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Addicted, Crazy or Both? Now What? Dual Diagnosis in the CD Patient Mark Menestrina, MD, FASAM Brighton Hospital / SEMCA [email protected] Michigan Judges’ MI 8/2011 Part 1 (the “teaser”) Addiction Review Classification of Mental Disorders Review of Common Disorders Association of Mental Health Disorders with SUDs Part 2 Review of Selected Classes of Psychiatric Medications Pharmacology for Recovery Safe Prescribing for Individuals with SUDs Addiction Review WE LIVE IN A MAGICAL THINKING MEDICATION SEEKING SOCIETY USA is 4.7% of the World Population But we consume almost 50% of the World’s Drugs and most of the World’s Pain Medication Media / TV / Radio flood us with messages… We are taught not to tolerate any discomfort without taking something to feel better ADDICTION IS A BRAIN CHEMISTRY DISEASE Involves the Meso-Limbic System (Primitive) Neurotransmitter Mediated (Not Conscious) Denial is a Hallmark Feature Emotional, Physical, Psychological Chronic, Progressive, potentially Fatal Affects Family, Community, Society and Schools ~10% are susceptible to Addiction…Treatable Disease Different than Abuse, anyone can Abuse Drugs or Alcohol.…Preventable Behavior IT’S NOT REALLY A DISEASE…IS IT? 1956 AMA designates Alcoholism as a disease, Drug Addiction as a disease followed “But you have a choice” Like depression 30 years ago, or oncology 40 years ago Compare to other Chronic Diseases When we do treat Addiction, we do so Acutely, and wonder why we have poor results Can you find the (alleged) future alcoholic? 12 LACK OF WILLPOWER? 13 IF ADDICTION / CHEMICAL DEPENDENCE IS TRULY A DISEASE….WHY DON’T WE TREAT IT AS SUCH? Leading Causes of Death Data for the U.S. 2007 Age 25-44 Age 15-24 Injury Cancer Heart Disease Suicide Homicide HIV Liver Disease Stroke Diabetes Injury Homicide Suicide Cancer Heart Disease Congenital Stroke Diabetes Google: Alcoholism + Humor ADDICTION vs. ABUSE ALCOHOLISM, DRUG ADDICTION, CHEMICAL DEPENDENCE A TREATABLE DISEASE DRUG ABUSE, ALCOHOL ABUSE A PREVENTABLE BEHAVIOR THE NEW GATEWAY FOR MANY YOUNG PEOPLE… ADDICTION TREATMENT MADE EASY…. “A” to “B” NEGATIVE Consequences: The job, liver, judge, wife, boss, friend get the individual’s attention! POSITIVE Reinforcement: The individual actually begins to like and enjoy “recovery” While this process is achievable, it is not likely to all make sense to the patient. It may involve 12 step, counseling, treatment of co-morbid conditions, Medication Assisted Treatments and other modalities. HOW TO SPOT A HUNTER WITH A DUI CONVICTION…. Co-Occurring Disorders Psychiatric Illness & Addiction Generalizations Both are common problems Having one increases the risk for having the other Having one complicates the treatment of the other when both are present “Dual Diagnosis” cases are over represented among homeless and incarcerated “Dual Diagnosis” have increased risk of HIV and other serious medical conditions Classification of Mental Disorders…DSM-IV-TR The official classification system of psychiatric conditions in use in the USA Criteria in DSM are used to facilitate communication among professionals, for research standards, and for 3rd party payor communication DSM- A mental disorder is a disorder with significant behavioral or psychological symptoms associated with present distress, disability or increased risk of suffering death, pain, disability or loss of freedom THE 5 AXES OF DSM I. II. CLINICAL DISORDERS PERSONALITY DISORDERS and MENTAL RETARDATION III. GENERAL MEDICAL CONDITIONS IV. PSYCHOSOCIAL AND ENVIORNMENTAL PROBLEMS V. GAF (Global