Objectives:
At the end of this training the participant will be able to:
Identify at least two reasons why persons with Co-occurring disorders oftentimes require psychotropic medication.
Identify 2 psychotropic medications utilized for treatment of
depression, anxiety, and bipolar disorder in the
Co-occurring disorders population.
Name at least 3 common side effects for each class of
psychotropic medications.
State three non-pharmacologic strategies used for treatment of
depression, anxiety, and bipolar disorder.
State two strategies for engaging the Co-occurring disorders
population in psychotropic medication treatment.
At the completion of this class the student should be able to:
Explain the relationship between addiction and co-occurring
disorders
Explain various co-occurring mental health and substance use
disorders, assessment tools, and treatment approaches.
Explain the difference between harmful use and addiction
identify the symptoms of substance use disorder
Acknowledge that addiction is a primary, chronic, genetic,
progressive, and potentially fatal disease
Recognize that people can have multiple (cross) addictions
Recognize what factors put people most at risk for having an addiction / SUD
Describe the phases of addiction (aka Jellinek Curve)
Recognize the cycle of addiction and the difficulty
of breaking this cycle
Develop a treatment plan for 2 clients with co-occurring mental
health and substance use disorders.
TWO DIAGNOSES/ DISORDERS
DOUBLE TROUBLE
MENTAL DISORDERS
› Schizophrenia › Bi-polar disorder
› Schizoaffective
› Major Depression › Borderline
Personality
› Post Traumatic Stress
› Social Phobia
› Generalized anxiety disorder
ADDICTION DISORDERS
› Alcohol
Abuse/Dependence
› Cocaine/ Amphet
› Opiates
› Marijuana
› Polysubstance
combinations
› Prescription drugs
Both Mental and Addiction Disorders
need to be over threshold
Personality Disorders, other than Borderline
not usually counted
Substance Induced Disorders cause diagnostic
confusion
Cross-Cutting Measures
Patient Health Questionnaire (PHQ-9)
Generalized Anxiety Disorder (GAD-7)
Mood Disorder Questionnaire (MDQ)
Adverse Childhood Events (ACE)
PCL-V (PTSD Questionnaire)
CAGE
AUDIT
A four-quadrant conceptual framework to guide systems integration and resource allocation in treating individuals with co-occurring disorders (NASMHPD,NASADAD, 1998; NY State; Ries, 1993; SAMHSA
Report to Congress, 2002)
Not intended to be used to classify individuals (SAMHSA,
2002)
Less severe
mental disorder/
less severe
substance
abuse disorder
More severe
mental disorder/
less severe
substance
abuse disorder
More severe
mental disorder/
more severe
substance
abuse disorder
Less severe
mental disorder/
more severe
substance
abuse disorder
High
severity
High
severity
Low
severity
Depression
Bipolar
ADHD
Anxiety
Thought Disorder
Depression
Bipolar
ADHD Anxiety
Thought Disorder lability
impulsivity
distractibility
concentration energy
nervousness
dysphoria
interest
worry
rumination
obsessiveness delusions
Norepinephrine
aggression
motivation
SE NE DA Other
Serzone + ... no 5HT2
Remeron + + hist/no 5HT2,3
Luvox/LuvoxCR ++ sigma
Lexapro/Celexa ++
Zoloft ++ +
Paxil ++ ... Ach
Prozac ++ +
Effexor XR/Pristiq ++ ++.. ... Cymbalta
Wellbutrin SR/XL ++ ++
Wo
rry
Mood
Worry
Energy
Side Effects
Mood
Worry
Energy
Side Effects
increase
dose?
increase
5HT?
increase
NE?
weight gain;
sexual side effects;
other diagnosis ?
Really New Way
› Use Rating Scale
› “Measurement-based Care”
to determine next steps
If it’s not working, do anything different
› Goal = Remission (all the way better)
Main 2 Questions
Scoring:
1-4 minimal depression
5-9 mild depression
10-14 moderate depression
15-19 moderately severe
depression
20+ severe depression
Patient Health Questionnaire-9
(PHQ-9)
< 4
> 9
5 - 8
PHQ-9 Critical Decision
Points:
Continue Current Strategy or
Increase Dose or Next Level
Continue Current Strategy
Increase Dose or Next Level
Anhedonia
Depressed mood
Insomnia,
hypersomnia
Poor appetite,
increased appetite
Moving too slow, or feeling fidgety and
restless.
