prof. baldacchino - ponencia
TRANSCRIPT
-
8/8/2019 Prof. Baldacchino - Ponencia
1/65
CoCo --morbidity in Europemorbidity in Europe
Dr Alexander BaldacchinoDr Alexander BaldacchinoUniversity of Dundee/NHS FifeUniversity of Dundee/NHS Fife
ScotlandScotland
11 stst International Conference on Dual DiagnosisInternational Conference on Dual DiagnosisMadrid: 19Madrid: 19 --2020 thth April 2007April 2007
-
8/8/2019 Prof. Baldacchino - Ponencia
2/65
OverviewOverview
Journey from the biological, psychological, epidemiologicalJourney from the biological, psychological, epidemiologicaland policy arenasand policy arenasDual Diagnosis; is it a virtual entity?Dual Diagnosis; is it a virtual entity?Neurobiological and neuropsychological issuesNeurobiological and neuropsychological issues
PsychopathologicalPsychopathologicalPopulations and coPopulations and co --morbidity: epidemiological issuesmorbidity: epidemiological issuesService provision and policy issuesService provision and policy issuesVulnerability and resilience and coVulnerability and resilience and co --morbiditymorbidityChronic care model and coChronic care model and co --morbiditymorbidityImplications for treatment: the way forwardImplications for treatment: the way forward
-
8/8/2019 Prof. Baldacchino - Ponencia
3/65
-
8/8/2019 Prof. Baldacchino - Ponencia
4/65
Neurobiology and neuropsychological issuesNeurobiology and neuropsychological issuesin dual diagnosisin dual diagnosis
-
8/8/2019 Prof. Baldacchino - Ponencia
5/65
Neurobiology and neuropsychologicalNeurobiology and neuropsychologicalissues in dual diagnosisissues in dual diagnosis
PFCACG
SCCN Ac c
Am y g
Amyg
-
8/8/2019 Prof. Baldacchino - Ponencia
6/65
Underactive ACC in
adult ADHD patients
-
8/8/2019 Prof. Baldacchino - Ponencia
7/65
Neurobiology and neuropsychologicalNeurobiology and neuropsychologicalissues in dual diagnosisissues in dual diagnosis
-
8/8/2019 Prof. Baldacchino - Ponencia
8/65
Neurobiology and neuropsychologicalNeurobiology and neuropsychologicalissues in dual diagnosisissues in dual diagnosis
-
8/8/2019 Prof. Baldacchino - Ponencia
9/65
AttentionalAttentional BiasBias -- CueCue --ReactivityReactivity -- CravingCraving RelapseRelapse
Detection Threshold Disinhibition
Attentional Bias Cue-Reactivity Craving Relapse
Conflict Registration
Repeated Reward
-
8/8/2019 Prof. Baldacchino - Ponencia
10/65
PsychpathologyPsychpathology andand comorbiditycomorbidityExample: Cannabis and Psychosis in acute psychiatricExample: Cannabis and Psychosis in acute psychiatricpopulationpopulation
Literature review of all publications on cannabis andLiterature review of all publications on cannabis andpsychosis using Cochrane techniquespsychosis using Cochrane techniques
EU Drug and Psychosis study (2001EU Drug and Psychosis study (2001 --2006)2006)
Result:Result: No differenceNo difference in psychopathology betweenin psychopathology between
individuals with cannabis psychosis and other typesindividuals with cannabis psychosis and other typesof psychosis. Treatment is alsoof psychosis. Treatment is also no different no different . Same. Sametreatment protocolstreatment protocols
-
8/8/2019 Prof. Baldacchino - Ponencia
11/65
Epidemiological studies andEpidemiological studies andcomorbiditycomorbidity
(1) General populations(1) General populations ::
ECA: 53% abuse drugs have MH problemsECA: 53% abuse drugs have MH problems
(current) and 32% (lifetime)(current) and 32% (lifetime)
NEMESIS study 43%NEMESIS study 43%
-
8/8/2019 Prof. Baldacchino - Ponencia
12/65
Lifetime Prevalence and Odds Ratios of MentalLifetime Prevalence and Odds Ratios of MentalDisordersDisorders
by Substance Use Disorder: ECAby Substance Use Disorder: ECAAlcohol Drug
ComorbidDisorder % O.R. % O.R.Any mental 36.6 2.3 53.1 4.5
Schizophrenia 3.8 3.3 6.8 6.2
Affective 13.4 1.9 26.4 4.7
Anxiety 19.4 1.5 28.3 2.5
Antisocial 14.3 21.0 17.8 13.8
(Regier et al., JAMA 264:2511-2518, 1990)
-
8/8/2019 Prof. Baldacchino - Ponencia
13/65
Population studiesPopulation studies(2) Substance misuse population :(2) Substance misuse population :
Cumulative 15%Cumulative 15% --93% !93% !
