SAMH Mental Health & Alcohol SAMH Mental Health & Alcohol ConferenceConference

Transforming the concept of Transforming the concept of Dual Diagnosis to the concept Dual Diagnosis to the concept

of Complex Needsof Complex Needs

Dr Fraser ShawDr Fraser ShawConsultant Psychiatrist in Addictions, West DunbartonshireConsultant Psychiatrist in Addictions, West Dunbartonshire

Fraser.Shaw@ggc.scot.nhs.ukFraser.Shaw@ggc.scot.nhs.uk

What is ‘dual diagnosis’ or ‘comorbidity’?

Two overlapping but discernible subgroups of patients:-

• Those with a major substance misuse disorder and another major psychiatric illness.

• Those who use alcohol and/or drugs in ways that affect course and treatment of their mental illness.

(Guehaly, 1990)

Prevalence

Depends on who is asking, how, what, where etc!

• OPCS institutional survey, UK (Farrell et al 1998) - 7% of those with schizophrenia reported ‘ever’ using drugs.

• Croydon, UK outpatients (Wright et al 2000) - 33% lifetime, 10% current prevalence of ‘substance misuse’ in cohort with regular CMHT contact.

• Inner city USA inpatients (Brady et al 1991) 64% lifetime prevalence of ‘substance abuse’.

Prevalence of Dual Diagnosis Prevalence of Dual Diagnosis (The Royal College of Psychiatrists’ Research Unit)(The Royal College of Psychiatrists’ Research Unit)

AuthorsAuthors DateDate LocationLocation PopulationPopulation Lifetime rate of Lifetime rate of substance usesubstance use

Current rate of Current rate of substance usesubstance use

Drake & Drake & WallachWallach

19891989 USAUSA Chronic Mental Health Chronic Mental Health ProblemsProblems

32%32%

Regier et al.Regier et al. 19901990 USAUSA SchizophreniaSchizophrenia 47%47%

BarbeeBarbee 19891989 USAUSA All PatientsAll Patients 47%47%

DukeDuke 19941994 UKUK Schizophrenia & Schizophrenia & AlcoholAlcohol

22%22% 36.6%36.6%

MenezesMenezes 19961996 UKUK PsychosisPsychosis 32%32% 60%60%

FowlerFowler 19981998 AustraliaAustralia SchizophreniaSchizophrenia 27%27%

ScottScott 19991999 UKUK PsychosisPsychosis

CantwellCantwell 19991999 UKUK 11stst Episode Psychosis Episode Psychosis 37%37%

20% drugs20% drugs

12% alcohol12% alcohol

WrightWright 20002000 UKUK PsychosisPsychosis 33%33% 13%13%

• Bipolar disorder has the greatest risk of any Axis 1 disorder for substance misuse comorbidity.

• People with schizophrenia three times more likely than those without to abuse alcohol, six times more likely to abuse drugs.

• Comorbid schizophrenics have higher rates of inpatient care and intensive crisis support.

““Mental disorder and substance Mental disorder and substance misuse sit on separate dimensions misuse sit on separate dimensions each with its own each with its own continuum of continuum of severity severity from mild to severe levels.”from mild to severe levels.”

Banerjee , Clancy and Crome (Eds), (2002)Banerjee , Clancy and Crome (Eds), (2002)

The Royal College of Psychiatrists’ Research UnitThe Royal College of Psychiatrists’ Research Unit

Dependent drinker who experiences increasing anxiety

HIGH

Person with schizophrenia who misuses Cannabis on a daily basis to compensate for social isolation

LOW Recreational misuser of dance drugs who has begun to struggle with low mood after weekend use

HIGH Person with bi-polar disorder whose occasional binge drinking & experimental use of other substances de-stabilises their mental health LOW

Severity of problematic drug use

Severity of mental illness

ASSESSMENT: SPECTRUM OF CO-MORBIDITY

Adapted from DOH Dual Diagnosis Good Practice Guide

Available from www.doh.gov.uk/mentalhealth

Why is co-morbidity important?Why is co-morbidity important?

