Week 9 - Dual Diagnosis Flashcards
What is dual diagnosis?
AKA: Co-morbidity/Co-occurrence
More than one diagnosis
- 2 or more health problems
- Medical, Mental health, Alcohol and Drug, Intellectual Impairment, etc..
Mostly refers to alcohol and drug issue in combination with mental health
The term is useful in a health setting when there is a relationship between them and one issue is complicating the other
Distinctions
Heterotypic / Homotypic
▪ E.g. mental health and physical disorder vs 2 mental health disorders
Concurrent / Successive
▪ E.g. alcohol dependence and depression at same time vs panic disorder in teenage years and cannabis abuse in twenties
Continuum
▪ ranging from mild symptoms to severe disorders
Incidence of dual diagnosis
“The statistics on sanity are that one out of every four Americans is suffering from
some form of mental illness. Think of your three best friends. If they’re okay, then it’s you.”
National Study of Mental Health and Wellbeing (2020-2022)
42.9% of population will experience MH disorder in lifetime
21.5% in the prior 12 months, with Anxiety being the most common 17.2%
38.8% aged 16-24 had a MH disorder in the prior 12 months
If have MH disorder
- likely to have substance use issues and vice
versa
Incidence of dual diagnosis (how likely)
– considerable variation in the answer
DD prevalence estimates range from 30-90%
Why does it vary?
▪ Depends on diagnostic criteria (Severe, Axis I/II, PD, Sub-clinical)
▪ In general, higher prevalence in A&D settings and higher in treatment settings
▪ More prevalent for Indigenous Australians
▪ Gender also a factor (higher among females)
Prof John McGrath QBI
Pervasive nature, so it didn’t really matter what disorder you had first, you were at increased risk of getting every other type of disorder.
Increased risk for developing other types
of disorders persisted 10, 15 or more years later than your first onset
The risk of getting a second comorbid
disorder is related to your age of onset
Incidence of dual diagnosis (DD) In A&D settings
48% of females with alcohol use disorder also have anxiety, affective, or drug use disorder.
34% of males with alcohol use disorder had another mental disorder,
Compared to 9% of males that didn’t have alcohol use disorder
If Alcohol dependant, 4.5 times more likely to have affective disorder and 4.4 times more likely to have anxiety disorder.
If Cannabis-dependent, 4.3 times more likely to have anxiety disorder.
Tobacco users 2.2 times more likely to have affective disorder and 2.4 times more likely to have anxiety disorder
Methamphetamine
Aus survey of people with meth dependence found 88% had major depression or an anxiety disorder in the
past year
Approximately 30% of dependent users experience psychotic episodes each year.”
Incidence of dual diagnosis (DD) in Mental Health
17% with affective disorder, also had alcohol use disorder,
16% with an anxiety disorder also had alcohol use disorder
Symptoms of Depression
Include
feeling sad or depressed
a loss of interest and pleasure in normal activities
loss of appetite or weight
inability to get to sleep or waking up early
feeling tired all the time
having trouble concentrating
feeling restless, agitated, worthless or guilty
feeling that life isn’t worth living
How could drugs cause depression
Alcohol
▪ Interferes with medications
▪ Long term effect on relationships, employment, health, etc…
Cannabis
▪ Long-term use may cause ‘depression-like’ symptoms
▪ Hypothesised ‘Amotivational syndrome’
Opioids
▪ Lifestyle related factors associated with opioid dependence
Stimulants
- Existing depression may get worse when coming down
- Common in the months following cessation
- Use/abuse may worsen the sleep / wake cycle
More Common Symptoms of Anxiety Disorders
feeling worried all the time
getting tired easily
unable to concentrate
feeling irritable
irregular heartbeats or palpitations
dizziness
muscle tensions and pains
How could drugs cause anxiety?
Depressants - Agitation, anxiety, and irritability common features of withdrawal
Alcohol
▪ Alcohol related problems can create new worries
Cannabis
▪ Paranoia a common symptom of intoxication
Stimulants
▪chronic use - anxiety states and panic
▪high doses - obsessive cognitions and compulsive behaviours
Hanxiety
Brain activity involving dopamine is lower during a hangover
Heightened stress during a hangover can also make it difficult for someone to cope with any additional stress
More trouble regulating emotions
Worse performance in key aspects of executive functions
People who “catastrophise” pain are more likely to experience anxiety
How could drugs cause psychosis
Reinforcing effect of drugs related to dopamine (dopamine hypothesis)
Cannabis
- Hypothesised to precipitate psychotic episodes
- Some evidence suggests a causal link, but still debated in literature
- Pharmacology and potency (THC vs CBD)
- Cannabis use known to increase rates of hospitalisation, psychotic relapse and psychotic symptoms
- Synthetic Cannabis a largely unknown area, but
anecdotal reports are concerning
Alcohol
- Negative symptoms worse and affects treatment
- Non-compliance with medication
- Higher relapse rates
Stimulants
- May directly cause psychotic episodes
- Amphetamine psychosis: brief psychotic reaction
that may last for several weeks
How could mental health cause A&D problems?
