substance use and comorbidity with mental health problems

Question 1

what is the definition of remission

Answer 1

• Early remission from a DSM-5 substance use disorder is deined as at least 3 but less than 12 months without substance use disorder criteria (except craving)
• Sustained remission is deined as at least 12 months without criteria (except craving)

Question 2

what are abstinence programmes

Answer 2

Based on the idea that there is no “safe” amount of use.
Aim = complete cessaion of use

e.g. – Detoxification programmes (opioid treatment programmes)
– 12 step self-help programmes (e.g. Alcoholics Anonymous)

Question 3

what are the 3 – Pharmacological intervenions. Medications such as:

Answer 3

• Disuliram - interferes with alcohol metabolism causing nausea & vomiing
• Naltrexone – reduces craving for alcohol / blocks efects of opiods in the brain (reducing pleasure)
• Methadone – reduces withdrawal symptoms (loosely linked to detox programmes - heroin)

Question 4

is there a strong evidence for pharmacological aids

Answer 4

– Good evidence for pharmacological aids but they are not available for all types of substance use (e.g.
cannabis; amphetamines)
opioids arent as commonly used but in many ways most problematic in terms of impact on the individual

Question 5

why is the success rate for abstinence programmes variable

Answer 5

– Detox/12 step approaches highly dependant on moivation to change; sometimes based on
coercion / mandatory

• Relapse may lead to discharge from treatment

Question 6

what is harm reduction

Answer 6

• Aim of treatment at individual level is to reduce the risks associated with substance use (e.g. from needle sharing, drinking when driving) and to reduce or prevent excess morbidity and mortality.
• Attempts to meet people “where they are at” with their drinking or drug use.
• Pragmatic approach, assuming small changes beter than none

e.g.Reduce excess death excess illness
HIV original use - needle swapping
Not reduce substance use reduce risk associated with substance use

Question 7

what are the goals of harm reduction

Answer 7

Goals:
– Reduce negaive consequences of substance use for the individual
– Promote recovery (whilst acceping relapse)
– Improve quality of life

less challenging - more likely to keep a person engaged in mental health treatment
approach that psychology as a whole uses

Question 8

what are the NICE guidelines for dual diagnosis

Answer 8

AIM: To help healthcare professionals guide people with psychosis and coexising substance misuse to stabilise, reduce or stop their substance misuse, to improve treatment adherence and outcomes, and to enhance their lives.

Question 9

what are the assumptions of the NICE guidelines

Answer 9

1. Absinence (total cessaion) is not necessary - reducing and stabilising substance use also a desirable outcome
2. Reducing substance use will lead to improved outcomes (greater treatment adherence; fewer relapses & hospitalisaions etc.)

Question 10

what do NICE reccommend for healthcare professionals to do

Answer 10

Healthcare professionals in all settings should rouinely ask adults and young people with known or suspected psychosis about their use of alcohol and/or prescribed and non-prescribed drugs. If the person has used substances ask they should be asked about:

• The particular substance(s) used
• The quanity, frequency and patern of use
• The route of administraion
• Duration of current level of use.

Question 11

how many people with psychosis use substances

Answer 11

50%

Question 12

what do NICE reccommend as evidence based treatment for psychosis

Answer 12

Psychosis: Anipsychoic medicaion, CBT and Family Intervenion. Discuss use of substances with the service user, and carer if appropriate

Question 13

what do NICE reccommend as evidence based treatment for substance use

Answer 13

Substance use: Motivational interventions; CBT; contingency management; family involvement

Question 14

what are psychosocial interventions for dual disorders

Answer 14

Typically involve a combinaion of the recommended intervenions (“integrated therapy”):
• Motivational interviewing; 
• CBT (including relapse prevention); 
• Psychoeducation; 
• Family therapy /systemic therapy

