Strategies for Effective Case-Planning in Clients with
Co-Occurring Mental Illness and Substance Use Disorders
Christina M. Delos Reyes, MDChief Clinical OfficerADAMHS Board of Cuyahoga County
Ohio Justice Alliance for Community Corrections
Conference
October 10, 2013
www.centerforebp.case.edu
Learning Objectives
Overview of mental illnesses and addiction Strategic approach to clients with co-occurring
mental illness and substance use disorders Principles of differential diagnosis to understand
client non-adherence and resistance to change How to write an effective case-plan, which takes into
account individual client needs and goals
The Human Brain
Most complex organ in the body Different brain areas control different things:
– Brain stem critical life functions such as heart rate, breathing, sleeping, etc.
– Limbic system reward circuit (ability to feel pleasure), perception of emotions, motivation, etc.
– Cerebral cortex sensory processing, thinking, planning, solving problems, making decisions, etc
What Is Mental Illness?
Mental illness or a mental disorder is a diagnosable condition that:– Affects a person’s thinking, emotional state, and
behavior– Disrupts the person’s ability to
Work Carry out daily activities Engage in satisfying relationships
Prevalence of Mental Illness
U.S. Adults with a Mental Disorder in Any One Year
Type of Mental Disorder % Adults Anxiety disorder 18.1 Major depressive disorder 6.7 Substance use disorder 3.8 Bipolar disorder 2.6 Eating disorders 2.1 Schizophrenia 1.1Any mental disorder 26.2
Mood Disorders
Types of Mood Disorders– Major depressive disorder– Bipolar I disorder– Bipolar II disorder– Dysthymia– Postpartum depression– Seasonal depression
Depression vs. Major Depressive Disorder
What Is Depression?– Everyday blues, sadness or a short-term depressed mood
is common– Many individuals may cope with these feelings without
significant impact on their everyday life.
Episodes of Major Depressive Disorder – last for at least 2 weeks– affect a person’s emotions, thinking, behavior, and physical
well-being– Ability to work and have satisfying relationships
Signs and Symptoms of Depression: Emotions
Sadness Anxiety Guilt Anger Mood swings Lack of emotional responsiveness Feelings of helplessness/hopelessness Irritability
Signs and Symptoms of Depression:Thoughts
Frequent self-criticism Self-blame Pessimism Impaired memory and concentration Indecisiveness and confusion Tendency to believe others see you in a
negative light Thoughts of death and suicide
Signs and Symptoms of Depression: Behaviors
Crying spells Withdrawal from others Neglect of responsibilities Loss of interest in personal appearance Loss of motivation Slow movement Use of drugs and alcohol
Signs and Symptoms of Depression: Physical
Fatigue/lack of energy Sleeping too much or too little Overeating or loss of appetite Weight loss or gain Constipation Headaches Irregular menstrual cycle Loss of sexual desire Unexplained aches and pains
Some Risk Factors for Depression
Distressing and uncontrollable event
Exposure to stressful life events
Difficult childhood Ongoing stress and anxiety Another mental illness Previous episode of
depression Family history More sensitive emotional
nature
Illness that is life threatening, chronic, or associated with pain
Medical conditions Side effects of medication Recent childbirth Premenstrual changes in
hormone levels Lack of exposure to bright
light in winter Chemical (neurotransmitter)
imbalance Substance misuse
Bipolar Disorder: Symptoms of Mania
Increased energy and over activity Need less sleep than usual Elated mood or severe irritability Rapid thinking and speech Lack of inhibitions Grandiose delusions Lack of insight
What is Psychosis?
