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Co-occurring Disorders: 
The Rule, Not The Exception : Constant Mouton

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A focused introduction to the importance of underpinning that a comprehensive understanding of a person’s behavioural, mental and emotional health issues, requires an understanding of the person, their environment and needs.

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Co-occurring Disorders: 
The Rule, Not The Exception : Constant Mouton

  1. 1. Dr C Mouton MBChB, FCPsychSA, KNMG Psychiatrist Medical Director Triora c.mouton@triora.com Co-occurring Disorders: The Rule, Not The Exception iCAAD Amsterdam November 2018
  2. 2. Disclosure (Potential) conflict of interest None Relevant relations with industry None Sponsoring or research money Honorarium or financial payments Shareholder Other None None None None
  3. 3. Definition of addiction (1)  Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors. https://www.asam.org/resources/definition-of-addiction
  4. 4. Definition of addiction (2)  Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death. https://www.asam.org/resources/definition-of-addiction
  5. 5. Dual Disorders / Dual Diagnosis  Dual disorders - Mental illness and substance abuse occurring together in the same person  Comorbidity - Two (or more) co-occurring disorders / dysfunctions  Co-occurrence - Two “things” happening at the same time © 2018 Constant Mouton
  6. 6. Co-occurring Disorders (COD)  Makes room for more disorders  Includes medical and other disorders, associated with the addiction  Doesn’t focus on morbidity  More accurate overall than other terms © 2018 Constant Mouton
  7. 7. Numbers and concepts
  8. 8. How frequently does it occur?  Lifetime prevalence of mood disorders 20,1%  Lifetime prevalence of anxiety disorders 19,6%  Lifetime prevalence of ADHD 9,2%  Lifetime prevalence of any mental illness 42,7%  Lifetime prev.: substance related disorders 19,1%  Lifetime prev: SUD in severe mental illness 40% - 60%  Pts in addiction units with mental illness 60% - 80% De Graaf et al, NEMESIS-2
  9. 9. How frequently does it occur?  Schizophrenia also with SUD 47%  Bipolar also with SUD 52% - 56%  Depression also with SUD 19% - 27%  ADHD also with SUD 20% - 25%  Anxiety disorders also with SUD 24% - 35%  Post Traumatic Stress Disorder also with SUD 22% - 43%  Personality Disorders also with SUD 44% (Alcohol) NIDA
  10. 10. How frequently does it occur?  Lifetime prevalence: any other psychiatric disorder 97%  + alcohol use disorder 75%  + drug use 40%  Personality disorders > 60%  Mood disorders ~ 50%  Anxiety disorders > 40%  Pathological Gambling Disorder Kesser RC, (2008) Petry (2005)
  11. 11.  Experimental  To feel good Why do people start using?  To feel better  To do better
  12. 12.  Primary mental illness leading to addiction  Self medicating psychiatric symptoms (e.g. Anxiety)  Self medicating side effects  Schizophrenia: nicotine use  decreased S/E of Rx and (-) symptoms  Mental illness itself can trigger or worsen addiction  Mania: increased impulsivity  increase risk of use/relapse  Panic: alcohol relieves symptoms  impulsivity other addiction  Prescribing addictive medicine What is the interaction in Co-occurring Disorders? © 2018 Constant Mouton
  13. 13.  Primary addiction leads to a psychiatric sequelae  Intoxication can cause symptoms of mental illness (Delirium)  Substance use can unmask underlying mental illness (Psychosis)  No clear evidence if substance use cause mental illness as such  Cannabis – inducing first psychosis  Substance use can worsen existing mental illness What is the interaction in Co-occurring Disorders? © 2018 Constant Mouton
  14. 14.  Unrelated primary diagnosis (Two or more separate diagnoses, unrelated, might interact)  Common aetiology  Bio-psycho-social factors lead to both conditions e.g.  Family dysfunction leading to addiction  Conduct disorder leading to addiction  Shared genetic risk e.g. ADHD and addiction have shared genomes involved What is the interaction in Co-occurring Disorders? © 2018 Constant Mouton