Question 15

what are the possible modalities of psychosocial disorders

Answer 15

Modaliies:
•Individual (one to one)
•Group (with strangers / partner / family members)
•Combinaion of above
•Increasingly, mHealth (use of internet and mobile apps to deliver therapy) - mainly as a form of education

Question 16

what does psycholoigcal assessment for substance use determine

Answer 16

Determines:
– Paterns of use (what substances; when used; where; how much?)
– History of use; previous treatment
– Motives for use
– Consequences (negative AND positive) – impact of use
– Moivation to address problems
– Personal strengths - e.g. readiness to change, family supporting

Question 17

what does psychological assessment seek to do

Answer 17

– To understand role played by substances in client’s life; identify factors maintaining substance use and obstacles to change / relapse risks

• May take several sessions and involve signiicant others (e.g. family members)

Question 18

what should the treatment plan be

Answer 18

Should:
– Be person centred: take individual’s needs and preferences into account
– address problems and goals ideniied during assessment
– take into account clients moivaion to address
substance use and obstacles to change – Idenify treatment goals and target behaviours (absinence?)
– Idenify measurable outcomes

Question 19

what are the stages of change

see slide 17

Answer 19

precontemplation stage
contemplation stage
preperation stage
action stage
maintenance stage
relapse stage
(in a circular way)

Question 20

do psychological treatments take into account the stage of change

Answer 20

Most psychological approaches take account of stage of change:
and target treatment accordingly (stage of change dictaing which methods are appropriate at a paricular ime.

Question 21

what is precontemplation

Answer 21

Precontemplation - Clients are not thinking about changing substance abuse behaviour and may not consider their substance abuse to be a problem.

Question 22

contemplation

Answer 22

Contemplaion - still using substances, but they begin to think about cuttng back or quittng substance use
acknowledging something they might do

Question 23

preperation

Answer 23

Preparation - still using substances, but intend to stop. Planning for change begins.

Question 24

action

Answer 24

Action - Clients choose a strategy for discontinuing substance use and begin to make the changes needed to carry out their plan

strategy has been chosen and things are starting to change

Question 25

maintenance

Answer 25

Maintenance - Clients work to sustain absinence (or maintain reduction) and evade relapse.
changes have been achieved - avoiding relapse- maintaining change for longer term so dont go back to earlier habits

Question 26

relapse

Answer 26

Relapse - Many clients will relapse and return to an earlier stage, but they will hopefully have gained new insights into problems (e.g. unrealisic goals or frequenting places that trigger relapse).

relapse - still want to quit - go back to contemplation stage
or
realise never wanted to quit - precontemplation
doesnt have to go in complete order - go back to different stages

Question 27

what is the stage model called

Answer 27

Stages of Change (Prochaska & DiClemete’s ‘stages of change’ model, 1983)

Question 28

what if in the precontemplation stage

Answer 28

Not considering change; may deny substance use a problem

options -

1. to not address substance use
2. to persuade the client to change/ challenge their position
3. to enhance motivation to change

psychology tends to do 3- a bit more inclined to achieve change
cohercion and shaming tends not to work as well as motivation

MOTIVATIONAL INTERVIEWING

Question 29

what is motivational interviewing (MI)

Answer 29

A person-centred counselling method for addressing the common problem of ambivalence about change

• A collaboraive conversaion to strengthen a person’s own moivation for and commitment to change
• Seeks to elicits and explore an individual’s own arguments for change

Question 30

what does motivational interviewing put emphasis on

Answer 30

Emphasis: helping clients to understand how their substance use keeps them from achieving their goals

Question 31

what is the view of motivational interviewing

Answer 31

• Views ambivalence as normal
• Resolving ambivalence key to change
• Responsibility for change is with the client • Accepts that clients goal unlikely to be absinence (or even reduction)

Question 32

what is important in terms of reasons for change in motivational interviewing

Answer 32

Reasons for change (reducing / stopping substance use) need to be stronger than the reasons for staying the same in order to “tip the balance” for change

Having a conversation about what’s stopping them from changing what’s keeping them the same and working with them to tip the balance so that change becomes something that the client wants to work for themselves

Question 33

what are some reasons for staying the same - positive expectancies about effects of substance?

