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Transcript
Comorbidity
Comorbidity
Detection of Comorbidity
• What are the barriers to GPs asking
about AOD-related issues?
• What are the barriers to GPs asking
about mental health issues?
• What prevents patients from raising
these issues with their GP?
• How can these problems be overcome?
Comorbidity
Comorbidity
“...is a theoretical concept that refers to having
more than one disorder at various times. It
indicates vulnerability to illness and points to
disability and higher need to use health
services.”
“The coexistence of [both] conditions…is a
particular challenge for clinicians as the
two...combine to produce substantially poorer
health and greater impairment of function than
would normally be attributed to either on its
own…”
Andrews et al. (1999, p. 19); McCabe & Holmwood (2003, p. 5)
Comorbidity
“Regardless of whether the substance
use and mental health issues are
primary, secondary or independent of
each other, they become intrinsically
connected over time and result in a
worsening clinical picture.”
McCabe & Holmwood (2003, p. 27)
Comorbidity
Of the 25% of adults who
experience a mental health
problem in any one year, the
majority will have a concurrent
AOD-related problem.
Comorbidity
Comorbid Affective, Anxiety and Substance
Use Disorders (Australian Males, 1999)
Substance Use
1.4
8.3
Anxiety
3.6
0.8
0.6
1.3
Affective
1.4
Teesson and Burns (2001, p. 8)
Comorbidity
Comorbid Affective, Anxiety and Substance
Use Disorders (Australian Females, 1999)
Anxiety
3.1
7.3
Affective
3.2
0.8
0.9
0.3
Substance
Use
2.4
Teesson and Burns (2001, p. 8)
Comorbidity
“The problem with GPs is that they are
in an ideal position to do everything!”
As GPs see 85% of the population each year, GPs are
well placed to offer:
– early detection and accurate diagnosis of
comorbidity
– information and treatment options
– brief interventions (for those with low disability)
– referral and coordinated care
– medical treatment for health issues
– family support
– long-term monitoring and follow-up.
Comorbidity
A Vital Role for the GP
• GPs can readily detect coexisting problems
early
• There is evidence that GPs can successfully
contribute to the management of these
cases with good outcomes
• Resourcing is an issue for most public health
services, so opportunistic GP intervention is
often crucial
• Many GPs feel there are barriers to
managing comorbidity including lack of
training and time, inadequate back-up.
Comorbidity
Detection
GPs routinely need to ask about both mental
health and AOD issues since:
• only 50% of depressed individuals tend to
raise the issue of depression with their GPs,
and
• only 10% of those with AOD-related
problems raise the issue with their GP.
If one problem is revealed,
always ask about the other
Comorbidity
Comorbidity
• GPs see many comorbid cases, and are often the first
or only point of contact with health services
• Around a quarter of those with a mental health
problem in a 12 month period will have a coexisting
AOD-related problem
• Nearly half the women and a third of men with mental
health problems will have an alcohol use disorder
• Between a quarter and a third of those who have ever
had a psychotic episode will have had an alcohol
and/or cannabis problem / dependence.
Comorbidity
Why Such a High Rate?
• High-risk use of AODs can precipitate or exacerbate
mental health problems:
– psychosis in the mentally vulnerable
(esp. from cannabis and stimulants)
– depression (esp. from alcohol)
– anxiety / social and phobia / panic attacks
(esp. alcohol & benzodiazepines)
• Shared underlying causes / antecedents
– genetics
– environmental influences
• ‘Self-medication’ hypothesis (controversial).
Problematic AOD use and mental health problems
share many antecedents.
Comorbidity
Some Comorbid Associations
• Increased rates of violence (perpetrator and
victims)
• Homelessness
• Poor treatment compliance
• Reduced or potentiated effect of medication
• Slower recovery from AOD-related problems
• Higher suicide rates.
Comorbidity
Courtesy of Dr. John Sherman, St. Kilda Medical Centre
Comorbidity
Comorbidity
Courtesy of Dr. John Sherman, St. Kilda Medical Centre
Comorbidity
Comorbidity
Suicide and AOD Use
• Psychoactive drugs are present at autopsy in
30–50% of suicides
• Intoxication predisposes to suicide in those at
risk by:
– disinhibiting usual constraints on the person
– providing ‘courage’
– clouding judgement and the ability to see
alternatives
– deepening mood or worsening psychosis
– misadventure.
Comorbidity
Screening & Assessment (1)
• Screen for high-risk AOD use in those
presenting with mental health problems and
vice versa
• Which came first?
– do the mental health symptoms persist
after withdrawal & during periods of
prolonged abstinence?
– is there a family history of mental health
problems and/or AOD dependence?
– did the symptoms of the mental health
problems predate problematic AOD use?
Comorbidity
Screening & Assessment (2)
• How are the mental health problems and AOD
use impacting on each other?