(A) Personality disorders (65%(A) Personality disorders (65% --85%)85%)
(B) Affective disorder (30%(B) Affective disorder (30% --55%)55%)(C) Psychotic disorders (20%)(C) Psychotic disorders (20%)
-
8/8/2019 Prof. Baldacchino - Ponencia
14/65
Population studiesPopulation studies(A) Substance misuse population: personality(A) Substance misuse population: personality
disordersdisordersVerhaulVerhaul (2000) 187 drug dependent in Holland: 23%(2000) 187 drug dependent in Holland: 23%
APD, 18% BPD (lifetime)APD, 18% BPD (lifetime)
FridellFridell (1996) 1052(1996) 1052 polydrugpolydrug dependent in Sweden:dependent in Sweden:23% APD (current)23% APD (current)FreiFrei (2002) 85 Heroin assisted in Switzerland: 58%(2002) 85 Heroin assisted in Switzerland: 58%
PD (lifetime)PD (lifetime)Nielson (2002) 104 alcohol dependent in Denmark:Nielson (2002) 104 alcohol dependent in Denmark:50% APD and 30% BPD (current)50% APD and 30% BPD (current)
-
8/8/2019 Prof. Baldacchino - Ponencia
15/65
Population studiesPopulation studies(B) Substance misuse population: affective(B) Substance misuse population: affective
disorders (anxiety and depression)disorders (anxiety and depression)
SiliqiuniSiliqiuni (2002) 58 drug users in Italy: 23% mood(2002) 58 drug users in Italy: 23% moodand 21% anxiety (current)and 21% anxiety (current)
TomassonTomasson (1995) 351(1995) 351 polydrugpolydrug users in Iceland:users in Iceland:33% mood and 65% anxiety (lifetime)33% mood and 65% anxiety (lifetime)
EnatescuEnatescu (2006) 304 drug and alcohol dependent:(2006) 304 drug and alcohol dependent:12% mixed anxiety and depression (lifetime)12% mixed anxiety and depression (lifetime)
-
8/8/2019 Prof. Baldacchino - Ponencia
16/65
Population studiesPopulation studies(C) Substance misuse population: affective(C) Substance misuse population: affective
disorders (psychotic including schizophrenia)disorders (psychotic including schizophrenia)
KokkeviKokkevi (1995) 176(1995) 176 opioidopioid users in Greece: 6%users in Greece: 6%schizophrenia (lifetime)schizophrenia (lifetime)
FacyFacy (1999) 3936 methadone users in France : 1.6%(1999) 3936 methadone users in France : 1.6%psychosispsychosis
Weaver (2003) 278Weaver (2003) 278 polydrugpolydrug users in England: 8%users in England: 8%psychosis (one year)psychosis (one year)
-
8/8/2019 Prof. Baldacchino - Ponencia
17/65
Population studiesPopulation studies(3) Psychiatric populations(3) Psychiatric populations
(Drugs and alcohol)(Drugs and alcohol)
Current: ~11.8%Current: ~11.8% -- 45%45%6 months: ~15%6 months: ~15%
One year: ~15%One year: ~15% -- 44 %44 %Lifetime: ~22%Lifetime: ~22% -- 74%74%
-
8/8/2019 Prof. Baldacchino - Ponencia
18/65
Population studiesPopulation studies(4) Other vulnerable populations:(4) Other vulnerable populations:
(A)(A) Young PeopleYoung People ::
Hannesdottir Hannesdottir (2001) 103 adolescents for (2001) 103 adolescents for
detoxdetox : 75% co: 75% co --morbiditymorbidity
-
8/8/2019 Prof. Baldacchino - Ponencia
19/65
Population studiesPopulation studiesOther vulnerable populations:Other vulnerable populations:
(B)(B) HomelessHomeless
Kershaw (2000) 22% in Glasgow homelessKershaw (2000) 22% in Glasgow homelessReinkingReinking (2001) 27% of Dutch homeless(2001) 27% of Dutch homeless
-
8/8/2019 Prof. Baldacchino - Ponencia
20/65
Population studiesPopulation studiesOther vulnerable populations:Other vulnerable populations:
(C)(C) PrisonersPrisoners ::
Singleton (1998) 81% in remand with coSingleton (1998) 81% in remand with co --morbiditymorbidity
-
8/8/2019 Prof. Baldacchino - Ponencia
21/65
Population studiesPopulation studiesOther vulnerable populations:Other vulnerable populations:
(D)(D) Street workers/ProstitutesStreet workers/Prostitutes
Gilchrist (2004) 70% current coGilchrist (2004) 70% current co --morbiditymorbidity
-
8/8/2019 Prof. Baldacchino - Ponencia
22/65
Epidemiological studiesEpidemiological studiesMethodological issues to consider:Methodological issues to consider:
(a)(a) DefinitionsDefinitions(b)(b) Exclusion and inclusion of groupsExclusion and inclusion of groups
(c)(c) Instruments usedInstruments used(d)(d) Settings and types of interventionsSettings and types of interventions
(e)(e) Time windowTime window(f)(f) Context (ethos and philosophies of care)Context (ethos and philosophies of care)
-
8/8/2019 Prof. Baldacchino - Ponencia
23/65
