Prof. Baldacchino - Ponencia

8/8/2019 Prof. Baldacchino - Ponencia

1/65

CoCo --morbidity in Europemorbidity in Europe

Dr Alexander BaldacchinoDr Alexander BaldacchinoUniversity of Dundee/NHS FifeUniversity of Dundee/NHS Fife

ScotlandScotland

11 stst International Conference on Dual DiagnosisInternational Conference on Dual DiagnosisMadrid: 19Madrid: 19 --2020 thth April 2007April 2007


2/65

OverviewOverview

Journey from the biological, psychological, epidemiologicalJourney from the biological, psychological, epidemiologicaland policy arenasand policy arenasDual Diagnosis; is it a virtual entity?Dual Diagnosis; is it a virtual entity?Neurobiological and neuropsychological issuesNeurobiological and neuropsychological issues

PsychopathologicalPsychopathologicalPopulations and coPopulations and co --morbidity: epidemiological issuesmorbidity: epidemiological issuesService provision and policy issuesService provision and policy issuesVulnerability and resilience and coVulnerability and resilience and co --morbiditymorbidityChronic care model and coChronic care model and co --morbiditymorbidityImplications for treatment: the way forwardImplications for treatment: the way forward


3/65


4/65

Neurobiology and neuropsychological issuesNeurobiology and neuropsychological issuesin dual diagnosisin dual diagnosis


5/65

Neurobiology and neuropsychologicalNeurobiology and neuropsychologicalissues in dual diagnosisissues in dual diagnosis

PFCACG

SCCN Ac c

Am y g

Amyg


6/65

Underactive ACC in

adult ADHD patients


7/65



8/65



9/65

AttentionalAttentional BiasBias -- CueCue --ReactivityReactivity -- CravingCraving RelapseRelapse

Detection Threshold Disinhibition

Attentional Bias Cue-Reactivity Craving Relapse

Conflict Registration

Repeated Reward


10/65

PsychpathologyPsychpathology andand comorbiditycomorbidityExample: Cannabis and Psychosis in acute psychiatricExample: Cannabis and Psychosis in acute psychiatricpopulationpopulation

Literature review of all publications on cannabis andLiterature review of all publications on cannabis andpsychosis using Cochrane techniquespsychosis using Cochrane techniques

EU Drug and Psychosis study (2001EU Drug and Psychosis study (2001 --2006)2006)

Result:Result: No differenceNo difference in psychopathology betweenin psychopathology between

individuals with cannabis psychosis and other typesindividuals with cannabis psychosis and other typesof psychosis. Treatment is alsoof psychosis. Treatment is also no different no different . Same. Sametreatment protocolstreatment protocols


11/65

Epidemiological studies andEpidemiological studies andcomorbiditycomorbidity

(1) General populations(1) General populations ::

ECA: 53% abuse drugs have MH problemsECA: 53% abuse drugs have MH problems

(current) and 32% (lifetime)(current) and 32% (lifetime)

NEMESIS study 43%NEMESIS study 43%


12/65

Lifetime Prevalence and Odds Ratios of MentalLifetime Prevalence and Odds Ratios of MentalDisordersDisorders

by Substance Use Disorder: ECAby Substance Use Disorder: ECAAlcohol Drug

ComorbidDisorder % O.R. % O.R.Any mental 36.6 2.3 53.1 4.5

Schizophrenia 3.8 3.3 6.8 6.2

Affective 13.4 1.9 26.4 4.7

Anxiety 19.4 1.5 28.3 2.5

Antisocial 14.3 21.0 17.8 13.8

(Regier et al., JAMA 264:2511-2518, 1990)


13/65

Population studiesPopulation studies(2) Substance misuse population :(2) Substance misuse population :

Cumulative 15%Cumulative 15% --93% !93% !