Suicidal thinking
Low energy, motivation
Poor concentration
Need 7 out of 13 symptoms.
Symptoms need to occur within the
same period of time.
Need to cause difficulty in functioning at
home, school, and/or work.
People having a manic episode may:
Feel very “up,” “high,” or elated Have a lot of energy Have increased activity levels Feel “jumpy” or “wired” Have trouble sleeping Become more active than usual Talk really fast about a lot of
different things Be agitated, irritable, or “touchy” Feel like their thoughts are going
very fast Think they can do a lot of things at
once Do risky things, like spend a lot of
money or have reckless sex
People having a depressive episode may:
Feel very sad, down, empty, or hopeless
Have very little energy
Have decreased activity levels
Have trouble sleeping, they may sleep too little or too much
Feel like they can’t enjoy anything
Feel worried and empty
Have trouble concentrating
Forget things a lot
Eat too little or too much
Feel tired or “slowed down”
Think about death or suicide
Sometimes, a person with severe episodes of mania or depression also has psychotic symptoms, such as hallucinations or delusions.
The psychotic symptoms tend to match the person’s extreme mood.
For example:
Someone having psychotic symptoms during a manic episode may believe she is famous, has a lot of money, or has special powers.
Someone having psychotic symptoms during a depressive episode may believe he is ruined and penniless, or that he has committed a crime.
History of an odd side effect to a medication.
History of irritability, agitation on an anti-depressant.
Family history of bipolar disorder (especially a parent)
Risk-taking behavior Impulsivity
Seasonal affective disorder
History of post-partum depression
Mood worsens as the day goes on Many tattoos (especially where can be seen on the
neck and face or cannot be covered up when going to a job).
http://myria.com/daily-mood-chart-
download-print
www.moodtracker.com
Are used to treat mental disorders.
They may also sometimes be referred
to as psychiatric medications or
psychotherapeutic medications.
SSRI’s SNRI’s NDRI’s Tricyclic MAOI’s Combo
Celexa
(Citalopram)
20-40mg
Effexor
(Venlafaxine)
37.5mg-
300mg
Wellbutrin
(Bupropion)
100mg-
450mg
Elavil
(Amitriptyline)
10-100mg
Marplan Trazodone
50-300mg
Lexapro
(Escitalopram)
10-20mg
Cymbalta
(Duloxetine)
30-120mg
Norpramine
(Desipramine)
Nardil Remeron
(Mirtazepine)
7.5mg-60mg
Zoloft
(Sertraline)
25-200mg
Pristiq (2008)
(Des-
venlafaxine)
Tofranil
(Imipramine)
Prozac
(Fluoxetine)
10-80mg
Levo-
milnacipran
(Fetzima)
2013
Pamelor
(Nortriptyline)
25mg-150mg
Paxil
(Paroxetine)
20-60mg
Milnacipran
(Savella) 2009
Anafranil
(Clomipramine)
50-300mg
Abilify 2-5mg
Seroquel
Rexulti 0.5mg-3mg
Potential increase in suicidality in first few months
Long-term weight gain possible (except Venlafaxine and Bupropion)
Sexual side effects common (except Bupropion & Mirtazepine)
Withdrawal symptoms can occur with abrupt discontinuation (except Fluoxetine)
Risk for serotonin syndrome (except Bupropion)
Serotonin syndrome symptoms often
begin within hours of taking a
new medication that affects serotonin
levels or excessively increasing the dose
of one that the client is already taking.
Serotonin Syndrome symptoms may include: Confusion
Agitation or restlessness
Dilated pupils
Headache
Changes in blood pressure and/or temperature
Nausea and/or vomiting
Diarrhea
Rapid heart rate
Tremor
Loss of muscle coordination or twitching muscles
Shivering and goose bumps
Heavy sweating
https://www.youtube.com/watch?v=sQ5rwuVP8Kc
In severe cases, serotonin syndrome can
be life threatening.