Assessment of Functioning) ASAM DIMENSIONS I. ACUTE INTOXICATION OR WITHDRAWAL POTENTIAL II. BIOMEDICAL CONDITIONS III. EMOTIONAL, BEHAVIORAL OR COGNITIVE CONDITIONS IV. READINESS TO CHANGE V. RELAPSE POTENTIAL VI. RECOVERY/LIVING ENVIORNMENT DSM at Work…(or not!) Major Depressive Episode A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. Note: Do not include symptoms that are clearly due to a general medical condition, or moodincongruent delusions or hallucinations MD…continued (1) Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful) Note: In children and adolescents, can be irritable mood. (2) Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others) MD…continued (3) Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains. (4) Insomnia or hypersomnia nearly every day (5) Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down) MD…continued (6) Fatigue or loss of energy nearly every day (7) Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick) (8) Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others MD…continued (9) Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. B. C. The symptoms do not meet criteria for a Mixed Episode (see p. 171) The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. MD…continued D. E. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism) The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation. MD…diagnosis in the real world S I G E C A P S Depressed mood plus…. sleep disturbance loss of interest or pleasure (anhedonia) feelings of guilt or worthlessness low energy poor concentration or memory appetite disturbance psychomotor agitation or retardation suicidal ideation REMEMBER THAT DSM CRITERIA ARE HELPFUL GUIDELINES…..BUT WE ALL HAVE A LITTLE (OR A LOT) IN EACH OF US!!! REVIEW OF COMMON DISORDERS SCHIZOPHRENIA AFFECTIVE DISORDERS ANXIETY DISORDERS (including PTSD) PERSONALITY DISORDERS ATTENTION DEFICIT HYPERACTIVITY EATING DISORDERS SUBSTANCE RELATED DISORDERS SCHIZOPHRENIA Complex illness, characterized by hallucinations, delusions, behavioral disturbances, disrupted social functioning, disorganized speech and ‘negative symptoms’ 0.5-1% Prevalence Violent acts no more frequent than the general population Reduced life expectancy, 40% attempt suicide, 1020% succeed Treatment antipsychotic medications AFFECTIVE DISORDERS~ MOOD DISORDERS DEPRESSION: common, often missed, not hard to diagnose when you look for it, often severe, often recurrent, costly and highly treatable BIPOLAR DISORDERS ~ Depression with episodes of elevated mood BIPOLAR I= with at least one manic episode BIPOLAR II= with hypomanic episodes Affective Disorders DIAGNOSIS CRITERIA MDD Severe Sx, >5 Sx, > 2 Wks DYSTHYMIA BIPOLAR I Less severe, more persistent Mania and Depression BIPOLAR II Hypomania, Depression? CYCLOTHYMIA Less severe, more persistent Consequence of Use or w/d SUBSTANCEINDUCED ANXIETY DISORDERS GENERALIZED ANXIETY DISORDER SOCIAL PHOBIA SIMPLE PHOBIAS PANIC DISORDER AGORAPHOBIA PTSD PERSONALITY DISORDERS CLUSTER DESCRIPTION A Odd/Eccentric DISORDERS Paranoid/Schizoid/ Schizotypal B Dramatic/Erratic Antisocial/Borderline/ Histrionic/Narcissistic C Anxious/Fearful Avoidant/Dependent/ Obsessive-Compulsive ADHD Inattention, hyperactivity, impulsivity ADHD does associate with higher risk for SUDs, but this may be limited to those with coexisting conduct or bipolar disorder Treating ADHD with stimulants actually appears to be associated with a decreased risk of developing a subsequent SUD EATING DISORDERS ANOREXIA: often severely restrict caloric intake or excessively exercise, are underweight BULEMIA: often alternate