Outline of Webinar 7/13/2012

Transcription

1 CO-OCCURRING DISORDERS: INTEGRATED TREATMENT OF ADDICTION AND MOOD AND ANXIETY DISORDERS Presented on July 18, 2012 by: Dennis Daley, PhD Antoine Douaihy, MD Produced by: NIDA CTN CCC Administrative and Training Coordination "This training has been funded in whole or in part with Federal funds from the National Institute on Drug Abuse, National Institutes of Health, Department of Health and Human Services, under Contract No.HHSN C." Outline of Webinar Brief overview of addiction & co-occurring mood/anxiety disorders Prevalence Effects DSM IV TR classifications Relationships between disorders Assessment and Treatment Approaches Psychosocial, medications, combined, other Integrated treatment Clinical interventions to manage disorders and promote recovery 2 OVERVIEW OF ADDICTION & CO-OCCURRING MOOD OR ANXIETY DISORDERS Prevalence DSM IV TR categories Effects of disorders Relationships between disorders 3 1

2 12-Month Prevalence Among Adults and % Considered Severe (NIMH) Any mood disorder: 9.5% & 45.0% Bipolar: 2.6% & 82.9% Dysthymia: 1.5% % 49.7% Depression: 6.7% & 30.4% Any anxiety disorder: 18.1% & 22.8% Agoraphobia: 0.8% & 40.6% GAD: 3.1% and 32.3%; OCD: 1.0% & 50.6% Panic: 2.7% & 44.8%; PTSD: 3.5% & 36.6% Phobia (social/specific): 6.8% & 29.9% 8.7% & 21.9%; 4 DSM IV TR Classification of Mood Disorders Major Depression Dysthymia Depressive Disorder NOS Bipolar Disorder Cyclothymia Mood dx due to a general medical condition Mood disorder due to substance use Many have co-morbid anxiety or SUD s 5 DSM IV TR Classification of Anxiety Disorders Panic Disorder (+/- Agoraphobia) Agoraphobia (without Panic Disorder) Specific Phobias Social Phobias Generalized Anxiety Disorder (GAD) Acute Stress Disorder Post-Traumatic Stress Disorder (PTSD) 6 2

3 DSM IV TR Classification of Anxiety Disorders Obsessive Compulsive Disorder (OCD) Anxiety Disorder NOS Anxiety Disorder Due to... Substance-Induced Anxiety Disorder Many have co-morbid mood or SUDs 7 Relationships Between Mood, Anxiety and Substance Use Disorders Each disorder increases risk of having the other A mood or an anxiety disorder can complicate treatment or recovery from a SUD A SUD can complicate treatment or recovery from a mood or anxiety disorder Substances may be used to self-treat anxiety or mood symptoms Depression and anxiety can be caused or worsened by withdrawal, early abstinence or facing addiction 8 Anxiety Disorders and Substance Use Disorders Dependence on anti-anxiety medication may develop from long-term use Patient may be dependent on medications for years before a referral is made or dependence is acknowledged Patient may doctor shop and secretly get meds from multiple sources Patient may believe that medications are needed for any and all symptoms or changes 9 3

4 Domains of Anxiety & Mood Disorders and Some Examples Cognitive Worry, catastrophic or negative thoughts, difficulty concentrating, memory problems, grandiosity Physical Restlessness, hard to relax, feel keyed up, GI & skin conditions, muscle tension, headaches, sleep problems Behavioral Pacing, fidgeting, avoiding or leaving anxiety provoking situations, isolation, inappropriate or manic behavior Affective Sadness, depression, emptiness, anxiety, fear, hopelessness, guilt, shame, euphoria 10 Effects of Disorders Increased risk of medical disorders, HIV, HepC Increased use of medical or psychiatric ERs Demoralization, shame & guilt Family conflicts and burden; impact on children Interpersonal problems Work, academic problems Financial Other 11 Patients at WPIC with Co-Occurring Disorders vs. Psychiatric Disorders Only More days in the psychiatric hospital Higher rates of psychiatric re-hospitalization Higher rates of suicidality Higher rates of homicidality Lower rates of treatment entry Lower rates of treatment completion Lower session attendance - Daley et al.; Cornelius et al.; Salloum et al. 12 4