(A) Personality disorders (65%(A) Personality disorders (65% --85%)85%)

(B) Affective disorder (30%(B) Affective disorder (30% --55%)55%)(C) Psychotic disorders (20%)(C) Psychotic disorders (20%)


14/65

Population studiesPopulation studies(A) Substance misuse population: personality(A) Substance misuse population: personality

disordersdisordersVerhaulVerhaul (2000) 187 drug dependent in Holland: 23%(2000) 187 drug dependent in Holland: 23%

APD, 18% BPD (lifetime)APD, 18% BPD (lifetime)

FridellFridell (1996) 1052(1996) 1052 polydrugpolydrug dependent in Sweden:dependent in Sweden:23% APD (current)23% APD (current)FreiFrei (2002) 85 Heroin assisted in Switzerland: 58%(2002) 85 Heroin assisted in Switzerland: 58%

PD (lifetime)PD (lifetime)Nielson (2002) 104 alcohol dependent in Denmark:Nielson (2002) 104 alcohol dependent in Denmark:50% APD and 30% BPD (current)50% APD and 30% BPD (current)


15/65

Population studiesPopulation studies(B) Substance misuse population: affective(B) Substance misuse population: affective

disorders (anxiety and depression)disorders (anxiety and depression)

SiliqiuniSiliqiuni (2002) 58 drug users in Italy: 23% mood(2002) 58 drug users in Italy: 23% moodand 21% anxiety (current)and 21% anxiety (current)

TomassonTomasson (1995) 351(1995) 351 polydrugpolydrug users in Iceland:users in Iceland:33% mood and 65% anxiety (lifetime)33% mood and 65% anxiety (lifetime)

EnatescuEnatescu (2006) 304 drug and alcohol dependent:(2006) 304 drug and alcohol dependent:12% mixed anxiety and depression (lifetime)12% mixed anxiety and depression (lifetime)


16/65

Population studiesPopulation studies(C) Substance misuse population: affective(C) Substance misuse population: affective

disorders (psychotic including schizophrenia)disorders (psychotic including schizophrenia)

KokkeviKokkevi (1995) 176(1995) 176 opioidopioid users in Greece: 6%users in Greece: 6%schizophrenia (lifetime)schizophrenia (lifetime)

FacyFacy (1999) 3936 methadone users in France : 1.6%(1999) 3936 methadone users in France : 1.6%psychosispsychosis

Weaver (2003) 278Weaver (2003) 278 polydrugpolydrug users in England: 8%users in England: 8%psychosis (one year)psychosis (one year)


17/65

Population studiesPopulation studies(3) Psychiatric populations(3) Psychiatric populations

(Drugs and alcohol)(Drugs and alcohol)

Current: ~11.8%Current: ~11.8% -- 45%45%6 months: ~15%6 months: ~15%

One year: ~15%One year: ~15% -- 44 %44 %Lifetime: ~22%Lifetime: ~22% -- 74%74%


18/65

Population studiesPopulation studies(4) Other vulnerable populations:(4) Other vulnerable populations:

(A)(A) Young PeopleYoung People ::

Hannesdottir Hannesdottir (2001) 103 adolescents for (2001) 103 adolescents for

detoxdetox : 75% co: 75% co --morbiditymorbidity


19/65

Population studiesPopulation studiesOther vulnerable populations:Other vulnerable populations:

(B)(B) HomelessHomeless

Kershaw (2000) 22% in Glasgow homelessKershaw (2000) 22% in Glasgow homelessReinkingReinking (2001) 27% of Dutch homeless(2001) 27% of Dutch homeless


20/65


(C)(C) PrisonersPrisoners ::

Singleton (1998) 81% in remand with coSingleton (1998) 81% in remand with co --morbiditymorbidity


21/65


(D)(D) Street workers/ProstitutesStreet workers/Prostitutes

Gilchrist (2004) 70% current coGilchrist (2004) 70% current co --morbiditymorbidity


22/65

Epidemiological studiesEpidemiological studiesMethodological issues to consider:Methodological issues to consider:

(a)(a) DefinitionsDefinitions(b)(b) Exclusion and inclusion of groupsExclusion and inclusion of groups

(c)(c) Instruments usedInstruments used(d)(d) Settings and types of interventionsSettings and types of interventions

(e)(e) Time windowTime window(f)(f) Context (ethos and philosophies of care)Context (ethos and philosophies of care)


23/65

Epidemiological StudiesEpidemiological StudiesEpidemiological Studies

Key patterns from epidemiologic dataKey patterns from epidemiologic data

Comorbidity is the rule rather than the exceptionComorbidity is the rule rather than the exceptionCrossCross --cultural findings show that the magnitude of cultural findings show that the magnitude of comorbidity is more similar than are the differencescomorbidity is more similar than are the differencesin baseline prevalencein baseline prevalence

