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

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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  1. WorkshopWhat do mental health workers need to know?June 2006 Dual Diagnosis introduction for mental health workers Gary Croton Eastern Hume Dual Diagnosis Service

  2. 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

  3. What is DDx?

  4. 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’:

  5. DDx cohorts Combinations of disorders Great variety in… Severity of disorders Treatment needs

  6. 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

  7. 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

  8. 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

  9. 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

  10. DDx cohorts How do I make sense of it?

  11. 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

  12. 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

  13. Relationships b/t the disorders More than 1 model may apply at different times What maintains the comorbidity is the most relevant to treatment

  14. Why does DDx matter?

  15. 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

  16. Prevalence General Population General Practice AT&OD treatment Mental Health

  17. 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.

  18. 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%

  19. 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

  20. 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%.

  21. 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

  22. 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’

  23. 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).

  24. 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.

  25. 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

  26. Potential Improving our recognition of and response to co-occurring SUDs will improve the effectiveness of our treatment of mental health disorders

  27. 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.

  28. 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

  29. 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

  30. 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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