Dual Diagnosis

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Dual Diagnosis

• Dr. Louise Sell
• Greater Manchester West Mental Health NHS
  Foundation Trust

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THE PROBLEM
POLICY
MANAGE-MENT
TREAT-MENT
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THE PROBLEM
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Dual diagnosis / co-morbidity

• a primary psychiatric illness precipitating or
  leading to substance misuse
• substance misuse worsening or altering the course
  of a psychiatric illness
• substance misuse leading to psychiatric symptoms
  or illnesses.
• Intoxication, withdrawal, problem use, harmful
  use, dependence

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(No Transcript)
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Epidemiological Catchment Area study - I

• Frequency of lifetime substance misuse disorder
• ASPD 83
• Bipolar 60
• Schizophrenia 47
• Panic disorder 36
• Depression 27
• Anxiety 24
• No mental illness 13

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Epidemiological Catchment Area study - II

• Frequency of lifetime psychiatric disorders
• alcohol other drugs
• Depression 13 26
• Anxiety 20 28
• Schizophrenia 4 7
• ASPD 14 18

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Drug treatment intake

• NTORS (Gossop et al 1998)
• New admissions, past 3 months
• 29 suicidal thoughts
• 10 psychiatric hospital admission

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Multiple morbidity in drug and alcohol treatment

• Weaver 2002
• Past year psychiatric disorder in drug services
  75, alcohol 85.
• 30 multiple morbidity
• 39 drug users with psychiatric disorder received
  no treatment for it

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Multiple morbidity in psychiatric treatment
Weaver et al 2002

• Patients of mental health services, past year
• Hazardous / harmful drinking 25
• Problem drug use 31
• Cannabis past year 25
• Poly drug use 13
• Opiates 5
• Dependent on one or more drug 17
• Very low level substance related intervention by
  mental health team or by specialist drug and
  alcohol services.

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Reasons for substance misuse in those with
mental health problems

• Self-medication
• Same reasons as for other people
• Availability
• Access to a social group
• Relief from boredom/ inactivity
• Coping with stressful relationships
• Coping with stressful situations

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Not just dual diagnosis.

• venous or arterial thrombosis
• blood-borne infections including HIV and
  Hepatitis B and C
• cardiac disease
• Smoking substances..respiratory disease
  including pneumonia and emphysema
• Alcohol - Korsakoffs syndrome, delirium and
  seizures.

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Consequences of co-morbidity

• Poor prognosis
• Increased relapse
• Increased hospitalization
• Greater service utilization
• Higher costs
• Increased risk HIV
• Less compliance with treatment

• Increased suicide rates
• Violence
• Criminality
• Housing instability
• Poorer social functioning
• Adverse impact carers, family
• Marginalization
• Poverty

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National enquiry into homicides and suicides

• A review of inquiries into homicides committed by
  people with a mental illness identified substance
  misuse as a factor in over half the cases, and
  substance misuse is over-represented among those
  who commit suicide

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POLICY
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Mainstreaming

• Substance misuse is usual rather than exceptional
  amongst people with severe mental health problems
• Individuals with these dual problems deserve high
  quality, patient focused and integrated care.
• This should be delivered within mental health
  services. This policy is referred to as
  mainstreaming.

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Mainstreaming

• local services develop focused definitions of
  dual diagnosis which reflect local patterns of
  need and clarify the target group for services
• Agree definitions between relevant agencies
• specialist teams of dual diagnosis workers should
  provide support to mainstream mental health
  services
• all staff in assertive outreach teams must be
  trained and equipped to work with dual diagnosis
• all services, including drug and alcohol
  services, must ensure that clients with severe
  mental health problems and substance misuse are
  subject to the Care Programme Approach and have a
  full risk assessment.
• integrated care delivered by one team appears
  to deliver better outcomes than serial care or
  parallel care .. Integrated treatment can be
  delivered by .. mental health services following
  training and with support from substance misuse
  services

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Co-morbidity in prisons

• Prisons have a high prevalence of drug dependency
  and dual diagnosis
• Forensic team
• MH in-reach
• Drug treatment
• CARAT
• IDTS
• ? Specialist team

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Care Programme Approach (Oct 2008)

• Single CPA process (replacing the old enhanced
  and standard CPA system).
• Ensures care planned and co-ordinated. Substance
  misuse care plan sits within CPA process
• CPA as default (DH 2008)
• parenting responsibilities
• caring responsibilities
• dual diagnosis (substance misuse)
• history of violence or self harm
• in unsettled accommodation.

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Mental Health Act 2007

• any disorder or disability of the mind
• Includes sexual deviancy
• Includes personality disorder
• Excludes dependence

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Personality disorder No longer a diagnosis of
exclusion (NIMHE, 2003)

• Personality disorder qualifies for treatment via
  mental health services
• Majority undiagnosed
• Co-morbidity with another serious mental health
  problem common
• Co-morbidity with substance misuse common
• Adverse outcomes.