- Depressant drugs used as a form of “self- medication” of anxiety symptoms
- ‘Social lubricant’
- Stimulant drugs used as self medication of depression - ‘Pick me up’
- Pain relieving drugs to manage chronic emotional pain/trauma
- Opiates and sedatives commonly linked to a
Hx of trauma (up to 90%) - ‘Drowning your sorrows’
- Personality characteristics may lead to use in greater quantities or greater frequency
Intermediary Factors
An indirect causal relationship
Reversed indirect causal relationship
Early AOD use –>
Don’t finish high school –>
Unemployment –>
Depression
Shared Risk Factors of substance abuse and mental health conditions
Factors may increase the risk of both AOD and mental health conditions
- Lower socioeconomic status
- Cognitive impairment
- Conduct disorder in childhood
- Antisocial personality disorder
Is Causality Important?
Useful in understanding the relationship
Once established, most likely that there is mutual influence
Anxiety –> Drink Alcohol,
then Drinking –> Increased Anxiety
Why is dual diagnosis of
concern? Issues for the
client
Greater severity of Disorders- More hallucinations, depressive symptoms and suicidal ideation
- Relapse risk increased
- Rehospitalisation
- Effects on medications
Examples of how dual diagnosis can be a
concern for the client
- Loss of support networks/extra challenges
- Unstable accommodation
- Family / relationship issues /stress
- Double stigmatisation
- Harder to receive/access service
- Lack of education
- Forensic mental health/legal issues
Poorer self care
- Increased risk-taking behaviour (esp. HIV)
- Less compliant with medication
- Sleep
- Diet
- Exercise
Is this a wider problem?
Mental health leading to stigmatisation and having less opportunities in life
Issues for treatment services
Complex presentations
More than one drug use/mental health issue
Psycho-social issues
Diagnoses are often unclear
Lack of screening
Misdiagnosis
Lack of dual expertise or awareness of issues
- Lack of confidence in DD
Added work vs More effective work
perceptions
Lack of flexibility in service provision
- Appointment based models
Confronts clinicians own issues?
Diagnostic issues (Schizophrenia)
Positive symptoms
▪ Hallucinations
▪ Delusional thinking
▪ Disorganised speech
Negative symptoms
▪ Flattened affect
▪ Lack of motivation
▪ Poverty of speech
Diagnostic issues (Depression)
Low mood or irritable
Loss of interest in things
Appetite issues/weight variations
Sleep problems
Reduced activity
Lack of energy
Guilt/worthlessness
Poor concentration
Suicidal ideation
How can we improve treatment service assessment?
Accurate history crucial
▪ Family history of mental health problems?
▪ Order of disease onset
Better screening
Cease drug use before assessing?
▪ 3 months of abstinence is considered adequate ( but can we wait this long to ID and treat mental health issues?)
Get lots of experience in both services
Issues for treatment services Treatment
Engagement and follow-up processes
Conflicts in philosophies/perspectives of different services
- Attitudes
- Harm minimisation vs Zero tolerance
- Different service entry requirements/exclusions
▪ What if not eligible for either service?
- Reluctance to work with DD
- What to treat first? (A&D or MH)
- Service priorities?
May not benefit from standard interventions
Poorer treatment response and outcomes
Relationships b/w MH & SUD
Use of substances causes or exacerbates an underlying mental health problem (Primarily Substance Disorder)
Mental Health disorders lead to substance use and abuse (Primarily Mental Health, e.g. Self-medication)
Mental health disorders and substance abuse disorders develop together and reinforce each other (Bi-directional Model, e.g. Benzodiazepines and Depression)
Both MH and SUD develop somewhat independently of each
other due to common causes or risk factors (Common Factors, e.g. Trauma/Adversity/etc…)
Regardless of relationship, usually become inter-connected over time and result in a worsening clinical picture
Research perspectives
Research provides no clear answer on causal relationships
Causal link has been demonstrated in both directions
Regardless, neither will assist in the recovery from, treatment of, or relapse prevention of the other
Best way to manage is not dependant on cause
concurrent treatment and management
Treatment models
Sequential
Parallel
*A&D Services and mental health services
Third specialist service
*DD services, A&D Services and mental health services
Collaborative
*A&D Services and mental health services
Integrated
A&D Services within mental health services
National and State Programs
Over the last 20 years, we have seen more focus on need to respond to DD
- Particularly in Victoria
National and State funding has been applied to provide guidelines and support, and some specific services for DD
E.g. Headspace, dual diagnosis specialist positions
Variations between states
▪ Need for greater alignment with what is working?
▪ Response within mental health systems the priority?
Evidence based treatment
Limited (but increasing) evidence base
Treatment more effective when:
Integrated
Focused on maintaining motivation & promoting treatment engagement
Assertive case management
Extends over several months
Based on “no wrong door” approach
Majority of research on pharmacological management
Some promising results – SSRIs supported in most cases
▪ Initial activation issues
▪ 2-6 weeks until effective
▪ less effective when alcohol misuse present
Cautions related to use of Benzodiazepines
Evidence based treatment cont..
Some support for use of CBT e.g. for depression in conjunction with treatment for alcohol abuse
More research needed
Some support for group treatments
e.g. Substance abuse and bipolar disorder
The question of which came first should not delay treatment of either disorder
Preferable to cease substance use to assist mental health treatment
Often not possible