If a client experiences any of these
symptoms, you should seek medical
attention immediately:
High fever
Seizures
Irregular heartbeat
Unconsciousness
Mood Stablizers Aypical Antipsychotics Antidepressants
Lithium Carbonate
150mg-1200mg
Seroquel (Quetiapine)
50-900mg
Prozac (Fluoxetine)
10mg-80mg
Depakote
(Valproic Acid)
250mg - Target dose=Take weight and add a “0” Target serum concentration: 80-100
Zyprexa (Olanzapine)
2.5mg-20mg
Zoloft (Sertraline)
25mg-200mg
Tegretol
(Carbamazepine)
Geodon (Ziprasidone)
20mg-240mg
Trileptal (Oxcarbazepine)
150mg-
Abilify (Aripiprazole)
2mg-30mg
Lamictal (Lamotrigine)
25mg-200mg
Latuda
10mg-160mg
Vraylar
Rexulti 0.5mg-
Vraylar 1.5mg-6mg
Bipolar depression Latuda (2010) $$$$ a newer expensive 2nd
generation antipsychotic
Lamotrigine (Lamictal)- decreased appetite,
rash, coordination difficulties, word finding difficulties
Trileptal (Oxcarbazepine)- change in
coordination, clumsiness, vision changes, decreased
NA
Topiramate (Topamax)- decreased appetite,
word finding difficulties, feeling “dopey.”
Tegretol (Carbamazepine)- Sedation,
headaches, decreased sodium.
Depakote (Divalproex Na) - weight gain, hand
tremors, nervousness, tiredness, weakness, hair loss,
liver problems.
Role in alcohol withdrawal acute and/or protracted withdrawal
Role in bipolar, especially rapid cycle
Role in early antipsychotic augmentation
Role in PTSD treatment
Great for ongoing sleep problems... Is this protracted withdrawal?
Is there a role in craving/relapse prevention?
49% of social
anxiety disorder
patients have
panic disorder**
50% to 65% of panic disorder
patients have depression†
11% of social
anxiety disorder
patients have OCD**
67% of OCD
patients have
depression*
70% of social anxiety
disorder patients have
depression
Depression
OCD
Social
Anxiety
Disorder
Panic
Disorder
HIGHLY
COMMON…
HIGHLY
COMORBID
Excessive anxiety and worry (apprehensive expectation),
occurring more days than not for at least 6 months,
about a number of events or activities (e.g., work, school performance)
The individual finds it difficult to control the worry.
Anxiety and worry is associated with three (ore more) of the following
symptoms: 1. Restlessness, or feeling keyed up or on edge.
2. Being easily fatigued
3. Difficulty concentrating or mind going blank.
4. Irritability. 5. Muscle tension.
6. Sleep disturbance (difficulty falling or staying asleep, or restless,
unsatisfying sleep)
The anxiety, worry or physical symptoms cause clinically significant distress or impairment
in social, occupational, or other important areas of functioning.
.
A discreet period of intense fear or discomfort
in which 4 or more of the following symptoms
developed abruptly and reached a peak within
10 minutes:
Palpitations, heart pounding
Sweating
Trembling, shaking
Dizziness
Chills or hot flushes
Feelings of unreality
Fear of losing control or going crazy
Fear of dying
Paresthesias
Choking feeling
Smothering or
shortness of breath
Chest pain or
discomfort
Abdominal distress
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th
ed. 2013.
Exposure to a traumatic event in which
the person:
› experienced, witnessed, or was
confronted by death or serious injury to
self or others
AND
› responded with intense fear,
helplessness, or horror
Symptoms
› appear in 3 symptom clusters:
re-experiencing, avoidance/numbing,
hyperarousal
› last for > 1 month
› cause clinically significant distress or
impairment in functioning
Persistent re-experiencing of 1 of the following:
› recurrent distressing recollections of event
› recurrent distressing dreams of event
› acting or feeling event was recurring
› psychological distress at cues resembling event
› physiological reactivity to cues resembling event
Avoidance of stimuli and numbing of general responsiveness indicated by 3 of the following: › avoid thoughts, feelings, or conversations*
› avoid activities, places, or people*
› inability to recall part of trauma
› interest in activities
› estrangement from others
› restricted range of affect
› sense of foreshortened future
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th
ed. 1994.
