WorkshopWhat do mental health workers need to know?

June 2006

Gary Croton

Eastern Hume Dual Diagnosis Service

Dual Diagnosis introduction for

mental health workers

Prevalence

Harms

Demand

Policy

This presentation….

Potential

Terminology

Definitions

DDxcohorts

Makingsenseof it

Relai’/ps b/t the

disordersWhat is DDx?

Why does it matter?

What is DDx?

Terminology

‘DualDiagnosis’

‘Comorbidity’

‘Co-occurringDisorders’

definition:co-occurrence of any Mental Health Disorder

with any Substance Use Disorder

Otherterms:

‘Concurrent disorders’….. ‘MICA’….. ‘MISA’…. ‘CAMI’…. ‘SAMI’…. ‘MISUD’…..

c.f.‘dual disability’:

people with both intellectual disability

and mental illness

Definitions

DDxcohorts

Great variety in…

Combinations of disorders

Severity of disorders

Treatment needs

Common dual diagnosis presentations

1. To Primary Care / General Practice

Depression with alcohol abuse or dependence

Early psychosis with cannabis abuse or dependence

Anxiety with alcohol abuse or dependence

DDxcohorts

Common dual diagnosis presentations

2. To an AT&OD treatment agency

Alcohol dependence with anxiety &/or depression symptoms or disorder

Amphetamine abuse with paranoid symptoms

Opiate abuse or dependence with personality disorder

DDxcohorts

Common dual diagnosis presentations

3. To an Mental Health treatment agency

Schizophrenia with alcohol, cannabis or polydrug abuse or dependence

Personality disorder with episodic polydrug abuse

Mood disorder with stimulant or depressant abuse or dependence

DDxcohorts

DDxcohorts

- Organic mental disorders

-Disorders with childhood/ adol’nce onset

- Disorders of Psyc’al develop’nt

Disorders of personality

- Neurotic disorders

- Mood disorders

- Schizophrenia & delusional disorders

- Multiple drug use

- Volatile solvents

- Tobacco

- Hallucinogens

- Other stimulants

- Cocaine

- Sedatives orhypnotics

- Cannabinoids

- Opioids

- Alcohol

- Acute intoxication

- Harmful use

- Dependence syndrome

- Withdrawal state

- Withdrawal state with delirium

MENTAL DISORDER

CLINICALSTATE

SUBSTANCE

ICD-10 combinations of disorders

How do I make sense of it?DDxcohorts

Tier 3

Tier 2

Tier 1

Tier 1 Lo MH & or Lo SUD with or without COD

Tier 2 Hi SUD with or without MH

Specialist mental healthClinical & PDRSS

Specialist AT&OD Possibly PMH teams

Primary Care General Practice Community Health

DDxcohorts

How do I make sense of it?

Tier 3 Hi MH with or without SUD

Victorian DHS Policy: Dual DiagnosisKey directions and priorities for service development

March 2006

4 models:

1. Common risk factors:

- Genetic risk factors- Trauma- Poor cognitive functioning

2. MH causes SUD

3. SUD causes MH

4. Bi-directional

- MHD ↑ vulnerability to SUD- Self medication- ↓ dysphoria- Super sensitivity

- Amphetamine psychosis- Cannabis psychosis?

- Ongoing interaction

Relationships b/t the

disorders

What maintains the comorbidity is the

most relevant to treatment

Relationships b/t the

disorders

More than 1 model may apply at different times

Why does DDx matter?

Prevalence

Co-occurring disorders are common in the general population

Keymessages

In treatment populations co-occurring disorders are

the expectation not the exception

Having 1 of the disorders substantially increases your risk of also developing the other disorder

Prevalence of particular combinations of disorders varies with different treatment settings

Prevalence

General Population

MentalHealth

General Practice

AT&OD treatment

Prevalence

General Population

Alcohol dependent: 4.5 x more likely to also have an Affective disorder 4.4 x more likely to also have an Anxiety disorder

Cannabis dependent: 4.3 x more likely to also have an Anxiety disorder

Tobacco users 2.2 x more likely to also have an Affective disorder 2.4 x more likely to also have an Anxiety disorder.

Australian population / any 12-month period Anxiety Disorder: 9.7%, Substance Use Disorder: 7.7% Mood Disorder: 5.8%

1 in 4 with one of the disorders also had one of the other disorders!!

1997 NSMHW

Prevalence

General Practice

Hickie et al, 2001 study: (n=46,515)Comorbidity of common mental disorders & alcohol or other

substance misuse in Australian general practice

Prevalence of mental health &/or substance use amongst persons attending General Practice

Co-occurring mental disorders & substance misuse in patients attending General Practice

56%

12%

Prevalence

AT&OD treatment

Depression &/or Anxiety Disorder

Weaver et al, 2002 (UK)

Alcoholserviceusers: (n = 62)

DrugServiceusers:(n= 216)

Personality Disorder

Psychotic Disorder

2 or more psych. disorders55%

19%

53%

81%

Psychotic Disorder

Depression or Anxiety Disorder alone

Personality Disorder

Depression & Anxiety Disorder

8%

36%

37%

68%

No MH disorder

MH disorder

No MH disorder

MH disorder

85%

75%

15%

25%

MentalHealthPrevalence

Vic MH Branch 2002 - 24hr census

Clinical sample:45% reported alcohol or drug abuse/ dependence(possible underestimate).

