Evaluating & ManagingThe Dual Diagnosis Patient

Peter A. DeMaria, Jr.., M.D., FASAMCoordinator of Psychiatric Services

Tuttleman Counseling ServicesClinical Associate Professor of Psychiatry & Behavioral

SciencesDepartment of Psychiatry & Behavioral Sciences

Temple University School of MedicinePhiladelphia, Pennsylvania

Case Study AAnne is a 19 year old student who tells you that

she has been diagnosed with ADHD, anorexia nervosa, depression, borderline personality disorder and alcoholism. She is prescribed methylphenidate (Concerta), citalopram (Celexa), quetiapine (Seroquel) and alprazolam (Xanax). She recently had a relationship break-up. She feels her depression is getting worse and she has started to drink again. She appears of average height and weight.

Case Study BBrian is a 20 year old student who complains of

problems with concentration and focus. He finds that he forgets to do important things; this forgetfulness has caused problems with his schoolwork and in his relationship with his GF. He has a well documented ADHD history and would like to restart his stimulant. He reports that he likes to party with his friends on the weekends and smokes MJ during the week to help him relax and sleep.

Case Study C

Bill is a 21 year old student who presents stating that he has mood swings and can’t sleep. He has a history of binge alcohol and cocaine use, but says he hasn’t had any cocaine in a month.

Presenting Psychiatric Symptoms

• Anxiety• Depression• Insomnia• Psychotic symptoms• Disruptive behavior

Causes of Psychiatric Symptoms

• Drug intoxication or withdrawal states• Medical illness• Psychiatric comorbidity

The Challenge

MentalIllness

Substance UseDisorder

DualDiagnosis

Definition of Addictive DiseaseAddiction is a primary, chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. The disease is often progressive and fatal. It is characterized by continuous or episodic impaired control over drinking or drug use, preoccupation with alcohol or drugs, use of alcohol or drugs despite adverse consequences, and distortion in thinking, most notably denial.

(Adapted from the NCADD and ASAM Definition of Alcoholism.)

Chronic Disease Model• Prototypes: CAD, HTN, DM• Development and course reflect an

interplay of genetic vulnerability, pathophysiology, and personal behaviors

• Treatment focuses on management not cure

• Goals include highest quality of life• Patient must take an active role in

treatment• Compliance is frequently an issue

Substance Use Is a Spectrum Disorder

Abstinence

Experimentation Substance abuse

Substance dependence

Lifetime Prevalence of Comorbidity - ECA Date

Mental Disorders, 22.5% Comorbidity = 29%

•Alcohol = 22%•Other drug = 15%

Alcohol Disorder, 13.5% Comorbidity = 45%

•Psychiatric - 37%•Other drug = 22%

Other Drug Disorder = 6.1% Comorbidity = 72%

•Psychiatric = 53%•Alcohol = 47%JAMA 264(19):2511-2518,1990

Epidemiology of Dual Diagnosis

• ECA Study: Alcoholics have 1.5 - 2 x higher incidence of depression than general population

• Alcoholics:

– At intake 70% have moderate to severe depression

– 4 - 6 weeks after detox 10-20% had major depression

• Psychiatric inpatients at McLean Hospital: 60% of males and 40% of females met criteria for alcohol or drug abuse or dependence

Epidemiology of Dual Diagnosis

• Cocaine addicts at McLean Hospital: 27% had affective illness.

• Opiate addicts: 54% had lifetime incidence and 24% had current episode of major depression.

• 15.2% of respondents in the NCS who had ADHD met criteria for any substance use disorder (3 x the rate of respondents without ADHD).

The Biopsychosocial Spiritual Orientation

Biological

Psychological Social

Spiritual

The Biopsychosocial Spiritual Orientation

• Biological– Genetics– Health issues– Brain chemistry

• Social– Living unit– Relationships– Work/school– Cultural factors

• Spiritual– Organizing principles– Morals/ethics– Cultural factors

• Psychological– Self esteem– Identity– Object relations– Drives/defenses/ conflicts– Developmental history– Trauma/abuse– Personality traits– Relationships

Dual Diagnosis

“Dual diagnosis is an expectation, not an exception.”

-Dr. Kenneth Minkoff

www.kenminkoff.com

The Four Quadrant Model for Co-Occurring Disorders

Both High Severity Mental Illness Low SeveritySubstance Use Disorder High Severity

Mental Illness High SeveritySubstance Use Disorder Low Severity

Both Low Severity

A guide to treatment planning.

