Transcript Concurrent Disorders: An Introduction – Annie - CSAM

CSAM-SCAM
Fundamentals
Concurrent
Disorders: An
Introduction
Presentation provided by
Annie Trépanier, MD, FRCPC
Clinical Fellow, Center for Addiction and
Mental Health, University of Toronto
Fundamentals: Concurrent Disorders
Disclosures
I
have no affiliations with a
pharmaceutical or medical device
company.
 I am a (very) recent graduate.
Fundamentals: Concurrent Disorders
Learning Objectives
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Discuss epidemiological data
Review underlying models and risk factors
explaining concurrent disorders.
Review the assessment process facilitating the
evaluation of patients with both mental
disorders and addictions.
Discuss common presentations of cooccurring disorders.
Describe approaches to treatment for
patients with concurrent disorders
Fundamentals: Concurrent Disorders
Definition: Concurrent Disorders

A condition in which a person has both a mental
illness and is experiencing harmful involvement
with alcohol, drugs and/or gambling.
(Pedersen, Management of Alcohol, Tobacco and other Drug Problems, 2000: 391-418)

Dual diagnosis (DD) has been defined as the
comorbidity of at least one substance use
disorder (SUD) and one severe mental illness
(SMI)
 There is a wide variety of combinations of
either a mental disorder or SUD.
(Adan & Benaiges, Neuropathology of Drug Addictions and Substance Misuse, 2016: 258-268)
Definition: Concurrent Disorders
Concurrent
disorders
Mental
disorders(s)
Use
disorders
+/-
Substanceinduced
disorders
(Pedersen, Management of Alcohol, Tobacco and other Drug Problems, 2000: 391-418)
Fundamentals: Concurrent Disorders
True or False?
•
True concurrent disorders
occur in less than 5% of
patients presenting a SUD.
Fundamentals: Concurrent Disorders
Concurrent substance use and
mental health disorders are
common.
“The rule rather than the
exception”.
Fundamentals: Concurrent Disorders
Assessing for CD is a complex task,
given that substances use (acute or
chronic) can mimic psychiatric
symptoms.
(Adan & Benaiges, Neuropathology of Drug Addictions and Substance Misuse, 2016: 258-268)
Highly heterogeneous set of
presentations and combinations.
(Pedersen, Management of Alcohol, Tobacco and other Drug Problems, 2000: 391-418)
Epidemiology of Concurrent Disorders
Epidemiology of Concurrent Disorders
(Hedden et al, NSDUH, 2015: 1-37)
Epidemiology of Concurrent
Disorder
(Hedden et al, NSDUH, 2012: 1-178)
Epidemiology of Concurrent Disorders
(Adan & Benaiges, Neuropathology of Drug Addictions and Substance Misuse, 2016: 258-268)
Epidemiology of Concurrent
Disorder
(Toftdahl, Nordentoft & Hjorthøj, Soc Psychiatry Psychiatr Epidemiol. 2016:129-140)
Epidemiology of Concurrent Disorder
Some Canadian Data
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CD = Prevalence of 18.5 %
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Highest in tertiary care (28 %)
Personality disorders(34 %)
Outpatient and community settings, CD
present with more impairment, more likely to
be young, single, male, and of low education.
CD strongly associated with antisocial
behaviour, risk of suicide or self-harm.
(Rush, Can J Psych, 2008: 810-821 )
Fundamentals: Concurrent Disorders
Risk factors for Concurrent
Disorders
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Early occurrence
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Of substance use
Of mental disorder
(NIH, Comorbidity: Addiction and Other Mental Illnesses, 2010)
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Genetic Factors
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Drug use often initiated during adolescence, associated with impulsivity
and wish for independence
(Dube et al, Pediatrics, 2003: 564-572)
Family history of concurrent disorders
Psychosocial experiences and environmental influences
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Unemployment, poverty or unstable income
Lack of social network
Stress related to work or school
Past or ongoing abuse or trauma
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Females with higher rates of physical, emotional and sexual abuse
(Daigre et al, Psychiatric Research , 2015: 743-749)
A Case in Brief
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Mr. Gent is a 37 year old men from the Caribbean
who moved to Canada more than 15 years ago in
hope of a better life with some of his family members.
He was always ostracised by his family and members
of his community because of his sexual orientation.
He alluded in the initial interview that he had
significant trauma and described vivid PTSD
symptoms.
Over the years, he has developed a substance use
disorder, previously with crack-cocaine and now he
has been using crystal meth for 3 years (first 2 weeks
of each month).
Fundamentals: Concurrent Disorders
Adverse Childhood Experiences (ACE)
In studies, ACEs known to be related to a myriad of negative health outcomes and
behaviors
Abuse
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Neglect
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Emotional
Physical
Sexual
Emotional
Physical
Household Dysfunctions
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Parental
Separation or divorce
Domestic violence
Substance abuse
Crime
Mental illness
(Dube et al, Pediatrics, 2003: 564-572)
Adverse Childhood Experiences (ACE)
 Each
with
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2-4 x increase illicit drug use by age 14
Increased risk of use as an adult.
 >5
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category of ACEs was associated
ACEs
7- to 10 x more likely to report drug use
problems, addiction to drugs, and IV drug
use.
(Dube et al, Pediatrics, 2003: 564-572)
Brain Changes
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With drug use
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Markedly decrease brain dopamine function.
Dysfunction of pre-frontal regions
(Volcow et al, The Journal of Clinical Investigation, 2003: 1444-1451)
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Stress modifies brain pathways
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Hypothalamus, pituitary and adrenal glands pathway
Involvement of CRF (corticotrophin releasing factor)
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In animal models of addiction, CRH increased drug use,
resistance to stopping drug use, and drug relapse
Involvement with reward processes
(Sinha, Psychopharmacology, 2001: 343-359)
Between the Substance Use and Mental
Health Problems
 Complex
interplay of different factors.
 Any diagnosis from either category may
cause, potentiate or predispose to the
other.
 Different models developed to explore
the complexity of CD.
How Do We Understand CD
Fundamentals: Concurrent Disorders
1. Self-medication Model
Psychiatric
Disorder
Dysphoric
State
Substance
use
(Adan & Benaiges, Neuropathology of Drug Addictions and Substance Misuse, 2016: 258-268)
Fundamentals: Concurrent Disorders
1. Self-Medication Model
 Substance
use to alleviate negative
emotional states or secondary effects of
medication.
 Sparse scientific findings, questionable
generalizability.
(Adan & Benaiges, Neuropathology of Drug Addictions and Substance Misuse, 2016: 258-268)
Fundamentals: Concurrent Disorders
2. Secondary
Psychopathology Model
SUD
Monoaminergic
systems and
others
Psychiatric
disorders
Fundamentals: Concurrent Disorders
2. Secondary
Psychopathology Model
«
Neural diathesis-stress model - a
neurobiological vulnerability can trigger
psychiatric disorders through complex
interactions between environmental
events such as substance abuse »
(Adan & Benaiges, Neuropathology of Drug Addictions and Substance Misuse, 2016: 258-268)
Fundamentals: Concurrent Disorders
3. Common Factor Model
Common
Factor
Substance
Abuse
Psychiatric
Illness
Fundamentals: Concurrent Disorders
3. Common Factor Model
Biological factors - determining
gene parallelism
o Some evidence that genes expressing the
dopamine receptors (D4 and D2
receptors) associated with addictive
behaviors and personality traits as novelty
seeking.
o Data remains inconsistent.
(Adan & Benaiges, Neuropathology of Drug Addictions and Substance Misuse, 2016: 258-268)
Fundamentals: Concurrent Disorders
4. Bi-directional Models
Psychiatric
Illness
Substance
(Adan & Benaiges, Neuropathology of Drug Addictions and Substance Misuse, 2016: 258-268)
Fundamentals: Concurrent Disorders
Conclusions from the Models
 Inconclusive
results.
 Likely complementary of each other.
 May explain certain concurrent
presentations.