Epidemiological StudiesEpidemiological StudiesEpidemiological Studies
Key patterns from epidemiologic dataKey patterns from epidemiologic data
Comorbidity is the rule rather than the exceptionComorbidity is the rule rather than the exceptionCrossCross --cultural findings show that the magnitude of cultural findings show that the magnitude of comorbidity is more similar than are the differencescomorbidity is more similar than are the differencesin baseline prevalencein baseline prevalence
Risk for drug dependence > drug abuseRisk for drug dependence > drug abuse
Risk varies by mental disorder (Anxiety < Mood male)Risk varies by gender (female > male)
Risk varies somewhat by specific drug disorder andRisk varies somewhat by specific drug disorder andnumber of drug disordersnumber of drug disorders
-
8/8/2019 Prof. Baldacchino - Ponencia
24/65
Policy andPolicy and ComorbidityComorbidity ::
The Scottish NationalThe Scottish National ComorbidityComorbidityStudyStudy
Identification of needsIdentification of needs
Service User experiencesService User experiences
Current provision in relation to needsCurrent provision in relation to needs
Relations between servicesRelations between services
Examples of good practiceExamples of good practice
-
8/8/2019 Prof. Baldacchino - Ponencia
25/65
MethodologiesMethodologies
Structured interviews with commissioners of Structured interviews with commissioners of servicesservices
InIn
--depth Interviewing with service usersdepth Interviewing with service users
Focus groups with coalface staff Focus groups with coalface staff
Framework Analysis (Ritchie & Spencer, 1994)Framework Analysis (Ritchie & Spencer, 1994)
-
8/8/2019 Prof. Baldacchino - Ponencia
26/65
Identified GapsIdentified GapsAccessAccess
Lack of signpostingLack of signpostingStructural obstaclesStructural obstaclesEligibility criteriaEligibility criteriaCapacityCapacity
Service responseService responseInflexibilityInflexibility
ContinuityContinuity
Lack of oneLack of one --toto --oneone
Traditional professionalTraditional professionaltrajectoriestrajectories
Service organizationService organizationExpertise in coExpertise in co --morbiditymorbidityBureaucracyBureaucracy
ExclusionExclusionStigmaStigma
-
8/8/2019 Prof. Baldacchino - Ponencia
27/65
FF rom Pillar to Postrom Pillar to PostI went there [local Drug Problems Service]I went there [local Drug Problems Service]and just got referred back to the hospitaland just got referred back to the hospitaland when I was in the hospital they saidand when I was in the hospital they saidlook welook we cannaecannae daedae nothing for you, younothing for you, you rere
gonnagonna have to get treated by the Drughave to get treated by the DrugProblems Service and then they [local DrugProblems Service and then they [local DrugProblem Service] just say go back to my ainProblem Service] just say go back to my ain
doctor and try to get something sorted outdoctor and try to get something sorted out
-
8/8/2019 Prof. Baldacchino - Ponencia
28/65
A Clear Path Through the Maze?A Clear Path Through the Maze?Integrated care pathways work well when youIntegrated care pathways work well when you ve got ave got a
history or a natural course of a disease or the processhistory or a natural course of a disease or the processis clearly understood. Once you get beyond somethingis clearly understood. Once you get beyond somethingas simple as an acute episode, integrated careas simple as an acute episode, integrated carepathways donpathways don t follow linear trajectories. We make thet follow linear trajectories. We make theassumption that somehow we can create a pathwayassumption that somehow we can create a pathwaythat zigzags between all of these possible sources of that zigzags between all of these possible sources of service. Even then they would work if we had peopleservice. Even then they would work if we had peoplecapable of keeping track of their own carecapable of keeping track of their own carerequirements. So if the person who has a mentalrequirements. So if the person who has a mentalillness plus another problem related to substanceillness plus another problem related to substancemisuse could actually manage their own way throughmisuse could actually manage their own way throughthat system that would be simple and straightforward.that system that would be simple and straightforward.They canThey can t.t.