• How are the problems impacting on the
patient’s broad psychosocial functioning?
(Inquire as for any mental health and AOD
assessment)
• Multiple reviews may be required if the clinical
presentation fluctuates
• Where managed withdrawal is indicated,
facilitate ongoing review, and engage the
patient in the care plan.
Comorbidity
To Improve Assessment Accuracy
• Assess when psychologically stable (not withdrawing)
• Use self-report plus other information (family, bloods,
urine tests etc.)
• Assure confidentiality
• Evaluate reasons for possible inaccuracies and
address these
• Use simple, direct, open-ended questions and clear
time frames
• Routinely asking about drug use normalises use
therefore increases likelihood of genuine response
• Repeat over time if possible.
Comorbidity
A Suitable Approach Requires
• An accurate assessment of both problems
• A focus on patient difficulties rather than a diagnosis
• Good patient–GP rapport (esp. knowledge of patient)
to identify recreational drug effects on clinical
presentations, and assist self-report accuracy
• GPs to recognise the many valid reasons that people
have for using psychoactive drugs
• Awareness of potential interactions between drug use
and mental health problems to ensure treatment is
appropriate and effective.
Comorbidity
Management of Comorbidity
• Based on patient’s ‘readiness to change’
• Aim to increase awareness of the impact of each
problem
• Involve family / carers
• Withdrawal management may assist long-term
engagement in care
• Include:
– information provision
– structured problem-solving
– motivational interviewing
– brief behavioural or cognitive approaches.
Comorbidity
A Behavioural Approach to
Intervention
Behavioural Symptom Checklist
• Loss of motivation
• Apathy and indifference
• Decreased productivity
• Difficulty problem-solving
• Social withdrawal
• Difficulty setting goals
• Impaired ability to make decisions.
Comorbidity
Pharmacological Approaches
• Avoid using drugs of dependence (e.g., methadone,
buprenorphine) unless they are part of your
treatment plan
• Only short-term use of (longer acting) BZDs
• To identify cause of symptoms, consider role of:
– prescribed medications
– other drug use
– drug interactions
• ‘Drug-seeking’ behaviour may necessitate a limited
prescribing plan.
Comorbidity
Time Frames for Symptom
Abatement with Abstinence
• Depression and anxiety due to alcohol
dependence: 4–6 weeks (maybe longer)
• Psychosis due to amphetamines and/or
cannabis: 7–10 days
• Prolonged symptoms beyond these
periods suggest an underlying mental
health problem.
Comorbidity
Engaging the Patient
• A non-confrontational approach is essential
to retain the patient in treatment –
a demanding approach can be stressful
and exacerbate mental health problems
• Discuss problem definition and negotiate
management options with the patient
• May require assertive care and involuntary
management to protect the patient or others
• Try to engage in the long term.
Comorbidity
Shared Care
• Integrated ‘shared care’ is essential:
– patients tend to move between services (different
services may fulfil different patient needs)
– a range of skills and approaches is required to meet
the multiple needs of these patients
– involve supportive family / friends and carers
whenever possible
• Referral is essential if:
– at risk of harm to self or others
– florid symptoms require psychiatric intervention
– withdrawal is likely to be complicated
– lifestyle remains chaotic
– patient has poor psychosocial support.
Comorbidity
Structured Management (1)
• Attend to both disorders concurrently
(‘integrated treatment’) – do not prioritise
one at the expense of the other
• Attempt to enhance motivation with a
simplified form of motivational interviewing:
– reasons for use, relationship between
use and mental health problems,
concerns about use
– difficult if lifestyle is unlikely to improve
after ceasing high-risk AOD use.
Comorbidity
Structured Management (2)
• Set small, highly achievable goals
• Take a structured problem-solving and
skills-enhancement approach
• Harm reduction is a priority – this population is
at high risk of:
– contracting blood-borne viruses
– poor nutrition
– accidents.
Recognise that few patients
will desire abstinence.
Comorbidity
Prescribing
• Prescribe medication cautiously
(assume some AOD use will persist,
with a risk of adverse interactions)
• Medication is generally less effective
in treating mental health problems if
high-risk AOD use persists
• Anticraving medication can be
considered.
Comorbidity
Longer-term Management
• Psychological interventions are often not as
effective, or may be totally ineffective esp. in
the short term, when high-risk AOD use
persists
• Accept multiple lapses in AOD use in this
group as the norm:
– relapse hotlines and support are essential
• Long-term support often required:
– actively encourage suitable
accommodation, nutrition, social supports.
Comorbidity
Referral
Consider referral when:
– self-harm or risk to others is present
– acute exacerbation of mental disorder occurs
– drug dependence with major associated
problems (legal, health, social) is present
– complicated withdrawal is anticipated.
Develop links between mental health and
local AOD services (where they exist) Comorbidity