mailto:Drbethagood.llc@gmail.com

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