Week 9 - Dual Diagnosis Flashcards
Dual diagnosis
Co-morbidity/Co-occurrence
- More than one diagnosis
dual diagnosis distinctions
- Heterotypic (mental & physical)/Homotypic (2 mental health disorders)
- concurrent (alcohol dependence and depression)/succesive (panic disorder in teens and cannabis abuse in 20s)
dual diagnosis continuum
ranging from mild symptoms to severe disorders
what is dual diagnosis?
- 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
What percentage of the population will experience a MH disorder in their lifetime
42.9%
what percentage of the population will experience a MH disorder in the past 12 months?
21.5%, with anxiety being the most common 17.2%
what percentage of the population aged 16-24 had a MH disorder in the prior 12 months
38.8%
If an individual has a mh disorder are they likely to have substance use issues and vice versa?
yes
How likely is the incidence of dual diagnosis?
DD prevalence estimates range from 30-90%
Why does the prevalence of DD 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)
What did prof John McGrath’s research find?
- 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
Dual diagnosis 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
- 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 and MH
- 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 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
- 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 does alcohol cause depression?
▪ Interferes with medications
▪ Long term effect on relationships, employment, health
Cannabis on depression
▪ Long-term use may cause ‘depression-like’ symptoms
▪ Hypothesised ‘Amotivational syndrome’
Opioids on depression
Lifestyle related factors associated with opioid dependence
Stimulant drugs and depression
- Existing depression may get worse when coming down
- Common in the months following cessation
- Use/abuse may worsen the sleep / wake cycle
Anxiety symptoms
- feeling worried all the time
- getting tired easily
- unable to concentrate
- feeling irritable
- irregular heartbeats or palpitations
- dizziness
- muscle tensions and pains
Depressants and anxiety
Agitation, anxiety, and
irritability common features of withdrawal
- alcohol: alcohol related problems can create new worries
- cannabis: Paranoia a common symptom of intoxication
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
Stimulant drugs and anxiety
chronic use - anxiety states and panic
high doses - obsessive cognitions and
compulsive behaviours
Psychosis
Reinforcing effect of drugs related to dopamine (dopamine hypthesis)
Cannabis and psychosis
- 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 and psychosis
- Negative symptoms worse and affects
treatment - Non-compliance with medication
- Higher relapse rates
Stimulants and psychosis
- May directly cause psychotic episodes
- Amphetamine psychosis: brief psychotic reaction that may last for several weeks
Other behavioural disorders
Formication - the feeling of bugs under the skin
Stereotypy/Punding - repetitive behaviour
poly-drug use
when a variety of drugs are used at the same time
- uppers and downers cycle
- stimulates bipolar affective disorder
How does mental health cause A&D problems?
- 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
Intermediary factors
- An indirect causal relationship
- Reversed indirect causal relationship
Early AOD use –> don’t finish high school –> unemployment –> depression
Shared risk factors for AOD and MH 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
What are the concerns for greater severity of disorders?
- More hallucinations, depressive symptoms and suicidal ideation
- Relapse risk increased
- Rehospitalisation
- Effects on medications
What are the concerns of 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
What are the concerns of poorer self-care
- Increased risk-taking behaviour (esp. HIV)
- Less compliant with medication
- Sleep
- Diet
- Exercise
Regular exercise
Increases:
- self-esteem
- improvement of sleep
Decreases:
- stress
- anxiety
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
positive and negative symptoms of schizophrenia
Positive:
▪ Hallucinations
▪ Delusional thinking
▪ Disorganised speech
Negative:
▪ Flattened affect
▪ Lack of motivation
▪ Poverty of speech
Diagnostic issues of 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 to improve assessment
- Accurate history crucial
- Better screening
- Cease drug use before assessing
- Get lots of experience in both services
How to improve treatment
- Engagement and follow-up processes
- Conflicts in philosophies/perspectives of different services
- May not benefit from standard interventions
Conflicts in philosophies/perspectives of different services cont.
- 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
relationships between MH and 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
Treatment models
- Sequential
- Parallel
- third specialist
- collaborative
- integrated
National and State programs
- 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
When is treatment more effective?
- Integrated
- Focused on maintaining motivation &
promoting treatment engagement - Assertive case management
- Extends over several months
- Based on “no wrong door” approach
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
- 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