Persistent symptoms of increased arousal
2: › difficulty sleeping
› irritability or outbursts of anger
› difficulty concentrating
› hypervigilance
› exaggerated startle response
SSRI’s
Mood stabilizers (due to hyperarousal
and hypoarousal- which oftentimes looks
like bipolar disorder
Prazosin (Minipress) for nightmares
Beidel. J Clin Psychiatry. 1998;59(suppl 17):27.
Blushing
Sweating
Trembling And Shaking
“Butterflies”
Palpitations
Stuttering
Is being embarrassed or looking stupid
among your worst fears?
Does fear of embarrassment cause you to
avoid doing things or speaking to others?
Do you avoid activities in which you are the
center of attention?
SSRI antidepressants – generally effective for anxiety if used in lower doses and carefully titrated. These are now the dominant medications used for anxiety.
Buspirone (Buspar) up to 30mg twice daily
Hydroxyzine (Vistaril, Atarax)
HCL- is less tiring
Pamoate- more tiring
Propranolol 10mg ½ to 1 tablet three times daily as needed for anxiety
Clonidine 0.1mg daily as needed for anxiety
Approximately 1/4 of United States residents
are likely to have some anxiety disorder
during their lifetime, and the prevalence is
higher among women than men.
About one half of individuals with a
substance use disorder have an affective or
anxiety disorder at some time in their lives.
Among women with a substance use
disorder, mood disorders may be
prevalent.
Women are more likely than men to
be clinically depressed and/or to
have posttraumatic stress disorder.
Certain populations are at risk for
anxiety and mood disorders (e.g., clients with HIV, diabetes, COPD, etc)
Both substance use and discontinuation
may be associated with depressive
symptoms.
Acute manic symptoms may be induced
or mimicked by intoxication with
stimulants, steroids, hallucinogens, or
polydrug combinations.
•Withdrawal from depressants, opioids, and
stimulants invariably includes potent anxiety
symptoms.
During the first months of sobriety, many people
with substance use disorders may exhibit
symptoms of depression that fade over time
and that are related to acute withdrawal.
Medical problems and medications
can produce symptoms of anxiety
and mood disorders.
About a quarter of individuals who
have chronic or serious general
medical conditions, such as diabetes
or stroke, develop major depressive
disorder.
Mood disturbances and anxiety are ever
present features of many people in
substance abuse treatment.
A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterized by (1) and/or (2):
1. Inattention: 6 or more of the following symptoms have persisted for at least 6 months that negatively impacts directly on social and academic/occupational activities.
Often fails to give close attention to details or makes careless mistakes in schoolwork, at work or during other activities
Often has difficulty sustaining attention in tasks or other activities (conversations, lectures, lengthy reading)
Often does not seem to listen when spoken to directly
Often does not follow through on instructions and fails to finish schoolwork, chores or duties in the workplace
Often has difficulty organizing tasks and activities
Often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort.
Often loses things necessary for tasks or activities
Is often easily distracted by extraneous stimuli
Is often forgetful in daily activities (doing chores, running errands).
Six (or more) of the following symptoms have persisted for at
least 6 months to a degree that is inconsistent with
developmental level and that negatively impacts directly
on social and academic/occupational activities.
A. Often fidgets with or taps hands or feet or squirms in seat
B. Often leaves seat in situations when remaining seated is
expected
C. Often runs about or climbs in situations where it is
inappropriate.
Often unable to play or engage in leisure activities quietly.
Is often ‘on the go” acting as if “driven by a motor.”
Often talks excessively.
Often blurts out an answer before a question has been
completed.
Often has difficulty waiting his/her turn
Often interrupts or intrudes on others.