Condition in which a person has lost some contact with reality
A person may have severe disturbances in thinking, emotion, and behavior
Usually occurs in episodes –not a constant or static condition
Psychotic disorders are not as common as depression and anxiety disorders
Psychotic Disorders
Types of Disorders in Which Psychosis Occurs– Schizophrenia– Schizoaffective disorder– Bipolar disorder– Psychotic depression– Drug-induced psychosis
Risk Factors for Psychotic Disorders
Genetic factors Biochemistry Stress Alcohol and Drug Use Other factors
Characteristics of Schizophrenia
Delusions Hallucinations Thinking difficulties Loss of drive Blunted emotions Social withdrawal
Anxiety Disorders
Anxiety disorders differ from normal stress and anxiety
An anxiety disorder is more severe, lasts longer and interferes with work, regular activities and relationships
Anxiety can range in severity from mild uneasiness to a panic attack or a flashback
Often co-occurs with mood disorders and substance use
Types of Anxiety Disorders
– Generalized Anxiety Disorder Persistent, overwhelming and unfounded anxiety/worry accompanied by
multiple physical and psychological symptoms
– Panic Disorder Recurring panic attacks & persistent worry about possibility of a future attack
– Phobic Disorders Avoids or restricts activities due to fear of specific objects/situations
– Post-Traumatic Stress Disorder & Acute Stress Disorder Anxiety after experiencing a distressing or catastrophic event
– Obsessive-Compulsive Disorder Obsessive thoughts & behaviors accompanying anxiety
Prevalence of Anxiety Disorders
U.S. Adults with an Anxiety Disorder in Any One Year
Type of Anxiety Disorder % Adults
Specific phobia 8.7 Social phobia 6.8 Post–traumatic stress disorder 3.5 Generalized anxiety disorder 3.1 Panic disorder 2.7 Obsessive–compulsive disorder 1.0 Agoraphobia (without panic) 0.8Any anxiety disorder 18.1
Signs and Symptoms of Anxiety: Physical
Cardiovascular:pounding heart, chest pain, rapid heartbeat, blushing
Respiratory: fast breathing, shortness of breath Neurological: dizziness, headache, sweating,
tingling, numbness Gastrointestinal: choking, dry mouth, stomach
pains, nausea, vomiting, diarrhea Musculoskeletal: muscle aches and pains
(especially neck, shoulders and back), restlessness, tremors and shaking, inability to relax
Signs and Symptoms of Anxiety:Psychological and Behavioral
Psychological– Unrealistic or excessive fear and worry (about past and
future events), mind racing or going blank, decreased concentration and memory, indecisiveness, irritability, impatience, anger, confusion, restlessness or feeling “on edge” or nervous, fatigue, sleep disturbance, vivid dreams
Behavioral– Avoidance of situations, obsessive or compulsive behavior,
distress in social situations, phobic behavior
Symptoms of a Panic Attack
– Palpitations, pounding heart, or rapid heart rate
– Chest pain or discomfort– Sweating – Chills or hot flashes– Trembling and shaking– Numbness or tingling– Shortness of breath,
sensations of choking or smothering
– Dizziness, light-headedness, feeling faint, unsteady
– Abdominal distress or nausea
– Feelings of unreality– Feelings of being
detached from oneself– Fear of losing control or
going crazy– Fear of dying
Risk Factors for Anxiety Disorders
People who are more likely to react with anxiety when they feel threatened are those who:
– Have a more sensitive emotional nature– Have a history of anxiety in childhood or adolescence– Are female– Abuse alcohol– Experience a traumatic event
Medical conditions or side effects of some prescription medications
Intoxication or withdrawal from alcohol, cocaine, sedatives, and anti-anxiety medications
Substance Use Disorders
The use of alcohol or drugs does not necessarily mean a person has a substance use disorder
Substances affect a person’s brain in different ways, and people may use alcohol or drugs because of these effects.
Substance use disorders may be characterized as mild, moderate, or severe
– “Mild” corresponds to the old concept of Substance ABUSE– “Moderate/severe” corresponds to the old concept of
Substance DEPENDENCE
Substance Use Disorders
Deciding to start drugs and Deciding to start drugs and experimentation with drugs experimentation with drugs are are preventable behaviorspreventable behaviors
Drug Addiction is a Drug Addiction is a treatable treatable brain diseasebrain disease
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Explanatory Models of Addiction
Moral wrong Spiritual empty Psychological impulse control Behavioral habit Medical disease
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Medical model of addiction
Sick person seeking wellness SUDs as chronic diseases
– Biological basis– Identifiable signs and symptoms– Predictable course and outcome
Treatment improves outcomes Lack of treatment may lead to morbidity and
mortality
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Medical model of addiction
A chronic relapsing disease of the brain– Drugs change brain structure and function– Brain changes can be long lasting and lead to
harmful behaviors
Characterized by compulsive drug seeking and use despite harmful consequences
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Facts About Substance Use Disorders
Lifetime Prevalence is 13-14% (1 in 8)– U.S. adults who have a SUD in their lifetime
Annual Prevalence is 3.8% – U.S. adults who have a SUD in any given year
Alcohol use disorders are three times as common as drug use disorders
75% of people who develop substance use disorders do so by age 27
Substance use disorders can co-occur with almost any mental illness
Signs and Symptoms of Substance Use Disorders
Increased use over time Increased tolerance for the substance Difficulty controlling use Symptoms of withdrawal Preoccupation with the substance Giving up important activities (work, social, family,
etc.) Continued use even after recognizing problems with
substance use
Commonly Used Substances
Alcohol Tobacco Marijuana Heroin (and other opioids) Sedatives and tranquilizers Cocaine Amphetamines and Methamphetamines Ecstasy and other hallucinogens Inhalants
Drug Use Disorders in the United States, 2001-2003
National Epidemiologic Survey on Alcohol and Related Conditions, 2004
Risk Factors for Substance Use Disorders
Availability and tolerance of the substance in society
Learning Social factors Genetic predisposition Sensitivity to the substance Other mental health problems
Does relapse = treatment failure?