Risk for drug dependence > drug abuseRisk for drug dependence > drug abuse

Risk varies by mental disorder (Anxiety < Mood male)Risk varies by gender (female > male)

Risk varies somewhat by specific drug disorder andRisk varies somewhat by specific drug disorder andnumber of drug disordersnumber of drug disorders


24/65

Policy andPolicy and ComorbidityComorbidity ::

The Scottish NationalThe Scottish National ComorbidityComorbidityStudyStudy

Identification of needsIdentification of needs

Service User experiencesService User experiences

Current provision in relation to needsCurrent provision in relation to needs

Relations between servicesRelations between services

Examples of good practiceExamples of good practice


25/65

MethodologiesMethodologies

Structured interviews with commissioners of Structured interviews with commissioners of servicesservices

InIn

--depth Interviewing with service usersdepth Interviewing with service users

Focus groups with coalface staff Focus groups with coalface staff

Framework Analysis (Ritchie & Spencer, 1994)Framework Analysis (Ritchie & Spencer, 1994)


26/65

Identified GapsIdentified GapsAccessAccess

Lack of signpostingLack of signpostingStructural obstaclesStructural obstaclesEligibility criteriaEligibility criteriaCapacityCapacity

Service responseService responseInflexibilityInflexibility

ContinuityContinuity

Lack of oneLack of one --toto --oneone

Traditional professionalTraditional professionaltrajectoriestrajectories

Service organizationService organizationExpertise in coExpertise in co --morbiditymorbidityBureaucracyBureaucracy

ExclusionExclusionStigmaStigma


27/65

FF rom Pillar to Postrom Pillar to PostI went there [local Drug Problems Service]I went there [local Drug Problems Service]and just got referred back to the hospitaland just got referred back to the hospitaland when I was in the hospital they saidand when I was in the hospital they saidlook welook we cannaecannae daedae nothing for you, younothing for you, you rere

gonnagonna have to get treated by the Drughave to get treated by the DrugProblems Service and then they [local DrugProblems Service and then they [local DrugProblem Service] just say go back to my ainProblem Service] just say go back to my ain

doctor and try to get something sorted outdoctor and try to get something sorted out


28/65

A Clear Path Through the Maze?A Clear Path Through the Maze?Integrated care pathways work well when youIntegrated care pathways work well when you ve got ave got a

history or a natural course of a disease or the processhistory or a natural course of a disease or the processis clearly understood. Once you get beyond somethingis clearly understood. Once you get beyond somethingas simple as an acute episode, integrated careas simple as an acute episode, integrated carepathways donpathways don t follow linear trajectories. We make thet follow linear trajectories. We make theassumption that somehow we can create a pathwayassumption that somehow we can create a pathwaythat zigzags between all of these possible sources of that zigzags between all of these possible sources of service. Even then they would work if we had peopleservice. Even then they would work if we had peoplecapable of keeping track of their own carecapable of keeping track of their own carerequirements. So if the person who has a mentalrequirements. So if the person who has a mentalillness plus another problem related to substanceillness plus another problem related to substancemisuse could actually manage their own way throughmisuse could actually manage their own way throughthat system that would be simple and straightforward.that system that would be simple and straightforward.They canThey can t.t.


29/65

Stickiness!Stickiness!I think X is the best because they get a hold oI think X is the best because they get a hold o ye and keepye and keeppursuing ye until they get ye. Some days I donpursuing ye until they get ye. Some days I don t come but theyt come but they rerepersistent tae get a hold opersistent tae get a hold o ye and they go looking for ye taeye and they go looking for ye tae yer yer friendfriend ss hoosehoose or your maor your ma ss hoosehoose or your familyor your family ss hoosehoose looking for looking for ye, somebodyye, somebody s theres there fer fer yeye

My key workers are constantly in touch and talking about whereMy key workers are constantly in touch and talking about wherethey think I should be going or what I should be doing or how Ithey think I should be going or what I should be doing or how I mmdoingdoing