  15. 15. Untreated Co-occurring Disorders  Addiction predicts worse outcome for mental illness  Mental illness predicts worse outcome for addiction  Negative effect on treatment  Non-response or poor response to regular treatment  More frequently non-compliant  Increased hospital admission rates  Increased suicidality rate  Increase overall health cost © 2018 Constant Mouton
  16. 16. Untreated Co-occurring Disorders  Higher rate of homelessness  Higher unemployment rate  More family problems  Legal problems / arrest more likely / frequent  Negative effect on psychosocial functioning  Medical problems  Higher HIV, Hepatitis and STD rate  Higher mortality rate © 2018 Constant Mouton
  17. 17. Untreated Co-occurring Disorders  More stigma within health sector  Less qualified staff to treat both disorders  More problems getting care / treatment  Lower availability of dual disorder facilities  Poor accessibility to health services © 2018 Constant Mouton
  18. 18. Assessment
  19. 19. Assessment – the bare minimum  Biographical assessment incl. family history (Lifespan + genogram)  Complete addiction history  Complete medical and psychiatric history (symptom clusters)  Trauma history (physical / emotional / ACE)  Functioning (QOL, different life domains)  First the big picture, then treatment strategy  Screening tools are not diagnostic  Assess safety © 2018 Constant Mouton
  20. 20. Genogram © 2018 Constant Mouton
  21. 21. Bio-psycho-social model Biological Psychological Social •Genetic predisposition •Physical development •Intelligence •Temperament •Medical comorbidity •Personality structure •Self-esteem •Insight •Defense mechanisms •Patterns of cognition •Responses to stressors •Trauma history •ACE (Adverse Childhood Events) •Coping strategies •Peer relationships •Family constellation •Transitions within the family (ARISE) •Work environment •Ethnic influences •Socioeconomic issues •Culture •Religion © 2018 Constant Mouton
  22. 22. Predisposing factors: “What made me VULNERABLE in the first place?” Protective factors: “Which positive things do I have going for me?” RESILIENCE Precipitating factors: “What TRIGGERED the most recent episode?” Perpetuating factors: Things that keep the problems going on / keeps me from recovery (RELAPSE) Problems/diagnoses: GOALS The Big Picture (Dynamic approach) © 2018 Constant Mouton
  23. 23. Diagnosis – some aspects  Does it matter?  Only diagnose if you are trained to do so  Be careful with sharing provisional / differential diagnoses  Stay clear of lay diagnoses  Questionnaires are never diagnostic  Capture the Big Picture  Psychodynamic diagnosis  DSM-5 / ICD
  24. 24. Treatment
  25. 25. GOAL of treatment is RECOVERY
  26. 26. Recovery from the patients perspective  Feeling supported by family and peers and being able to participate in the community - BEING CONNECTED  Holistic and individualized treatment approach, seeing the person “behind the symptoms” – INDIVIDUALIZED TREATMENT/ SHARED DECISION MAKING De Ruysscher C, et al.. The Concept of Recovery as Experienced by Persons with Dual Diagnosis: A Systematic Review of Qualitative Research From a First-Person Perspective. J Dual Diagn. 2017 Jul 12:1-16.
  27. 27. Recovery from the patients perspective  Having personal beliefs, such as fostering feelings of hope, building a new sense of identity, gaining ownership over one's life, and finding support in spirituality – SPIRITUALITY  Importance of meaningful activities that structure one's life and give one motivation to carry on - MEANINGFULLNESS De Ruysscher C, et al.. The Concept of Recovery as Experienced by Persons with Dual Diagnosis: A Systematic Review of Qualitative Research From a First-Person Perspective. J Dual Diagn. 2017 Jul 12:1-16.