5 ASSESSMENT & TREATMENT OF ANXIETY, MOOD, SUBSTANCE USE & COMBINED DISORDERS Psychosocial Medication & Other Medical Combined 13 Assessment: Baseline & Follow-up Clinical interviews Questionnaires related to substance use Questionnaires related to moods Questionnaires related to anxiety symptoms Quality of life questionnaire Lab tests Psychosocial Interventions: Individual, Group, Family Depression CBT, IPT, supportive, skills training, dynamic, family, other Bipolar CBT, IPT+Social Rhythm, family, other Anxiety CBT, behavioral, trauma, disorder specific, other Substance Use Disorders CBT, IPT, IDC, GDC, MI, MET, MotInc, RP, TSF, Family, other Co-occurring disorders Integrated treatment Other (used with different disorders) Relaxation, meditation, exercise, mindfulness 5

6 Types of Exposure Exposure to social situations provoking anxiety or compulsions Imagined vs. live exposure Gradual vs. rapid exposure Can also use for exposure to alcohol or drugs or substance cues such as drug paraphenalia (NIDA has model incorporating Cue Exposure + Relapse Prevention) 16 Examples of Practices for Public Speaking Speak up at meeting (AA, NA, at work) Offer to give a presentation Ask question at public lecture Take a course at college or university Make impromptu speech Take public speaking course Join Toastmasters 17 INTEGRATED TREATMENT APPROACHES 18 6

7 Content 1. General principles 2. Pre-group interview 3. Integrated session 4. Topics of 12 sessions Combined disorders Triggers Depression Denial, ambivalence Early warning signs Refusing substances Mutual support groups Medications Thinking Self care & maintenance Contents Based on 5 Principles 1. Safety first: 3 stages: safety, mourning reconnection 2. Integrated care: PTSD & SUD 3. Ideals: meaning, honesty, integrity, connection, values, 4. Content areas: 25 topics in cognitive, behavioral, interpersonal & case management 5. Therapist processes: alliance, compassion, modeling, feedback from pt on treatment Dual Disorders Recovery Counseling (Daley & Thase) 1. An integrated model 2. Used with all combinations 3. Overview of dual disorders 4. Counselor training & supv 5. Assessment 6. Role of family 7. Overview of groups txs 8. Curriculum for 43 topics: Disorders, recovery, emotions, relationships, Support, self-change, lifestyle change, relapse, maintenance 7

8 Medications for Depression SSRIs: Prozac, Paxil, Zoloft, Celexa, Lexapro SNRIs: Effexor, Cymbalta TCAs: Elavil, Pamelor, etc; serotonin, NE, DA MAOIs: Nardil, Parnate; work on serotonin, NE, DA Wellbutrin: works on NE and DA Remeron: works on NE and serotonin 22 Medications for Bipolar Disorder Evidence Based Lithium Valproate/divalproex Carbamazepine Lamotrigine Typical antipsychotics Atypical antipsychotics Antidepressants Other Gabapentin Topiramate Omega-3 fatty acids Calcium channel antagonists T3/T4 Tiagabine 23 Medications for Anxiety Disorders SSRIs/SNRIs TCAs MAOIs Buspirone Benzodiazepines also widely used, but should be avoided or monitored very closely in patients with SUD 24 8