-
8/8/2019 Prof. Baldacchino - Ponencia
29/65
Stickiness!Stickiness!I think X is the best because they get a hold oI think X is the best because they get a hold o ye and keepye and keeppursuing ye until they get ye. Some days I donpursuing ye until they get ye. Some days I don t come but theyt come but they rerepersistent tae get a hold opersistent tae get a hold o ye and they go looking for ye taeye and they go looking for ye tae yer yer friendfriend ss hoosehoose or your maor your ma ss hoosehoose or your familyor your family ss hoosehoose looking for looking for ye, somebodyye, somebody s theres there fer fer yeye
My key workers are constantly in touch and talking about whereMy key workers are constantly in touch and talking about wherethey think I should be going or what I should be doing or how Ithey think I should be going or what I should be doing or how I mmdoingdoing
They [Key workers] end up moving on and the case doesnThey [Key workers] end up moving on and the case doesn t gett getpicked up or if youpicked up or if you daedae get picked up you get picked up by fiveget picked up you get picked up by fivedifferent people, then I got fivedifferent people, then I got five CPNsCPNs in a row. Iin a row. I couldnaecouldnae work withwork withlike five different people I find it hard enough to trust one pelike five different people I find it hard enough to trust one pe rsonrsonover a long period of time then to be asked to be moved to anothover a long period of time then to be asked to be moved to anoth er er person in two weeks, on to another person and then another itperson in two weeks, on to another person and then another it s justs justimpossibleimpossible
-
8/8/2019 Prof. Baldacchino - Ponencia
30/65
Specialists or Specialist ServicesSpecialists or Specialist Services ??It [specialistIt [specialist comorbiditycomorbidity service] doesnservice] doesn tt
seem to work well for us. Itseem to work well for us. It s certainly nots certainly notknitted in well to the mental health system,knitted in well to the mental health system,not knitted into the addiction system, so thenot knitted into the addiction system, so theclassic thing is you create a specialistclassic thing is you create a specialistservice which has defined its own roleservice which has defined its own role
existingexisting in splendid isolationin splendid isolation ..
-
8/8/2019 Prof. Baldacchino - Ponencia
31/65
CoCo --morbid Mental Health andmorbid Mental Health andSubstance Misuse in ScotlandSubstance Misuse in Scotland
ClaireClaire --Louise HodgesLouise HodgesSheila PatersonSheila Paterson
MatiraMatira TaikatoTaikatoSarahSarah McGarrolMcGarrol
IlanaIlana CromeCromeAlex BaldacchinoAlex Baldacchino
May 2006May 2006
Scottish Executive Social ResearchScottish Executive Social ResearchSubstance Misuse ResearchSubstance Misuse Research
ProgrammeProgramme
-
8/8/2019 Prof. Baldacchino - Ponencia
32/65
ISADORA:ISADORA: Integrated Services Aimed at Dual Diagnosis andIntegrated Services Aimed at Dual Diagnosis andOptimal Recovery from AddictionOptimal Recovery from Addiction
EstablissementEstablissement de santde sant MaisonMaison --Blanche, Paris, FranceBlanche, Paris, FranceUniversity of University of TampereTampere , Finland, FinlandUniversity of Dundee, ScotlandUniversity of Dundee, Scotland
Institute of Psychiatry and Neurology, Warsaw, PolandInstitute of Psychiatry and Neurology, Warsaw, PolandMiddlesex University, London, EnglandMiddlesex University, London, EnglandCambridge University, EnglandCambridge University, England
The Psychiatric Services in the County of The Psychiatric Services in the County of AarhusAarhus ,,DenmarkDenmark
-
8/8/2019 Prof. Baldacchino - Ponencia
33/65
ISADORA:ISADORA: Integrated Services Aimed at Dual DiagnosisIntegrated Services Aimed at Dual Diagnosisand Optimal Recovery from Addictionand Optimal Recovery from AddictionTo describe the psychiatric service opportunitiesTo describe the psychiatric service opportunities
for treatmentfor treatmentTo determine and compare the coTo determine and compare the co --morbiditymorbidity
patternpatternTo followTo follow --up a cohort of patientsup a cohort of patientsTo identify predictors of prognosisTo identify predictors of prognosisTo explore the views of dual diagnosis patientsTo explore the views of dual diagnosis patients
and of staff and of staff To use study results as a basis for developingTo use study results as a basis for developing
