Concurrent Disorders Christian G. Schütz MD PhD MPH FRCPC Associate Professor UBC Research and Education Medical Manager BCMHA/PHSA
Overview What Are Concurrent Disorders? How Common Are They? Treatment Principles and Issues Summary
What are Concurrent Disorders? Any combination of: mental disorder + substance use disorder ------------------------------------------ concurrent disorders / dual diagnoses / co-occuring disorders 3
B. Rush 2010 How Common Are They? Canada
B. Rush 2010 How Common Are They? Canada
B. Rush 2010 How Common Are They? Canada
B. Rush 2010 How Common Are They? Canada
Odds of concurrent mental disorder Rush 2010
Concurrent disorders Two or more chronic conditions Highly vulnerable population High burden of morbidity and mortality Under-diagnosed Under-treated Lacks a solid research base, as they are often excluded from trials
Why is overlap so common? Overlapping neurobiological pathways
Why is overlap so common? Overlapping neurobiological pathways underlying genetic factors (common vulnerabilities)
Alcoholism/Addiction Levey et al. 2014 SNCA DRD2 GABRB3 SYN2 MOBP ATNX1 GNAI1 GRM3 Anxiety Le-Niculescu et al. 2011 Schizophrenia Ayalew et al. 2012 GRIA1 HTR2A MBP Bipolar Disorder Patel et al. 2010 Genetic overlap Adapted from Levy 2014
Why is overlap so common? Overlapping. neurobiological pathways and common vulnerabilities underlying genetic factors exposure to trauma, chronic stress, and loss
PTSD Bipolar Schizophrenia Substance use disorders Adapted from Stahl Essential Psychopharmacology
Why is overlap so common? Overlapping. neurobiological pathways and common vulnerabilities underlying genetic factors exposure to trauma, chronic stress, and loss Disorder as a risk factor for second disorder bi-directional complex inducting, propelling and upholding
Concurrent disorder Higher rates of: history of traumatization (childhood, adult) poverty and deprivation victimization, violence, incarceration, homelessness neurocognitive impairment cluster B personality traits relapse, hospitalization medical complications (Hep C, HIV, COPD, stroke ) Suicides Worse clinical course, treatment outcome and prognosis
Anxiety Disorders Concurrent Disorders Christian G. Schütz MD PhD MPH FRCPC Associate Professor UBC Research and Education Medical Manager BCMHA/PHSA Lifetime 25-35% http://getridofstress.org
Anxiety Disorders cause clinically significant distress or functional impairment Concurrent Disorders Christian G. Schütz MD PhD MPH FRCPC Associate Professor UBC Research and Education Medical Manager BCMHA/PHSA Lifetime 25-35% http://getridofstress.org
Affective Disorders cause clinically significant distress or functional impairment mood instability MANIC EPISODE Lifetime 40% dysth cyclothymia DEPRESSIVE EPISODE
Affective Disorders Affective instability Affective instability mood instability MANIC EPISODE DEPRESSIVE EPISODE dysth cyclothymia Lifetime 40% Adapted from Bonsall 2011
Psychotic Disorders Substance induced Stimulant intoxication Sedative withdrawal (-O = delirium) Cannabis intoxication NOT oipioids
Cluster A (odd) Paranoid * distrust and suspiciousness Schizoid * social detachment emotionally cold Schizotypal *** odd, eccentric, peculiar Cluster B (dramatic) Antisocial **** deceitful hostile disregard for others Borderline *** intense and unstable emotional relationships Histrionic ** attention seeking, exaggerated emotionality Narcissistic * entitlement, excessive selfworth Cluster C (fearful) Avoidant social inhibition Dependent strong need to be taken care of, needs reassurance Obsessive compulsive * preoccupied with rules and orderliness
Cluster A (odd) Paranoid * distrust and suspiciousness Schizoid * social detachment emotionally cold Schizotypal *** odd, eccentric, peculiar Cluster B (dramatic) Antisocial **** deceitful hostile disregard for others Borderline *** intense and unstable emotional relationships Histrionic ** attention seeking, exaggerated emotionality Narcissistic * entitlement, excessive selfworth Cluster C (fearful) Avoidant social inhibition Dependent strong need to be taken care of, needs reassurance Obsessive compulsive * preoccupied with rules and orderliness
Screener? Mental Disorder: Depression: ADHD: Personality Disorder Modified MINI Mental Screener GHB-9 Questionnaire Adult ADHD Self-Report Scale Self Harm Inventory (Borderline)
Models of Care
Models of Care
Models of Care
