chapter 10 mental health and drugs. introduction 33% of people with mental illness also abuse...

CHAPTER 10 Mental Health and Drugs

Introduction33% of People with mental illness also

abuse substances50-70% of drug abusers have mental

disordNeurotransmitters sameDrugs may cause symptoms

Stimulants – mania, anxiety, psychosisStimulant withdrawal – depression, anxietyDepressants – depressionPsychedelics – hallucination/psychosis

Substance related disordersSubstance use

Dependence – impairment - continue in spite of consequences

Abuse – disruption of life function - continue in spite of consequences

Substance inducedIntoxicationWithdrawalDisorders – delirium, dementia, amnesia, etc.

Determining factorsHeredityEnvironmentUse of drugs

Determining factorsHeredity

SchizophreniaBipolarDepressionAnxietyBinge eatingGamblingADHDGreatly increased risk if stressed by

environment or drugs

Determining factorsEnvironment

Stress depletes norepinephrineAbuse/molestation – 75% of female addictsEnvironment potentiates risk of abuse

Determining factors

Psychoactive drugsChange balance of neurotransmittersDrugs may induce mental disorder in any

personPredisposed brain more likely to suffer

permanent harmType of drug impacts type of harmPredisposed to depression – alcohol/sed-hypPredisposed to schizophrenia - psychedelics

Dual diagnosisMental disorder and substance abusePreexisting

Thought – psychotic/schizophreniaMood – affective - depression. BipolarAnxiety panic/ADHD

Substance inducedStimulant induced psychotic disorderAlcohol induced mood disorderMarijuana induced delirium

Dual diagnosisMust distinguish between symptoms and the

diseaseAbusers often present with symptoms that

may disappear with sobriety

Dual diagnosisEpidemiology

Alcohol 44%Drugs 64%Mentally ill 29-34% abusers

Manic depressive 61% Schizophrenia 47% Prisoners with mental illness 81%

Dual diagnosisPatterns

Preexisting – self medicationSubstance induced – neurotransmitter

imbalance

DiagnosisAddress all symptomsAvoid making diagnosis until abuser soberFactors

Particular patternPreexisting mental illnessSelf medicationAge of onsetRelationship of the symptoms to substance use

DiagnosisIncreased population on streets

Decreasing IP facilitiesSubstance abuse upIncrease in number and expertise of

practitionersIncreased awarenessOP pays more – over-diagnosisDisruptive – unwanted at substance abuse

centers or at psychiatric treatment centers

Mental health vs. substance abuseCure the disease, abuse will go awayGet them sober, MH problems will resolveMH – partial recovery OKMH – stigmaMH/some SA – medicationsMH – shepherding, SA – self-relianceMH – supportive, SA - confrontive

Mental health vs. substance abuseMH sharing info easierMH – more professionals, SA recovering

addictsMH – scientific approaches, SA, less

structuredMH – prevent getting worse, SA hit bottomMH – individual, SA – one size fits all

Mental health vs. substance abuseMust treat simultaneouslySA must connect with MHEach must see the other as a complementCase management improves outcome

Multiple diagnosisPolydrug useOther medical problems

Chronic painHepatitisEpilepsyCancerHeart/kidney diseaseDiabetes Sickle cellSexual dysfunctionHIV – triple diagnosis

DisordersThought – schizophrenia

Mostly inheritedHallucinationsDelusionsInappropriate affectAmbivalencePoor associationImpaired ability to care for oneselfAutismPoor job performanceStrained social relations

DisordersThought – schizophrenia

Usually late teens/early adultDrugs mimic

Stimulants Steroids Mdma/marijuana Psychedelics Withdrawal from downers

DisordersMajor depressive disorder

15% of all have in lifetime9% per yearDepressed moodDiminished interestDiminished pleasureSleep disturbanceInability to concentrateWorthlessnessSuicidal thoughtsMost of the day for 1 week

DisordersMajor depressive disorder

AlcoholAmphetamine withdrawalPsychedelic 80% due to drugs, not heredity

DisordersBipolar affective disorder

Depression/normalcy/maniaDepression can be suicidalMania

Persistent elevated, expansive, irritated mood Inflated self esteem Depressed need for sleep Talkative Flight of ideas Distractibility Goal directed activity Excessive involvement with pleasurable activities

DisordersBipolar affective disorder

Usually begins in 20sDrugs

Stimulants Psychedelics

DisordersAnxiety

16% of adults per yearPTSD – persistent re-experience

20-25% of those in drug treatmentPanic - intense fear/discomfort when no real

danger Agoraphobia Social phobia Simple (specific) phobia OCD GAD Toxic effects of stimulants Withdrawal from opioids, sed/hyp or alcohol