an educational programmean educational programmeTo develop common assessment instrumentsTo develop common assessment instruments
-
8/8/2019 Prof. Baldacchino - Ponencia
34/65
Methodology of the studyMethodology of the study
A descriptive study of treatmentA descriptive study of treatmentopportunitiesopportunitiesA descriptive study of the pathwayA descriptive study of the pathway
through carethrough careA followA follow --up studyup studyAn exploration of the views of staff An exploration of the views of staff A study of risk factorsA study of risk factorsA development of an educationalA development of an educational
programme for staff programme for staff 34
-
8/8/2019 Prof. Baldacchino - Ponencia
35/65
ISADORAISADORA
A cohort study: 50/site, F30A cohort study: 50/site, F30 --33.9 (350)33.9 (350)Case studies (20)Case studies (20)
Focus group interviews: service users andFocus group interviews: service users andproviders (12)providers (12)Epidemiological data (local/regional)Epidemiological data (local/regional)
35
-
8/8/2019 Prof. Baldacchino - Ponencia
36/65
Service mapping and service usersService mapping and service users perspectives: ISADORA (1)perspectives: ISADORA (1)
Lack of coordinationLack of coordinationImproved signpostingImproved signpostingLead clinicians are often absent from case conferencesLead clinicians are often absent from case conferencesStructural and procedural changes militate against effectiveStructural and procedural changes militate against effectivenetworkingnetworkingClient autonomy and choice may inhibit referral processesClient autonomy and choice may inhibit referral processesFeedback is limitedFeedback is limited
Confidentiality issuesConfidentiality issuesComplexity for the sake of itComplexity for the sake of it
-
8/8/2019 Prof. Baldacchino - Ponencia
37/65
Service mapping and Service usersService mapping and Service users perspectives: ISADORA (2)perspectives: ISADORA (2)
Lack of designated time for networkLack of designated time for networkdevelopment/joint workingdevelopment/joint workingIgnorance regarding othersIgnorance regarding others roles and remitsroles and remits
Attitudinal barriersAttitudinal barriersDifferent professional silos andDifferent professional silos andDifferent clinical approaches e.g. medical versusDifferent clinical approaches e.g. medical versussocial modelssocial modelsLack of expertise on dual diagnosis and on howLack of expertise on dual diagnosis and on howbest to networkbest to network
-
8/8/2019 Prof. Baldacchino - Ponencia
38/65
Service mapping and Service usersService mapping and Service users perspectives: ISADORA (3)perspectives: ISADORA (3)
Clients often miss appointments leading toClients often miss appointments leading to
discordance and discontinuitydiscordance and discontinuityGeographical spread of services creates logisticalGeographical spread of services creates logisticalproblemsproblemsStaff turnover Staff turnover Unclear who should take primary responsibility for Unclear who should take primary responsibility for DD clientsDD clientsLack of tolerance for substance misuse createsLack of tolerance for substance misuse creates
barriers to appropriate carebarriers to appropriate careWaiting times and bureaucracy cause lengthyWaiting times and bureaucracy cause lengthydelays and fragmentationdelays and fragmentation
-
8/8/2019 Prof. Baldacchino - Ponencia
39/65
ISADORA: Contact to services (psychiatric, substance use,ISADORA: Contact to services (psychiatric, substance use,social and medical) at different research sites at baseline, 3,social and medical) at different research sites at baseline, 3,
6 and 9 month f/up6 and 9 month f/up
CambridgeMiddlesexWarsawDundeeTampereParisAarhus
site
4,00
3,00
2,00
1,00
0,00
M e a n
contact with 4 areasof services (soc.,med., smu., psych.) 9months follow up
contact with 4 areasof services (soc.,med., smu., psych.) 6months follow up
contact with 4 areasof services (soc.,med., smu., psych.) 3months follow up
contact with 4 areasof services (soc.,med., smu., psych.)baseline
-
8/8/2019 Prof. Baldacchino - Ponencia
40/65
ISADORAISADORALongLong --term planning is needed beginning at aterm planning is needed beginning at apolicy level supported by chief clinical leads andpolicy level supported by chief clinical leads andcommissioners and underpinned by good practicecommissioners and underpinned by good practiceThe voluntary sector should be developed toThe voluntary sector should be developed toimprove capacity. Integrated services more user improve capacity. Integrated services more user