Careful individual assessment.
(Adan & Benaiges, Neuropathology of Drug Addictions and Substance Misuse, 2016: 258-268)
Fundamentals: Concurrent Disorders
Assessment
 Challenges
in assessing for a primary
disorder versus secondary to the effect of
a substance:
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Intoxication
Withdrawal
Substance-induced disorders
(Adan & Benaiges, Neuropathology of Drug Addictions and Substance Misuse, 2016: 258-268)
Primary Mental Disorder versus
Substance-Induced Disorder
(Adan & Benaiges, Neuropathology of Drug Addictions and Substance Misuse, 2016: 258-268)
A Case in Brief
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He was first seen by a psychiatrist urgently
because of his disturbing behaviours in the waiting
room (i.e.: he was throwing coins in a specific
corner of the room). At the time, he presented a
significant thought disorder, appeared very
agitated, irritable and most of his words were
“mumbled”.
A few weeks later, he was seen by me, in a
generally much improved state. He is now calm,
polite, speaks clearly though with still some delay
in response.
A Case in Brief
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He reports low grade psychotic symptoms for the last 2 to 3
years and hoards computer devices secondary to these
symptoms, using up a good amount of his already low
income.
He was recently diagnosed with HIV, remains untreated
(low viral count, normal CD4 according to his case worker).
His level of functioning is very low, he benefits from the
structure and stimulation from the subsidised living where
he lives.
He steals secondary to his spending habits, low income and
likely lack of appropriate cognitive skills. He was recently
arrested for shoplifting food.
Poor medication compliance.
Fundamentals: Concurrent Disorders
Clinical Presentation of
Substance Induced Disorder
 Intoxication
or withdrawal from drugs or
alcohol can mimic nearly every psychiatric
disorder:
 Cocaine Intoxication may induce symptoms
similar to mania
 Cocaine withdrawal may induce/mimic a
depressive episode
 Alcohol-Induced Mood Disorder
(Pedersen, Management of Alcohol, Tobacco and other Drug Problems, 2000: 391-418)
Fundamentals: Concurrent Disorders
Substance Induced Disorders
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After acute intoxication
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During or within 1 month of intoxication
Involved substance is capable of producing the
mental disorder
(DSM-V, Substance-Related and Addictive Disorders)
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Anxiety and or psychosis usually ameliorate within
2 to 3 weeks.
(Adan & Benaiges, Neuropathology of Drug Addictions and Substance Misuse, 2016: 258-268)
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With heavy and chronic use
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> 6 month abstinence for some substanceinduced psychiatric sx and cognitive changes to
reverse
Fundamentals: Concurrent Disorders
Substance Induced Disorders
 Intoxication
and withdrawal
 Mood Disorders
 Anxiety Disorders
 Neurocognitive Disorder
 Psychotic Disorder
(DSM-V, Substance-Related and Addictive Disorders)
Fundamentals: Concurrent Disorders
Consequences Associated with
Concurrent Disorders
(Adan & Benaiges, Neuropathology of Drug Addictions and Substance Misuse, 2016: 258-268)
A Case in Brief
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His substance use, behaviour (especially when
intoxicated) and issues with the law has put his
lodging at the subsidized housing at risk for
eviction.
If he loses his apartment, he loses his case worker.
He wants help, knows he “becomes this other
person when he uses crystal meth” but certain outpatient’s treatment setting cannot take him
because of his volatility when he uses or shortly
thereafter.
Fundamentals: Concurrent Disorders
Steps to Treatment
 Careful,
individualized assessment of needs
and clinical presentation
 Safety
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Severe psychiatric symptoms may necessitate
immediate use of medication.
(Adan & Benaiges, Neuropathology of Drug Addictions and Substance Misuse, 2016: 258-268)
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Suicidal ideation
Dangerous withdrawal
Fundamentals: Concurrent Disorders
Steps to Treatment
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Substance use treatment
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Different phases
 First Phase (Getting
Started)
 Second Phase (Learning to
Live Drug Free)
 Third Phase (Rehabilitation
and Relapse Prevention)
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Engagement
Preparation
Active treatment
Continuing care and
support.
Acute intoxication or
withdrawal symptoms
subsided prior to entering
more active therapy program
(Pedersen, Management of Alcohol, Tobacco
and other Drug Problems, 2000: 391-418)
(Skinner, 2005 Treating Concurrent Disorders)
Fundamentals: Concurrent Disorders
Four Quadrant Model
Fundamentals: Concurrent Disorders
Integrated Approach

