different
Different
Laws…commitment/confid.
funding..audits etc
personnel
training
certification
sites
Norms
DOUBLE TROUBLE
 Hall
 Alterman
 Solomon
 Safer
 Drake
 Barbee
 Lyons
 Chen
’77
’85
’86
’87
’89
’89
’89
’92
Poor out-pt attendance, discontinue Rx
More mood changes, intensive staffing
More noncompliance, arrests
Over twice hosp. rate and criminal behav
More hostility, noncompliance
More psych symptoms
More noncompliance, ER, jail, rehosp.
Worse treatment course
Likelihood of a Suicide Attempt
Increased Odds Of
Attempting Suicide
Risk Factor
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Cocaine use
Major Depression
Alcohol use
Separation or Divorce
NIMH/NIDA
62 times more likely
41 times more likely
8 times more likely
11 times more likely
ECA EVALUATION
Therapy Plan
Bio
Psych
Social
Psych
Labs
Meds (antipsychotics
etc.)
1:1 cog/beh
Psychoeducation
Groups etc
Couples conf.
D/C planning
housing, etc.
CD
Labs
Meds (withdrawal, craving,
etc.)
Step work
Groups
AA Meetings
Intervention
Sober housing
Engaging the Chronically
Psychotic Patient
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Noncoercive engagement techniques
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Assistance obtaining food, shelter, and clothing
Assistance obtaining entitlements and social
services
Drop-in centers as entry to treatment
Recreational activities
Low-stress, non-confrontational approaches
Outreach to patient’s community
Coercive engagement techniques
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Involuntary commitment
Mandated medications ( parole etc)
Representative payee strategies
CSAT TIP 1994
CHARACTERISTICS OF THE DUAL
DIAGNOSIS CLIENT IN KING COUNTY
Severity of
Chemical Dependency
High
LH
HH
2
Severity of
Psychiatric
Condition
1
4
Low
3
HL
LL
Low
High
CURRENT SUBSTANCE USE PROBLEMS
in acute psychiatric inpatients
% None
% Current but low SI sx
% Current and high SI sx
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Bipolar, Depressed
Comtois, Ries & Russo 2004
Bipolar, Manic
Unipolar Depression Schizophrenia/Schizoaffective
DIAGNOSTIC GROUP: BIPOLAR DEPRESSED
Recent Suicide Crisis %
100
90
80
70
60
50
40
30
20
10
0
Lifetime Suicide Attempt %
OR 2.1***
OR 2.5***
OR 1.5*
OR 1.0
None
Odds Ratios are
adjusted for age,
gender, and ethnicity
*p<.05**, **p<.01, ***p<.001
Current Problems,
Symptoms not Substance
Induced
Current Problems and
Substance Induced
Symptoms
Current Substance Use Problems
Comtois, Ries & Russo 2004
DIAGNOSTIC GROUP: BIPOLAR MANIC
Recent Suicide Crisis %
100
90
80
70
60
50
40
30
20
10
0
Lifetime Suicide Attempt %
OR 3.4***
OR 2.5***
OR 2.2**
None
Odds Ratios are
adjusted for age,
gender, and ethnicity
*p<.05**, **p<.01, ***p<.001
Current Problems,
Symptoms not Substance
Induced
OR 3.1***
Current Problems and
Substance Induced
Symptoms
Current Substance Use Problems
Comtois, Ries & Russo 2004
DIAGNOSTIC GROUP: UNIPOLAR DEPRESSION
Recent Suicide Crisis %
100
90
80
70
60
50
40
30
20
10
0
Lifetime Suicide Attempt %
OR 1.6***
OR 1.2
None
Odds Ratios are
adjusted for age,
gender, and ethnicity
*p<.05**, **p<.01, ***p<.001
Current Problems,
Symptoms not Substance
Induced
OR 1.6***
OR 1.0
Current Problems and
Substance Induced
Symptoms
Current Substance Use Problems
Comtois, Ries & Russo 2004
CAGE QUESTIONS
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Cut Down (or stopped)
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Annoyed when asked drug/alc. use discussed
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Because symptoms worsened
Because doctor or therapist suggested
Annoyed, angry, fights when using
Admitted to ER or hospital when using
Guilty about use
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Guilty, depressed, suicidal when using
Ever made a suicide attempt when using
CAGE Questions
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Eye opener: taken drink or drug in AM to feel
better
 Taken drink or drug with meds
 Not taken meds because of using drug/alc
(forgot, avoid mixing, etc.)
