Copyright Alcohol Medical Scholars Program 1 Integrated Treatment of Co-Occurring Mental Illness...

Copyright Alcohol Medical Scholars Program 1

Integrated Treatment of Co-Occurring Integrated Treatment of Co-Occurring Mental Illness (MI) and Substance Use Mental Illness (MI) and Substance Use

Disorders (SUD)Disorders (SUD)

Krishna Balachandra, M.D., FRCPC Krishna Balachandra, M.D., FRCPC

Concurrent Disorders Program Concurrent Disorders Program

University of Western OntarioUniversity of Western Ontario


Co-Occurring Disorders Co-Occurring Disorders (COD)(COD)

~50% Serious disorders have SUD~50% Serious disorders have SUD

Physicians inadequately trained in SUDPhysicians inadequately trained in SUD

Pts with COD Pts with COD suboptimal care suboptimal care

Pts with COD at Pts with COD at risk risk


DefinitionsDefinitions

Mental disordersMental disorders

Substance abuse ≥ 1 ofSubstance abuse ≥ 1 of

Obligations Obligations

Hazardous useHazardous use

Legal Legal

Interpersonal Interpersonal

problemsproblems

Substance dependence ≥ Substance dependence ≥ 3 of3 of ToleranceTolerance WithdrawalWithdrawal Amounts/timeAmounts/time CutCut TimeTime ActivitiesActivities Physical/psychological Physical/psychological

problemsproblems


Co-Occurring DisordersCo-Occurring Disorders

Mental IllnessSubstance Use Disorder

COD


This Lecture ReviewsThis Lecture Reviews

EpidemiologyEpidemiology

EtiologyEtiology

Treatment overallTreatment overall

Relevance of integrated treatmentRelevance of integrated treatment


Epidemiology of CODEpidemiology of COD

SUD AUD DUD

17


SUD


Bipolar

3-5 X’s

AUD DUD

17

56



ASPD

5-7 X’s

SUD AUD DUD

17

56

83


Etiology of CODEtiology of CODCommon VulnerabilityCommon Vulnerability

Common genesCommon genes Twin study of AUD + DepressionTwin study of AUD + Depression

ASPDASPD

Common physiology in bothCommon physiology in both HPA axis HPA axis

Hippocampus/frontal cortexHippocampus/frontal cortex

Cannabinoid, dopamine receptorsCannabinoid, dopamine receptors


Etiology of CODEtiology of CODSUD as Response to MISUD as Response to MI

SymptomsSymptoms

Social skillsSocial skills

Medication side effectsMedication side effects

Mental Illness Substance Use Disorder


Etiology of CODEtiology of CODMI as Response to SUDMI as Response to SUD

Cannabis use Cannabis use ↑ rates of ↑ rates of psychosispsychosis

Meta-analysis supports Meta-analysis supports ↑ risk↑ risk

Possible genetic mechanismPossible genetic mechanism

Mental IllnessSubstance Use Disorder


We Have ReviewedWe Have Reviewed

Epidemiology Epidemiology

Etiology Etiology

Treatment overallTreatment overall

Relevance of integrated treatmentRelevance of integrated treatment


Treatment StrategiesTreatment Strategies

AdvantagesAdvantages DisadvantagesDisadvantages

Sequential RxSequential Rx ++ ++++++++++

Parallel Rx Parallel Rx ++ ++++++ ++++

Integrated Rx Integrated Rx +++ +++++ ++


Integrated TreatmentIntegrated Treatment

Simultaneous treatmentSimultaneous treatment

Consistency of location and providers Consistency of location and providers

AdvantagesAdvantages

DisadvantagesDisadvantages


Integrated Rx: Clinical CaseIntegrated Rx: Clinical Case

27 M, Bipolar, Alc dep27 M, Bipolar, Alc dep

++ ER visits++ ER visits

No show apptsNo show appts

Frustrated docsFrustrated docs

Legal chargesLegal charges

HomelessHomeless


Principles of Integrated RxPrinciples of Integrated Rx

““No wrong door”No wrong door”

