CO-OCCURRING DISORDERS Sunil Khushalani, MD Addictions Is this

CO-OCCURRING DISORDERS Sunil Khushalani, MD Addictions Is this

CO-OCCURRING DISORDERS Sunil Khushalani, MD Addictions Is this the population we work with?

Mental Illness Substance Misuse Or is this the population we work with?

LEGAL Homelessnes s Hepatitis


Or is this the population we work with? CASE EXAMPLE 49 year old single female Who has been admitted to the hospital more than a dozen times With h/o suicidal behavior, aggressive behavior

CASE EXAMPLE She has a h/o Bipolar I disorder Eating disorder Post-traumatic Disorder Borderline Personality Disorder

CASE EXAMPLE Chronic Pain On very high doses of opioids H/o cocaine abuse Heavy smoker CASE EXAMPLE-3

36 year old male H/o schizoaffective disorder, Bipolar type Has been living on the streets H/o non-adherence to his medications CASE EXAMPLE-3 Has heavy alcohol use, 4 or more times a week

H/o cannabis abuse and cocaine abuse Smokes cigarettes daily DUAL DIAGNOSIS? Terms used to describe dual diagnosis MICA (mentally ill chemically addicted) CAMI (chemical abusing mentally ill)

d n a n o m m co abuser)

MISA (mentally ill substance e r a s n o

i t i SAMI e nd (substance abusing

x mentally ill) o e l c

p es om c h T MICD (mentally ill chemically dependent)

COAMD (co-occurring addictive and mental disorders) ACD (addiction and co-occurring disorders) DUAL DIAGNOSIS? The term dual diagnosis is an unfortunate misnomer Firstly, the term has been used to describe other

combination of illnesses, such as individuals with mental illness and developmental disabilities DUAL DIAGNOSIS? Secondly, individuals rarely experience only two disorders

They have multiple interacting disabilities, psychosocial problems, and disadvantages CO-OCCURRING DISORDERS Individuals who have at least one mental disorder as well as alcohol or drug use disorder

CO-OCCURRING DISORDERS Common and highly complex Affect 7 to 10 million adult Americans in any one year CO-OCCURRING DISORDERS According to the U.S Surgeon General report in 1999,

41-65% of individuals with a lifetime substance abuse disorder also have a lifetime history of at least one mental disorder CO-OCCURRING DISORDERS According to the National Co-morbidity Survey , 47% of individuals with schizophrenia also had a substance abuse disorder (4 times more than the

general population) 61% of Individuals with Bipolar disorder also had a substance abuse disorder (5 times as likely as the general population) CO-OCCURRING DISORDERS According to the National Co-morbidity Survey,

90% of those with a lifetime co-occurring disorder had at least one mental disorder prior to the onset of a substance abuse disorder. Generally, the mental disorder occurred in early adolescence {median age 11); followed by the substance abuse disorder 5 to 10 years later (median age 21)

CO-OCCURRING DISORDERS These individuals have particular difficulty seeking and receiving diagnostic and treatment services They present significant challenges to the Nations public health and to health policy makers as well

CO-OCCURRING DISORDERS The difficulty is compounded by the existence of two separate service systems, one for mental health services and another for substance abuse treatment CO-OCCURRING DISORDERS

If one of the co-occurring disorders goes untreated, both usually get worse and additional complications often arise IMPLICATIONS Increased risk of relapse and hospitalizations Poor treatment adherence and worse outcomes

Increased risk of suicide IMPLICATIONS Increased burdens on family, interpersonal conflicts More hostility, aggression, violence Housing instability and homelessness

IMPLICATIONS More legal encounters Increase high risk behaviors- leading to HIV, Hepatitis Prone to victimization Considerable morbidity and early mortality IMPLICATIONS