eating with starvation or purging, are usually normal weight Both groups may abuse appetite suppressants, diuretics or laxatives BULEMICS appear to be at risk for SUDs One study found ANOREXICS to be at lower risk for SUDs SUBSTANCE INDUCED DISORDERS These disorders mimic other psychiatric disorders, but they are in fact caused, directly or indirectly, by use of substances This is a tremendous source of misdiagnosis, and results in ineffective treatment of the substance disorder We live in a society where it is more socially acceptable to be mentally ill than chemically dependent Diagnoses Associated with Class of Substances…..DSM-IV-TR Depend Abuse Intox W/D Alcohol + + + + Amphetamines + + + + Cannabis + + + Cocaine + + + + Opioids + + + + Sedatives + + + + Substance Induced Mental Disorders Organic Brain Syndromes SI Delirium SI Persisting Dementia SI Amnestic Disorder Mimic Axis I Disorders SI Psychotic Disorder SI Mood Disorder SI Anxiety Disorder Hallucinogen Persisting Perceptual Disorder SI Sexual Dysfunction SI Sleep Disorder ASSOCIATION OF MENTAL DISORDERS WITH SUDs SUDs include ADDICTION: a treatable disease ABUSE: a preventable behavior 2003 National Survey of Drug Use and Health (NSDUH) 21.3% of Adults with Serious Mental Illness (SMI) had a Substance Use Disorder (SUD) 7.9% of Adults without SMI had a SUD Nicotine and Mental Illness Grant, B.F. et al, 2004 12 MONTH ODDS RATIO PREVALENCE MOOD DISORDER 21% 3.3 ANXIETY DISORDER 22% 2.7 PERSONALITY DISORDER 32% 3.3 Serious Mental Illness and Its CoOccurrence with Substance Use Disorders, 2002 Epstein, Barker, Vorburger and Murtha, 2004 SAMHSA.GOV 17.5 million Adults with SMI (Serious Mental Illness) 8.3% of population 18-25yo 13.2% 26-49yo 9.5% >50yo 4.9% 28.9% used illicit drug/yr Illicit drug/yr 17.1% No drug/yr 6.9% Female Male 10.5% 6.0% >1 race 13.6% Nat Am 12.5% SMI did not vary by past year alcohol use ‘Heavy” alcohol/mo 11.1% vs. 8.1% Co-Occurrence of SMI & SUD 33.2 million SMI or SUD 13.4 million (40.4%) SMI 15.5 million (47.4%) SUD 4.0 million (12.2%) SMI + SUD SMI Both Disorders: 23.2% of 20.4% of SUD Rates of SMI……. Without any SUD 7.0% Alcohol Dependence or Abuse 19.0% Illicit Drug Dependence or Abuse 29.1% Alcohol and Drug Use Disorder 30.1% Lifetime SUD Among Persons with Mental Disorders….Regier et al, 1990 MENTAL DISORDER schizophrenia LIFETIME PREV 1.5% LIFETIME PREV SUD 47.0% ODDS RATIO antisocial p.d. 2.6% 83.6% 29.6 anxiety disorders 14.6% 23.7% 1.7 OCD 2.5% 32.8% 2.5 affective disorders 8.3% 32.0% 2.6 any disorder 16.2% 28.9% 2.7 4.6 Why the Association?? Common Risk Factors & Etiologies, genetic or environmental Addiction might lead to Mental Illness Psychiatric Illness might lead to Addiction…the “Self-Treating Hypothesis” Self-Limiting Acute Effects of a Substance (or withdrawal from it) may be mistaken for a psychiatric illness Affective Disorders…Association with SUD Regier et.al. 1990 SMI SUD ODDS RATIO Any Affective Alcohol 1.9 Any Affective Cocaine 5.9 Any Affective Opiates 5.0 Any Affective Barbiturates 6.6 Any Affective Hallucinogens 5.9 Bipolar Disorder Any SUD 6.6 Unipolar d/o Any SUD 1.9 Summary Points Co-Occurring Disorders are Common May be difficult to differentiate from Substance Induced Disorders Consider “Watchful Waiting” in less definite cases when degree of impairment is not as severe Treatment is often Challenging Both Disorders need to be addressed when both are truly present May be “Road Blocked” by Insurance/Funding Sources “NEVER DOUBT THAT A SMALL GROUP OF DEDICATED CITIZENS CAN CHANGE THE WORLD…INDEED IT IS THE ONLY THING THAT EVER HAS” Margaret Meade