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Concurrent Disorders Christian G. Schütz MD PhD MPH FRCPC Associate Professor UBC Research and Education Medical Manager BCMHA/PHSA
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
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Any combination of:
mental disorder + substance use disorder ------------------------------------------ concurrent disorders / dual diagnoses / co-occuring disorders
What are Concurrent Disorders?
How Common Are They?
B. Rush 2010
Canada
How Common Are They?
B. Rush 2010
Canada
How Common Are They?
B. Rush 2010
Canada
How Common Are They?
B. Rush 2010
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
Anxiety Le-Niculescu et al. 2011
Schizophrenia Ayalew et al. 2012
Bipolar Disorder Patel et al. 2010
ATNX1 GNAI1 GRM3
GRIA1 HTR2A MBP
GABRB3 SYN2
SNCA
DRD2 MOBP
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
Adapted from Stahl Essential Psychopharmacology
PTSD Bipolar Schizophrenia Substance use disorders
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
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
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
mood instability
DEPRESSIVE EPISODE MANIC EPISODE
dysth cyclothymia
Affective Disorders
Lifetime 40%
cause clinically significant distress or functional impairment
mood instability
DEPRESSIVE EPISODE MANIC EPISODE
dysth cyclothymia
Affective instability Affective instability
Lifetime 40% Adapted from Bonsall 2011
Affective Disorders
Substance induced Stimulant intoxication Sedative withdrawal (-O = delirium) Cannabis intoxication NOT oipioidS
Psychotic Disorders
Cluster A (odd)
Cluster B (dramatic)
Cluster C (fearful)
Paranoid * distrust and suspiciousness
Antisocial **** deceitful hostile disregard for others
Avoidant ‘ social inhibition
Schizoid * social detachment emotionally cold
Borderline *** intense and unstable emotional relationships
Dependent ‘ strong need to be taken care of, needs reassurance
Schizotypal *** odd, eccentric, peculiar
Histrionic ** attention seeking, exaggerated emotionality
Obsessive compulsive * preoccupied with rules and orderliness
Narcissistic * entitlement, excessive self-worth
Cluster A (odd)
Cluster B (dramatic)
Cluster C (fearful)
Paranoid * distrust and suspiciousness
Antisocial **** deceitful hostile disregard for others
Avoidant ‘ social inhibition
Schizoid * social detachment emotionally cold
Borderline *** intense and unstable emotional relationships
Dependent ‘ strong need to be taken care of, needs reassurance
Schizotypal *** odd, eccentric, peculiar
Histrionic ** attention seeking, exaggerated emotionality
Obsessive compulsive * preoccupied with rules and orderliness
Narcissistic * entitlement, excessive self-worth
Screener?
Mental Disorder: Modified MINI Mental Screener
Depression: GHB-9 Questionnaire
ADHD: Adult ADHD Self-Report Scale
Personality Disorder Self Harm Inventory
(Borderline)
Models of Care
Models of Care
Models of Care
The Four Quadrant Framework for Concurrent Disorders
More severe mental disorder/
less severe substance abuse disorder
More severe mental disorder/
more severe substance abuse disorder
High severity
Ries
The Four Quadrant Framework for Concurrent Disorders
More severe mental disorder/
less severe substance abuse disorder
More severe mental disorder/
more severe substance abuse disorder
High severity
Ries
Integrated programs are rare and often have low fidelity ratings
Rebuild hope and sense of control: • Safety • Trust • Choice • Empowerment • Client - centered
Trauma Informed Care
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
Leucht S et al. BJP 2012;200:97-106
Summary of effect sizes.
Leucht S et al. BJP 2012;200:97-106
Summary of effect sizes.
X
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!
Health Canadian Guidelines: http://www.hc-sc.gc.ca/hc-ps/alt_formats/hecs-sesc/pdf/pubs/adp-apd/bp_disorder-mp_concomitants/bp_concurrent_mental_health-eng.pdf
CANMAT 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
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