- Cannabis abuse/dependence = 37% of all comorbidity- Alcohol abuse/dependence = 31% - Amphetamine abuse/ dependence = 10%.

Severely mentally ill:

• More frequent relapse and hospitalisation

• Greater housing difficulties & homelessness

• Violence and exploitation

• Forensic involvement: Wallace, Mullen and Burgess (2004). - persons with schizophrenia committed 8 x the # of offences as non-schizophrenia matched control group - much higher rates of criminal conviction for

persons with schizophrenia with substance abuse than for those without substance abuse problems (68.1% versus 11.7%).

• Physical disorders

• Increased treatment costs

• Carer trauma & loss

• Blood-borne infections

• Suicide risk

• Unemployment / work instability / poverty

Harms

Demand 2006 Senate Mental Health Inquiry

submissions & reports

2003 ‘Out of Hospital, Out of Mind’ 2 top priorities:- Implementation of earlier intervention strategies- Attention to the overlap between mental health & drug &alcohol abuse

SANE Mental Health Report card 2004 ‘There are no coherent national strategies covering key issues

such as dual diagnosis’

2005 ‘Not for service’

Policy

Policy:March 2006

ForumApril 2006

1. Dual diagnosis is systematically identified and responded to in a timely evidence-based

manner as core business in both mental health and d & a services.

Dual Diagnosis: Key directions and priorities

for service development

VictorianMH &

DP&S Branches

2. Staff in mental health and d&a services are dual diagnosis capable (have the necessary

knowledge and skills to provide integrated responses to people with dual diagnosis).

5 mandated service development outcomes:

Policy

3. Specialist mental health and d&a services develop partnerships for the provision of

integrated treatment and care.(No wrong door service system)

Dual Diagnosis: Key directions and priorities

for service development

VictorianMH &

DP&S Branches

5. Consumers and carers are involved in the planning and evaluation of service responses.

5 mandated service development outcomes:

4. Client outcomes and service responsiveness to dual diagnosis clients are monitored and regularly reviewed

Policy

Commonwealth /State COAG:

2006/07 budget:

$21.6 mill: campaign alerting community to

links b/t illicit drug use & mental health.

Federalinitiatives

$73.9 mill : training/ resources to assist AT&OD workers

to provide effective Rx

National Comorbidity Initiative

ADGP – Managing the mix – primary care initiative

National Youth Mental Health Foundation

Potential

Improving our recognition of and response to co-occurring SUDs will improve the effectiveness of our treatment of mental health disorders

References• Andrews, G., Hall, W., Teesson, M., Henderson, S.

(1999). National survey of mental health and wellbeing: Report 2: The mental health of Australians. Canberra, Department of Health and Aged Care

• Croton, G. (2005): Australian treatment system’s recognition of and response to co-occurring mental health & substance use disorders Senate Mental Health Inquiry Submission

• Degenhardt, L., Hall, W., Lynskey, M (2001) Alcohol, cannabis and tobacco use among Australians: a comparison of their associations with other drug use and use disorders, affective and anxiety disorders and psychosis. Addiction 96, 1603-1614.

References

• Groom et al, (2003), ‘Out of Hospital, Out of Mind' Mental Health Council of Australia

• Hickie, I, Koschera, A, Davenport, T., Naismith, S., Scott, E. Comorbidity of common mental disorders and alcohol or other substance misuse in Australian general practice. Med J Aust. 2001 Jul 16; 175 Suppl: S31-6.

• Mental Health Council of Australia, (2005) Not For Service: Experiences of Injustice and Despair in Mental Health Care in Australia, Canberra

• SANE (2004) SANE Mental Health Report 2004

References• Victorian DHS: Dual Diagnosis: Key directions and

priorities for service development. Draft policy version March 2006

• Wallace, C., Mullen, P., Burgess, P. (2004). Criminal offending in Schizophrenia over a 25-year period marked by deinstitutionalisation and increasing prevalence of comorbid substance use disorders. Am J Psychiatry 161:4, April 2004.

• Weaver, T., Madden, P., Charles, V. (2003) Comorbidity of substance misuse and mental illness in community mental health and substance misuse services. BJPsychiatry , 183 304-313

• WHO International Statistical Classification of Diseases and Related Health Problems 10th Revision Version for 2006

Resources / More info• Dual Diagnosis Australia & NZ / Co-occurring disorders

roundup www.dualdiagnosis.org.au

• National Comorbidity Initiative http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-pubhlth-strateg-comorbidity-index.htm

• Managing the Mix http://www.adgp.com.au/site/index.cfm?display=4614

• CCISC model / Drs Ken Minkoff & Christie Clinehttp://www.kenminkoff.com/index.htmlhttp://www.zialogic.org/

• TIP 42: Substance Abuse Treatment for Persons With Co-Occurring Disorders http://store.health.org/catalog/ProductDetails.aspx?ProductID=16979