Shared decision makingShared decision making

ComprehensivenessComprehensiveness

AssertivenessAssertiveness



Negative consequencesNegative consequences

Time unlimitedTime unlimited

Multiple therapiesMultiple therapies

Cultural sensitivityCultural sensitivity



Motivation based treatmentMotivation based treatment

EngagementEngagement

PersuasionPersuasion

Active treatmentActive treatment

Maintenance/Relapse preventionMaintenance/Relapse prevention


Integrated TreatmentIntegrated TreatmentEngagementEngagement

Goal: Establish working relationshipGoal: Establish working relationship

OutreachOutreach

Practical assistancePractical assistance

E.g. housingE.g. housing

Crisis interventionCrisis intervention


Integrated TreatmentIntegrated TreatmentEngagement Engagement

Support + assistance to social networkSupport + assistance to social network

Stabilize medical/psychiatric illnessStabilize medical/psychiatric illness

Address legal issuesAddress legal issues

Family visitsFamily visits

Close monitoringClose monitoring


Integrated Treatment Integrated Treatment PersuasionPersuasion

Goal: Goal: awareness of problem awareness of problem

Individual + family educationIndividual + family education

Groups to discuss pros/cons of usingGroups to discuss pros/cons of using

Non substance social skillsNon substance social skills


Integrated Treatment Integrated Treatment PersuasionPersuasion

Structured activityStructured activity

E.g. supported employmentE.g. supported employment

Social + rec activitiesSocial + rec activities

““Damp” housingDamp” housing

Psychiatric stabilizationPsychiatric stabilization


Integrated Rx: Clinical CaseIntegrated Rx: Clinical Case

27 M, Bipolar, Alc dep27 M, Bipolar, Alc dep

ER visitsER visits

Keeps apptsKeeps appts

Happier docsHappier docs

Legal assistanceLegal assistance

HousingHousing

Alcohol use continuesAlcohol use continues


Integrated Treatment Integrated Treatment Active RxActive Rx

Goal: Goal: substance use substance use

Strategies to Strategies to substance usesubstance use


E.g. refusal skillsE.g. refusal skills

Self help groupsSelf help groups

E.g. “Double Trouble”E.g. “Double Trouble”


Integrated Treatment Integrated Treatment Active RxActive Rx

Individual psychotherapyIndividual psychotherapy

Substitute activitiesSubstitute activities

Meds Meds Substance use (e.g. disulfiram, naltrexone)Substance use (e.g. disulfiram, naltrexone)

““Dry” housingDry” housing

Stress/coping skillsStress/coping skills


Goal: maintain and extend recoveryGoal: maintain and extend recovery


E.g. interpersonal relationshipsE.g. interpersonal relationships

Problem solvingProblem solving

E.g. new ways to cope E.g. new ways to cope

Integrated Treatment Integrated Treatment Maintenance/Relapse PreventionMaintenance/Relapse Prevention


Lifestyle improvementLifestyle improvement

E.g. smoking cessationE.g. smoking cessation

Independent housingIndependent housing

Role modelingRole modeling

E.g. leading groupsE.g. leading groups

Integrated Treatment Integrated Treatment Maintenance/Relapse PreventionMaintenance/Relapse Prevention


Hank’s 12 step program


Efficacy of Integrated RxEfficacy of Integrated Rx

RetentionRetention

55% Integrated Rx > 35% usual Rx 55% Integrated Rx > 35% usual Rx

Substance useSubstance use

40% Abstinence post Rx vs 2% baseline 40% Abstinence post Rx vs 2% baseline

60% Negative urine integrated Rx > 25% usual Rx 60% Negative urine integrated Rx > 25% usual Rx



Financial stressFinancial stress

40% Employed vs 5% baseline40% Employed vs 5% baseline

60% Housing vs 50% baseline60% Housing vs 50% baseline

70% $ For basic needs > 45% usual Rx70% $ For basic needs > 45% usual Rx

6000 $/pt Criminal justice cost savings6000 $/pt Criminal justice cost savings



HospitalizationHospitalization

7% Post-integrated Rx vs 30% pre Rx7% Post-integrated Rx vs 30% pre Rx

Rates of arrestRates of arrest

13% Post-integrated Rx vs 30% pre Rx13% Post-integrated Rx vs 30% pre Rx


We Have ReviewedWe Have Reviewed

Epidemiology Epidemiology

Etiology Etiology

Treatment overall Treatment overall

Relevance of integrated treatment Relevance of integrated treatment

Copyright Alcohol Medical Scholars Program 1 Integrated Treatment of Co-Occurring Mental Illness...

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