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MANAGEMENT
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Drug misuse and dependence UK guidelines on
clinical management 2007

• Given the high prevalence of mental health
  difficulties, the majority attending substance
  misuse services will have mental health needs
  that need treatment and if not appropriately
  managed may affect outcome and retention in
  services.

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Strathdee et al 2002, Dual diagnosis in a primary
care group (PCG) A step by step epidemiological
needs assessment and design of a training and
service response model.

• Most substance misuse clients would not have
  sufficient mental health problems for eligibility
  at community mental health teams which prioritise
  those with severe and enduring mental illness. It
  is recommended that the majority with mild and
  moderate mental health problems should be managed
  by specialist substance misuse services and or
  primary care or by counselling services. Staff
  training may be required.

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Management of co-morbidity

• Care planning, care-coordination
• Joint working / liaison / referral to mental
  health services
• primary care psychology
• primary care mental health
• crisis resolution HTT
• early intervention
• CMHT)
• in house management of mild to moderate mental
  health problems

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Management in house

• Diagnostic uncertainty
• difficult presentation, unable to abstain
• Patient refusal or inability to engage with
  others
• Barriers to referral to primary or secondary care
  services
• commissioning
• service personnel attitude / beliefs
• diagnostic disagreement

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We Can Manage in House?

• Assess
• Diagnose
• Prescribe
• ? Psychological therapy
• ? Social care
• ? Housing
• ? Employment

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Workforce

• Match needs of patient to skill and competency of
  clinical team, minimise multiple referrals and
  teams
• Substance misuse competence in mental health
  staff
• Mental health competence in substance misuse staff

ITEP
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TREATMENT
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Treatment of co-morbidity

• Mental health and substance misuse problems
  common Physical morbidity also
• The literature
• few RCTs, small sample size, short follow up.
• Primary or secondary?
• Does it really matter?

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Treatment of co-morbidity

• 3 4 weeks abstinence
• Complete substance history
• blood / urinalysis
• Comprehensive history
• chronology, mental health symptoms during
  abstinence, family history
• Medication, drug interactions
• Risk of self harm

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Alcohol depression

• Tri-cyclics, mixed results, no clear benefit,
  risks of drug interaction, toxicity.
• SSRI, doses higher than routine, mixed results
  but overall modest beneficial effect.
• Nunes Levin, 2004, meta-analysis of placebo
  controlled trials of treating depression in
  alcohol or drug dependence.
• Anti-depressants modest benefit
• Only minimal benefit to substance misuse
• Concurrent treatment substance misuse needed
• Waiting a week improves response rate
• Prescribe SSRIs where clear depression, regualr
  review effectiveness, compiance, adverse effects.
  

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Opioids depression

• Studies often complicated by use of cocaine.
• As for alcohol, modest benefit on depression, not
  necessarily on substance use.

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Cocaine depression

• On-going use likely to affect mood, risk of self
  harm.
• Anti-depressants may reverse / ameliorate the
  reduction in DA, NA, 5HT caused by cocaine
• Included in Nunes Levin meta-analysis
• SSRI / TCA improve depression but not cocaine
  use, may reduce craving. TCA increased risk
  toxicity / interactions

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Nicotine

• Commonly abused by those with mental illness
• Tendency to heavy smoking
• Review of smoking cessation studies in those with
  mental illness(el Guebaly et al 2002)
• Pharmacotherapy / psychoeducational
• Similar quit rate outcomes to other groups
• ? No effect of making hospitals smoke -free

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Alcohol anxiety

• Anxiety / alcohol diagnostic difficulty,
  anxiety feature withdrawal
• Buspirone not shown to improve anxiety or
  drinking
• SSRI first choice
• Caution benzodiazepines
• Esp. severe dependence, ASPD, polysubstance abuse

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Bi-polar disorder

• Alcohol dependence common
• Valproate more acceptable (Li, warning no
  alcohol)
• Cocaine abuse
• ?lamotrigine improved mood , drug craving but not
  drug use
• Quetiapine adjunct improved mood, craving and use

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Schizophrenia

• ? Typical anti-psychotics may contribute to
  illicit drug use
• Atypical anti-psychotic treatment may be
  associated with better substance misuse outcomes
• Clozapine may confer additional benefit

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PSI for severe mental illness

• Systematic review of RCTs Cleary et al 2008
• Diversity of interventions, outcome measures,
  trial quality
• CBT, MI, group therapy, integrated ACT, intensive
  case management, residential programmes, CM,
  forensic settings

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• MI highest quality evidence of reduced
  substance in short term
• MI CBT, also improvement in mental state
• Long term integrated residential reduced
  substance misuse
• CM 3 RCTs reduced substance misuse, 1 RCT
  CMMICBT increased retention and drug free urines

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www.lifeline.org.uk

• Mental health and
• Cannabis
• Ecstasy
• Alcohol and other drugs
• Heroin and crack

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THANK YOU