friendly and better retention. Quality rather thanfriendly and better retention. Quality rather thantype of service importanttype of service importantSystem needs to be more flexible. The moreSystem needs to be more flexible. The morecontact patients have the more contact at followcontact patients have the more contact at followup with resulting positive outcomes in mostup with resulting positive outcomes in mostdomains including psychopathologydomains including psychopathologyImproved deployment and increase of resourcesImproved deployment and increase of resources
needed. Site most resources is site with better needed. Site most resources is site with better retention and outcomesretention and outcomes
-
8/8/2019 Prof. Baldacchino - Ponencia
41/65
Way forwardWay forward ....Another way of looking at coAnother way of looking at co --morbidity ?morbidity ?
MicrosystemMicrosystem (vulnerability and(vulnerability andresilience)resilience)
MacrosystemMacrosystem (chronic care models)(chronic care models)
-
8/8/2019 Prof. Baldacchino - Ponencia
42/65
: Vulnerability and resilience: Vulnerability and resilienceExploring concepts of mental health andExploring concepts of mental health and
substance misuse:substance misuse:Never culture freeNever culture free
Never morally and ethically neutralNever morally and ethically neutral
What we understand or want to understand of What we understand or want to understand of coco --morbid substance misuse and mentalmorbid substance misuse and mentalhealth will depend on:health will depend on: ....
-
8/8/2019 Prof. Baldacchino - Ponencia
43/65
Vulnerability and resilience and coVulnerability and resilience and co --morbiditymorbidity
Our valuesOur values
Preconceptions and assumptions on:Preconceptions and assumptions on:
(a)(a) Nature of health and illnessNature of health and illness(b)(b) Nature of societyNature of society(c)(c) Place of the individual within society (normality)Place of the individual within society (normality)(d)(d) Desirable behavioursDesirable behaviours
This is either indicative of diversity or an excuse to excludeThis is either indicative of diversity or an excuse to excludedue to its complex naturedue to its complex nature
-
8/8/2019 Prof. Baldacchino - Ponencia
44/65
Vulnerability and resilience and coVulnerability and resilience and co --morbiditymorbidity
VulnerabilityVulnerability
We are all vulnerableWe are all vulnerable
Much human effort is dedicated in managingMuch human effort is dedicated in managingthat uncertainty in order to reduce or removethat uncertainty in order to reduce or removevulnerabilityvulnerabilityNature and nurtureNature and nurture
l b l d l d
-
8/8/2019 Prof. Baldacchino - Ponencia
45/65
Vulnerability and resilience and coVulnerability and resilience and co --morbiditymorbidity
It is a function of susceptibility to loss andIt is a function of susceptibility to loss and
the capacity to recover. This capacity isthe capacity to recover. This capacity istermed resiliencetermed resilience
Resilience is the ability to cope fromResilience is the ability to cope fromadverse eventsadverse eventsNot a justification for labelling and stigmaNot a justification for labelling and stigma
but an opportunity to identify communitiesbut an opportunity to identify communitiesand groups most in needand groups most in need
l b l d l dV l bili d ili d
-
8/8/2019 Prof. Baldacchino - Ponencia
46/65
Vulnerability and resilience and coVulnerability and resilience and co --morbiditymorbidity
Potential indicatorsPotential indicators ::
Livelihood security (wealth, income)Livelihood security (wealth, income)Access to crisis supportAccess to crisis supportHousing qualityHousing quality
Psychological state :Psychological state :(a) Strong coping and problem solving abilities/skills(a) Strong coping and problem solving abilities/skills
and role modelsand role models
(b) Awareness of personal networks and stable(b) Awareness of personal networks and stableemotional relationshipemotional relationship
-
8/8/2019 Prof. Baldacchino - Ponencia
47/65
Vulnerability and resilienceVulnerability and resilience(c) Internal locus of control(c) Internal locus of control
(d) Positive cognitions(d) Positive cognitions(e) Life events (intrauterine, postnatal and beyond)(e) Life events (intrauterine, postnatal and beyond)(f) A sense of humour!(f) A sense of humour!
