Psychosis and Substance Use Prevalence Attitudes to substance use Assessment Approaches and interventions
WHO IS LIKELY TO TAKE SUBSTANCES? 83.6% Antisocial Personality Disorder 56.1% Bipolar Affective Disorder 47.0% Schizophrenia 32.0% Affective Disorder 23.7% Anxiety Disorder ECA Study (1990, US)
PSYCHOSIS & SUBSTANCE USE PREVALENCE Psychoactive substance abuse is the major comorbidity problem Alcohol 30% Abuse/Dependence History - 39% M and 17% F Cannabis 25% Abuse/Dependence History 33% M and 13% F Other Substance 13%Abuse/Dependence History 17% M and 7% F Current smoking was reported 73% M and 56% F (from NSMHWB1997)
PSYCHOSIS & ILLICIT SUBSTANCE USE In decreasing order: Cannabis Amphetamines LSD Heroin Tranquillisers with 19.1% having used more than one drug
Early Psychosis and Substance Use Prevalence Data problems - mostly retrospective 20-30% USA studies Australian prospective cohorts 30-50% acutely distressed adolescents then 50% had psychotic illness develop UK prospective first presentation 37% alcohol or drug use (odd definitions)
Relevance to psychosis and interventions Clinically common Affects outcome especially psychotic symptoms, depressed mood, suicidality, violence and relapse. More likely to readmitted, to be homeless and gaoled. Interventions help and do improve outcome.
Differences in groups of clients with first presentation of psychosis Those that use substances maybe higher functioning premorbidly, shorter duration of illness prior to treatment and earlier age of onset. (Addington) Current use of substances is associated with poorer quality of life and less negative symptoms. Cesstion of drug use especilly THC will lead to improved symptoms and outcome globally. (Rolfe)
Substance Dependence A maladaptive pattern of SU leading to clinically significant impairment or distress, manifested by 3 or more of tolerance withdrawal taking more or same over longer periods than intended desire or attempts to cut down or control use great deal of effort goes into obtaining substance social, recreational activities are given up continued use despite knowledge of physical or psychological problems
MODELS OF TREATMENT PARALLEL MODEL Simultaneous provision of treatment services at different sites SEQUENTIAL MODEL Definitive treatment in one service before other INTEGRATED MODEL Simultaneous provision of treatment by same person, team or organisation at same site
PRINCIPLES OF MANAGEMENT INTEGRATED COMPREHENSIVE PHASE SPECIFIC ASSERTIVE LONG TERM
ASSERTIVE SERVICE Assertive engagement Non-coercive strategies such as assistance with food, housing, social security entitlements, recreational activities Coercive strategies such as involuntary hospitalisation, medication, financial control
LONG TERM SERVICE Both disorders can be chronic, relapsing conditions Long-term approach Time frame is years, not months Planning and evaluating programmes implications
Motivational Interviewing Model or style of counselling which utilizes the client s concerns and motivations, and their ambivalences to assist them to identify changes they wish to make and aims to enhance their self efficiacy and confidence to achieve these changes. Same underlying assumptions as most therapies used in D&A; based on concepts such as self responsibility, an open honest appraisal of the problems and assesses willingness to engage in process of change.
Principles Empathic listening - reflective, affirmative, using open questions and summarizing selectively. Avoiding argument and resistance - to maintain rapport. This is the major trap for therapists. Supporting self efficacy - helping clients feel empowered to succed at the change Use of discrepancy as a catalyst
Assumptions and Problems Dependencies are a motivational problem. Clients are able to think and construct along these lines. (concrete thinking + comorbidity) Consultation time is not so limited. Other aspects of the interview eg diagnostic issues are covered where?
GROUPS - PERSUASION GROUPS Non-judgmental and psychoeducational often lifestyle groups Weekly or regular Relatively brief Drop-in basis Resistant clients encouraged to attend Case Managers encourage attendance by providing transport and scheduling other events suitable for clients in precontemplation/contemplation but don t mix with people in other stages of stages of change
GROUPS - PERSUASION GROUPS Non-judgmental and psychoeducational often lifestyle groups Weekly or regular Relatively brief Drop-in basis Resistant clients encouraged to attend Case Managers encourage attendance by providing transport and scheduling other events suitable for clients in precontemplation/contemplation but don t mix with people in other stages of stages of change