DisordersDementias

Brain dysfunction due to physical changes Marijuana and prescription drugs mimic

Developmental disordersRetardationAutismCommunicationADHDPsychedelic use can be mistaken for DD

DisordersSomatoform

Physical symptoms without obvious cause Hypochondria Munchausen’s Stimulant psychosis – bugs Psychedelics

DisordersPersonality

Inflexible behavior leading to distress/impairment

AngerDisruptive behaviorHard to treat

DisordersEating

Weak impulse controlCo-occur with many other disorders and

substance use – depression/PTSD

DisordersGambling

Impulse controlAlcoholStimulants, esp. methamphetamine

Substance-induced DisordersAlcohol induced

Impulse control Violence Suicide Unsafe sex High risk behavior

Sleep Suppresses REM Sleep

Substance-induced DisordersAlcohol induced

Anxiety Withdrawal related Last 2-3 days

Depression 45% have concurrent major depressive disorder After 4 weeks of sobriety 6% Antidepressants contraindicated

Substance-induced DisordersAlcohol

Psychosis Develop after decades of heavy drinking Hallucinations Delusional thoughts Antipsychotics effective (not during withdrawal)

Dementia Neurotoxic Cognitive deficits May regain some function Mimics Alzheimer’s

Substance-induced DisordersStimulant induced

Impulse controlMania

Resolve without treatment if only induced Medication not indicated if non-abstinent

Panic Drug use increases panic focus – can become

chronic even if abstinent

Substance-induced DisordersStimulant induced

Depression Imbalance of neurotransmitters Can last 10 weeks Antidepressants helpful during detox only

Anxiety Intoxication Withdrawal Treatment

Substance-induced DisordersStimulant induced

Psychosis Short term and long term in some For those, each use increases frequency and duration Can last for months after last use

Cognitive impairment Transient damage Permanent damage Revealed by high tech imaging

Substance-induced DisordersMarijuana

Delirium Disturbance of consciousness Change in cognition Memory Multi-step tasking 3 months to clear

Psychosis Paranoia Hallucinations Tend to be transient

Substance-induced DisordersPanic

While intoxicatedAmotivational syndrome

Chicken and egg question

TreatmentRebalancing brain chemistry

Education – primary preventionCannot change hereditary factorsImprove environment

Avoid stressors Leave abusive relationship Avoid drug users Sleep Avoid bad situations New friends Self-help Nutrition

TreatmentStabilize both mental and substance abuse

problemsHomicidal/suicidal DetoxDiagnosis

Psycho-pharmaceuticals helpful

TreatmentImpaired cognition

50% of patientsReasoning, memory impairedMay not be ready to help with treatment for

weeks/monthsTreatment must match patient capabilities

TreatmentDevelopmental arrest

Arrested emotional developmentLack of maturation

Low frustration tolerance Can’t work toward goal independently Lie to avoid punishment Test limits Feelings expressed as behavior Shallowness of mood Fear of rejection Live in present (no hope) Denial, non-compliant For me or against me - absolutes

TreatmentTherapies

CounselingGroupPsychopharmacology

Primary treatment for mental illness

1st Achieve abstinence2nd Maintain abstinence3rd Continued therapy – emphasis on

abstinence

Psychopharmacology Used only after thorough assessmentShort term, medium term, lifetime basis

Increase neurotransmitter releaseBlock receptorInhibit reuptakeInhibit metabolism (MAO)Enhance Monitor and adjust dose - mandatory

PsychopharmacologyPrescribed vs. street

Most not addictingCompliance is a problemSense of control

PsychopharmacologyDepression

Serotonin/norepinephrine Most drugs increase SSRI – prozac, zoloft Serotonin syndrome Sexual dysfunction Tricylics work well for chronic MAOs – block metabolism – food drug interactions Stimulants increase norepinephrine - amps

PsychopharmacologyBipolar

Lithium Stabilizes mostly highs Side effects Non-compliance Requires monitoring

PsychopharmacologyPsychoses

PhenothiazinesHaldol, etc.Excess dopamine relatedMedications block receptorsTreat symptoms, not diseaseMuscle problems, tremor, sedation, apathy

PsychopharmacologyAnxiety disorders

Benzodiazepines Safer than barbs/mepro Act quickly Addictive-poor choice for addict GABA

Buspirone Serotonin modulator 1-2 weeks for 1st response

SSRIsOCD – poor results in generalPanic - SSRIs

PsychopharmacologyCompliance

Patient must take the med for it to workFeedback and face-to-face required