Well being (good physical health and lack of Well being (good physical health and lack of chronicitychronicity ))Local economic security (social capital)Local economic security (social capital)Employment and educationEmployment and educationEnvironmental minority groups with noEnvironmental minority groups with no rightsrights or or avenues for justiceavenues for justice
V l bili d ili dV l bili d ili d
-
8/8/2019 Prof. Baldacchino - Ponencia
48/65
Vulnerability and resilience and coVulnerability and resilience and co --morbiditymorbidity
Linked to concepts of emotional intelligence, self Linked to concepts of emotional intelligence, self regulation, social competence and self regulation, social competence and self organisationorganisation
The social and biological factors are very closelyThe social and biological factors are very closelyinterlinked but still do not know enoughinterlinked but still do not know enough
It is not a set of static protective factors but aIt is not a set of static protective factors but a
dynamic one that include accumulated anddynamic one that include accumulated andmultiple risks at a point inmultiple risks at a point intimetime .Role of assessments.Role of assessments
Ch i di / d l dCh i di / d l d
-
8/8/2019 Prof. Baldacchino - Ponencia
49/65
Chronic disease/care model and coChronic disease/care model and co --morbiditymorbidity
Current view of health and social careCurrent view of health and social care
Geared towards acute conditionsGeared towards acute conditions
Hospital centredHospital centredDoctor dependentDoctor dependentEpisodic and disjointed and/or reactive careEpisodic and disjointed and/or reactive care
Patient passive with self care infrequentPatient passive with self care infrequentCarers undervaluedCarers undervaluedLow technology (databases, evaluation etc)Low technology (databases, evaluation etc)
Ch i di / d l dCh i di / d l d
-
8/8/2019 Prof. Baldacchino - Ponencia
50/65
Chronic disease/care model and coChronic disease/care model and co --morbiditymorbidity
Evolving model of chronic careEvolving model of chronic care
Geared towards long term conditionsGeared towards long term conditionsEmbedded in communitiesEmbedded in communities
Team basedTeam basedContinuous careContinuous careIntegrated careIntegrated care
Preventative carePreventative carePatient/client as partner Patient/client as partner Self care encouraged and facilitatedSelf care encouraged and facilitated
Ch i di / d l dChronic disease/care model and co
-
8/8/2019 Prof. Baldacchino - Ponencia
51/65
Chronic disease/care model and coChronic disease/care model and co --morbiditymorbidity
15th November 2005
Chronic disease/care model and coChronic disease/care model and co
-
8/8/2019 Prof. Baldacchino - Ponencia
52/65
Chronic disease/care model and coChronic disease/care model and co --morbiditymorbidity
Chronic disease/care model and coChronic disease/care model and co
-
8/8/2019 Prof. Baldacchino - Ponencia
53/65
Chronic disease/care model and coChronic disease/care model and co --morbiditymorbidity
Relapse rates for drug addiction are similar
to other chronic medical conditionsMental illness and substance misuse arechronic relapsing conditionsCo-morbid substance misuse and mentalhealth problems are 2 co-existent chronic
care conditions
Chronic disease/care model and coChronic disease/care model and co
-
8/8/2019 Prof. Baldacchino - Ponencia
54/65
Chronic disease/care model and coChronic disease/care model and co --morbiditymorbidity
Looking at coLooking at co --morbidity as another aspect of morbidity as another aspect of
the overall chronic disease model willthe overall chronic disease model willdemystify thedemystify the complexitycomplexity of the conditionof the conditionThis will then be seen as a situation that isThis will then be seen as a situation that issimilar to diabetes, cardiovascular disorderssimilar to diabetes, cardiovascular disordersand other conditions that merits adequateand other conditions that merits adequate
resources and integrated approachesresources and integrated approaches
Chronic disease/care model and coChronic disease/care model and co
-
8/8/2019 Prof. Baldacchino - Ponencia
55/65
Chronic disease/care model and coChronic disease/care model and co --morbiditymorbidity
This will change the way we intervene,This will change the way we intervene,
treat and evaluate cotreat and evaluate co --morbid conditionsmorbid conditionsTreatment should be:Treatment should be:
