Health Mental & Addictions Pharmacological Interventions in Concurrent Disorders
Dr. K.D. Kok MD, FRCPC Consultant Psychiatrist, Mental Health Services Clinical Assistant Professor, Dept. of Psychiatry U of S
Outline
Learning Objectives Definitions Prevalence of Co-occurring Disorders Approach to Treatment
Non-pharmacological treatments Pharmacological Approaches
Concurrent Disorders Substance Specific Conditions
Objectives
Appreciate the prevalence rates of co-occuring Mental Illness & Substance Use Disorders Understand the key principles of treating the dually diagnosed Ensure medications are not utilized in place of needed non-pharmacological interventions Develop awareness of appropriate indications for pharmacotherapy in this population
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Definitions
Substance-Related Disorders
Abuse Dependence Intoxication Withdrawal Substance Induced Conditions (psychosis, mood disorder, sleep disorders, dementia, etc.)
Mental Disorders
Substance Abuse:
maladaptive pattern of use within 12 month period distress and/or impairment as manifested by:
failure to fulfil major role obligations multiple legal problems use in hazardous situations continued use despite persistent problems
DSM-IV, 1994
Substance Dependence:
maladaptive pattern of use within 12 month period distress or impairment as manifested by:
tolerance withdrawal larger amounts/longer than intended unsuccessful efforts to cut down time spent in activities necessary to obtain substance important activities given up continued use despite recurrent problems
DSM-IV, 1994
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Addiction:
preoccupation with the substance compulsive use "loss of control" which inevitably leads to social/occupational consequences or impairment relapse
Substance Induced Disorders
The specific condition (psychosis, depression, anxiety) occurs due to the physiological effects of the substance. This can occur during with "intoxication" or "withdrawal" from the substance; but the diagnosis should only be made if the symptoms are in excess of those usually associated with the intoxication or withdrawal syndrome.
Mental Disorder:
A clinically significant behavioural or psychological syndrome or pattern that occurs in an individual and that is associated with present distress or disability or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom. This syndrome or pattern must not be merely an expectable and culturally sanctioned response to a particular event.
DSM-IV, 1994
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Dual Diagnosis / Concurrent Disorders:
Terms recognizing comorbidity in patients who have both a Psychiatric Illness and a Substance Use Disorder (Abuse or Dependence)
Mental Disorders
Axis I Clinical Disorders Axis II Personality Disorders Mental Retardation Axis III Physical Illnesses Axis IV Stressors Axis V Global Assessment Functioning
(0-100)
Clinical Disorders
Disorders usually first evident in childhood / adolescence Substance Related Disorders Schizophrenia & related Psychotic Disorders Mood Disorders Anxiety Disorders Somatoform Disorders Factitious Disorders Dissociative Disorders Sleep Disorders Sexual & Gender Identity Disorders Impulse Control Disorders Adjustment Disorders
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Lifetime Prevalence
Schizophrenia Bipolar Disorder Affective Disorders Anxiety Disorder Panic disorder OCD 47 61 32 15 36 33
29-56 % lifetime prevalence rates of dual diagnosis disorders Comorbidity occurred at 2.7 - 7 times the expected odds ratio
S. Zimberg, 1993
Dual Diagnosis Treatment Principals
Stabilize acute psychiatric and substance abuse symptoms first 3-6 weeks substance free prior to making a firm diagnosis of a mental illness Be aware of frequent relapses for both conditions Be aware of countertransference issues Plan frequent treatment sessions (> 1/week)
Be less rigid and confrontational early in treatment Strongly encourage but do not mandate participation in 12 Step programs Addictions counselling/AA alone is not effective treat both conditions effectively or neither will improve (integrated treatment planning involving appropriate collaboration and consultation)
S. Zimberg, 1993
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Approach to Treatment
1. 2. 3. 4. Assessment Setting Non-pharmacological therapies Medications
* Integrated management model
Treatment Setting
Outpatient medical office, 12 Step Programs, Addictions Services offices, MHS, private counselors detox, rehabilitation medical ( detox), psychiatric
Residential Inpatient
Approach to Treatment
1. 2. 3. 4. Assessment Setting Non-pharmacological therapies Medications
* Integrated management model
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Non Pharmacological Treatment
Psychoeducation Intensive Counseling: - individual / group / family - CBT, Relapse Prevention - Motivational Enhancement Therapy - FP office, Psychiatrist/counselor's office, - Addictions Services, Mental Health Services Psychiatric Rehabilitation Programs 12 Step Programs (AA, NA) Community Support Groups (Schizophrenia Society, etc.)
Approach to Treatment
1. 2. 3. 4. Assessment Setting Non-pharmacological therapies Medications
* Integrated management model
Pharmacological Principles in Concurrent Disorders
Always include appropriate non-pharmacological strategies Be aware of possible interactions between prescribed and nonprescribed drugs Should be initiated & maintained for "severe and persistent" mental illnesses regardless of continuing substance use: Schizophrenia and other chronic psychoses Bipolar Disorder Major Depressive Disorder (severe) & PTSD (severe) Can be considered for "psychiatrically complicated" individuals not responding to other measures Attempt to avoid prescription of other drugs of dependence unless part of a harm reduction strategy Could...possibly involve the use of anti-craving / harm reduction medications
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The treatment is not an absolute "science" (no fixed rules) Involves ongoing clinical relationship Continuous re-evaluation of diagnosis and treatment "Artful" utilization of medication strategies to promote optimal outcome of both disorders
Treatment Priorities: 1. Safety 2. Stabilization of Serious Mental Illness 3. Sobriety 4. Stabilization of other Psychiatric Illness
Minkoff (2001)
Pharmacological Treatment
Specific Conditions:
Intoxication Withdrawal Substance Dependence Psychiatric Illness:
Schizophrenia Bipolar Disorder severe MDD etc...