What are 2 or 3 reasons you use alc/drugs?
What are 2 or 3 reasons you should stop or cut
down?
Substance Induced Mania
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Methamphet/Cocaine
Ecstacy
Halucinogens
Alc/Benzo withdrawal?
Med/Substance induced true Bipolar
Dual Bipolar Video
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Bipolar vs Sub induced sytmptoms
Types of substance
Addiction vs Psych behavioral problems
Denial
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Psych
Substance
Recovery Issues
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Meds
12 step, other groups
Risk of Relapse in Patients With
Schizophrenia
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Rate of relapse among patients treated with
conventional
antipsychotics for first-episode schizophrenia and
schizoaffective disorder
 16% at 1 year
 54% at 2 years
 82% at 5 years
*
Stable patients were allowed the option to discontinu
antipsychotic medication after 1 year of treatment
The risk for a first and second relapse was almost 5
times
greater than when not taking medication*
 Risk is diminished by maintenance
antipsychotic drug treatment
Based on a survival analysis of relapse using medication
status as a time-dependent covariate.
Source:
Robinson D, Woerner MG, Alvir JMJ, et al. Arch Gen
Psychiatry. 1999;56:241-247.
Barriers to Adherence to
Antipsychotic Therapy
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Cognitive impairment
Complex drug regimen (eg, BID dosing)
Adverse events (eg, side effects, weight gain,
EPS, diabetes )
Monitoring of selected adverse events (eg, ECG,
blood, glucose, liver functioning, electrolyte, slitlamp testing)
Cost of medication
Source:
Substance abuse
Perkins DO. J Clin Psychiatry.
1999;60(suppl 21):25-30.
Comorbid Substance Abuse Associated With
Noncompliance in Schizophrenia
P < 0.05
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Nearly half of all patients in
a prospective 4-year study
(N = 99) were active
substance abusers (n = 42)
Patients who actively
abused substances were
significantly more likely to
be noncompliant
67%
% Noncompliant
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80
60
47%
40
34%
20
0
No Past
Past
Current
History History
User
Hunt GE et al. Schizophrenia Res. 2002;54:253-264.
It may not be that the med(s) stopped
working, but……
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The patient stopped the med
The patient stopped the med AND used drugs
and/or alcohol…...
OR lowered the med and used…
OR used on top of the med….
OR used twice the dose on one day and
nothing the next….
Stimulants ( cocaine/amphets) are most MSE
destructive.
Features of Schizophrenia
Positive
Symptoms
Delusions
Hallucinations
Disorganized
Speech
Cognitive Deficits
Attention
Memory
Executive Functions
(e.g., abstraction)
FUNCTION
Work
Interpersonal
Relationships
Self-care
Negative
Symptoms
Affective Flattening
Alogia
Avolition
Anhedonia
Social Withdrawal
Comorbid
Conditions
Depression
Anxiety
Aggression
Substance use
disorder
DIAGNOSTIC GROUP:
SCHIZOPHRENIA/SCHIZOAFFECTIVE
Recent Suicide Crisis %
100
90
80
70
60
50
40
30
20
10
0
Lifetime Suicide Attempt %
OR 1.8***
OR 1.5**
None
Odds Ratios are
adjusted for age,
gender, and ethnicity
*p<.05**, **p<.01, ***p<.001
Current Problems,
Symptoms not Substance
Induced
OR 1.7***
OR 1.7***
Current Problems and
Substance Induced
Symptoms
Current Substance Use Problems
Comtois, Ries & Russo 2004
Substance Induced Schizophrenia
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Methamphetamine/Cocaine
Ecstacy
Hallucinogens ( strong THC too)
Alcohol Hallucinosis
Meth vs Schiz
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Meth
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Later onset
Clear regular heavy drug
use
Lifestyle
More likely to preserve
general function
Usually paranoid and
voices, but not many
negative sx
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Schiz
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Earlier onset
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Prodrome of withdrawal,
negative symptoms, few
friends
More global impairment,
thought disorder
May have drug use but
usually much less
Schizophrenia Patient video
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Positive and Negative features
Substance effects
Medications and side effects
Social interactions
Harborview Dual Dx Program
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Ongoing diagnosis and Rx adjustment
Patient/Treatment matching (stage of change,
women’s issues etc
Bio-psycho-social approach incorporating
psychiatric, addiction, and rehabilitation principles
and staff
Interactive with spectrum of care on-site, off-site
resources, shelters, AA etc
Consumer involvement
Pre-vocational and vocational and housing
incentives, Legal, as well as Social Security
payeeship, etc. (carrot and stick)
HARRP Program
In MICA Patients:
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Diagnoses are complicated
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Presence of severe and persistent mental illness
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Compliance is a major problem
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Falling between the “cracks” of treatment systems
Engaging the Chronically
Psychotic Patient
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Noncoercive engagement techniques
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Assistance obtaining food, shelter, and clothing
Assistance obtaining entitlements and social
services
Drop-in centers as entry to treatment
Recreational activities
Low-stress, non-confrontational approaches
Outreach to patient’s community
Coercive engagement techniques
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Involuntary commitment
Mandated medications
Representative payee strategies
CSAT TIP 1994
The primary goals of
PACT treatment
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Increase community tenure
Lessen or eliminate debilitating psychiatric symptoms
Prevent relapse of psychiatric symptoms
Meet basic needs and enhance quality of life
Reduce substance abuse and money management
problems
Improve functioning in adult social and employment
roles/activities
Lessen the family’s burden of providing care
What are the Fundamental
PACT Principles?