The Four Quadrant Framework for Concurrent Disorders More severe mental disorder/ more severe substance abuse disorder More severe mental disorder/ less severe substance abuse disorder High severity Ries
The Four Quadrant Framework for Concurrent Disorders More severe mental disorder/ more severe substance abuse disorder Integrated programs are rare and often have low fidelity ratings More severe mental disorder/ less severe substance abuse disorder High severity Ries
Trauma Informed Care Rebuild hope and sense of control: Safety Trust Choice Empowerment Client - centered
Pharmacotherapy for Concurrent Disorders A thorough assessment is essential Consider sequence, time lines, and periods of abstinence Both substance use and mental disorder must be treated Little evidence beyond treatment of independent disorders Continue to re-evaluation diagnosis and medications
Polypharmacy risks with methadone/burprenorphine Additive or synergistic effects: sedating antidepressants antipsychotics Benzodiazepines! Additive side effects: QTc prolongation Haloperidol, Chlorpromazine, Olanzapine, Citalopram Pharamacokinetic interaction: CYP induction: Carbamazepine CYP inhibition: Fluvoxamine, Fluoxetine, paroxetine
Summary of effect sizes. Leucht S et al. BJP 2012;200:97-106
Summary of effect sizes. X Leucht S et al. BJP 2012;200:97-106
Counselling & Community Resources Detoxification Centres Outpatient Counselling Services & Day Programs Support Recovery Houses Residential Treatment Centres Self-Help Support Groups Specific Concurrent Disorders Programs?
Counselling & Community Resources Transitions, Stepping Stones Assertive Community Team, Urgent Response Team Concurrent Disorders Intervention Unit (CDIU), Heartwood Centre for Women Burnaby Centre for Mental Health & Addiction (BCMHA)
Summary Comorbidity is common (the rule not the exception)
Summary Comorbidity is common (the rule not the exception) Recognize and assess the interdependent, and overlapping clinical picture for substance use disorders and mental illnesses
Summary Comorbidity is common (the rule not the exception) Recognize and assess the interdependent, and overlapping clinical picture for substance use disorders and mental illnesses Acknowledge that a lot of processes of the mind, including drug seeking, is outside of consciousness
Summary Comorbidity is common (the rule not the exception) Recognize and assess the interdependent, and overlapping clinical picture for substance use disorders and mental illnesses Acknowledge that a lot of processes of the mind, including drug seeking, is outside of consciousness Re-evaluate regularly
Summary Comorbidity is common (the rule not the exception) Recognize and assess the interdependent, and overlapping clinical picture for substance use disorders and mental illnesses Acknowledge that a lot of processes of the mind, including drug seeking, is outside of consciousness Re-evaluate regularly Treat the substance use disorders
Summary Comorbidity is common (the rule not the exception) Recognize and assess the interdependent, and overlapping clinical picture for substance use disorders and mental illnesses Acknowledge that a lot of processes of the mind, including drug seeking, is outside of consciousness Re-evaluate regularly Treat the substance use disorders Treat the mental illnesses
Summary Comorbidity is common (the rule not the exception) Recognize and assess the interdependent, and overlapping clinical picture for substance use disorders and mental illnesses Acknowledge that a lot of processes of the mind, including drug seeking, is outside of consciousness Re-evaluate regularly Treat the substance use disorders Treat the mental illnesses Change takes time!
Thank you very much for your attention If you have any further questions: christian.schutz@ubc.ca
Health Canadian Guidelines: CANMAT http://www.hc-sc.gc.ca/hc-ps/alt_formats/hecs-sesc/pdf/pubs/adp-apd/bp_disordermp_concomitants/bp_concurrent_mental_health-eng.pdf w.canmat.org/articles-mdh/5.%20beaulieu,%20canmat%20comorbidity%20- %20Substances,%20Ann%20Clin%20Psyt%202012.pdf US SAMSAH http://store.samhsa.gov/product/integrated-treatment-for-co-occurring-disorders-evidence-based- Practices-EBP-KIT/SMA08-4367 US APA http://psychiatryonline.org/content.aspx?bookid=28§ionid=1675010 UK NICE http://www.nice.org.uk/nicemedia/live/13414/53729/53729.pdf Australian NHMRC http://www.dassa.sa.gov.au/webdata/resources/files/comorbidity_substanceuse_guide_full_report.pdf Cochrane Library --