Bupropion (Wellbutrin)
Guanfacine
Clonidine
Atomoxetine (Strattera)
Venlafaxine (Effexor- higher doses)
Two (or more) of the following, each present for a significant portion of time during a 1-month period. At least one of these must be 1,2 or 3
1. Delusions. 2. Hallucinations
3. Disorganized speech (e.g., frequent
derailment or incoherence) 4. Grossly disorganized or catatonic behavior
5. Negative symptoms (i.e., diminished emotional expression or avolition).
Second Generation Antipsychotics (2GAPs), introduced starting in 1990
Risperidone (Risperdal) 0.25mg to 6mg
Quetiapine (Seroquel) 12.5mg-900mg
Aripiprazole (Abilify) 2mg-30mg Olanzapine (Zyprexa) 2.5-20mg
Clozapine (Clozaril) 25mg-
Ziprasidone (Geodon) 20mg-240mg
Latuda (Lurasidone) 10mg-160mg
Vraylar 1.5mg to 3mg (in bipolar mania)
3-6mg (in schizophrenia)
Rexulti 0.5-3mg
Risperdal Consta (every 14 days)
Invega Sustenna (every 28 days)
Invega TRINZA (every 3 months)
Abilify Maintenna (every 28 days)
Haldol Decanoate
Metabolic dysregulation (appetite
increase, weight gain)
Akathisia
Extrapyrimidal symptoms
Multifactorial etiology Abnormal brain development
Evidence for neurodegenerative process in schizophrenia; neuronal atrophy; progressive structural brain changes; genetic vulnerability
Neurotransmitter abnormalities: glutamate/excitatory amino acid neurotransmission deficits that alter dopamine neurotransmission
Evidence of more refractory symptoms and more severe course of illness ; increased duration of untreated psychosis
Medications to address psychosis are also associated with improvement in cognitive function, attention, memory, learning
Early intervention improves function and diminishes impact of illness
General diagnostic criteria for a personality disorder
A. An enduring pattern of inner experience and behavior that deviates markedly
from the expectations of the individual’s culture.
This pattern is manifested in two (or more) of the following areas:
(1) Cognition (i.e., ways of perceiving and interpreting self, other people, and
events)
(2) Affectivity (i.e., the range, intensity, lability, and appropriateness of emotional
response)
(3) Interpersonal functioning
(4) Impulse control B. The enduring pattern is inflexible and pervasive across a
broad range of personal and social situations.
C. The enduring pattern leads to clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
D. The pattern is stable and of long duration, and its onset can be traced back at
least to adolescence or early adulthood.
E. The enduring pattern is not better accounted for as a manifestation or
consequence of another mental disorder.
F. The enduring pattern is not due to the direct physiological effects of a substance
(e.g., a drug of abuse, a medication) or a general medical condition (e.g., head
trauma).
Diagnostic criteria : A pervasive pattern of instability of interpersonal
relationships, self-image, and affects, and marked impulsivity beginning
by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
1) Frantic efforts to avoid real or imagined abandonment. Note: Do not
include suicidal or self-mutilating behavior covered in Criterion 5.
2) A pattern of unstable and intense interpersonal relationships
characterized by alternating between extremes of idealization and
devaluation.
3) Identity disturbance: markedly and persistently unstable self-image or sense of self.
4) Impulsivity in at least two areas that are potentially self-damaging
(e.g., spending, sex, substance abuse, reckless driving, binge eating).
Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.
(5) Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
(6) Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
(7) Chronic feelings of emptiness.
(8) Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
(9) Transient, stress-related paranoid ideation or severe dissociative symptoms
• Slow progress in therapy
•Suicidal behavior
• Self-injury or harming behavior
•Client contracting
• Transference and counter transference
•Clear boundaries
•Resistance
•Subacute withdrawal
•Symptom substitution
•Somatic complaints
•Therapist well-being
Differentiate between substance-induced disorders that resolve when substance use stops and independent, co-occurring mental disorders that require ongoing intervention
(American Psychiatric Association, 2004; McCance-Katz, 2009; Rosenthal & Ries, 2009; Substance Abuse and Mental Health Services Administration, 2004);
include a review of current and previous pharmacotherapy for behavioral disorders effectiveness and problems encountered; and
include a review of family history of both mental and substance use disorders.
Addiction is primary because it is not
secondary to another underlying
illness, such as a psychological
disorder like anxiety or depression.