(a)(a) OngoingOngoing(b)(b) PrioritisedPrioritised(c)(c) Encourage patient/client to participate inEncourage patient/client to participate in
their own recovery (self management)their own recovery (self management)
Chronic disease/care model and coChronic disease/care model and co -
-
8/8/2019 Prof. Baldacchino - Ponencia
56/65
Chronic disease/care model and coChronic disease/care model and co --morbiditymorbidity
(a)(a) Enable partnerships based on competenciesEnable partnerships based on competencies
(b)(b) Based on evidence based guidelinesBased on evidence based guidelines(c)(c) Integrated specialist expertise and primary careIntegrated specialist expertise and primary care(d)(d) Identify high risk groups with proactive careIdentify high risk groups with proactive care(e)(e) Facilitate individualised patient/client careFacilitate individualised patient/client care
planningplanning
(f)(f)
Approach evaluation as a chronic care coApproach evaluation as a chronic care co
--
morbidity systemmorbidity system
-
8/8/2019 Prof. Baldacchino - Ponencia
57/65
ConclusionConclusionCoCo --morbidity assessment and treatmentmorbidity assessment and treatment
interventions needs to look at:interventions needs to look at:
The individualThe individual s and populations/groups resiliences and populations/groups resilience
against coagainst co --morbidity in order to treat proactivelymorbidity in order to treat proactivelyUse the chronic disease processes to planUse the chronic disease processes to plandelivery of health and social care for delivery of health and social care for individuals/groups with coindividuals/groups with co --morbid conditionsmorbid conditions
-
8/8/2019 Prof. Baldacchino - Ponencia
58/65
RecommendationsRecommendations(A) Strategic Plan(A) Strategic Plan
A national strategyA national strategyAgreed definitions and overall model of careAgreed definitions and overall model of careJoined up provisionJoined up provision
Greater integration of mental health andGreater integration of mental health andsubstance misuse servicessubstance misuse servicesDevelopment of policies, protocols and proceduresDevelopment of policies, protocols and procedures
Commissioning:Commissioning:
-
8/8/2019 Prof. Baldacchino - Ponencia
59/65
RecommendationsRecommendations(B)(B) Operational Operational
Stigma and prejudiceStigma and prejudiceHealth promotionHealth promotionMeans and mechanismsMeans and mechanismsAccessibilityAccessibilityEducation, training, employmentEducation, training, employment
Ethnic minoritiesEthnic minoritiesCarer supportCarer support
-
8/8/2019 Prof. Baldacchino - Ponencia
60/65
RecommendationsRecommendations(C)(C) Training and educationTraining and education
Defining the objectiveDefining the objectiveTraining needs analysisTraining needs analysisEducation:Education:Training resourcesTraining resourcesFaceFace --toto --facefaceSpecial groupsSpecial groupsChildhood traumaChildhood traumaOther relevant organisationsOther relevant organisations
-
8/8/2019 Prof. Baldacchino - Ponencia
61/65
RecommendationsRecommendations(D)(D) Clinical Clinical
InclusivityInclusivity rather than exclusivityrather than exclusivityEthos and philosophyEthos and philosophyNeedsNeeds --led rather than serviceled rather than service --ledled
Assessment frameworkAssessment frameworkDevelopment of a user Development of a user --friendly screening and assessmentfriendly screening and assessmenttooltoolWorking with childhood traumaWorking with childhood traumaCare planningCare planningProvision of the range of psychological andProvision of the range of psychological andpharmacological interventions:pharmacological interventions:
-
8/8/2019 Prof. Baldacchino - Ponencia
62/65
RecommendationsRecommendations(E)(E) ResearchResearch
Understanding and enhancing theUnderstanding and enhancing theeffectiveness of treatment interventionseffectiveness of treatment interventionsService development modelsService development modelsSpecific (generally hard to reach)Specific (generally hard to reach)populationspopulations
Research on different patterns of coResearch on different patterns of co --morbiditiesmorbidities
-
8/8/2019 Prof. Baldacchino - Ponencia
63/65
A note of cautionA note of caution
-
8/8/2019 Prof. Baldacchino - Ponencia
64/65
Another noteAnother note of cautionof caution ..
Thank you:Thank you:
-
8/8/2019 Prof. Baldacchino - Ponencia
65/65
yy
[email protected]@dundee.ac.uk