workshop what do mental health workers need to know? june 2006 gary croton eastern hume dual...
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WorkshopWhat do mental health workers need to know?
June 2006
Gary Croton
Eastern Hume Dual Diagnosis Service
Dual Diagnosis introduction for
mental health workers
Prevalence
Harms
Demand
Policy
This presentation….
Potential
Terminology
Definitions
DDxcohorts
Makingsenseof it
Relai’/ps b/t the
disordersWhat is DDx?
Why does it matter?
What is DDx?
Terminology
‘DualDiagnosis’
‘Comorbidity’
‘Co-occurringDisorders’
definition:co-occurrence of any Mental Health Disorder
with any Substance Use Disorder
Otherterms:
‘Concurrent disorders’….. ‘MICA’….. ‘MISA’…. ‘CAMI’…. ‘SAMI’…. ‘MISUD’…..
c.f.‘dual disability’:
people with both intellectual disability
and mental illness
Definitions
DDxcohorts
Great variety in…
Combinations of disorders
Severity of disorders
Treatment needs
Common dual diagnosis presentations
1. To Primary Care / General Practice
Depression with alcohol abuse or dependence
Early psychosis with cannabis abuse or dependence
Anxiety with alcohol abuse or dependence
DDxcohorts
Common dual diagnosis presentations
2. To an AT&OD treatment agency
Alcohol dependence with anxiety &/or depression symptoms or disorder
Amphetamine abuse with paranoid symptoms
Opiate abuse or dependence with personality disorder
DDxcohorts
Common dual diagnosis presentations
3. To an Mental Health treatment agency
Schizophrenia with alcohol, cannabis or polydrug abuse or dependence
Personality disorder with episodic polydrug abuse
Mood disorder with stimulant or depressant abuse or dependence
DDxcohorts
DDxcohorts
- Organic mental disorders
-Disorders with childhood/ adol’nce onset
- Disorders of Psyc’al develop’nt
Disorders of personality
- Neurotic disorders
- Mood disorders
- Schizophrenia & delusional disorders
- Multiple drug use
- Volatile solvents
- Tobacco
- Hallucinogens
- Other stimulants
- Cocaine
- Sedatives orhypnotics
- Cannabinoids
- Opioids
- Alcohol
- Acute intoxication
- Harmful use
- Dependence syndrome
- Withdrawal state
- Withdrawal state with delirium
MENTAL DISORDER
CLINICALSTATE
SUBSTANCE
ICD-10 combinations of disorders
How do I make sense of it?DDxcohorts
Tier 3
Tier 2
Tier 1
Tier 1 Lo MH & or Lo SUD with or without COD
Tier 2 Hi SUD with or without MH
Specialist mental healthClinical & PDRSS
Specialist AT&OD Possibly PMH teams
Primary Care General Practice Community Health
DDxcohorts
How do I make sense of it?
Tier 3 Hi MH with or without SUD
Victorian DHS Policy: Dual DiagnosisKey directions and priorities for service development
March 2006
4 models:
1. Common risk factors:
- Genetic risk factors- Trauma- Poor cognitive functioning
2. MH causes SUD
3. SUD causes MH
4. Bi-directional
- MHD ↑ vulnerability to SUD- Self medication- ↓ dysphoria- Super sensitivity
- Amphetamine psychosis- Cannabis psychosis?
- Ongoing interaction
Relationships b/t the
disorders
What maintains the comorbidity is the
most relevant to treatment
Relationships b/t the
disorders
More than 1 model may apply at different times
Why does DDx matter?
Prevalence
Co-occurring disorders are common in the general population
Keymessages
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
MentalHealth
General Practice
AT&OD treatment
Prevalence
General Population
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.
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!!
1997 NSMHW
Prevalence
General Practice
Hickie et al, 2001 study: (n=46,515)Comorbidity of common mental disorders & alcohol or other
substance misuse in Australian general practice
Prevalence of mental health &/or substance use amongst persons attending General Practice
Co-occurring mental disorders & substance misuse in patients attending General Practice
56%
12%
Prevalence
AT&OD treatment
Depression &/or Anxiety Disorder
Weaver et al, 2002 (UK)
Alcoholserviceusers: (n = 62)
DrugServiceusers:(n= 216)
Personality Disorder
Psychotic Disorder
2 or more psych. disorders55%
19%
53%
81%
Psychotic Disorder
Depression or Anxiety Disorder alone
Personality Disorder
Depression & Anxiety Disorder
8%
36%
37%
68%
No MH disorder
MH disorder
No MH disorder
MH disorder
85%
75%
15%
25%
MentalHealthPrevalence
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%.
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
Harms
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
Policy:March 2006
ForumApril 2006
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.
Dual Diagnosis: Key directions and priorities
for service development
VictorianMH &
DP&S Branches
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).
5 mandated service development outcomes:
Policy
3. Specialist mental health and d&a services develop partnerships for the provision of
integrated treatment and care.(No wrong door service system)
Dual Diagnosis: Key directions and priorities
for service development
VictorianMH &
DP&S Branches
5. Consumers and carers are involved in the planning and evaluation of service responses.
5 mandated service development outcomes:
4. Client outcomes and service responsiveness to dual diagnosis clients are monitored and regularly reviewed
Policy
Commonwealth /State COAG:
2006/07 budget:
$21.6 mill: campaign alerting community to
links b/t illicit drug use & mental health.
Federalinitiatives
$73.9 mill : training/ resources to assist AT&OD workers
to provide effective Rx
National Comorbidity Initiative
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 Clinehttp://www.kenminkoff.com/index.htmlhttp://www.zialogic.org/
• TIP 42: Substance Abuse Treatment for Persons With Co-Occurring Disorders http://store.health.org/catalog/ProductDetails.aspx?ProductID=16979