Workshop what do mental health workers need to know june 2006
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Workshop What do mental health workers need to know ? June 2006. Dual Diagnosis introduction for mental health workers. Gary Croton Eastern Hume Dual Diagnosis Service. This presentation…. DDx cohorts. Making sense of it. Definitions. Terminology. Relai’/ps b/t the disorders.

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Workshop What do mental health workers need to know ? June 2006

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WorkshopWhat do mental health workers need to know?June 2006

Dual Diagnosis introduction

for

mental health workers

Gary Croton

Eastern Hume Dual Diagnosis Service


This presentation….

DDx

cohorts

Making

sense

of it

Definitions

Terminology

Relai’/ps

b/t the

disorders

What is DDx?

Prevalence

Why does it matter?

Potential

Policy

Harms

Demand


What is DDx?


Terminology

Definitions

‘Dual

Diagnosis’

definition:

co-occurrence of any Mental Health Disorder

with any Substance Use Disorder

‘Co-occurring

Disorders’

‘Comorbidity’

Other

terms:

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

people with both intellectual disability

and mental illness

c.f.

‘dual disability’:


DDx

cohorts

Combinations of disorders

Great variety in…

Severity of disorders

Treatment needs


DDx

cohorts

Common dual diagnosis presentations

1. To Primary Care / General Practice

Early psychosis with cannabis abuse or dependence

Anxiety with alcohol abuse or dependence

Depression with alcohol abuse or dependence


DDx

cohorts

Common dual diagnosis presentations

2. To an AT&OD treatment agency

Amphetamine abuse with paranoid symptoms

Opiate abuse or dependence with personality disorder

Alcohol dependence with anxiety &/or depression symptoms or disorder


DDx

cohorts

Common dual diagnosis presentations

3. To an Mental Health treatment agency

Personality disorder with episodic polydrug abuse

Mood disorder with stimulant or depressant abuse or dependence

Schizophrenia with alcohol, cannabis or polydrug abuse or dependence


ICD-10 combinations of disorders

DDx

cohorts

MENTAL

DISORDER

CLINICAL

STATE

SUBSTANCE

- Alcohol

  • Organic mental

  • disorders

  • Acute

  • intoxication

- Opioids

- Schizophrenia &

delusional disorders

- Cannabinoids

- Harmful use

- Sedatives or

hypnotics

  • Mood disorders

- Neurotic disorders

- Dependence

syndrome

- Cocaine

Disorders of

personality

- Other stimulants

- Withdrawal

state

- Hallucinogens

- Disorders of

Psyc’al develop’nt

- Tobacco

- Withdrawal

state with

delirium

-Disorders with

childhood/ adol’nce

onset

- Volatile solvents

- Multiple drug use


DDx

cohorts

How do I make sense of it?


DDx

cohorts

How do I make sense of it?

Tier 3

Hi MH with or without SUD

Victorian DHS Policy: Dual Diagnosis

Key directions and priorities for service development

March 2006


Relationships

b/t the

disorders

4 models:

  • Common

  • risk factors:

- Genetic risk factors

- Trauma

- Poor cognitive functioning

2. MH causes

SUD

- MHD ↑ vulnerability to SUD

- Self medication

- ↓ dysphoria

- Super sensitivity

3. SUD

causes MH

  • Amphetamine psychosis

  • Cannabis psychosis?

4. Bi-

directional

- Ongoing interaction


Relationships

b/t the

disorders

More than 1 model may apply at different times

What maintains the comorbidity is the

most relevant to treatment


Why does DDx matter?


Prevalence

Key

messages

Co-occurring disorders are common in the

general population

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

General

Practice

AT&OD

treatment

Mental

Health


General

Population

Prevalence

1997 NSMHW

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!!

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.


General

Practice

Prevalence

Hickie et al, 2001 study:(n=46,515)

Comorbidity of common mental disorders & alcohol or other

substance misuse in Australian general practice

56%

Prevalence of mental health &/or substance use

amongst persons attending General Practice

Co-occurring mental disorders & substance misuse in

patients attending General Practice

12%


AT&OD

treatment

Prevalence

Weaver et al, 2002 (UK)

55%

2 or more psych. disorders

Alcohol

service

users:

(n = 62)

No MH

disorder

15%

19%

Psychotic Disorder

53%

Personality Disorder

MH

disorder

85%

81%

Depression &/or Anxiety Disorder

8%

Psychotic Disorder

Drug

Service

users:

(n= 216)

No MH

disorder

25%

36%

Depression or Anxiety Disorder alone

68%

Depression & Anxiety Disorder

MH

disorder

75%

37%

Personality Disorder


Mental

Health

Prevalence

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%.


Harms

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


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

Dual Diagnosis:

Key directions and priorities

for service development

Victorian

MH &

DP&S Branches

Policy:

March 2006

Forum

April 2006

5 mandated service development outcomes:

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.

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).


Policy

Dual Diagnosis:

Key directions and priorities

for service development

Victorian

MH &

DP&S Branches

5 mandated service development outcomes:

3. Specialist mental health and d&a services

develop partnerships for the provision of

integrated treatment and care.

(No wrong door service system)

4. Client outcomes and service responsiveness to dual diagnosis

clients are monitored and regularly reviewed

5. Consumers and carers are involved in the planning

and evaluation of service responses.


Policy

Commonwealth /

State COAG:

2006/07 budget:

$21.6 mill:

campaign alerting community to

links b/t illicit drug use & mental health.

$73.9 mill:

training/ resources to assist AT&OD workers

to provide effective Rx

National Comorbidity Initiative

Federal

initiatives

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 Cline

    http://www.kenminkoff.com/index.html

    http://www.zialogic.org/

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


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