SAMHSA supports an integrated
treatment approach to treating cooccurring mental and substance use
disorders.
 Collaboration across disciplines
 Client-centered, patient’s goals
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Integrated treatment associated with
lower costs and better outcomes :
 Reduced substance use
 Improved psychiatric symptoms
and functioning
 Decreased hospitalization
 Increased housing stability
 Fewer arrests
 Improved quality of life
Other models of treatment
 Sequential
 Parallel
(SAMHSA, Behavioral Health Treatments and
Services, 2016)
(SAMHSA’s WORKING DEFINITION OF RECOVERY, 2016)
Fundamentals: Concurrent Disorders
Treatment Approaches
Other approaches
Integrated Approach:
Components
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Staged interventions
Assertive outreach
Motivational interventions
Counseling
Social support interventions
Long-term perspective
Comprehensiveness
Cultural sensitivity
Competence
(Drake et al, Psychiatric Services, 2001:
469-476)
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Seeking Safety
(Najavits, Journal of Traumatic Stress, 2001: 437-456)
Fundamentals: Concurrent Disorders
Pharmacotherapy

Mental health symptoms should be treated
concurrently, especially if severe.
(Health Canada, Best Pratices, 2002)
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Avoid addictive medications if possible (e.g.
benzodiazepines, stimulants)
Sertraline + naltrexone or mirtazapine superior in
co-occurring depression and EtOH use
(Beaulieu et al, Annals of Clinical Psychiatry, 2012: 38-55)
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ADHD: treat SUD first than ADHD. Can treat ADHD
but high potential for diversion and misuse
(Caddra, 2010)
Some Useful Links
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SAMHSA http://www.samhsa.gov/treatment#cooccurring
Health Canada, Best Practices
http://www.hc-sc.gc.ca/hc-ps/pubs/adpapd/bp_disorder-mp_concomitants/index-eng.php
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Substance Abuse in Canada: Concurrent
Disorders
http://www.ccsa.ca/Resource%20Library/ccsa011811-2010.pdf