concurrent disorders...2016/10/01  · concurrent disorders two or more chronic conditions highly...

Concurrent Disorders

Christian G. Schütz MD PhD MPH FRCPC Associate Professor UBC Research and Education Medical Manager BCMHA/PHSA

Overview

What Are Concurrent Disorders? How Common Are They? Treatment Principles and Issues Summary

3

Any combination of:

mental disorder + substance use disorder ------------------------------------------ concurrent disorders / dual diagnoses / co-occuring disorders

What are Concurrent Disorders?

How Common Are They?

B. Rush 2010

Canada

How Common Are They?

B. Rush 2010

Canada

How Common Are They?

B. Rush 2010

Canada

How Common Are They?

B. Rush 2010

Canada

Odds of concurrent mental disorder

Rush 2010

Concurrent disorders

Two or more chronic conditions Highly vulnerable population High burden of morbidity and mortality Under-diagnosed Under-treated Lacks a solid research base, as they are

often excluded from trials

Why is overlap so common?

Overlapping neurobiological pathways

Why is overlap so common?

Overlapping neurobiological pathways underlying genetic factors (common

vulnerabilities)

Alcoholism/Addiction Levey et al. 2014

Anxiety Le-Niculescu et al. 2011

Schizophrenia Ayalew et al. 2012

Bipolar Disorder Patel et al. 2010

ATNX1 GNAI1 GRM3

GRIA1 HTR2A MBP

GABRB3 SYN2

SNCA

DRD2 MOBP

Genetic overlap Adapted from Levy 2014

Why is overlap so common?

Overlapping…. neurobiological pathways and common

vulnerabilities underlying genetic factors exposure to trauma, chronic stress, and loss

Adapted from Stahl Essential Psychopharmacology

PTSD Bipolar Schizophrenia Substance use disorders

Why is overlap so common?

Overlapping…. neurobiological pathways and common

vulnerabilities underlying genetic factors exposure to trauma, chronic stress, and loss

Disorder as a risk factor for second disorder bi-directional complex inducting, propelling and upholding

Concurrent disorder

Higher rates of: history of traumatization (childhood, adult) poverty and deprivation victimization, violence, incarceration, homelessness neurocognitive impairment cluster B personality traits relapse, hospitalization medical complications (Hep C, HIV, COPD, stroke…) Suicides

Worse clinical course, treatment outcome and prognosis

Concurrent Disorders

Christian G. Schütz MD PhD MPH FRCPC Associate Professor UBC Research and Education Medical Manager BCMHA/PHSA

Lifetime 25-35% http://getridofstress.org

Anxiety Disorders

Concurrent Disorders

Christian G. Schütz MD PhD MPH FRCPC Associate Professor UBC Research and Education Medical Manager BCMHA/PHSA

Lifetime 25-35% http://getridofstress.org

Anxiety Disorders cause clinically significant distress or functional impairment

mood instability

DEPRESSIVE EPISODE MANIC EPISODE

dysth cyclothymia

Affective Disorders

Lifetime 40%

cause clinically significant distress or functional impairment

mood instability

DEPRESSIVE EPISODE MANIC EPISODE

dysth cyclothymia

Affective instability Affective instability

Lifetime 40% Adapted from Bonsall 2011

Affective Disorders

Substance induced Stimulant intoxication Sedative withdrawal (-O = delirium) Cannabis intoxication NOT oipioidS

Psychotic Disorders

Cluster A (odd)

Cluster B (dramatic)

Cluster C (fearful)

Paranoid * distrust and suspiciousness

Antisocial **** deceitful hostile disregard for others

Avoidant ‘ social inhibition

Schizoid * social detachment emotionally cold

Borderline *** intense and unstable emotional relationships

Dependent ‘ strong need to be taken care of, needs reassurance

Schizotypal *** odd, eccentric, peculiar

Histrionic ** attention seeking, exaggerated emotionality

Obsessive compulsive * preoccupied with rules and orderliness

Narcissistic * entitlement, excessive self-worth

Cluster A (odd)

Cluster B (dramatic)

Cluster C (fearful)

Paranoid * distrust and suspiciousness

Antisocial **** deceitful hostile disregard for others

Avoidant ‘ social inhibition

Schizoid * social detachment emotionally cold

Borderline *** intense and unstable emotional relationships

Dependent ‘ strong need to be taken care of, needs reassurance

Schizotypal *** odd, eccentric, peculiar

Histrionic ** attention seeking, exaggerated emotionality

Obsessive compulsive * preoccupied with rules and orderliness

Narcissistic * entitlement, excessive self-worth

Screener?