Disorder Parallels

Addiction Major Mental Illness

A biological illness A biological illness

Heredity (in part) Heredity (in part)

Chronic disease Chronic diseaseIncurable Incurable

Leads to lack of control of behavior and emotions

Leads to lack of control of behavior and emotions

Positive & negative symptoms

Positive & negative symptoms

Disorder Parallels

Addiction Major Mental Illness

Affects the whole family Affects the whole family

Progression of the disease without treatment

Progression of the disease without treatment

Symptoms can be controlled with proper treatment

Symptoms can be controlled with proper treatment

Disease of denial Disease of denial

Facing the disease can lead to depression & despair

Facing the disease can lead to depression & despair

Disorder Parallels

Addiction Major Mental Illness

Disease is often seen as a “moral issue” due to personal weakness rather than having biological causes

Disease is often seen as a “moral issue” due to personal weakness rather than having biological causes

Feelings of guilt and failure Feelings of guilt and failure

Feelings of shame and stigma

Feelings of shame and stigma

Physical, mental, & spiritual disease

Physical, mental, & spiritual disease

Screening-Assessment-Treatment

• High index of suspicion

• Screen everyone; revisit regularly

• Assess which Stage of Change

• Engage in treatment

• Use Motivational Interviewing techniques

• Use behavioral/contingency contacts

• Involve others

• Consult/Refer

Precontemplation

Contemplation

Preparation

Action

Maintenance

Stages of Change

Differentiating Substance Related Disorders from Psychiatric Disorders

• Relationship of symptoms to drug use• Which came first?• Presence of symptoms during periods of sobriety• Past treatment history• Atypical presentation• Poor or unpredictable response to treatment• Family history-psychiatric or addiction• Look for common co-morbidities:

– Bipolar disorder and alcoholism– ADHD and substance abuse– Cluster B personality traits/disorder

General Approach to the Dual Diagnosis Patient

• Comprehensive biopsychosocial spiritual assessment.

• Engage patient in treatment and develop a therapeutic relationship.

• Develop a treatment plan– Addressing both psychiatric & addiction issues

• Assess response• Adjust treatment plan

Treatment Planning• Treatment planning must be individualized.• The treatment plan must follow a careful

assessment.• The treatment plan is not static, it is dynamic

and changes as the providers learns more and the patient changes with interventions.

• Develop a treatment team utilizing the expertise in other clinicians.

• Ensure regular and thorough communication between all treatment team members.

Possible Treatment Modalities• Individual counseling/therapy (psychiatric/addiction)• Group counseling/therapy (psychiatric/addiction)• Self-help (12 step) programs• Behavioral/contingency management• Couple’s Therapy• Family therapy• Disability Resources & Services Involvement• IOP/Partial hospitalization• Inpatient psychiatric (dual diagnosis) hospitalization• Psychotropic medication (psychiatric/addiction)

Issues Specific to College MH Practice

• Hospitalization necessary/indicated?

• Treat in-house or refer out?

• Is drug screening available?

• Must the student be clean for everything?

• If not, what is acceptable?

• What support is available on campus?

Pharmacotherapy of Addictive Disorders

• Detoxification• Aversive agents

– Disulfiram (Antabuse)

• Anti-craving Agents– Naltrexone (ReVia, Vivitrol)– Acamprosate (Campral)– Bupropion (Wellbutrin, Zyban)– Varenicline (Chantix)

Pharmacotherapy of Addictive Disorders

• Maintenance pharmacotherapy– Nicotine replacement therapy (NRT)

• Patch, gum, inhaler, lozenge

– Opioid maintenance pharmacotherapy• Methadone• Buprenorphine (Subutex/Suboxone)

General Approach to Psychopharmacology

• Use biopsychosocial spiritual model• Avoid addictive substances (e.g. BZ)• Treat psychiatric condition if it prevents

engagement in addiction treatment.• Avoid making psychiatric diagnosis and

initiating medication until 2-4 weeks into abstinence from substances.

• Less is better

Case Study AAnne is a 19 year old student who tells you that

she has been diagnosed with ADHD, anorexia nervosa, depression, borderline personality disorder and alcoholism. She is prescribed methylphenidate (Concerta), citalopram (Celexa), quetiapine (Seroquel) and alprazolam (Xanax). She recently had a relationship break-up. She feels her depression is getting worse and she has started to drink again. She appears of average height and weight.

Case Study BBrian is a 20 year old student who complains of

problems with concentration and focus. He finds that he forgets to do important things; this forgetfulness has caused problems with his schoolwork and in his relationship with his GF. He has a well documented ADHD history and would like to restart his stimulant. He reports that he likes to party with his friends on the weekends and smokes MJ during the week to help him relax and sleep.

Case Study C

Bill is a 21 year old student who presents stating that he has mood swings and can’t sleep. He has a history of binge alcohol and cocaine use, but says he hasn’t had any cocaine in a month.