Co-Occurring Mental Health and Substance Use Disorders. DATE: 11/14/2017 PRESENTED BY: John Mahan, MD

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1 Co-Occurring Mental Health and Substance Use Disorders DATE: 11/14/2017 PRESENTED BY: John Mahan, MD

2 Disclosure Information Speaker: John Mahan, MD has nothing to disclose

3 Learning Objectives Understand that psychiatric symptoms occur during substance intoxication and withdrawal Learn more about substance-induced psychiatric syndromes (as distinct from intoxication and withdrawal) Introduce Hallucinogen Persisting Perception Disorder Discuss how to differentiate between non-substancerelated psychiatric illness from substance-related syndromes Discuss Dual Diagnosis treatment principles

4 Unfortunately A comprehensive review of non-substance-related psychiatric syndromes is beyond the scope of the lecture. But there is likely an ECHO for that.

5 Nomenclature The terms Co-occurring Disorders, or Dual Diagnosis, refer to the co-occurrence of at least two psychiatric diagnoses, one of which relates to substance use.

6 Co-occurring Disorders Co-occur, indeed. The stress-diathesis model postulates that there are genetic underpinnings (diathesis), as well as acquired stresses (biological, environmental, psychological, etc) that conspire to cause mental illness. Diatheses for psychiatric syndromes and substance use disorders may co-occur more frequently than chance The same stresses may act towards the evolution of both psychiatric syndromes and substance use disorders.

7 Co-occurring Disorders Psychiatric symptoms may increase the likelihood that a substance is first used, or the degree to which it is reinforcing (the self-medication hypothesis) Substance use itself may act as an inciting stress Adolescent cannabis use (though neither necessary nor sufficient alone) is one of the few known component causes of schizophrenia! Trauma and altered life circumstances may occur during substance use, precipitating psychiatric disorders related to post-traumatic stress, depression, anxiety, sleep-wake, etc (really any disorder)

8 Epidemiology (brief) Epidemiologic Catchment Area study (Regier et al 1990): Lifetime prevalence of any SUD in a community sample was 16.7% Prevalence of any SUD in patients with a history of mental illness was 29% In those with history of a SUD, more than half had a lifetime history of a mental disorder and had more than four times the risk (OR=4.5) of having a mental disorder compared to those with no history of SUD

9 Epidemiology (brief) National Comorbidity Survey (Kessler et al 1996): Odds Ratio of 2.4 for comorbidity between any lifetime mental illness and any lifetime SUD. 50.8% of individuals with a history of mental illness had a history of a SUD 51.4% of those with a history of a SUD had a history of a mental disorder in their lifetime

10 Epidemiology (brief) Prevalence of Co-Occurring Disorders (Hendrickson 2006): 3%-4% in the community 40%-60% in mental health treatment settings 50%-60% in substance abuse treatment settings

11 Psychiatric Symptoms and Diagnosis Psychiatric symptoms in isolation are not rare, and occur both with and without other symptoms that could indicate the presence of a full psychiatric syndrome or diagnosis. Common examples are irritability, insomnia, anger, low energy, worry, decreased appetite, and poor concentration (more to follow).

12 Psychiatric Symptoms and Diagnosis To represent a psychiatric diagnosis, these symptoms should: Occur in a recognized grouping (syndrome) Persist for a specified duration Cause clinically significant distress or impairment in social, occupational, or other important areas of functioning Not be attributable to another medical condition Not be better explained by another mental disorder

13 Diagnoses Associated with Substance Use (DSM5)

14 Objectives Understand that psychiatric symptoms occur during substance intoxication and withdrawal Learn more about substance-induced psychiatric syndromes (as distinct from intoxication and withdrawal) Introduce Hallucinogen Persisting Perception Disorder Discuss how to differentiate between non-substancerelated psychiatric illness from substance-related syndromes

15 Psychiatric Symptoms in Intoxication (during or shortly after use) Clinically significant problematic behavioral or psychological changes that developed during, or shortly after, [substance] ingestion. (DSM5 Criterion B of an intoxication syndrome)

16 Psychiatric Symptoms in Intoxication (during or shortly after use) What follows is a non-exhaustive list of psychiatric symptoms mentioned in DSM5 diagnostic criteria that occur during substance intoxication syndromes.