Mental Disorder: Modified MINI Mental Screener

Depression: GHB-9 Questionnaire

ADHD: Adult ADHD Self-Report Scale

Personality Disorder Self Harm Inventory

(Borderline)

Models of Care

Models of Care

Models of Care

The Four Quadrant Framework for Concurrent Disorders

More severe mental disorder/

less severe substance abuse disorder

More severe mental disorder/

more severe substance abuse disorder

High severity

Ries

The Four Quadrant Framework for Concurrent Disorders

More severe mental disorder/

less severe substance abuse disorder

More severe mental disorder/

more severe substance abuse disorder

High severity

Ries

Integrated programs are rare and often have low fidelity ratings

Rebuild hope and sense of control: • Safety • Trust • Choice • Empowerment • Client - centered

Trauma Informed Care

Pharmacotherapy for Concurrent Disorders

A thorough assessment is essential Consider sequence, time lines, and periods of

abstinence Both substance use and mental disorder

must be treated Little evidence beyond treatment of

independent disorders Continue to re-evaluation diagnosis and

medications

Polypharmacy risks with methadone/burprenorphine

Additive or synergistic effects: sedating antidepressants antipsychotics Benzodiazepines!

Additive side effects: QTc prolongation Haloperidol, Chlorpromazine, Olanzapine, Citalopram

Pharamacokinetic interaction: CYP induction: Carbamazepine CYP inhibition: Fluvoxamine, Fluoxetine, paroxetine

Leucht S et al. BJP 2012;200:97-106

Summary of effect sizes.

Leucht S et al. BJP 2012;200:97-106

Summary of effect sizes.

X

Counselling & Community Resources

Detoxification Centres Outpatient Counselling Services & Day Programs Support Recovery Houses Residential Treatment Centres Self-Help Support Groups

Specific Concurrent Disorders Programs?

Counselling & Community Resources

Transitions, Stepping Stones… Assertive Community Team, Urgent Response

Team… Concurrent Disorders Intervention Unit (CDIU),

Heartwood Centre for Women Burnaby Centre for Mental Health & Addiction

(BCMHA)

Summary

• Comorbidity is common (the rule not the exception)

Summary

• Comorbidity is common (the rule not the exception) • Recognize and assess the interdependent, and overlapping

clinical picture for substance use disorders and mental illnesses

Summary

• Comorbidity is common (the rule not the exception) • Recognize and assess the interdependent, and overlapping

clinical picture for substance use disorders and mental illnesses • Acknowledge that a lot of processes of the mind, including drug

seeking, is outside of consciousness

Summary

• Comorbidity is common (the rule not the exception) • Recognize and assess the interdependent, and overlapping

clinical picture for substance use disorders and mental illnesses • Acknowledge that a lot of processes of the mind, including drug

seeking, is outside of consciousness • Re-evaluate regularly

Summary

• Comorbidity is common (the rule not the exception) • Recognize and assess the interdependent, and overlapping

clinical picture for substance use disorders and mental illnesses • Acknowledge that a lot of processes of the mind, including drug

seeking, is outside of consciousness • Re-evaluate regularly • Treat the substance use disorders

Summary

• Comorbidity is common (the rule not the exception) • Recognize and assess the interdependent, and overlapping

clinical picture for substance use disorders and mental illnesses • Acknowledge that a lot of processes of the mind, including drug

seeking, is outside of consciousness • Re-evaluate regularly • Treat the substance use disorders • Treat the mental illnesses

Summary

• Comorbidity is common (the rule not the exception) • Recognize and assess the interdependent, and overlapping

clinical picture for substance use disorders and mental illnesses • Acknowledge that a lot of processes of the mind, including drug

seeking, is outside of consciousness • Re-evaluate regularly • Treat the substance use disorders • Treat the mental illnesses • Change takes time!

Thank you very much for your attention

If you have any further questions: christian.schutz@ubc.ca

Health Canadian Guidelines: http://www.hc-sc.gc.ca/hc-ps/alt_formats/hecs-sesc/pdf/pubs/adp-apd/bp_disorder-mp_concomitants/bp_concurrent_mental_health-eng.pdf

CANMAT w.canmat.org/articles-mdh/5.%20Beaulieu,%20CANMAT%20Comorbidity%20-%20Substances,%20Ann%20Clin%20Psyt%202012.pdf

US SAMSAH http://store.samhsa.gov/product/Integrated-Treatment-for-Co-Occurring-Disorders-Evidence-Based-Practices-EBP-KIT/SMA08-4367

US APA http://psychiatryonline.org/content.aspx?bookid=28&sectionid=1675010

UK NICE http://www.nice.org.uk/nicemedia/live/13414/53729/53729.pdf

Australian NHMRC http://www.dassa.sa.gov.au/webdata/resources/files/Comorbidity_Substanceuse_Guide_full_report.pdf

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