They [Key workers] end up moving on and the case doesnThey [Key workers] end up moving on and the case doesn t gett getpicked up or if youpicked up or if you daedae get picked up you get picked up by fiveget picked up you get picked up by fivedifferent people, then I got fivedifferent people, then I got five CPNsCPNs in a row. Iin a row. I couldnaecouldnae work withwork withlike five different people I find it hard enough to trust one pelike five different people I find it hard enough to trust one pe rsonrsonover a long period of time then to be asked to be moved to anothover a long period of time then to be asked to be moved to anoth er er person in two weeks, on to another person and then another itperson in two weeks, on to another person and then another it s justs justimpossibleimpossible


30/65

Specialists or Specialist ServicesSpecialists or Specialist Services ??It [specialistIt [specialist comorbiditycomorbidity service] doesnservice] doesn tt

seem to work well for us. Itseem to work well for us. It s certainly nots certainly notknitted in well to the mental health system,knitted in well to the mental health system,not knitted into the addiction system, so thenot knitted into the addiction system, so theclassic thing is you create a specialistclassic thing is you create a specialistservice which has defined its own roleservice which has defined its own role

existingexisting in splendid isolationin splendid isolation ..


31/65

CoCo --morbid Mental Health andmorbid Mental Health andSubstance Misuse in ScotlandSubstance Misuse in Scotland

ClaireClaire --Louise HodgesLouise HodgesSheila PatersonSheila Paterson

MatiraMatira TaikatoTaikatoSarahSarah McGarrolMcGarrol

IlanaIlana CromeCromeAlex BaldacchinoAlex Baldacchino

May 2006May 2006

Scottish Executive Social ResearchScottish Executive Social ResearchSubstance Misuse ResearchSubstance Misuse Research

ProgrammeProgramme


32/65

ISADORA:ISADORA: Integrated Services Aimed at Dual Diagnosis andIntegrated Services Aimed at Dual Diagnosis andOptimal Recovery from AddictionOptimal Recovery from Addiction

EstablissementEstablissement de santde sant MaisonMaison --Blanche, Paris, FranceBlanche, Paris, FranceUniversity of University of TampereTampere , Finland, FinlandUniversity of Dundee, ScotlandUniversity of Dundee, Scotland

Institute of Psychiatry and Neurology, Warsaw, PolandInstitute of Psychiatry and Neurology, Warsaw, PolandMiddlesex University, London, EnglandMiddlesex University, London, EnglandCambridge University, EnglandCambridge University, England

The Psychiatric Services in the County of The Psychiatric Services in the County of AarhusAarhus ,,DenmarkDenmark


33/65

ISADORA:ISADORA: Integrated Services Aimed at Dual DiagnosisIntegrated Services Aimed at Dual Diagnosisand Optimal Recovery from Addictionand Optimal Recovery from AddictionTo describe the psychiatric service opportunitiesTo describe the psychiatric service opportunities

for treatmentfor treatmentTo determine and compare the coTo determine and compare the co --morbiditymorbidity

patternpatternTo followTo follow --up a cohort of patientsup a cohort of patientsTo identify predictors of prognosisTo identify predictors of prognosisTo explore the views of dual diagnosis patientsTo explore the views of dual diagnosis patients

and of staff and of staff To use study results as a basis for developingTo use study results as a basis for developing

an educational programmean educational programmeTo develop common assessment instrumentsTo develop common assessment instruments


34/65

Methodology of the studyMethodology of the study

A descriptive study of treatmentA descriptive study of treatmentopportunitiesopportunitiesA descriptive study of the pathwayA descriptive study of the pathway

through carethrough careA followA follow --up studyup studyAn exploration of the views of staff An exploration of the views of staff A study of risk factorsA study of risk factorsA development of an educationalA development of an educational

programme for staff programme for staff 34


35/65

ISADORAISADORA

A cohort study: 50/site, F30A cohort study: 50/site, F30 --33.9 (350)33.9 (350)Case studies (20)Case studies (20)

Focus group interviews: service users andFocus group interviews: service users andproviders (12)providers (12)Epidemiological data (local/regional)Epidemiological data (local/regional)

35


36/65

Service mapping and service usersService mapping and service users perspectives: ISADORA (1)perspectives: ISADORA (1)