17 Psychiatric Symptoms in Intoxication (during or shortly after use) Alcohol: hypersexuality, aggression, mood lability, poor judgment, impaired attention Caffeine: restlessness, nervousness, insomnia, rambling thought/speech, inexhaustibility Cannabis: euphoria, anxiety, sensation of slowed time, poor judgment, social withdrawal, perceptual disturbances PCP: aggression, impulsivity, psychomotor agitation, poor judgment

18 Psychiatric Symptoms in Intoxication (during or shortly after use) Other Hallucinogens: anxiety, depression, ideas of reference, fear, paranoia, poor judgment, depersonalization, derealization, illusions, hallucinations Inhalants: aggression, apathy, poor judgment, lethargy, euphoria Opioids: euphoria, apathy, dysphoria, psychomotor agitation or depression, poor judgment, poor concentration, perceptual disturbances

19 Psychiatric Symptoms in Intoxication (during or shortly after use) Sedatives: hypersexuality, aggression, mood lability, poor judgment, poor concentration Stimulants: euphoria, flattened affect, hypersocial, social withdrawal, hypervigilence, interpersonal sensitivity, anxiety, tension, anger, stereotypies, poor judgment, psychomotor agitation or retardation, perceptual disturbances (No diagnosis of tobacco intoxication in DSM5)

20 Psychiatric Symptoms in Withdrawal (within hours or days of cessation/reduction of sufficient use) Alcohol: Insomnia, anxiety, psychomotor agitation, perceptual disturbances Caffeine: low energy, dysphoria, depressed mood, irritability, poor concentration Cannabis: irritability, anger, aggression, nervousness, anxiety, insomnia, nightmares, decreased appetite, restlessness, depressed mood (No diagnoses of Hallucinogen or Inhalant Withdrawal in DSM5)

21 Psychiatric Symptoms in Withdrawal (within hours or days of cessation/reduction of sufficient use) Opioids: dysphoria, insomnia, *perceptual disturbances (methadone, NMDA dysregulation?) Sedatives: insomnia, transitory perceptual disturbances, anxiety, psychomotor agitation, Stimulants: dysphoria (required), low energy, nightmares, insomnia, hypersomnia, increased appetite, psychomotor retardation or agitation Tobacco: irritability, frustration, anger, anxiety, poor concentration, increased appetite, restlessness, depressed mood, insomnia

22 Objectives Understand that psychiatric symptoms occur during substance intoxication and withdrawal Learn more about substance-induced psychiatric syndromes (as distinct from intoxication and withdrawal) Introduce Hallucinogen Persisting Perception Disorder Discuss how to differentiate between non-substancerelated psychiatric illness from substance-related syndromes

23 Substance-Induced Disorders Diagnosed instead of substance intoxication or withdrawal only when the symptoms are sufficiently severe to warrant independent clinical attention The discussion that follows is not exhaustive, but reflects current DSM5 categorization and recognition.

24 Alcohol-Induced Disorders Psychotic Disorder Bipolar Disorder (mania) Depressive Disorder Anxiety Disorder Sleep Disorder Sexual Dysfunction

25 Alcohol-Induced Disorders Minor Neurocognitive Disorder Major Neurocognitive Disorder Delirium (instead of intoxication or withdrawal) when impaired attention and a second cognitive disturbance (memory, disorientation, language, visuospatial, or perception) predominate and are sufficiently severe to warrant clinical attention

26 Caffeine-Induced Disorders Anxiety Disorder Sleep Disorder

27 Cannabis-Induced Disorders Psychotic Disorder Anxiety Disorder Sleep Disorder Delirium (instead of intoxication or withdrawal) when impaired attention and a second cognitive disturbance (memory, disorientation, language, visuospatial, or perception) predominate and are sufficiently severe to warrant clinical attention

28 Inhalant-Induced Disorders Psychotic Disorder Depressive Disorder Anxiety Disorder Neurocognitive Disorder (major or mild) Delirium (instead of intoxication or withdrawal) when impaired attention and a second cognitive disturbance (memory, disorientation, language, visuospatial, or perception) predominate and are sufficiently severe to warrant clinical attention

29 Opioid-Induced Disorders Depressive Disorder Anxiety Disorder Sleep-Disorder Sexual Dysfunction Delirium (instead of intoxication or withdrawal) when impaired attention and a second cognitive disturbance (memory, disorientation, language, visuospatial, or perception) predominate and are sufficiently severe to warrant clinical attention

30 Sedative-Induced Disorders Psychotic Disorder Bipolar Disorder (mania) Depressive Disorder Anxiety Disorder Sleep-Disorder Sexual Dysfunction

31 Sedative-Induced Disorders Minor Neurocognitive Disorder Major Neurocognitive Disorder Delirium (instead of intoxication or withdrawal) when impaired attention and a second cognitive disturbance (memory, disorientation, language, visuospatial, or perception) predominate and are sufficiently severe to warrant clinical attention

32 Stimulant-Induced Disorders Psychotic Disorder Bipolar Disorder (mania) Depressive Disorder Anxiety Disorder Obsessive Compulsive Disorder * Bonus - What is punding?