9 Medications for SUD Disulfiram (Antabuse) Naltrexone (ReVia, Vivitrol) Acamprosate (Campral) Methadone Buprenorphine (Subutex, Suboxone) Other medications have been used with cocaine or marijuana dependence (none are approved by the FDA) 25 Issues with Medications in SUD Substance use can affect medication adherence Alcohol may increase blood levels of medications Chronic drinking can decrease blood plasma levels Perception of drug use in recovery when taking medications Others in recovery may give a message that all drugs need to be given up 26 Collaborative Treatment of Physician and Therapists Medication management not enough, especially with co-morbidity Need strong psychoeducation and therapy components Therapeutic alliance is the most predictive measure of patient compliance with treatment 27 9

10 Interventions for Inadequate Treatment Response Optimization: Full dose and duration of meds and therapy Drug substitution Combination: add a 2 nd antidepressant Augmentation: add a different agent Lithium, thyroid hormone, atypical antipsychotics Electroconvulsive therapy Transcranial Magnetic Stimulation Vagus Nerve Stimulation Light Therapy 28 A SUMMARY OF CLINICAL INTERVENTIONS Individual Therapy Group Therapy Combination therapy 29 Strategy 1: Help Client Understand and Accept Disorders Deal with denial of illness Feeling depressed or having high energy vs. having a mood disorder Drinking too much vs. having alcohol dependence Know and understand diagnosis Symptoms, causes, effects, treatments, recovery Review treatment options & other services May require long-term treatment (e.g, bipolar or recurrent depression; OCD; opioid addiction) Use motivational strategies 30 10

11 Strategy 2: Manage the Psychiatric Disorder(s) Monitor acute symptoms of disorder(s) Use daily ratings in early recovery Mood, anxiety, other symptoms Help client monitor and rate persistent symptoms (that do not go away totally) Help client learn ways to tolerate some distress Help client learn self-soothing strategies Impact of substance use on symptoms Impact of symptoms on substance use 31 Strategy 3: Manage the Substance Use Disorder Obsessions and cravings (use daily ratings in early recovery) People, places, events, things Impact on family and relationships Establishing a recovery network Managing negative affect Becoming aware of relapse triggers Impact of mood or anxiety symptoms on substance use Impact of substance use on psychiatric illness 32 Strategy 4: Consider the Use of Medications Discuss medication as option and facilitate medication evaluation Monitor medication adherence Help client use time with doctor wisely (e.g., go prepared with questions, take therapy issues to therapist) Discuss impact of substances on meds Collaborate with physician as needed 33 11

12 Strategy 5: Promote Recovery from Co-Occurring Disorders Educate on recovery As a long-term process Phases of recovery Requires commitment, discipline, hard work, practice of new skills, and openness Occurs outside of treatment Link with recovery resources in community Psychiatric, addiction, dual disorders General or illness specific 34 Strategy 6: Focus on Managing Emotions & Moods Educate about emotions (feelings) and moods Anger, anxiety or fear, boredom, depression, emptiness, loneliness, guilt, shame, positive emotions Monitor emotions and moods Reduce negative, increase positive emotions Discriminate normal moods from symptoms Express feelings (appropriately) Connect moods to behavior, thoughts, relationships and life circumstances Use pen and paper inventories when needed 35 Strategy 7: Address Family Issues Involve family in sessions when appropriate and feasible; elicit input into treatment plan Review impact of disorders on family Provide education on disorders, treatment, recovery Address family concerns and problems Fear of passing illness on to offspring Worries about relapse Impact of disorder(s) on children in family 36 12

13 Other Ways to Help the Family & Individual Members Identify and reduce enabling behaviors Address emotional burden of family Anger, guilt, confusion, anxiety, worry Reduce negative interactions Deal with specific behaviors or symptoms of member (depression, mania, obsessions, poor adherence, relapse, etc) Help access other resources Facilitate individual assessments if family member may have SUD or psychiatric disorder 37 Strategy 8: Evaluate and Enhance Interpersonal Relationships Identify IP strengths and resiliencies Decrease isolation; increase social interactions Identify and resolve interpersonal disputes or conflicts Address high risk relationships Identify interpersonal deficits Improve social skills 38 Strategy 9: Facilitate Active Use Of Mutual Support Programs AA, NA and other 12-step programs Non-12 Step Programs (SOS, WFS, Smart Rec) Dual Recovery Anonymous Mood or Anxiety related programs Other (EA, EHA, Recovery, Inc) Programs exist for families, too Programs offer support and tools to manage disorders and engage in recovery 39 13