  28. 28. Quadrants of Minkhoff Implication for specific treatment © 2018 Constant Mouton
  29. 29. Sequential treatment © 2018 Constant Mouton
  30. 30. Sequential treatment © 2018 Constant Mouton
  31. 31. Integrated Dual Disorder Treatment © 2018 Constant Mouton
  32. 32.  Same team  Same location  Same time  More effective than parallel treatment  At least ten studies show integrated treatment is more effective than traditional sequential treatment Drake et al, Schiz Bulletin 1998; Drake et al, Psych Services 2001 for summaries Integrated Dual Disorder Treatment
  33. 33.  Multidisciplinary Team  Stage-Wise Interventions (stages of change, stages of treatment)  Access to Comprehensive Services (e.g., residential, etc.)  Time-Unlimited Services Assertive Outreach  Motivational Interventions (And invitational interventions, ARISE?)  Substance Abuse Counseling Drake et al, Schiz Bulletin 1998; Drake et al, Psych Services 2001 for summaries Integrated Dual Disorder Treatment
  34. 34.  Group Treatment  Family Participation  Participation in Alcohol & Drug Self-Help Groups  Pharmacological Treatment  Interventions to Promote Health  Secondary Interventions for Treatment of Non- Responders Drake et al, Schiz Bulletin 1998; Drake et al, Psych Services 2001 for summaries Integrated Dual Disorder Treatment
  35. 35. Collaborative Care
  36. 36. UBUNTU - “I am because we are”
  37. 37. Mental Health Law Addiction Psychiatrist Person Of Medical Social Recovery Psychologist Nurse Enforcement Counsellor Concern Doctor Work Specialists
  38. 38. Transitional Field Map Landau-°©‐Stanton, J. and Clements, C. (1993) AIDS, health and mental health: a primary sourcebook. New York: Brunner/Mazel.
  39. 39. Strength in Numbers PoC  Individual  Biological  Psychological © 2018 Constant Mouton
  40. 40. Strength in Numbers PoC Psychiatrist Psychologist Counsellor Social Work MH Nurse Art TherapistPhysical Therapy  Individual  Biological  Psychological  Ancillary/Professional (traditional) © 2018 Constant Mouton
  41. 41. Strength in Numbers PoC Psychiatrist PsychologistCounsellor Social Work MH Nurse Sponsor Self-help Coach GP Interventionist Recovery Coach Art TherapistPhysical Therapy Pharmacist Dentist  Individual  Biological  Psychological  Ancillary/Professional (extensive) © 2018 Constant Mouton
  42. 42. Strength in Numbers PoC Psychiatrist PsychologistCounsellor Social Work MH Nurse Sponsor Self-help Coach GP Interventionist Recovery Coach Art TherapistPhysical Therapy Pharmacist Dentist Partner Brother Son Sister in Law Uncle Niece  Individual  Biological  Psychological  Family/Intimate  Ancillary/Professional © 2018 Constant Mouton
  43. 43. Strength in Numbers PoC Psychiatrist PsychologistCounsellor Social Work MH Nurse Sponsor Self-help Coach GP Interventionist Recovery Coach Art TherapistPhysical Therapy Pharmacist Dentist Partner Brother Son Sister in Law Uncle Niece Colleague Friend Neighbour TeacherBaker Friend  Individual  Biological  Psychological  Family/Intimate  Extended natural  Ancillary/Professional © 2018 Constant Mouton
  44. 44. Strength in Numbers PoC Psychiatrist PsychologistCounsellor Social Work MH Nurse Sponsor Self-help Coach GP Interventionist Recovery Coach Art TherapistPhysical Therapy Pharmacist Dentist Partner Brother Son Sister in Law Uncle Niece Colleague Friend Neighbour TeacherBaker Friend Religious Leader Community Leader Spiritual Guide Cultural Leader Community projects Self Help groups Community Group  Individual  Biological  Psychological  Family/Intimate  Extended natural  Ancillary/Professional  Cultural / Community  Spiritual © 2018 Constant Mouton
  45. 45. Key factors for Collaborative Care  Coordination and Case Management  Refer as necessary  Stay in your own lane… ;-)  Respect privacy (share only what is necessary)  Involve the PoC in all steps (Shared Decision Making)  All efforts should be towards recovery (shared therapeutic goal) © 2018 Constant Mouton
  46. 46. Key factors for Collaborative Care  It’s both/and not either/or (inclusive, not exclusive)  Trust within team  Communication and Respect  5 professionals = 1 relative (don’t forget the family!)  Ethics apply to everyone!  Privacy and Autonomy of the PoC should be guaranteed © 2018 Constant Mouton
  47. 47. Dr C Mouton MBChB, FCPsychSA, KNMG Psychiatrist Medical Director Triora c.mouton@triora.com Thank You

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