Answer 33

– “It helps me relax” (I can’t relax without it)
– “It stops me feeling nervous in a crowd” (I can’t socialise without it; don’t enjoy socialising)
– “It gets rid of the voices” (the voices will be too much if I stop)

Question 34

what us the aim of MI

Answer 34

Aim of MI: to enhance motivation to change; get client ready to make changes

– Typically brief, delivered as a stand alone intervention or can be integrated with another (e.g. CBT)

Question 35

can MI be used alongside MI

Answer 35

The changes that might be required to address those beliefs would happen in another intervention e.g. CBT but the motivational aspect is not about getting those changes to occur but about getting a person ready to change and to make the changes themselves

In dual diagnosis motivational interventions are delivered alongside something like CBT
In primary care interventions may happen as a one off stand alone things so if go to GP and they ask if smoke or drink - if yes - motivational conversation about problematic or not - Brief
Motivational interviewing is a more intense conversation delivered by people trained in motivational interviewing - got same aim - beyon just a single conversation

Question 36

what is psychoeducation

Answer 36

• Psychoeducaion typically included in MI and other individual intervenions (key component of brief moivational interventions)

– provision of informaion about the impact of substance use on mental health (Prevalence; How does your substance use compare? Withdrawal symptoms)

– information sheets; leaflets; computer resources;

– DVDs

Question 37

what does psychoeducation do

Answer 37

Psychoeducaion groups designed to educate clients aboutsubstance abuse, and related behaviours and consequences; idenify resources; counteract denial

Key to motivational intervention

Psychoeducation - provision of information about the impact of substance use or mental or physical health

Might be information on prevalence and comparisons
Drugs meter - normalising data - come back with e.g. your in top 5% of drinkers - if people think my drinking is normal or my drug use is in line with everybody else

Question 38

is psychoeducation a treatment in its own right

Answer 38

• Useful adjunct but not suffcient as treatment in own right

On own may not be expected to achieve any impact but if someone’s contemplative or precontemplative theyre a good source of education

A good part of every interventions but a key part of motivational interviewing

Motivational interviewing may often lead to a more intensive therapy something like CBT

Question 39

what is the aim of CBT

Answer 39

• CBT aims to change learned behaviour by changing thinking
patterns, beliefs, and percepions and assumpions.

CBT is about challenging those beliefs with the hope of replacing them with more adaptive ones

Question 40

what does CBT help identify

Answer 40

Ideniies antecedents of drug use (‘high risk situations’)

E.g. physical situation when person is around friends or in a pub but also may be an emotional state when a person is feeling sad hearing voices blaming themselves fo9r somethings

High risk situation is any situation where you are more likely to use a drug or use alcohol

CBT can be really useful in working with a person to identify those

Question 41

whats does CBT focus on

Answer 41

Focus on teaching substance user new / more efecive skills for dealing with high risk situaions (such as negaive emotional states, interpersonal conlict, and social pressure) and craving

Question 42

how does CBT help cognitive restructuring around alcohol and drug expectancies

Answer 42

– Diaries - e.g. see how much cannabis youve been using
– Behavioural experiments - go to bed without cannabis see what happens
• Assists making lifestyle changes so as to decrease need /urges for substance or to increase healthy alternatives (e.g. acivity planning when boredom a high risk situation)

Understanding if this person has this belief a maladaptive or irrational belief about substance use and the role it has in their life and can they understand that a different way

Question 43

what is cognitive restructuring

Answer 43

(process of learning to idenify and adapt irraional or maladapive thoughts)

Question 44

what are relapse prevention techniques

Answer 44

• Similar to CBT with focus on coping skills in high risk situations but speciic to relapse (avoiding temptation in the threatening situaion)
e.g. smoking when drinking