Primary provider of services
 Fixed point of responsibility
 Community-based services
 Highly individualized services
 An ‘assertive’ can-do approach
 Continuous long-term services
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Counseling strategies….1:1
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Problem identification,
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Addiction, housing, job, MOOD etc
Treatment planning
ASI domains…one of these is psych.
Biopsychosocial
What are availabilities of your site/agency
Counseling strategies
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Social support/case management
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Linkage to onsite/offsite services
12 step facilitation
Cog/behavioral
Motivational Interviewing
Couples/family
Group
Group Therapy
What types of pts?
only non-psychotic…only motivated, only
female, only alcoholics…only noncompliant?????
How often/week, how long/session
Single or co-therapy
Dual Group Therapy
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Process group , or theme/didactic
Structured/ unstructured
Pt co-therapist
Activities/celebrating birthdays etc
Using a “check-in”
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Name/ Addiction dx/sobriety date/what I’m
doing to stay sober
Psych dx/meds/what I’m doing to get better
Dual Check In
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Using a “check-in”
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Name/ Addiction dx/sobriety date/what I’m
doing to stay sober
Psych dx/meds and compliance/ what I’m
doing to get better
How am I feeling on a 10 pt scale
Relapse cues
Do I need time in group for a current problem
Harborview Co-occurring subprograms
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Different strokes for different folks
Case management vs psychotherapy
Mix of CD and MH
Psychotic/Non-Psychotic
Male/Female
Homeless
Residential/Therapeutic Community
TWO DIMENSIONAL AXIS OF PSYCHIATRIC
AND CHEMICAL DEPENDENCY
Substance Abuse
MICA
Severe
ACT
Moderate
Psychopatholog
y
Borderline
Mild
Rehab
Mild
Severe
Moderat
e
Wingerson & Ries,
1999
CLINICAL SEVERITY OF PATIENTS BY TREATMENT
TEAM
ACT
REHAB
MICA
BORDERLINE
12
10
8
6
4
2
0
Average # Lifetime
Psych Hosp
Average # Invol Lifetime Average # Incarcerations
Psych Hosp
Past 5 Yrs
Wingerson & Ries, 1999
CONTINGENT BENEFITS STUDY-NIDA
POWER: THEORETICAL ANALYSIS
 100
Contingency effect
 75
Multiple, weekly dispersals
 50
 25
Having Rx center be payee
0
Ries: Psych
Serv 04
4. Substance use
a. Total # of days/week use
(if “0”, leave b,c,d blank)
b. Specific Days Alcohol
M T W Th F Sa S
c. Specific Days Drugs
M T W Th F Sa S
d. Unknown substance
M T W Th F Sa S
Weekly Substance Use Summary Code
days
0=No use; 1=1 day; 3=2+
5. Treatment Adherence
a. Attendance
(% of Rx plan)
b. Medications
(frequency/amount; % correctly taken)
c. Enter lowest %
of attendance or medication adherence
Weekly Adherence Summary Code 0>80%; 1=60-79%; 3<60%
6. Money Management
Budgets and spends payee money appropriately
• Circle best response:
0-19%
20-49%
Weekly Money Management Summary Code
50-79%
80-100%
0>80%; 1=50-69%; 3<50%
Scoring: WEEKLY DECISION SUMMARY
INSTRUCTIONS
•If Weekly Status Sum=0, circle “0” in Decision Summary Score (below),
congratulate, give gold award.