33 Stimulant-Induced Disorders Sleep Disorder Sexual Dysfunction Delirium (instead of intoxication or withdrawal) when impaired attention and a second cognitive disturbance (memory, disorientation, language, visuospatial, or perception) predominate and are sufficiently severe to warrant clinical attention

34 Tobacco-Induced Disorder(s) Sleep Disorder

35 Phencyclidine-Induced Disorders Psychotic Disorder Bipolar Disorder (mania) Depressive Disorder Anxiety Disorder Delirium (instead of intoxication or withdrawal) when impaired attention and a second cognitive disturbance (memory, disorientation, language, visuospatial, or perception) predominate and are sufficiently severe to warrant clinical attention

36 Other Hallucinogen-Induced Disorders Psychotic Disorder Bipolar Disorder (mania) Depressive Disorder Anxiety Disorder Delirium (instead of intoxication or withdrawal) when impaired attention and a second cognitive disturbance (memory, disorientation, language, visuospatial, or perception) predominate and are sufficiently severe to warrant clinical attention

37 Objectives Understand that psychiatric symptoms occur during substance intoxication and withdrawal Learn more about substance-induced psychiatric syndromes (as distinct from intoxication and withdrawal) Introduce Hallucinogen Persisting Perception Disorder Discuss how to differentiate between non-substancerelated psychiatric illness from substance-related syndromes

38 Hallucinogen Persisting Perceptual DO Following cessation, reexperiencing (when sober) one or more of the perceptual symptoms that were experienced during intoxication: Geometric hallucinations False perceptions of movement in the periphery Flashes of color Intensified colors Trails of images of moving objects

39 Hallucinogen Persisting Perceptual DO Following cessation, reexperiencing (when sober) one or more of the perceptual symptoms that were experienced during intoxication: Positive afterimages Halos around objects, Macropsia Micropsia Etc.

40 Hallucinogen Persisting Perceptual DO The reexperiencing of these perceptual symptoms causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

41 Hallucinogen Persisting Perceptual DO Not attributable to another medical condition like Anatomical lesions of the brain Infections of the brain Visual epilepsy

42 Hallucinogen Persisting Perceptual DO Not better explained by another mental disorder like Delirium Major Neurocognitive Disorder Schizophrenia (or by) Hypnopompic hallucinations

43 Hallucinogen Persisting Perceptual DO Reality testing (insight into their illusory nature) remains intact Usually resolves within 1-2 years of last use, but may be triggered by use of other substances or in adaptation to dark environments Thought to occur in 4.2% of people who have used a hallucinogen

44 Diagnoses Associated with Substance Use (DSM5)

45 Objectives Understand that psychiatric symptoms occur during substance intoxication and withdrawal Learn more about substance-induced psychiatric syndromes (as distinct from intoxication and withdrawal) Introduce Hallucinogen Persisting Perception Disorder Discuss how to differentiate between non-substancerelated psychiatric illness from substance-related syndromes

46 Differential Diagnosis Confusion is a common problem in multiply diagnosed patients. Is impairment Due to substance use alone? Due to mental illness alone? Due to a complex interaction between substance use, mental illness, and medical illness? Due to other factors? Co-existing cognitive impairment is also frustrating in the diagnostic process.

47 Differential Diagnosis Common pitfalls (Galanter et al 2015): Using a single assessment (especially in the acute setting Using a single source of information Underdiagnosis (etiological, most elegant solution) vs Overdiagnosis (suggested by epidemiological data)

48 Differential Diagnosis Optimally (Galanter et al 2015): Use serial, longitudinal assessments Can control for a variable, like abstinence Use multiple sources of data Interview, pt self-report, collateral information, physical examination, laboratory tests, etc

49 Overdiagnosis vs. Underdiagnosis (Galanter et al 2015) Assuming that the most elegant solution, an etiological diagnosis (eg psychiatric symptoms are caused by substance use) is correct can delay needed treatment for mental illness that may be worsening outcomes for treatment of co-occurring SUD. Depending on where you encounter a patient, diagnosing multiple non-etiological co-occurring diagnoses may be correct more often, given the epidemiologic data discussed earlier (co-occurring illness in at least half of all patients in either mental health or substance abuse treatment systems). Conversely, overdiagnosis can lead to harmful exposure to long-term treatment.

