A healthy lifestyles approach to co-existing mental health and substance use problems Amanda Baker PhD

Transcription

1 A healthy lifestyles approach to co-existing mental health and substance use problems Amanda Baker PhD

2 Outline 2 Context Early studies addressing co-existing problems Depression and AOD use Smoking in people treated within mental health settings Health behaviours among people treated within mental health settings Healthy lifestyle interventions

3 Health Issues 1980s 3 Deinstitutionalization Severe mental illness NDARC Sydney 1989 Motivational interviewing

4 Treatment Silos 4 Mental health Drug & alcohol

5 Dual Diagnosis 1990s 5 Mental Disorders Substance Use Disorders Dual Diagnosis

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7 Early Studies 7 People with mixed MH & AOD diagnoses People with SMI and using alcohol and/or other drugs

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9 Categorical Change in Alcohol Users Across Treatment 9 Treatment categories Total Brief Adv ice 1 session MI 10 Session CBT Count % Count % Count % Count % Category of decline in alcohol use No 50 to 99 improv ement Up to 49% percent /worsening reduction reduction Abstinence Total % 10.6% 57.4% 14.9% 100.0% % 14.0% 48.8% 14.0% 100.0% % 24.5% 54.7% 3.8% 100.0% % 16.8% 53.8% 10.5% 100.0%

10 Categorical Change in Cannabis Users Across Treatment 10 Category of decline in cannabis use Treatment categories Total Brief Adv ice 1 session MI 10 Session CBT Count % Count % Count % Count % No 50 to 99 improv ement Up to 49% percent /worsening reduction reduction Abstinence Total % 15.6% 22.1% 28.6% 100.0% % 13.5% 26.9% 19.2% 100.0% % 14.9% 43.2% 20.3% 100.0% % 14.8% 31.0% 23.2% 100.0%

11 Alcohol and Cannabis 11 Alcohol misuse: Responds to assessment and BI Cannabis use: Longer interventions more effective Barrowclough et al: MIDAS trial

12 Early findings 12 A range of treatment strategies are needed Flexible interventions needed: Screening & assessment Stepped interventions for alcohol, cannabis & other drug use

13 Further research 13 Report on alcohol, cannabis and other drug use separately, as well as combined Larger RCTs Longer interventions for cannabis use

14 Depression and AOD use 14 Focus on depression Then on depression and alcohol misuse Included computer delivery

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17 Assessment Case Formulation 1 session MI, feedback from assessment Self-help material, Mood monitoring Current depression (N=274) Current AOD use 17 SHADE Therapy 9 sessions integrated CBT delivered by therapist SHADE Therapy Computer 9 sessions integrated CBT delivered by computer PCT 9 sessions person-centred therapy delivered by therapist Follow-up Assessments Post 6-months post-treatment 12-months post-treatment

18 SHADE Findings (3 months) 18 PCT: significantly less reduction in depression and alcohol consumption Computer: depression outcome equivalent to that achieved by therapist-delivered treatment Significantly superior results for alcohol consumption

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20 DAISI Methodology (N=284) 20 Assessment 1 session MI, feedback from assessment Self-help material, monitoring Case Formulation Depression Focused Therapy Alcohol Focused Therapy Integrated Therapy Brief Intervention (integrated) 9 sessions depression focused CBT 9 sessions alcohol focused CBT 9 sessions integrated CBT No further treatment Follow-up Assessments 15-weeks post-initial 6-months post-initial 12-months post-initial 24-months post-initial 36-months post-initial

21 Treatment Focus 21 Depression Focus Alcohol Focus Integrated Mood monitor Craving monitor Craving & mood monitor Negative automatic thoughts Permissive thoughts about drinking alcohol Permissive thoughts about alcohol as a response to negative automatic thoughts

22 DAISI Findings sessions more effective in: reducing depression in the long-term improving alcohol consumption in the short-term Integrated treatment: earlier improvement in depression Alcohol-focused treatment: = depression-focused treatment at reducing depression more effective in reducing alcohol misuse.

23 Recommendations from DAISI 23 Focus on both conditions followed by additional integrated- or alcoholfocused sessions

24 Findings Depression and AOD 24 Brief interventions appear helpful Computer delivery feasible and effective Screen, assess and treat both domains Start with a brief integrated intervention and step up treatment to integrated (or alcohol focus).

25 SMOKING Why has tobacco dependence been treated differently to other drug dependence in mental health or substance abuse settings? 25

26 Fears about worsening mental health symptoms & AOD use 26

27 Tobacco 27 Less behavioural disturbance Fears of patients not coping/aggression NRT widely available Hughes & Weiss (2005)

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29 A national disgrace National Mental Health Commission. A Contributing Life, the 2012 National Report Card on Mental Health and Suicide Prevention (2012) 29 Life expectancy shorter Cardiovascular disease: single largest cause of the death

30 Leading causes of death (AIHW 2012) 30 Men % Women % CHD 16.7 CHD 15.3 Lung cancer 6.6 Stroke 9.8 Stroke 6.2 Dementia 8.0 Respiratory 4.4 Lung cancer 4.4 Prostate cancer 4.3 Breast cancer 4.1

31 Unhealthy behaviours and leading preventable causes of death (AIHW 2012) 31 Disease Behaviour Biomedical CHD/ stroke Smoking, Inactivity, Alcohol, Diet Obesity, high BP, Cholesterol Cancers Smoking, Inactivity, Alcohol, Diet Obesity Respiratory Smoking

