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PYB159 - Alcohol & Drugs > Week 9 - Dual Diagnosis > Flashcards

Week 9 - Dual Diagnosis Flashcards

1
Q

Dual diagnosis

A

Co-morbidity/Co-occurrence
- More than one diagnosis

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2
Q

dual diagnosis distinctions

A
  • Heterotypic (mental & physical)/Homotypic (2 mental health disorders)
  • concurrent (alcohol dependence and depression)/succesive (panic disorder in teens and cannabis abuse in 20s)
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3
Q

dual diagnosis continuum

A

ranging from mild symptoms to severe disorders

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4
Q

what is dual diagnosis?

A
  • 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
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5
Q

What percentage of the population will experience a MH disorder in their lifetime

A

42.9%

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6
Q

what percentage of the population will experience a MH disorder in the past 12 months?

A

21.5%, with anxiety being the most common 17.2%

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7
Q

what percentage of the population aged 16-24 had a MH disorder in the prior 12 months

A

38.8%

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8
Q

If an individual has a mh disorder are they likely to have substance use issues and vice versa?

A

yes

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9
Q

How likely is the incidence of dual diagnosis?

A

DD prevalence estimates range from 30-90%

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10
Q

Why does the prevalence of DD vary?

A

▪ 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)

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11
Q

What did prof John McGrath’s research find?

A
  • 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
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12
Q

Dual diagnosis in A&D settings

A
  • 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
  • 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
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13
Q

Methamphetamine and MH

A
  • 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.
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14
Q

Incidence of dual diagnosis in mental health

A
  • 17% with affective disorder, also had
    alcohol use disorder
  • 16% with an anxiety disorder also had
    alcohol use disorder
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15
Q

Symptoms of depression

A
  • 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
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16
Q

How does alcohol cause depression?

A

▪ Interferes with medications
▪ Long term effect on relationships, employment, health

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17
Q

Cannabis on depression

A

▪ Long-term use may cause ‘depression-like’ symptoms
▪ Hypothesised ‘Amotivational syndrome’

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18
Q

Opioids on depression

A

Lifestyle related factors associated with opioid dependence

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19
Q

Stimulant drugs and depression

A
  • Existing depression may get worse when coming down
  • Common in the months following cessation
  • Use/abuse may worsen the sleep / wake cycle
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20
Q

Anxiety symptoms

A
  • feeling worried all the time
  • getting tired easily
  • unable to concentrate
  • feeling irritable
  • irregular heartbeats or palpitations
  • dizziness
  • muscle tensions and pains
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21
Q

Depressants and anxiety

A

Agitation, anxiety, and
irritability common features of withdrawal
- alcohol: alcohol related problems can create new worries
- cannabis: Paranoia a common symptom of intoxication

22
Q

Hanxiety

A
  • 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
23
Q

Stimulant drugs and anxiety

A

chronic use - anxiety states and panic
high doses - obsessive cognitions and
compulsive behaviours

24
Q

Psychosis

A

Reinforcing effect of drugs related to dopamine (dopamine hypthesis)

25
Q

Cannabis and psychosis

A
  • 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
26
Q

alcohol and psychosis

A
  • Negative symptoms worse and affects
    treatment
  • Non-compliance with medication
  • Higher relapse rates
27
Q

Stimulants and psychosis

A
  • May directly cause psychotic episodes
  • Amphetamine psychosis: brief psychotic reaction that may last for several weeks
28
Q

Other behavioural disorders

A

Formication - the feeling of bugs under the skin
Stereotypy/Punding - repetitive behaviour

29
Q

poly-drug use

A

when a variety of drugs are used at the same time
- uppers and downers cycle
- stimulates bipolar affective disorder

30
Q

How does mental health cause A&D problems?

A
  • Depressant drugs used as a form of “self-medication” of anxiety symptoms
  • Stimulant drugs used as self-medication of depression
  • Pain relieving drugs to manage chronic
    emotional pain/trauma
  • Personality characteristics may lead to
    use in greater quantities or greater
    frequency
31
Q

Intermediary factors

A
  • An indirect causal relationship
  • Reversed indirect causal relationship
    Early AOD use –> don’t finish high school –> unemployment –> depression
32
Q

Shared risk factors for AOD and MH conditions

A
  • Lower socioeconomic status
  • Cognitive impairment
  • Conduct disorder in childhood
  • Antisocial personality disorder
33
Q

Is causality important?

A
  • Useful in understanding the relationship
  • Once established, most likely that there is mutual influence
    Anxiety –> drink alcohol, then drinking –> increased anxiety
34
Q

What are the concerns for greater severity of disorders?

A
  • More hallucinations, depressive symptoms and suicidal ideation
  • Relapse risk increased
  • Rehospitalisation
  • Effects on medications
35
Q

What are the concerns of loss of support networks/extra challenges

A
  • Unstable accommodation
  • Family / relationship issues / stress
  • Double stigmatisation
  • Harder to receive/access service
  • Lack of education
  • Forensic mental health/legal issues
36
Q

What are the concerns of poorer self-care

A
  • Increased risk-taking behaviour (esp. HIV)
  • Less compliant with medication
  • Sleep
  • Diet
  • Exercise
37
Q

Regular exercise

A

Increases:
- self-esteem
- improvement of sleep
Decreases:
- stress
- anxiety

38
Q

Is this a wider problem?

A

Mental health leading to stigmatisation
and having less opportunities in life

39
Q

Issues for treatment services

A

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

40
Q

positive and negative symptoms of schizophrenia

A

Positive:
▪ Hallucinations
▪ Delusional thinking
▪ Disorganised speech
Negative:
▪ Flattened affect
▪ Lack of motivation
▪ Poverty of speech

41
Q

Diagnostic issues of depression

A
  • 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
42
Q

How to improve assessment

A
  • Accurate history crucial
  • Better screening
  • Cease drug use before assessing
  • Get lots of experience in both services
43
Q

How to improve treatment

A
  • Engagement and follow-up processes
  • Conflicts in philosophies/perspectives of different services
  • May not benefit from standard interventions
44
Q

Conflicts in philosophies/perspectives of different services cont.

A
  • Attitudes
  • Harm minimisation vs Zero tolerance
  • Different service entry requirements/exclusions
  • Reluctance to work with DD
  • What to treat first? (A&D or MH)
  • Service priorities
45
Q

relationships between MH and SUD

A
  • 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
46
Q

Research perspectives

A
  • 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
47
Q

Treatment models

A
  • Sequential
  • Parallel
  • third specialist
  • collaborative
  • integrated
48
Q

National and State programs

A
  • Over the last 20 years, we have seen more focus on need to respond to DD, esp 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) varies between states
49
Q

When is treatment more effective?

A
  • Integrated
  • Focused on maintaining motivation &
    promoting treatment engagement
  • Assertive case management
  • Extends over several months
  • Based on “no wrong door” approach
50
Q

Research on pharmacological management

A

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

51
Q

Evidence based treatment

A
  • Some support for use of CBT e.g. for
    depression in conjunction with treatment for alcohol abuse
  • Some support for group treatments
  • The question of which came first should not delay treatment of either disorder
  • Preferable to cease substance use to assist mental health treatment

PYB159 - Alcohol & Drugs (6 decks)

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