• Homelessness or Homelessness or unstable housingunstable housing

• Interpersonal conflict Interpersonal conflict and family problemsand family problems

• ViolenceViolence• Victim of crimeVictim of crime• History of sexual, History of sexual,

physical and/or physical and/or emotional abuseemotional abuse

• Suicide and self-harm Suicide and self-harm

• Poor compliance with Poor compliance with medicationmedication

• Treatment recidivismTreatment recidivism• Poor prognosis of Poor prognosis of

mental health problemsmental health problems• Increased criminal Increased criminal

justice system contactjustice system contact• Early mortalityEarly mortality

(Drake et al.,1998; Drake et al., 2001; Banerjee et al. (Eds.), 2002)

Vulnerability:

Integrated treatmentIntegrated treatment

• Presents fewer hurdles to treatment access Presents fewer hurdles to treatment access for patients with co-morbidityfor patients with co-morbidity

• Better retention in treatmentBetter retention in treatment

• Potential to reduce substance misuse and Potential to reduce substance misuse and attain remissionattain remission

• Improved psychological functioningImproved psychological functioning

(Drake et al., 1998, Drake & Mueser, 2000; Mueser et al., 1998).

Components of effective integrated Components of effective integrated treatment approachestreatment approaches

• Close monitoringClose monitoring

• Case managementCase management

• Assertive outreachAssertive outreach

• Comprehensive treatmentComprehensive treatment

• Stepped CareStepped Care

• Motivation based interventionMotivation based intervention

• Longitudinal perspectiveLongitudinal perspective

(Drake et al., 1993; Mueser & Drake, 2003)

Comorbidity, Dual Diagnosis (blah blah.....)

Transform to:-

- Complex needs

- Recovery Agenda

Complex NeedsComplex Needs• Mental health problems Mental health problems

• Substance misuse problemsSubstance misuse problems

• Traumatic brain injury/head in juryTraumatic brain injury/head in jury

• Learning disabilityLearning disability

• Literacy and communication skillsLiteracy and communication skills

• Personality disorderPersonality disorder

• History of traumaHistory of trauma

Complex Needs IIComplex Needs II

• Attention deficit hyperactivity disorder Attention deficit hyperactivity disorder

• Chronic painChronic pain

• Sleep disordersSleep disorders

• HomelessnessHomelessness

• Involvement with criminal justice systemInvolvement with criminal justice system

Complex Needs IIIComplex Needs III

Alcohol use:Alcohol use:

• In a general UK population, 40% said alcohol made them feel In a general UK population, 40% said alcohol made them feel less anxious, 26% said less depressed. less anxious, 26% said less depressed.

• Up to 65% of suicides have been linked to excessive alcohol Up to 65% of suicides have been linked to excessive alcohol use.use.

• Specific anxiety disorders and/or depression were found to be Specific anxiety disorders and/or depression were found to be related to frequent and/or heavy alcohol misuse in a primary care related to frequent and/or heavy alcohol misuse in a primary care setting.setting.

• Alcohol and/or drug misuse correlated with more frequent Alcohol and/or drug misuse correlated with more frequent

hospitalisations for patients with schizophreniahospitalisations for patients with schizophrenia..

Complex Needs IVComplex Needs IVBenzodiazepine use:Benzodiazepine use:

• Frequent accompaniment to alcohol misuse. Frequent accompaniment to alcohol misuse.

• Anterograde amnesia associated with benzodiazepine use will impact Anterograde amnesia associated with benzodiazepine use will impact processing and retention of interventions.processing and retention of interventions.

• Effectiveness of CBT-based interventions reduced with benzodiazepine Effectiveness of CBT-based interventions reduced with benzodiazepine use.use.

• Mounting evidence for persistent cognitive deficits in chronic Mounting evidence for persistent cognitive deficits in chronic benzodiazepine use.benzodiazepine use.

Other drug use:Other drug use:

• Study of methadone maintenance patients found impairment across all Study of methadone maintenance patients found impairment across all cognitive domains. Lifetime diagnosis of alcohol dependence, and cognitive domains. Lifetime diagnosis of alcohol dependence, and number of non-fatal heroin overdoses, were independent predictors.number of non-fatal heroin overdoses, were independent predictors.