32 Health behaviours & health protection (Khaw et al 2008) 32

33 Health score of 0 vs 4 = 14 year difference in chronological age for mortality risk (Khaw et al 2008) 33

34 CVD risk behaviours in people with psychosis vs general population (Morgan et al, 2012; AIHW 2012) 34 Behaviour Psychosis General Smoking 72% men 59% women 18% men 15% women Alcohol use disorder (lifetime) 59% men 38% women 35% men 14% women Insufficient physical activity 97% 62% Insufficient fruit & vegetables 100% 94%

35 Cannabis and other illicit substances (Morgan et al, 2012; AIHW 2012; 2005) 35 Behaviour Psychosis General Any illicit drug abuse or dependence (lifetime) 63% men 42%women 12% men 6% women Cannabis use (past year) 33% 12% Daily cannabis use 38% of users 16% of users Amphetamines (past year) 13% 3%

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37 The Treatment Roundabout 37

38 The Treatment Roundabout 38 Some poor outcomes possible

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40 Healthy Lifestyles Methodology (N=235) 40 Initial Assessment Case Formulation 1 Session 90 minutes Feedback from Assessment, motivational interviewing and goal setting. NRT distributed Face-to-Face Therapy Intervention (60 minutes) 8 weekly sessions 3 fortnightly sessions 6 monthly sessions Minimal Telephone Intervention (10 minutes) 8 weekly sessions (F to F session 4, 8,15) 3 fortnightly sessions 6 monthly sessions Follow-up Assessments 15 weeks (mid-treatment, session 10) 12 month follow-up (3 months post treatment) 18, 24, 30 and 36 month assessment (long term)

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42 Summary of results 42 NRT + face-to-face vs NRT + phone check-in Smoking: no difference between groups F&V: no change in either group Attendance: higher in phone group (11 vs 8 sessions, p<.0001)

43 Interrelationship of multiple health 43 behaviours (deruiter et al 2014) Large longitudinal Canadian study over 14 years leisure time PA smoking alcohol consumption smoking Health behaviours interrelated Specific behavioural interventions may improve other risk behaviours

44 44 Decrease Fat Increase Walking Increase F&V Increase Walking Decrease Fat Decrease Sitting Increase F&V Decrease Sitting p<.001 F&V + leisure screen time: Increased F&V (1.2 to 5.5 serves) Decreased leisure screen time (219 to 89 mins) Decreased saturated fat intake (12% to 9.5% total energy) December 4,

45 Better Health Choices 45 Telephone delivered 8 sessions (weekly or twice a week) Session 1 = 1 hour; sessions 2-8 = min Targets F&V and leisure screen time Can target smoking and/or alcohol use Motivational interviewing approach Resources manual & F&V pack sent out at start 45

46 Primary Outcomes 46 (n=17) Measures Pre-treatment Post-treatment P-value M (SD) M (SD) Fruit consumption (ARFS) 5.1 (3.1) 6.6 (2.9).008 Vegetable consumption (ARFS) 12.2 (4.0) 13.5 (3.5).018 Screen time (min/day) 298 (200) 163 (107)

47 Secondary Outcomes (n=17) 47 Measures Pre-treatment M (SD) Post-treatment M (SD) P-value Diet Quality (ARFS) 33.2 (10.5) 38.2 (8.1).001 Weekday sitting (min/day) 555 (191) 412 (211).008 Walking (min/week) 252 (353) 356 (470).099 Cigarettes/day (n=5) 29.0 (10.3) 13.2 (14.3).082 Cannabis use/day (n=3) 16.2 (18.3) 4.0 (6.9).220 Depression 4.5 (3.3) 3.7 (2.8).149 Quality of life 25.6 (5.6) 28.4 (6.6).017 Global Functioning

48 BHC Outcomes 48 Better Health Choices is feasible and well accepted High attendance & satisfaction Associated with: increased F&V intake and diet quality reduced sedentary activity improved quality of life and global functioning 48

49 Multiple risk profiles in inpatients (Prochaska et al 2014) 49 Behaviour % at risk Behaviour % prepared 30 days Tobacco 100 Depression prevent 76 High fat diet 68 Stimulant use 74 F & V 67 Stress management 69 Sleep hygiene 53 Sleep hygiene 69 Inactivity 52 Non-Rx opiate use 68 Cannabis 46 Binge drinking 57 Depression prevent 43 Inactivity 51 Stress management 42 F & V 46 Binge drinking 26 High fat diet 43 Stimulant use 22 Cannabis 23 Non-Rx opioids 11 Tobacco 23

50 Multi-component interventions: feasible, effective, and more efficient (Spring et al 2010) 50

51 ASSIST: intervention guide 51

52 Smoking 52 Scale Fagerstrom Test for Nicotine Dependence What it measures 6-items The most widely used measure of nicotine dependence Smokerlyzer Carbon Monoxide Monitor

53 Diet 53 Measure Fruit & Veg frequency How many servings of fruit to you typically eat? How many servings of vegetables to you typically eat? Healthy Eating Quiz

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55 Physical Activity 55 Measure International Physical Activity Questionnaire (IPAQ) Widely used assessment of physical activity Vigorous, moderate, walking & sitting time Pedometer / accelerometer External monitors of physical activity Alternative to self report

56 Lifestyle Medicine (Sarris et al 2014) 56 Lifestyle issues are negatively effecting our mental health Evidence is accumulating Lifestyle modification should be a routine part of treatment

57 CONCLUSIONS 57 Healthy lifestyle interventions promising as a way to address smoking, alcohol and other drug use Face to face (brief or longer), telephone, group, online worthy of further study Aim to develop a suite of interventions clinicians can use according to consumer interest and needs

58 Newcastle, Australia THANK YOU

59 ACKNOWLEDGEMENTS Funding NHMRC NRT GlaxoSmithKline Address for correspondence