We acknowledge the traditional custodians of the land on which we meet today and pay respect to Elders past, present and emerging.

Transcription

1 We acknowledge the traditional custodians of the land on which we meet today and pay respect to Elders past, present and emerging. We also extend that respect to other Aboriginal and/or Torres Strait Islanders who are joining us here today. David R Horton, creator, Aboriginal Studies Press, AIATSIS and Auslig/Sinclair, Knight, Merz, View an interactive version of the AIATSIS map Header Artwork produced for Queensland Health by Gilimbaa

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

3 Overview History Co-existing MH /AOD Treatment findings Why healthy lifestyles? Results from healthy lifestyles studies Recommendations for practice

4 Health Issues Deinstitutionalization Severe mental illness Motivational Interviewing HIV epidemic & harm reduction

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

6 Early Studies 6 People with mixed MH & AOD diagnoses People with SMI and using alcohol and/or other drugs

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8 Categorical Change in Alcohol Users Across Treatment 8 Treatment categories Total Brief Advice 1 session MI 10 Session CBT Count % Count % Count % Count % Category of decline in alcohol use No 50 to 99 improvement 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%

9 Categorical Change in Cannabis Users Across Treatment 9 Treatment categories Total Brief Advice 1 session MI 10 Session CBT Count % Count % Count % Count % Category of decline in cannabis use No 50 to 99 improvement 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%

10 Alcohol and Cannabis 10 Alcohol misuse: Respond to assessment and BI Cannabis use: Does not generally respond to BI Similar to results to Barrowclough et al (2001) Significant superior global functioning for the treatment group

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12 Treatment Focus 12 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

13 DAISI Methodology (N=284) 13 Assessment Case Formulation 1 session Motivation enhancement, feedback from assessment Self-help material 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

14 BDI-II Mean Change Scores (time p<.001; BI<10 at 12- and 36months p<.05; Integrated > single focus 18 weeks p<.05) Weeks 6 months 12 months 24 months 36 months Brief Depression Alcohol Integrated

15 Standard Drinks Per Day Mean Change Scores (time p<.01; Alcohol > Depression at 6- and 24-months (p<.01) and 12-months (p<.05) weeks 6 months 12 months 24 months 36 months -6 Brief Depression Alcohol Integrated

16 Treatment findings 16 Large proportion of clients If undetected, can affect progress Screen, assess and treat MH / AOD Start with a brief integrated intervention and step up treatment, monitoring MH / AOD

17 Why has tobacco dependence been treated differently to other drug dependence in mental health or substance abuse settings? 17

18 Fears about worsening mental health symptoms & AOD use 18

19 Tobacco 19 Less behavioural disturbance Fears of patients not coping/aggression NRT widely available Hughes & Weiss (2005)

20 A national disgrace National Mental Health Commission. A Contributing Life, the 2012 National Report Card on Mental Health and Suicide Prevention (2012) 20 Life expectancy shorter Cardiovascular disease: single largest cause of the death

21 Leading causes of death (AIHW 2012) 21 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

22 Unhealthy behaviours and leading preventable causes of death (AIHW 2012) 22 Disease Behaviour Biomedical CHD/ stroke Smoking, Inactivity, Alcohol, Diet Obesity, high BP, Cholesterol Cancers Smoking, Inactivity, Alcohol, Diet Obesity Respiratory Smoking

23 Health behaviours & health protection (Khaw et al 2008) 23

24 Health score of 0 vs 4 = 14 year difference in chronological age for mortality risk (Khaw et al 2008) 24

25 CVD risk behaviours in people with psychosis vs general population (Morgan et al, 2012; AIHW 2012) 25 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%

26 Cannabis and other illicit substances (Morgan et al, 2012; AIHW 2012; 2005) 26 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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28 Healthy Lifestyles Methodology (N=235) 28 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)

29 Results: Point prevalence abstinence 29

30 Results: Cigarettes per day (change from baseline, p<.001) 30

31 Minutes walking per week (p=0.02 Therapy vs Phone 12 m) 31

32 Serves of fruit per day 32

33 Serves of vegetables per day 33

34 GAF Score 34

35 35 CVD Risk Score Significant improvement both conditions overall time points Psychiatric Symptomatology Significant decrease on BDI-II, no worsening on BPRS

36 Multi-component interventions: feasible, effective, and more efficient (Spring et al 2010) 36

37 37 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)

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39 Better Health Choices 39 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 39

40 Primary Outcomes 40 (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)

41 Secondary Outcomes (n=17) 41 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

42 Limitations of BHC study 42 Limitations Non-controlled study with small sample Short follow-up time period Self-report measures Future directions RCT Delivery by other professionals/ consumers 42

43 Peer Delivered Better Health Choices Pilot RCT (Kelly et al) 43 Trained peer workers Also address smoking and alcohol 31 people completed so far (18 = tx, 13 = control) 14/18 completed all 8-sessions

44 Pilot RCT 44 Client Satisfaction Questionnaire indicates treatment satisfaction is high (M = 27.5 out of a possible 32) Overall satisfaction with the program mostly satisfied (29%) or very satisfied (71%)

45 Multiple risk profiles in inpatients (Prochaska et al 2014) 45 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

46 Early smoking outcomes from a stepped wedge RCT of a healthy lifestyle intervention in residential substance abuse treatment Peter J. Kelly, Amanda L. Baker, Frank P. Deane, Robin Callister, Clare Collins, Isabella Ingram, Camilla Townsend & Jessica Hazleton

47 This research was funded by: 47

48 48 Research conducted in partnership

49 Risk Behaviours 49 Kelly, Baker, Kay-Lambkin, Deane & Bonevski, 2012

50 50 Healthy Recovery 8 session group based program Designed for substance abuse populations Program Goals Reduce smoking Increase physical activity Improve diet

51 51 Healthy Recovery Components of the intervention Education and rationale Group based motivational interviewing Goal setting and monitoring Contingency management (smoking) Nicotine replacement therapy

52 Methods Participants (N = 172) Attending The Salvation Army Recovery Service Centres 74% males, average age = 38 years, 72% alcohol problems All participants were smokers 52 Design Stepped wedge randomized controlled trial Intention to treat analysis Procedure 5-week group program delivered Researcher + drug/alcohol workers co-facilitated the groups

53 Eligible participants interested in participating Percentage % 70% % 24% 0 Interested in participating Not interested in participating

54 Average daily cigarettes smoked Baseline 2 Months 5 Months 8 Months Control Intervention

55 Quit Rates at Follow-up 2-months 5-months 8-months Control 2% 6% 8% Healthy Recovery 18% 12% 15%

56 Use of Nicotine Replacement Therapy (NRT) 2-months 5-months 8-months Control 21% 19% 26% Healthy Recovery 60% 45% 29%

57 Healthy Recovery 57 Healthy Recovery Significantly better reductions in smoking Trend for better quit rates Self efficacy mediates reductions on smoking Challenge is to embed these types of programs as part of routine care

58 Conclusions 58 MH / PH Health behaviours cluster together We can help people to work on a few behaviours at a time if they want to Allows flexibility, success over time

59 Newcastle, Australia THANK YOU

60 ACKNOWLEDGEMENTS Funding NHMRC NRT GlaxoSmithKline Address for correspondence

61 Thanks for joining us today! Please fill out a short evaluation Join us on 4 th October for AOD and the Law What you should know Presented by Penny Williams.