Lack of coordinationLack of coordinationImproved signpostingImproved signpostingLead clinicians are often absent from case conferencesLead clinicians are often absent from case conferencesStructural and procedural changes militate against effectiveStructural and procedural changes militate against effectivenetworkingnetworkingClient autonomy and choice may inhibit referral processesClient autonomy and choice may inhibit referral processesFeedback is limitedFeedback is limited

Confidentiality issuesConfidentiality issuesComplexity for the sake of itComplexity for the sake of it


37/65

Service mapping and Service usersService mapping and Service users perspectives: ISADORA (2)perspectives: ISADORA (2)

Lack of designated time for networkLack of designated time for networkdevelopment/joint workingdevelopment/joint workingIgnorance regarding othersIgnorance regarding others roles and remitsroles and remits

Attitudinal barriersAttitudinal barriersDifferent professional silos andDifferent professional silos andDifferent clinical approaches e.g. medical versusDifferent clinical approaches e.g. medical versussocial modelssocial modelsLack of expertise on dual diagnosis and on howLack of expertise on dual diagnosis and on howbest to networkbest to network


38/65

Service mapping and Service usersService mapping and Service users perspectives: ISADORA (3)perspectives: ISADORA (3)

Clients often miss appointments leading toClients often miss appointments leading to

discordance and discontinuitydiscordance and discontinuityGeographical spread of services creates logisticalGeographical spread of services creates logisticalproblemsproblemsStaff turnover Staff turnover Unclear who should take primary responsibility for Unclear who should take primary responsibility for DD clientsDD clientsLack of tolerance for substance misuse createsLack of tolerance for substance misuse creates

barriers to appropriate carebarriers to appropriate careWaiting times and bureaucracy cause lengthyWaiting times and bureaucracy cause lengthydelays and fragmentationdelays and fragmentation


39/65

ISADORA: Contact to services (psychiatric, substance use,ISADORA: Contact to services (psychiatric, substance use,social and medical) at different research sites at baseline, 3,social and medical) at different research sites at baseline, 3,

6 and 9 month f/up6 and 9 month f/up

CambridgeMiddlesexWarsawDundeeTampereParisAarhus

site

4,00

3,00

2,00

1,00

0,00

M e a n

contact with 4 areasof services (soc.,med., smu., psych.) 9months follow up



contact with 4 areasof services (soc.,med., smu., psych.)baseline


40/65

ISADORAISADORALongLong --term planning is needed beginning at aterm planning is needed beginning at apolicy level supported by chief clinical leads andpolicy level supported by chief clinical leads andcommissioners and underpinned by good practicecommissioners and underpinned by good practiceThe voluntary sector should be developed toThe voluntary sector should be developed toimprove capacity. Integrated services more user improve capacity. Integrated services more user

friendly and better retention. Quality rather thanfriendly and better retention. Quality rather thantype of service importanttype of service importantSystem needs to be more flexible. The moreSystem needs to be more flexible. The morecontact patients have the more contact at followcontact patients have the more contact at followup with resulting positive outcomes in mostup with resulting positive outcomes in mostdomains including psychopathologydomains including psychopathologyImproved deployment and increase of resourcesImproved deployment and increase of resources

needed. Site most resources is site with better needed. Site most resources is site with better retention and outcomesretention and outcomes


41/65

Way forwardWay forward ....Another way of looking at coAnother way of looking at co --morbidity ?morbidity ?

MicrosystemMicrosystem (vulnerability and(vulnerability andresilience)resilience)

MacrosystemMacrosystem (chronic care models)(chronic care models)


42/65

: Vulnerability and resilience: Vulnerability and resilienceExploring concepts of mental health andExploring concepts of mental health and

substance misuse:substance misuse:Never culture freeNever culture free

Never morally and ethically neutralNever morally and ethically neutral

What we understand or want to understand of What we understand or want to understand of coco --morbid substance misuse and mentalmorbid substance misuse and mentalhealth will depend on:health will depend on: ....