Co-occurring disorders are frequently interactive and cyclical: Substance abuse can worsen the course of psychiatric illness, and worsening psychiatric disorders can lead to increased substance abuse CO-OCCURRING DISORDERS According to Drake et al, presence of severe mental

illness may create additional vulnerability so that even small amounts of psychoactive substances may have adverse consequences for individuals with schizophrenia and other brain disorders The NASMHPD-NASADAD National dialogue recognized in1999 There is no single locus of responsibility for people with

COD Both MH and SA systems largely operate independent of each other Lack of coordination means that neither consumers nor Behavioral health systems have historically been organized to see people and families with co-occurring

mental health and substance use disorders and other complex needs - as misfits - Kenneth Minkoff, M.D. EVOLUTION OF TREATMENT MODELS Serial or Sequential

Parallel Integrated SERIAL OR SEQUENTIAL MODEL Ping-Pong Therapy If their mental health issues are more than the S.A facility can handle many a times instead of sending

the patient back they are just d/ced In essence this becomes No treatment SERIAL OR SEQUENTIAL MODEL Many mental health professionals are not well trained to deal with addictions and vice versa

SERIAL OR SEQUENTIAL MODEL Mental Health Professionals Feel Ineffective Feel patient is resistant or unmotivated As long as patient is using they cant be helped Significant negative attributions to this population which leads to significant counter-transference issues

SERIAL OR SEQUENTIAL MODEL Philosophical differences in the two separate systems leaves the client confused PARALLEL MODEL The tough task of navigating two systems, with different

appointments, different philosophies, conflicting advice, and multiple providers falls on the fragile and already challenged patient PARALLEL MODEL Various funding sources provide widely disparate benefits for mental health and substance abuse treatment, forcing

clinicians to decide which of the disorders is primary PARALLEL MODEL Managed care only tends to focus on acute states leaving many aspects of care for the chronically ill unfulfilled CO-OCCURRING DISORDERS

Despite strides in research over last 20 yrs, little remains known about the etiology and temporal ordering of co-occurring disorders For this reason, many researchers and clinicians believe that both disorders must be considered as primary and treated as such

INTEGRATED MODEL Clinically more effective Better outcomes Has evidence base to support it INTEGRATED MODEL Fiscally more sound

Much more patient friendly Recognizes that there is a need to make clinical decisions and interventions even in the context of diagnostic uncertainty High severity

Less severe mental disorder/ more severe substance abuse disorder

The Four Quadrant Framework for Co-Occurring Disorders Less severe mental disorder/ less severe

substance abuse disorder Low severity More severe mental disorder/

more severe substance abuse disorder More severe mental disorder/ less severe

substance abuse disorder High severity The four--quadrant conceptual framework to

guide systems integration and resource allocation in treating individuals with co--occurring disorders CO-OCCURRING DISORDERS Low MH in an acute psych ER might be High MH in an

Addictions Outpt clinic Low Addiction in a Methadone program might be High Addiction in a primary care clinic CO-OCCURRING DISORDERS The threshold of substance abuse that might be harmful is significantly lower in people with mental illness

The more severe the mental illness, the lower the amount that is harmful Co-occurring issues and conditions are an expectation, not an exception

The foundation of a recovery partnership is an empathic, hopeful, integrated, strength-based relationship All people with co-occurring conditions are not the same, so different parts of the system have responsibility to provide co-occurring capable services for different populations

When co-occurring issues and conditions co-exist, each issue or condition is considered to be primary Recovery involves moving through stages of change and phases of recovery for each co-occurring condition or issue

Progress occurs through adequately supported, adequately rewarded skill-based learning for each cooccurring condition or issue Recovery plans, interventions, and outcomes must be individualized. Consequently, there is no one correct co-occurring program or intervention for everyone

. CCISC is designed so that all policies, procedures, practices, programs, and clinicians become welcoming, recovery- or resiliency-oriented, and co-occurring capable.

INTEGRATED MODEL No Wrong Door Policy Each provider with the healthcare delivery system has a responsibility to address the range of client needs wherever and whenever a client presents for care (CSAT 2000a)

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