Specific Substances of Abuse:
Alcohol Opiates Sedatives & Hypnotics Cocaine, Meth & other Stimulants Cannibinoids Hallucinogens Nicotine Others...(PCP, Inhalants, etc.)
Classes of Psychotropics
Antipsychotics - Chlorpromazine, Haldol, Risperidone, Olanzapine Mood Stabilizers* - Lithium, Valproic acid, Carbamazepine Antidepressants - Amitriptyline, Fluoxetine, Venlafaxine, Bupropion Anxiolytics - Buspirone, Diazepam, Alprazolam, Hydroxyzine Sedatives & Hypnotics - Chloral Derivatives, Barbiturates,
Benzodiazepines, Zopiclone, Zaleplon
Psychostimulants - Methylphenidate, Dextroamphetamine Antiparkinsonian agents - Benztropine, Procyclidine Misc...
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Psychosis
Including Schizophrenia, Schizoaffective Disorder, Bipolar Disorder (Type 1) and other chronic psychotic conditions antipsychotic medications ( +/- benzodiazepines) are often required in the early treatment of Substance-Induced Psychosis Substances can precipitate or symptoms exacerbate in predisposed or affected individuals (esp. cannabis & stimulants) Psychiatric inpatient (in/voluntary) treatment may be required for acute stabilization Continuing medication for mental illness Medication for treatment of addiction may be appropriate
Case #1 (Schizophrenia)
Ms.S is a 22 year old single woman from the city History of sexual abuse, body image concerns and abnormal eating behaviours as a teen. Working in the entertainment industry as an adult (travels). History of Stimulant Abuse (Cocaine, Ecstasy) and one psychiatric admission 2 years earlier for "Substance Induced Mania". 4 admissions to hospital in past 6 months for psychotic episodes, without full inter-episode recovery; no evidence for ongoing substance abuse. Psychosis characterized by "confusion", thought disorder, psychomotor slowing, paranoia, hallucinations, no agitation
Dx:
Schizophrenia (? Psychotic Disorder NOS) Stimulant Abuse (??early remission) Eating Disorder ?? Personality Disorder Involuntary admission to hospital Risperidone (low dose antipsychotic) continue for >2 years Lorazepam prn (used rarely, only in hospital for anxiety) Referral to Addictions Services, Mental Health Services (for CMHN & counselling) Early psychiatric review ?? Future counselling for Eating Disorder, past abuse issues
Tx:
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Case #2 (Substance Induced Psychosis)
27 year old unemployed man from the city, lives alone, on social assistance. Presents to ER with hallucinations, paranoia, delusions of reference, perplexed with thought disorder. One previous admission 4 years ago for "Substance Induced Psychosis". On MMT, but missed taking last 3 doses of methadone. UDT positive for methadone and THC; test 2 weeks ago also positive for Cocaine; eventually admits to recent alcohol, stimulant & hallucinogen use. Admitted voluntarily and prescribed 2 antipsychotics.
Dx:
Polysubstance Dependence (including Opioids & Stimulants) Stimulant Induced Psychosis Brief voluntary admission (rapid resolution of psychosis) Stopped one antipsychotic immediately. Continue low dose Risperidone for approximately 2 weeks Restart Methadone (initially dose) Order prn benzodiazepine for agitation / withdrawal (this was not required and stopped 2 days later). Follow-up with Addictions Counsellor & recommend more intensive rehab. Planned single psychiatric follow-up in 6 weeks.
Tx:
Depression
The question of which disorder came first can be problematic, but should not delay treatment of either Long term use of stimulants, benzodiazepines, alcohol and possibly cannabis have been implicated in causing/aggravating depression Benzodiazepines may be helpful for associated anxiety and insomnia (short term), but tolerance develops limit use If possible assess symptoms in a "drug-free setting" Women more commonly drink in response to primary depression Severe and/or unresolving depression (with cessation of substance use) suggests indication for antidepressant medication SSRIs, Venlafaxine are usually better tolerated and safer choices due to lower risk of fatal overdose and fewer drug interactions
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Case #3 Depression
25 year old single man; labourer, living with friends Previously diagnosed with & treated for ADHD and Depression with Zoloft, Dexedrine & Ativan Polysubstance Dependence since early teens with no long periods of abstinence. Saw outpatient Addiction counsellors, but no previous detox or rehab prior to Calder Centre He described mood variability that he called "a bipolar thing". Reports typical depressive episode symptoms lasting up to a few weeks; elevated mood symptoms less clear; brief and mild psychotic symptoms with drug misuse. Requesting a "downer to help him sleep at night".
Dx:
Polysubstance Dependence Benzodiazepine Withdrawal Psychoeducation around Substance use Disorders, withdrawal symptoms, Mental Disorders. No medications necessary to address withdrawal. No medications at present for Mental Illness. Discourage any future prescriptions of potentially addictive substances (stimulants, sedatives). Psychiatric review in 2 weeks for reassessment in context of longer period of sobriety.
Tx:
Anxiety
Anxiety Disorders are the most common form of mental disorder Includes: Panic Disorder, Social Phobia, OCD, PTSD, GAD Frequently complicated by other mental disorders (depression), and often accompanie...