•If Weekly Status Sum=1 or 2, circle “1” in Decision Summary Score
(below), encourage better behavior, give silver award.
•If Weekly Status Sum=3 or greater, circle “3” in Decision Summary Score
(below), encourage better behavior, give red award.
Weekly Decision Summary Score (circle one): 3
Type of Award Given (circle one):
Gold
1
Red
0
Silver
Preliminary Findings - 5/99
Contingent Benefits Study (Ries NIDA)
65%
Cont.
51%
p<
.008
Non-Cont.
53%
51%
alcohol weeks clean / total weeks = %
Ries, Am J
Addict 04
Medication monitoring and
motivating
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Know who is on what and what for
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Know the prescriber if possible
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Sit in on med sessions now and then if possible
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Know something about meds…(Tech transfer centers
summary, NEW CO-OCCURRING TIP)
Ask the pt about taking or not/side effects, fears, biases,
pressure from others..use motivational strategies
Medications
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Essential to Treatment of Severely
Mentally Ill
Substance Use and Not-Taking Meds are
the 2 top reasons for De-Comp
Should be part of court orders
Monitored by Case managers, nurses,
doctors
Anti-psychotics
New: Clozaril, Zyprexa, Risperdal, Seroquel,
Geodon, Abilify……better response, fewer
side effects ( except wt gain) and better
compliance. Consta = 2 week IM risperdal
Old: Haldol, Prolixin ( both come as oral and
as 2-4 week shots, called decanoate),
others include Navane, Trilafon…….all
cause more side effects
Weight, Lipids,
Diabetes….
…Isn’t that what being an
American
is all about ?
HMHS: Body Mass Index (BMI)
from Vital Exam:
44.8
45
40
% of Clients
35
29
30
23
25
20
15
10
5
3.2
0
Underweight
Normal
Weight
Overweight
Obese
Mean=29.8 (sd=6.7), Median=29.1, Range from 14.4 to 49.9
BMI Categories: Underweight<18.5; Normal=18.5-24.9; Overweight=25-29.9; Obese>30
Cause of death in HMHS long term
patients
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Cardiac…………………………. 50%
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profile average is 49 yo male
Other medical illnesses and
accidents…………………………25%
Suicide …………………………..17%
Other ………………………………8%
Atypicals and Health issues
Drug
Weight
gain
Risk for
diabetes
Worsening
lipid profile
Clozapine
+++
+
+
Olanzapine
+++
+
+
Risperidone
++
D
D
Quetiapine
++
D
D
Aripiprazole*
+/-
-
-
Ziprasidone*
+/-
-
-
+ = increase effect; - = no effect; D = discrepant results.
*Newer drugs with limited long-term data.
Source: Diabetes Care, February 2004
Anti-depressants
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Used for Major depressions
Also used as auxillary meds in Bipolar,
Schizophrenia, others
SSRI’s include Prozac, Paxil, Zoloft, Celexa.
Others: Serzone, Trazedone (sleep), Remeron,
Effexor, Welbutrin
Older ones: Elavil, Sinequan…more side effects
Anti-Bipolar Meds
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Lithium..oldest, cheap
Anticonvulsants : Depakote, Tegretol,
Gabapentin, Lomotragine……gaining share…may
also help impulse control….expensive
Newer Antipsychotics…Zyprexa most researched,
expensive, wt gain, but effective…also Geodon,
Abilify- effective and NO Wt GAIN, also appear
Diabetes/lipid neutral
Ziprasidone: What about IM
use?
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IM Ziprasidone has virtually replaced IM
Haldol in ER’s at Harborview, the Seattle
VA and on Harborview’s most intense,
locked psychotic unit
IM Haldol has been one of the most
longstanding, unchanging, acute
interventions in all branches of Medicine
Dealing with SMI persons in court
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If clearly psychotic, agitated or confused,…use
fewer more direct statements and questions,
which don’t require complex responses
Be Direct, for example: “Mr Smith, it appears
that you might be having some difficult to
understand experiences and that maybe these
are causing you to get agitated and I therefore
wonder if you might sit down”
………..versus……..”Please sit down and behave
Mr Smith”
Keep Calm