Question 45

what are clients taught in relapse prevention techniques

Answer 45

Clients taught to:
– Understand relapse as a process
– Implement damage control procedures during a lapse to minimize negaive consequences / chances of relapse
– Stay engaged in treatment even ater a relapse

Question 46

is relapse prevention longer than CBT

Answer 46

Longer term intervenion, 6 – 26 sessions

Question 47

what is family/ systemic therapy used for

Answer 47

Recommended for substance users with psychosis
Family intervention is recommended for psychosis and has got a very good evidence base
NICE guidelines

Question 48

what should family and carers do in family therapy

Answer 48

– have the opportunity to be involved in decisions about treatment and care
– be given informaion and support
– be offered family intervention
– be offered informaion about local family or carer support groups and voluntary organisations

Question 49

what are the components of family therapy

Answer 49

• Large psychoeducaion component:
– Provides informaion about dual disorders
• Teaches communicaion skills and builds problem solving skills in family members, including the client
• Helps family develop relapse prevenion strategies
– increase support; reduce burden; decrease conlict

e.g. Family Intervenion for Dual Diagnosis (FIDD, Mueser et al, 2013)

Question 50

what do NICE guidelines reccomend about family therapy

Answer 50

Nice guidelines do strongly recommend the inclusion of family in dual diagnosis

Question 51

what is integrated therapy

Answer 51

• Typically starts with MI (pre-contemplaion > contemplaion)
• Moves on to CBT (action; development of behavioural acion / change plan) and relapse prevention
• Moves back and forth between approaches
• Includes psychoeducaion (e.g. MIDAS Trial, Barrowcloughet al, 2010) and can involve family intervenion

Question 52

what is contingency management

Answer 52

• Behaviour Modiicaion (Based on learning theory, Skinner, 1953)
– Coningency management (CM) – incentivises and reinforces absinence with the aid of vouchers, privileges, prizes or financial incenives (clear urine screen = reward)
can also used in intervenions to reduce substance use

– Recommended by NICE for substance use intervenions but evidence currently
lacking for dual diagnosis

– Circle Trial (Johnson et al, 2019) recruited 500+ cannabis users with psychosis. No
diference in outcome between those receiving CM and control

not really a psychosocial appraoch but in NICE guidelines

Question 53

what is the evidence summary for MI-CBT

Answer 53

MI-CBT: positive results in small trials but not replicated in larger ones – MI-CBT may reduce amount of substance used, but this doesn’t translate to improved symptoms and functioning

Question 54

what is the evidence summary for family intervention

Answer 54

Family intervenion very promising, but needs more evidence

in dually-diagnosed samples

Question 55

what is the evidence summary for contigency management

Answer 55

Coningency management: good evidence in SUD more

generally, but not in dual diagnosis

Question 56

what did the Cochrane Review 2019 (Hunt et al) conclude

Answer 56

“There is currently no high quality evidence to support any ‐ one psychosocial treatment over standard care for important outcomes such as remaining in treatment, reduction in substance use or improving mental or global state in people with serious mental illnesses and substance misuse. Furthermore, methodological difficulties exist which hinder pooling and interpreing results. Further high quality trials ‐ are required which address these concerns and improve the evidence in this important area”

one doesnt stand out above the othe

Question 57

whats next for enhancing existing interventions

Answer 57

• Enhance exising intervenions
– Better targeting? (only those who are ready to change; only those who meet criteria for SUD?)
– Include technological advances
e.g. personalised ‘in the moment’ feedback

• Develop new models and approaches
virtual reality

Question 58

what are the conclusions

Answer 58

• Rates of substance use higher in people with afecive and non-affecive psychosis
• Substance use results in worse outcomes for people with psychosis
• Several psychosocial intervenions available (as single or integrated approaches)
• Evidence base is currently lacking – no conclusive evidence to support one over another
• Agreement that substance use must be reduced, remains a focus in therapy