People may start using alcohol or
other drugs to mask their depression or
anxiety, but once the person with an
addiction starts using alcohol or other
drugs, addiction emerges as the
primary disorder, separate from
psychological disorders
The patient stopped the med
The patient stopped the med AND used
drugs and/or alcohol…...
OR lowered the med and used…
OR used on top of the med….
OR used twice the dose on one day and
nothing the next….
Stimulants (cocaine/amphets) are most
MSE destructive.
Know who is on what and what for
Know the prescriber if possible
› Sit in on medication sessions onsite
› Talk to off-site doctor or nurse
› Know something about meds…
› New COD TIP ( Dec 04)
› NIMH web site, NAMI web site
Ask the pt about : › Compliance/Adherence…
“sometimes people forget their medications…how often does this happen to you?”
› Effectiveness… “how well do you think the meds are working?…
what do you notice…
here is what I notice
› Side Effects…. “ are you having any side effects to the medication?…
what are they…
have you told the prescriber?
do you need help with talking to the prescriber?
Can reinforce addiction denial if recovery is not integrated and supported…esp. by the prescriber..( so work with them)
Can be expensive, cause side effects, could be used in overdose.
Encourage client to see MD or MH prescriber.
See if there are any cost, convenience issues
Active participation in recovery can be both antidepressant and antianxiety… but if these problems continue, or disrupt recovery, medications should be considered
Abnormal for weeks/months in most
Poor sleep associated with relapse, anxiety,
depression, PTSD, and PROTRACTED
WITHDRAWAL
Treat the comorbid disorder causing the sleep problem ….ie depression/anxiety etc, with an antidepressant
And/or protracted withdrawal…..with anticonvulsants (for one to several months)
Melatonin 3-10mg at bedtime as needed
Trazodone 50mg-300mg at bedtime as needed
Hydroxyzine Pamoate 25mg-100mg at bedtime
Amitriptyline (Elavil), Doxepin (Sinequan)
Remeron (Mirtazepine)
Prazosin (minipress) 1-5mg for PTSD nightmares
aids
Opioid Replacement Therapy
Suboxone /Methadone - opioids
specifically prescribed to treat withdrawal
and cravings
Naltrexone/Vivitrol -
helps with cravings but not withdrawal
Methadone has a higher rate of lethal
overdose than Suboxone
Suboxone is less likely to be injected
Naltrexone /Vivitrol is the safest of all
since there is no overdose risk.
The BRIDGE works through neuro-stimulation. An auricular peripheral nerve field stimulator. Blocks pain signals from getting through the brain.
Naltrexone (ReVia and Vivitrol)
Acamprosate (Campral)
Disulfiram (Antabuse)
Topiramate (Topamax)
Nicotine patches +/- gum or lozenges
Bupropion (Zyban or Wellbutrin)
Varenicline (Chantix)
In general, the most appropriate medication for addressing an individual’s mental disorder is likely to be the same medication for addressing these symptoms when the individual is diagnosed with a co-occurring substance use disorder.
Likewise, the most appropriate medication for addressing an individual’s substance use disorder is likely to be the same one when they are diagnosed with a co-occurring mental disorder
(Blanco et al., 2010; Brady et al., 2010; Substance Abuse and Mental Health
Services Administration, 2004, 2005a, 2005b).
Be aware that certain medications that
are effective for one condition may
have a crossover benefit for the other
co-occurring condition
(e.g., Valproate for the treatment of
bipolar disorder may also benefit a
co-occurring substance use disorder)
[Green et al., 2007; Salloum et al., 2005]).
Within the shared decision-making partnership, the selection of pharmacologic interventions should move from low risk to higher risk strategies, dependent on clinical response.
The use of medications with the potential for abuse is risky in individuals with COD, and requires careful risk/benefit assessment within a prescribing relationship prior to initiation
(Minkoff & Ajilore, 1998; Minkoff & Cline, 2004).
There is also concern that commonly used medications
can interfere with the metabolism of substance abuse
and psychiatric medication, and vice versa,
and may cause increased or decreased drug levels
and potency (e.g., fluoxetine)
Coordinated treatment of COD and concurrent medical
conditions benefits overall recovery.
(Manubay & Horton, 2010).
