CSAM-SCAM Fundamentals Concurrent Disorders: An Introduction Presentation provided

CSAM-SCAM Fundamentals Concurrent Disorders: An Introduction Presentation provided by Annie Trpanier, 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 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 co-occurring 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 & Hjorthj, Soc Psychiatry Psychiatr Epidemiol. 2016:129140)

Epidemiology of Concurrent Disorder Some Canadian Data CD = Prevalence of 18.5 % 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 Early occurrence

Of substance use Of mental disorder (NIH, Comorbidity: Addiction and Other Mental Illnesses, 2010) Drug use often initiated during adolescence, associated with impulsivity and wish for independence (Dube et al, Pediatrics, 2003: 564-572) Genetic Factors

Family history of concurrent disorders Psychosocial experiences and environmental influences Unemployment, poverty or unstable income Lack of social network Stress related to work or school Past or ongoing abuse or trauma

Females with higher rates of physical, emotional and sexual abuse (Daigre et al, Psychiatric Research , 2015: 743-749) A Case in Brief 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

Emotional Physical Sexual Neglect Emotional Physical Household Dysfunctions

Parental Separation or divorce Domestic violence Substance abuse Crime Mental illness (Dube et al, Pediatrics, 2003: 564-572) Adverse Childhood Experiences (ACE) Each

2-4 x increase illicit drug use by age 14 Increased risk of use as an adult. >5 category of ACEs was associated with 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 With drug use Markedly decrease brain dopamine function. Dysfunction of pre-frontal regions (Volcow et al, The Journal of Clinical Investigation, 2003: 1444-1451) Stress modifies brain pathways

Hypothalamus, pituitary and adrenal glands pathway Involvement of CRF (corticotrophin releasing factor) 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 Psychiatri

c Disorder Dysphoric State Substanc e 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 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 Commo n Factor Substanc e Abuse Psychiatri c 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 Psychiatri c 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: 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

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 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 After

acute intoxication During or within 1 month of intoxication Involved substance is capable of producing the mental disorder (DSM-V, Substance-Related and Addictive Disorders) Anxiety and or psychosis usually ameliorate within 2 to 3 weeks. (Adan & Benaiges, Neuropathology of Drug Addictions and Substance Misuse, 2016: 258-268) With

heavy and chronic use > 6 month abstinence for some substance-induced 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

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 out-patients 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 Severe psychiatric symptoms may necessitate immediate use of medication. (Adan & Benaiges, Neuropathology of Drug Addictions and Substance Misuse, 2016: 258-268) Suicidal ideation Dangerous withdrawal

Fundamentals: Concurrent Disorders Steps to Treatment Substance use treatment Different phases First Phase (Getting Started) Second Phase (Learning to Live Drug Free) Third Phase (Rehabilitation and Relapse Prevention) 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) Engagement Preparation Active treatment Continuing care and

support. (Skinner, 2005 Treating Concurrent Disorders) Fundamentals: Concurrent Disorders Four Quadrant Model Fundamentals: Concurrent Disorders Integrated Approach SAMHSA supports an integrated treatment approach to treating co-occurring mental and substance use disorders.

Collaboration across disciplines Client-centered, patients goals Other models of treatment Sequential Parallel 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 (SAMHSA, Behavioral Health Treatments and Services, 2016) (SAMHSAs WORKING DEFINITION OF RECOVERY, 2016) Fundamentals: Concurrent Disorders Treatment Approaches Other approaches Integrated Approach: Components Staged

interventions Assertive outreach Motivational interventions Counseling Social support interventions Long-term perspective Comprehensiveness Cultural sensitivity Competence (Drake et al, Psychiatric Services, 2001: 469476) Seeking Safety (Najavits, Journal of Traumatic Stress, 2001: 437456)

Fundamentals: Concurrent Disorders Pharmacotherapy Mental health symptoms should be treated concurrently, especially if severe. (Health Canada, Best Pratices, 2002) Avoid addictive medications if possible (e.g. benzodiazepines, stimulants)

Sertraline + naltrexone or mirtazapine superior in cooccurring depression and EtOH use (Beaulieu et al, Annals of Clinical Psychiatry, 2012: 38-55) ADHD: treat SUD first than ADHD. Can treat ADHD but high potential for diversion and misuse (Caddra, 2010) Some Useful Links SAMHSA http:// www.samhsa.gov/treatment#co-occurring Health

Canada, Best Practices http:// www.hc-sc.gc.ca/hc-ps/pubs/adp-apd/bp_disorder -mp_concomitants/index-eng.php Substance Abuse in Canada: Concurrent Disorders http://www.ccsa.ca/Resource %20Library/ccsa-011811-2010.pdf