14 Strategy 10: Identify and Change Inaccurate Thinking All or none thinking Awfulizing Overgeneralizing Expecting the worse outcome Disqualifying the positive Jumping to conclusions Emotional responses 40 Identify and Change Inaccurate Thinking Should or must statements Labeling and mislabeling Personalization Cognitive therapy framework: cognitive distortions AA/NA framework: stinking thinking -Beck; Burns; Greenberger & Padesky 41 Probability Overestimation of Risk, Harm or Danger Prediction person believes will become true even if likelihood is very low My presentation will be a disaster I will be overwhelmed with panic I won t be able to resist drinking at... A very small chance of something bad happening is the same as a large chance of it happening 42 14

15 Using Slogans, Self-Talk or Mottos Anxiety is part of life My anxiety/panic/fear won t last forever I can t live the rest of my life afraid People are not as critical as I think One day at a time Keep it simple Recovery is contagious, catch it! 43 Strategy 11: Address Relapse and Recurrence Depression Risk of Recurrence First Episode = 50% Second Episode = 70% Third Episode = 90% Bipolar Illness Risk of Recurrence Recurrence rate is 50% at 30 months Addiction First 90 days is greatest risk period 44 Strategies to Reduce Relapse Risk Actively managing disorders and staying in recovery are ways to reduce relapse risk Identifying and managing early relapse warning signs: obvious, subtle, disorder specific signs Identifying and managing high-risk relapse factors based on individual: severity of illness, motivation, coping strategies, support systems 45 15

16 Strategy 12: Facilitate Lifestyle Change Participate in pleasurable activities; new activities Use a daily or weekly plan in order to structure time Use relaxation, breathing techniques Use meditation or mindfulness techniques Get physical exercise Learn sleep hygiene techniques Develop regular social rhythms Money management (especially for bipolar conditions) 46 Strategy 13: Assess Suicidality Risk Factors Recent loss or threat of loss, suicide by significant other, prior attempt or a current plan, history of selfdestructive behavior, poor health, lack of support Interventions Discuss suicidal thoughts and feelings Seek help immediately if there is a plan Focus on the why of suicide Suicide thoughts and feelings go away Catch early signs of psychiatric or addiction relapse 47 Strategy 14: Address Sleep Related Problems Definition Epidemiology of sleep problems Medications Psychological Treatments -Morin 48 16

17 Psychological Treatments for Insomnia Relaxation training Stimulus control Sleep restriction Cognitive therapy Sleep hygiene 49 Medications for Insomnia Benzodiazepines (BZD) Non-BZD hypnotics Antidepressants Over-the-counter medications Can use when patient unresponsive to psychological interventions Avoid using with patients getting high on substances, those with severe sleep apnea, those on call (nurse, fireman) or pregnant 50 QUESTIONS FROM PARTICIPANTS 51 17

18 Thank You Thanks for attending this program and sharing in our discussions. Survey Reminder The CCC encourages all to complete the survey issued to participants directly following the webinar session, as this is the primary collective tool for rating your experience with this and other webinars, and communicating the interests and needs of CTN members and associates. Upcoming Webinars DATE AUG 15 SEPT 19 OCT 24 NOV 14 DEC 19 WEBINARS Personality Disorders and Addiction Build Your Team for Research Success Managing Safety & Crisis Situations Practical Statistical Reasoning in Clinical Trials for Non-Statisticians Helping Patients with Substance Use Disorders and Pain Requests can be sent to: 53 A copy of this presentation will be available electronically after the meeting