Members of 24 DTR groups (n=240) New York City, 1 year outcomes
Drug/alcohol abstinence = 54% at baseline, increased to 72% at follow-up.
More attendance = better Medication adherence
Better Medication adherence = less hospitalization
› Magura Add Beh 2003, Psych Serv 2002
Medication alone is not enough
Individual and group counseling help patients to learn how to cope with everyday life without drugs.
Family Support
Family and friends can help by understanding the addiction, need for intensive treatment, which often includes medication.
Need for Al-anon for family members.
Aromatherapy/essential oils,
Alpha-stim (CES device)
Touchpoints
www.thetouchpointsolution.com
Reflexology
Accupuncture
Massage
All CODs tend to worsen with a high sugar, high refined, high stimulant diet
High-fiber and high-antioxidant diets (vegetables and fruits) generally benefit CODs
Protein- the building blocks of the brain; protein “wakes” up the brain.
Fish (salmon, tuna, sardines), chicken, lean beef, shellfish, veal increased alertness, focus, motivation, mental endurance as they are high in tyrosine
Moderate tyrosineskimmed or low-fat milk,
Low-fat or non-fat yogurt, turkey
Fruit- citrus, dates, raisins, figs, avocado,
papaya, mangos, raspberries, bananas,
oranges, tangerines, pears, grapefruit,
apples, kiwi
Vegetables- lima beans, pinto beans,
navey beans, onions, eggplant,
tomatoes, pea pods, spinach
Dairy Products- hard cheese, aged
cheese, sour cream, buttermilk, yogurt
Milk, Pumpkin, Sunflower seeds, turkey,
banana
If you crave sugar, increase intake of
Vitamin B6:
Dairy, whole grains, brown rice, walnuts,
hazelnuts, sunflower seeds, cantaloupe,
avocodos, bananas, carrots, salmon,
shrimp, tuna.
Vitamin D3
Multiple Vitamins
Fish Oil (Omega 3 fatty acids)
1,200mg/day
Vitamin E for those on antipsychotics
Moderate consistent exercise is the Universal Remedy for all psychiatric conditions- and almost all medical conditions
30 minutes of moderate walking 5-6 days per week can be recommended
More exercise is often better, but >1 hour per day is of little benefit to the psyche
Other exercise equivalents: calisthenics, dancing, yoga, gym workouts, Wii fit.
When a determination has been made that
both a mental and substance use disorder are present,
the prescriber should consider both disorders
to be “primary.”
Treatment plans should integrate best practice interventions—
including both psychosocial interventions and
pharmacotherapy—to address each of the CODs
(American Psychiatric Association, 2004; Blanco et al., 2010; Brady et al., 2010;
Minkoff & Ajilore, 1998; Minkoff & Cline, 2004; Power et al., 2005; Rosenthal & Ries,
2009; Substance Abuse and Mental Health Services Administration, 2005b, 2008).
• immediate risk and safety
• recovery goals
• cognitive functioning
• social and physical functioning and disability
• other medical conditions and medications
prescribed to treat them
• strengths, skills, and periods of success
• history of treatment response
• motivation and stage of change
• phase/stage of treatment
• age and gender
• culture and background (Blanco et al., 2010; Brady et al., 2010; Minkoff & Ajilore, 1998; Minkoff & Cline, 2004;
Rosenthal & Ries, 2009; Substance Abuse and Mental Health Services
Administration, 2004, 2005b, 2008).
Triage
Follow-up visits in between psychiatry visits,
Development and compiling of behavioral health handouts & resources for primary care providers
Behavioral health consultation to primary care providers.
Integration of evidence based protocols for screening, referral and management of chronic mental health conditions
*(IOM, The Future of Nursing, 2010)
Use of billing codes
H0023 Behavioral health outreach
(planned approach to reach a targeted population)
H0031 MH assessment, non-physician
H0032 MH service plan development by non-physician
H0033 Oral medication administration,
direct observation)
H0034 Medication training and support, per 15”
Our brains greatly make us who we are
and who we become.
Yet also we are constantly making our
brains, by each thing we do and each
thought we think .
https://drbethagoodllc.wixsite.com/good