NO! Relapse is likely, and is a part of the chronic nature of the disease
Relapse rates for drug addiction are similar to relapse rates in other chronic diseases– 40-60% relapse rate for addiction in 1 yr period
Relapse often indicates that treatment needs to be reinstated, adjusted, or changed to an alternate form
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Comparison of Addiction to Other Chronic Diseases
Med compliance
Required hospital stay annually
Follow diet & behavior
change
DM I <60 % ~40 % <30 %
HTN <40 % ~60 % <30 %
Asthma <40 % ~60 % <30 %
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Addiction and Mental Illness
Co-exist commonly Mental illness may precede addiction Drug use and abuse may trigger or worsen
mental illness in vulnerable individuals
Prevalence of substance use disorders in mental illness
0
10
20
30
40
50
60
% of respondents
with substance use disorder
Gen pop Schiz Bipolar Maj dep OCD Panic
Regier et al., JAMA, 1990
A complex relationship…
Substance use and mental illness may co-occur by coincidence
Substance use may cause or increase severity of mental illness
Mental illness may cause or increase severity of substance use
Both conditions may be caused by a third condition Substance use and withdrawal may mimic symptoms
of mental illness
Strategic Approach to Dual Disorders: Decreasing resistance & Increasing Engagement
1. Question & Answer
2. Expert
3. Information Overload
4. Labeling
5. Blaming/shaming
6. Demanding change
1. Ask and Listen
2. Shared Responsibility
3. Check Understanding
4. Person-Centered
5. Acceptance of Person
6. Change is the Person’s Decision
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Common Traps & How to Avoid Them
Question & Answer
Asking a series of close-ended questions can lead to:
Restricted information
Frustration
Defensiveness
Passivity
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Solution: Ask and Listen
Use open-ended questions Some closed questions, as needed Yields more information Communicates understanding Doesn’t necessarily take more time People feel heard and engaged in their
care
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Expert
Provider telling person what to do can lead to:
Passivity
Half-hearted commitments
Verbalized “compliance”50
Solution: Shared Responsibility
Ask permission to share information Avoid jargon Acknowledge person’s expertise Information sharing - a two way street Offer options/choices
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Information Overload
Providing too much information at one time can lead the person to:
Feel overwhelmedBe unable to act Stop listening Not absorb Information
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Solution: Check Understanding
Share small amounts of information
Stop and check understanding before offering further information
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Labeling
Referring to person as their condition or in negative terms can lead to:
Barriers in relationship
Resistance (people don’t like labels)
Dissatisfaction with provider
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Solution: Person-Centered
Be person-centered Seek to understand the person’s
experience Treat person with respect Address person according to their
preference View person as capable
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Blaming/Shaming
Criticizing person for behavior that may be worsening their health condition can lead to:
Defensiveness
Not feeling empowered
Decreased motivation to change
Increase in unhealthy behavior56
Solution: Acceptance of Person
Acceptance of the person Learn what matters to the person Acknowledge behavior change is hard Repeated attempts at change are normal Affirm small change efforts
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Demanding Change
Attempting to force behavior change can lead to:
Resistance
Creates a power struggle nobody wins!
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Solution: Change is the Person’s Decision
It’s the Person’s Decision Choice and control belongs to the person View person as capable Express optimism about ability to change Create opportunities for person to voice
need for change Be a resource
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Differential Diagnosis of Difficult Behavior
Mental illness symptoms Addiction symptoms
– intoxication, withdrawal, codependency Antisocial traits Medication side effects Other undiagnosed/untreated medical illness Reaction to remote or recent trauma Other reasons? …or a combination…
Case-Planning Areas of Emphasis
SUBSTANCE ABUSE MENTAL HEALTH PHYSICAL HEALTH HOUSING CRIMINAL THOUGHTS CRIMINAL PEERS / FRIENDS FAMILY / SOCIAL SUPPORT EDU / EMPL / FINANCIAL LEISURE / RECREATION
Case-planning Examples
Summary
Overview of mental illnesses and substance use disorders
Six strategies for increasing engagement and six traps to avoid
Differential diagnosis of difficult behavior
Effective case planning for co-occurring disorders
Resources
National Institute on Mental Health website: http://www.nimh.nih.gov
National Institute on Drug Abuse website: http://www.nida.nih.gov
National Alliance on Mental Illness website: http://www.nami.org
Mental Health First Aid website: http://www.thenationalcouncil.org/cs/about_the_program
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Contact Information
Christina M. Delos Reyes, MDChief Clinical Officer
Alcohol, Drug Addiction, and Mental Health Services [ADAMHS] Board of Cuyahoga County
2012 West 25th Street, Cleveland, Ohio 44113Phone 216-241-3400 Fax 216-241-0805
Medical ConsultantCenter for Evidence Based Practices at Case
http://www.centerforebp.case.edu