50 Differential Diagnosis To differentiate etiological (substance-induced) diagnoses from co-occurring mental health and substance use diagnoses: 1) Understand which substances are capable of causing which substance-induced disorders

51 Differential Diagnosis (DSM5)

52 Differential Diagnosis To differentiate etiological (substance-induced) diagnoses from co-occurring mental health and substance use diagnoses: 2) Consider the typology of symptoms Most substances cause only positive symptoms of psychosis, where NMDA antagonists (PCP/ketamine/dextromethorphan-dextrorphan) can induce positive, negative, and cognitive symptoms of psychosis

53 Differential Diagnosis To differentiate etiological (substance-induced) diagnoses from co-occurring mental health and substance use diagnoses: 3) Establish a timeline of when the psychiatric symptoms occurred in relation to the onset of substance use Age at first use Does the severity of symptoms vary with intoxication or withdrawal, or is it rather constant? Consider family history

54 Differential Diagnosis To differentiate etiological (substance-induced) diagnoses from cooccurring mental health and substance use diagnoses: 4) Understand the appropriate mount of abstinence required before substance-induced symptoms typically resolve Do not diagnose mental illness due to symptoms only present during intoxication or withdrawal For most substances, wait for 1 month of abstinence before differentially diagnosing the mental illness Methamphetamine-, Cathinone-, Cannabinoid-, and chronic Alcohol-induced psychoses may persist for several months post cessation. Psychosis from Korsakoff s psychosis (B1 def) may be irreversible, and psychosis related to toxic leukoencephalopathy from toluene may similarly persist (Galanter et al 2015)

55 Differential Diagnosis (summary) To differentiate etiological (substance-induced) diagnoses from co-occurring mental health and substance use diagnoses: 1) Understand which substances are capable of causing which substance-induced disorders 2) Consider the typology of symptoms 3) Establish a timeline of when the psychiatric symptoms occurred in relation to the onset of substance use 4) Understand the appropriate mount of abstinence required before substance-induced symptoms typically resolve

56 Treatment (briefly) Let assessment and diagnosis guide your referral Co-occurring mental health and substance use diagnoses are optimally treated in a co-occurring capable setting when capable (prevent pinball) Perhaps this is you, in your community? Agencies are becoming increasingly more co-occurring capable, check back for updates Patient-centered treatment and individualization is the guiding principle in dual diagnosis care Wrap-around community care vs residential Individual therapy vs group-focused care

57 Treatment (briefly) Psychopharmacotherapy (Galanter et al 2015): Aim for Acute stabilization of mental health and SUD symptoms Remission of mental health and SUD symptoms Avoid addictive medications (remembering that all medications are abusable, but not necessarily addictive) Use psychiatric medications with broad spectrum of activity for multiple disorders Bupropion for depression, ADHD (off label), and tobacco UD Clozapine for schizophrenia and SUD (off label) Taper medications when remission of substance-induced psychiatric symptoms is achieved to limit long-term harm

58 Thank YOU! It s been my pleasure to serve you today. Please come again!

59 References American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5 th Edition. Washington, DC, American Psychiatric Association, 2013 Avery JD, Barnhill JW: Co-occurring Mental Illness and Substance Use Disorders; a guide to diagnosis and treatment. Arlington, VA, American Psychiatric Association Publishing, 2018 Compton, MT: Marijuana and Mental Health. Arlington, VA, American Psychiatric Association Publishing, 2016 Galanter M, Kleber HD, Brady KT: The American Psychiatric Publishing Textbook of substance abuse treatment, 5 th Edition. Arlington, VA, American Psychiatric Publishing, 2015 Hendrickson EL: Designing, Implementing, and Managing Treatment Services for Individuals with Co-Occurring Mental Health and Substance Use Disorders: Blueprints for Action. Binghamton, New York, Haworth, 2006 Kessler RC, Nelson CB, McGonagle KA, et al: The epidemiology of Co-occurring addictive and mental health disorders: implications for prevention and service utilization. Am J Orthopsychiatry 66(1):17-31, Regier DA, Farmer ME, Rae DS, et al: Comorbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) Study. JAMA 264(19): ,

Co-Occurring Mental Health and Substance Use Disorders. DATE: 4/17/18 PRESENTED BY: John Mahan, MD

Co-Occurring Mental Health and Substance Use Disorders DATE: 4/17/18 PRESENTED BY: John Mahan, MD Disclosure Information Speaker: John Mahan, MD has nothing to disclose Planning Committee: The members