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Comorbidity:Best Practice Behavioral Health Approaches
for American Indians and Alaska NativesSan Diego, California
June 28-30, 2005
Dale Walker, MD, Elizabeth Hawkins, PhD, MPH Patricia Silk Walker, PhD, Douglas Bigelow, PhD, Laura Loudon, MS
The American Indian/Alaska Native National Resource Center for Substance Abuse Services
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Overview Overview of comorbidity issues
AI/AN comorbidity
Comorbidity best practices
Barriers to integrated treatment
Solutions
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OVERVIEW OF COMORBIDITY
ISSUES
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Comorbidity Defined
“Individuals who have at least one mental disorder as well as an alcohol
or drug use disorder. While these disorders may interact differently in
any one person….at least one disorder of each type can be diagnosed independently of the other.”
- Report to Congress of the Prevention and Treatment of Co-Occurring Substance Abuser Disorders and Mental Disorders, SAMHSA, 2002
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Lifetime History
Mental Disorder22.5%
Comorbidity29%
Alcohol Disorder13.5%
Comorbidity45%
Drug Disorder6.1%
Comorbidity72%
Regier, 1990
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Prevalence and Pattern
7-10 million Americans affected Antisocial personality disorder, bipolar
disorder, schizophrenia most likely to coexist with substance use disorder
high prevalence of trauma histories and related symptoms
more likely to have cardiovascular disease, cirrhosis, or cancer
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Prevalence and Pattern in Youth
Among adolescents entering substance abuse treatment, 62% of males and 83% of females had at least one emotional/behavioral disorder
Almost 90% of those with a lifetime co-occurring disorder had at least one mental health disorder prior to the onset of a substance abuse disorder
Mental disorder likely to occur in early adolescence, followed by the substance abuse disorder 5-10 years later
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Multiple Diagnoses Increase
Treatment seeking
Use of services
Likelihood of no services
Treatment costs
Poor outcome
Suicide risk
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Affective Disorders and SUD
56% of people with Bipolar Disorder 20% of youth with depression have
history of substance abuse 15 – 75% of patients in substance
abuse treatment have affective disorder
Use of TCAs and SSRIs show hope for treating affective disorder and reducing alcohol and drug intake
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Schizophrenia and SUD
47% have substance use disorders Alcohol use may decrease negative
symptoms (depression, apathy, anhedonia, passivity and withdrawal)
May also decrease positive symptoms of hallucinations and paranoia
Schizophrenics often use and abuse stimulants
Drug-induced psychosis marked by prominent hallucinations or delusions
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Anxiety Disorders and SUD
27% have a substance use disorder Anxiety disorders may be treated with TCAs,
SSRIs and Benzodiazepines (with caution) Generalized anxiety disorder: Buspirone
shown to treat anxiety and reduce alcohol consumption
Social anxiety is a big risk factor for alcohol and drug use
With PTSD, people will often use drugs or alcohol to sleep and stop recurrent nightmares, or to reduce anxiety
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Disruptive Disorders and SUD
23% of people with ADHD have a substance use disorder
Combination of ADHD and CD place a child at greater risk of substance abuse than either one alone The greater the number of CD symptoms, the
more severe the substance abuse is likely to be When CD precedes substance abuse, youth are
at highest risk for ongoing delinquency and drug use in adulthood
Stimulants are a primary treatment choice but risk of abuse is high
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COMORBIDITY AMONG AMERICAN INDIANS
AND ALASKA NATIVES
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American Indians
Have same disorders as general population
Greater prevalence Greater severity Much less access to treatment Cultural relevance more challenging Social context disintegrated
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Trends among AI/AN Youth
AI/AN youth are more likely to: Use tobacco, inhalants, alcohol, and marijuana daily Consume alcohol in a binge-drinking style Engage in high risk behaviors and experience harmful
consequences
AI/AN youth tend to initiate substance use at a younger age
Higher rates of polysubstance use Substance use often does not follow the “Gateway”
model Highest rates of emotional/behavioral problems
and suicide
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Alcohol and Other Drug Use
May cause or mimic psychiatric symptoms
May initiate or exacerbate a psychiatric disorder
Can mask psychiatric symptoms May last for days to weeks Drug-induced psychiatric symptoms
may clear spontaneously
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COMORBIDITY BEST PRACTICES
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Best Practices
“Examples and cases that illustrate the use of community knowledge and
science in developing cost effective and sustainable survival strategies to
overcome a chronic illness.”- WHO
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Service Planning Guidelines
1. Dual diagnosis is an expectation, not an exception.
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Treatment Models
Sequential treatment: First one provider, then the other
Parallel treatment: Two separate providers at the same time
Integrated treatment: Both services provided by same clinician or group of clinicians
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Co-occurring Disorders by Severity
IIILess severe
mental disorder/more severe
substance abuse disorder
IVMore severe
mental disorder/more severe
substance abuse disorder
ILess severe
mental disorder/less severe
substance abuse disorder
IIMore severe
mental disorder/less severe
substance abuse disorderA
lco
ho
l an
d o
ther
dru
g a
bu
se
Mental IllnessHigh Severity
Low Severity
High Severity
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Unified Services Plan
Case management should address:
Mental health Education/vocation Leisure/social Parenting/family Housing Financial Daily living skills Physical health
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Integrated Treatment
“Any mechanism by which treatment interventions for co-occurring
disorders are combined within the context of a primary treatment relationship or service setting.”
-CSAT
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Effective Interventions for Adults
Cognitive/Behavioral Approaches Motivational Interventions Psychopharmacological Interventions Modified Therapeutic Communities Assertive Community Treatment Vocational Services Dual Recovery/Self-Help Programs Consumer Involvement Therapeutic Relationships
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Effective Interventions for Youth
Family TherapyMultisystemic TherapyCase ManagementTherapeutic CommunitiesCircles of Care
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NIDA Recommended Approaches
Contingency Management
Relapse Prevention Therapy
Community Reinforcement Approach
Motivational Enhancement Therapy
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BARRIERS TO INTEGRATED TREATMENT
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Disconnect Between Systems
Professionals are undertrained in one of two domains
Patients are underdiagnosed Patients are undertreated Neither integrates well with medical
and social service
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Difficulties of Integrated Approach
Separate funding streams and coverage gaps
Agency turf issues Different treatment philosophies Different training philosophies Lack of resources Poor cross training Consumer and family barriers
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SOLUTIONS
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World Conference on Science
Recommended that scientific and indigenous knowledge be integrated in interdisciplinary projects dealing
with culture, environment and chronic illness.
- 1999
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Identify Best Practices
Best Practice
Clinical/servicesResearch
TraditionalHealing
MainstreamPractice
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Circle of Care
Best Practices
Child & Adolescent Programs
Prevention Programs
Primary Care
EmergencyRooms
TraditionalHealers
A&D Programs
Colleges & Universities
Boarding Schools
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Resources SAMHSA Co-occurring Disorders
http://alt.samhsa.gov/Matrix/matrix_cooc.asp National Institute of Alcohol Abuse and Alcoholism
http://www.niaaa.nih.gov National Institute of Drug Abuse
http://www.nida.nih.gov National Institute of Mental Health
http://www.nimh.nih.gov Treatment Improvement Protocol (TIP) Series
(800) 729-6686 Monitoring the Future Study
http://www.monitoringthefuture.org
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For more information, contact: R Dale Walker, MD
One Sky National Resource Center 503-494-3703
Visit us online at www.oneskycenter.org