43/65

Vulnerability and resilience and coVulnerability and resilience and co --morbiditymorbidity

Our valuesOur values

Preconceptions and assumptions on:Preconceptions and assumptions on:

(a)(a) Nature of health and illnessNature of health and illness(b)(b) Nature of societyNature of society(c)(c) Place of the individual within society (normality)Place of the individual within society (normality)(d)(d) Desirable behavioursDesirable behaviours

This is either indicative of diversity or an excuse to excludeThis is either indicative of diversity or an excuse to excludedue to its complex naturedue to its complex nature


44/65


VulnerabilityVulnerability

We are all vulnerableWe are all vulnerable

Much human effort is dedicated in managingMuch human effort is dedicated in managingthat uncertainty in order to reduce or removethat uncertainty in order to reduce or removevulnerabilityvulnerabilityNature and nurtureNature and nurture

l b l d l d


45/65


It is a function of susceptibility to loss andIt is a function of susceptibility to loss and

the capacity to recover. This capacity isthe capacity to recover. This capacity istermed resiliencetermed resilience

Resilience is the ability to cope fromResilience is the ability to cope fromadverse eventsadverse eventsNot a justification for labelling and stigmaNot a justification for labelling and stigma

but an opportunity to identify communitiesbut an opportunity to identify communitiesand groups most in needand groups most in need

l b l d l dV l bili d ili d


46/65


Potential indicatorsPotential indicators ::

Livelihood security (wealth, income)Livelihood security (wealth, income)Access to crisis supportAccess to crisis supportHousing qualityHousing quality

Psychological state :Psychological state :(a) Strong coping and problem solving abilities/skills(a) Strong coping and problem solving abilities/skills

and role modelsand role models

(b) Awareness of personal networks and stable(b) Awareness of personal networks and stableemotional relationshipemotional relationship


47/65

Vulnerability and resilienceVulnerability and resilience(c) Internal locus of control(c) Internal locus of control

(d) Positive cognitions(d) Positive cognitions(e) Life events (intrauterine, postnatal and beyond)(e) Life events (intrauterine, postnatal and beyond)(f) A sense of humour!(f) A sense of humour!

Well being (good physical health and lack of Well being (good physical health and lack of chronicitychronicity ))Local economic security (social capital)Local economic security (social capital)Employment and educationEmployment and educationEnvironmental minority groups with noEnvironmental minority groups with no rightsrights or or avenues for justiceavenues for justice

V l bili d ili dV l bili d ili d


48/65


Linked to concepts of emotional intelligence, self Linked to concepts of emotional intelligence, self regulation, social competence and self regulation, social competence and self organisationorganisation

The social and biological factors are very closelyThe social and biological factors are very closelyinterlinked but still do not know enoughinterlinked but still do not know enough

It is not a set of static protective factors but aIt is not a set of static protective factors but a

dynamic one that include accumulated anddynamic one that include accumulated andmultiple risks at a point inmultiple risks at a point intimetime .Role of assessments.Role of assessments

Ch i di / d l dCh i di / d l d


49/65

Chronic disease/care model and coChronic disease/care model and co --morbiditymorbidity

Current view of health and social careCurrent view of health and social care

Geared towards acute conditionsGeared towards acute conditions

Hospital centredHospital centredDoctor dependentDoctor dependentEpisodic and disjointed and/or reactive careEpisodic and disjointed and/or reactive care

Patient passive with self care infrequentPatient passive with self care infrequentCarers undervaluedCarers undervaluedLow technology (databases, evaluation etc)Low technology (databases, evaluation etc)

Ch i di / d l dCh i di / d l d


50/65


Evolving model of chronic careEvolving model of chronic care

Geared towards long term conditionsGeared towards long term conditionsEmbedded in communitiesEmbedded in communities

Team basedTeam basedContinuous careContinuous careIntegrated careIntegrated care

Preventative carePreventative carePatient/client as partner Patient/client as partner Self care encouraged and facilitatedSelf care encouraged and facilitated

Ch i di / d l dChronic disease/care model and co


51/65


15th November 2005

Chronic disease/care model and coChronic disease/care model and co


52/65




53/65


Relapse rates for drug addiction are similar

to other chronic medical conditionsMental illness and substance misuse arechronic relapsing conditionsCo-morbid substance misuse and mentalhealth problems are 2 co-existent chronic

care conditions



54/65


Looking at coLooking at co --morbidity as another aspect of morbidity as another aspect of

the overall chronic disease model willthe overall chronic disease model willdemystify thedemystify the complexitycomplexity of the conditionof the conditionThis will then be seen as a situation that isThis will then be seen as a situation that issimilar to diabetes, cardiovascular disorderssimilar to diabetes, cardiovascular disordersand other conditions that merits adequateand other conditions that merits adequate

resources and integrated approachesresources and integrated approaches



55/65


This will change the way we intervene,This will change the way we intervene,

treat and evaluate cotreat and evaluate co --morbid conditionsmorbid conditionsTreatment should be:Treatment should be:

(a)(a) OngoingOngoing(b)(b) PrioritisedPrioritised(c)(c) Encourage patient/client to participate inEncourage patient/client to participate in

their own recovery (self management)their own recovery (self management)

Chronic disease/care model and coChronic disease/care model and co -


56/65


(a)(a) Enable partnerships based on competenciesEnable partnerships based on competencies

(b)(b) Based on evidence based guidelinesBased on evidence based guidelines(c)(c) Integrated specialist expertise and primary careIntegrated specialist expertise and primary care(d)(d) Identify high risk groups with proactive careIdentify high risk groups with proactive care(e)(e) Facilitate individualised patient/client careFacilitate individualised patient/client care

planningplanning

(f)(f)

Approach evaluation as a chronic care coApproach evaluation as a chronic care co

--

morbidity systemmorbidity system


57/65

ConclusionConclusionCoCo --morbidity assessment and treatmentmorbidity assessment and treatment

interventions needs to look at:interventions needs to look at:

The individualThe individual s and populations/groups resiliences and populations/groups resilience

against coagainst co --morbidity in order to treat proactivelymorbidity in order to treat proactivelyUse the chronic disease processes to planUse the chronic disease processes to plandelivery of health and social care for delivery of health and social care for individuals/groups with coindividuals/groups with co --morbid conditionsmorbid conditions


58/65

RecommendationsRecommendations(A) Strategic Plan(A) Strategic Plan

A national strategyA national strategyAgreed definitions and overall model of careAgreed definitions and overall model of careJoined up provisionJoined up provision

Greater integration of mental health andGreater integration of mental health andsubstance misuse servicessubstance misuse servicesDevelopment of policies, protocols and proceduresDevelopment of policies, protocols and procedures

Commissioning:Commissioning:


59/65

RecommendationsRecommendations(B)(B) Operational Operational

Stigma and prejudiceStigma and prejudiceHealth promotionHealth promotionMeans and mechanismsMeans and mechanismsAccessibilityAccessibilityEducation, training, employmentEducation, training, employment

Ethnic minoritiesEthnic minoritiesCarer supportCarer support


60/65

RecommendationsRecommendations(C)(C) Training and educationTraining and education

Defining the objectiveDefining the objectiveTraining needs analysisTraining needs analysisEducation:Education:Training resourcesTraining resourcesFaceFace --toto --facefaceSpecial groupsSpecial groupsChildhood traumaChildhood traumaOther relevant organisationsOther relevant organisations


61/65

RecommendationsRecommendations(D)(D) Clinical Clinical

InclusivityInclusivity rather than exclusivityrather than exclusivityEthos and philosophyEthos and philosophyNeedsNeeds --led rather than serviceled rather than service --ledled

Assessment frameworkAssessment frameworkDevelopment of a user Development of a user --friendly screening and assessmentfriendly screening and assessmenttooltoolWorking with childhood traumaWorking with childhood traumaCare planningCare planningProvision of the range of psychological andProvision of the range of psychological andpharmacological interventions:pharmacological interventions:


62/65

RecommendationsRecommendations(E)(E) ResearchResearch

Understanding and enhancing theUnderstanding and enhancing theeffectiveness of treatment interventionseffectiveness of treatment interventionsService development modelsService development modelsSpecific (generally hard to reach)Specific (generally hard to reach)populationspopulations

Research on different patterns of coResearch on different patterns of co --morbiditiesmorbidities


63/65

A note of cautionA note of caution


64/65

Another noteAnother note of cautionof caution ..

Thank you:Thank you:


65/65

yy

[email protected]@dundee.ac.uk

Date post:	10-Apr-2018
Category:	Documents
Upload:	verito3tres
View:	218 times
Download:	0 times

Prof. Baldacchino - Ponencia

Documents