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Treatment of Addiction and Co-occurent Mental Problems: The Power of Interdisciplinary Knowledge Maja Rus Makovec University Psychiatric Hospital Ljubljana Chair of Psychiatry, Medical Faculty Ljubljana M Rus-Makovec 11 EFTC 2007 How people change their behavior? Can we agree: – People have their own way how they can learn (develop, change …): pressure, support, alone, in group, …; capacity for self-treatment – Their capacity for change differs in time (“it was not the right time”) – People are specific mixture of sources of power and vulnerabilities, yet there are some universal features for change – Addicted people differ: special heterogeneity of legal drugs addiction – Equifinality of legal drug (alcohol) addiction: there can be different pathways to similar condition M Rus-Makovec 11 EFTC 2007 Bio-psycho-social model of addiction • State-of-art: do not stop at the level of brain neurotransmitter biochemistry but to place a person’s mental dysfunction manifesting itself in their human suffering and certain behavior into the person’s psychosocial context (Eisenberg, 1999). • Addicted person: does not want to change or can not because of biological or other obstacles? Who or what is responsible for change? • In western culture learning “per partes” is favoured (Bateson): different levels of experience are rarely coconstructed – “to fell in love” with one’s own experience M Rus-Makovec 11 EFTC 2007 “What everybody in addiction professional community should know about co-occurrent mental problems” • Following co-occurent metal problems with mainly or partly neurobiological basis can severly damage addicted persons’ ability for psycho-social change (and are not only a construct): – neuro-cognitive impairment of working memory • restrict abilities to receive, encode and integrate the newly introduced information – dual diagnosis of serious mental disorder (as depression, anxiety, psychosis …) – trauma experience – personal development resulting in serious personal or relational disorder (developmental trauma) M Rus-Makovec 11 EFTC 2007 What to do with information about co-occurent problems? • To help patients with co-occurent mental problems efficiently - need for – More patience – More time – More interdisciplinary cooperation – To have realistic goals of treatment M Rus-Makovec 11 EFTC 2007 Different levels of interactions between drug and other mental disorder (co-occurent, dual diagnosis, comorbide state …) • Drug or end of drug use can induce depression • Popular theory about drug use as secondary to an “underlying depressive disorder” • Two mental problems independently at the same time • Each mental problem worsen the other • Addiction can be extremely dramatic per se and without co-occurrent disorders • Addiction can be less dramatic in appearance but more reluctant to change because of co-occurrent disorders M Rus-Makovec 11 EFTC 2007 Major consequences of comorbidity • At least one-half of the patients in psychiatric and substance use treatment with comorbid disorder (Regier et al. 1990, Kessler et al. 1994) • Higher service utilization … • More severe symptoms … • Greater functional disability (Bijl, Ravelli, 2000) M Rus-Makovec 11 EFTC 2007 One of many perspectives on addiction: • “Altered and and damaged neurochemistry underlies (their) tragic vulnerability …– the addicts have to struggle with powerful midbraincircuits (Dackis, Gold, 1998) • Such perspective counters the notion about “lack of will power”: surprising, empowering, respect- and hopeintroducing fact is, that so many addicted people challenge their biology efficiently because of right motivation and support • Some addicted people have such an enormous obstacle of co-occurent mental problems, that they need special help and special context of treatment to reach their human capacity for change M Rus-Makovec 11 EFTC 2007 Center for Alcohol Addiction Treatment of University Psychiatric Hospital Ljubljana • Started in 1970 with phylosophy of therapeutic community, now-a-day “addiction psychiatry – psychotherapy” orientation with some aspects of TC • 33 slots in inpatient and 30 slots in outpatient treatment for patients with alcohol and benzodiazepine addiction, in last year some patients with previous experience of TC • After-care: cca 300 visits per month • Abstinence-based programme: predominantly psychosocial interventions combining with pharmacologic agents for dual diagnosis M Rus-Makovec 11 EFTC 2007 • Indications for admission are severe psychosocial or psychiatric conseqences of addiction or difficulties / inability to attain abstinency despite previous attempts. • Population of patients is not preselected. • Treatment offers (mainly) group psychotherapy and individual interventions. Heterogenous groups • The program is encouraging admission of patients with co-occurrent mental (psychiatric) disorders • Patients with severe impairment in neuropsychological functioning ordinary can not follow the program, as well as acutely suicidal or psychotic patients without longterm stable remission M Rus-Makovec 11 EFTC 2007 • Intensive treatment is conceptualised as: – 1st part: in-patient setting – 2nd part: out-patient setting (day-hospital). • Active participation of important others is stressed as the essential part of the programme. • After-care recovery is strongly recommended • If comorbide disorders or/and severe interpersonal problems are identified during the intensive treatment period, psychotherapy (individual, couple, family therapy) or psychiatric care is offered to the patients after discharge M Rus-Makovec 11 EFTC 2007 • Team need to negotiate how to combine the focus – on behavioural changes (“rehabilitation”, normative part of approach) and – non-directive encouragement for increasing autonomy of patients, attainment of insight and cultivation of the patient / therapist relationship • “Matching comorbid psychiatric severity in substance-related disorders to treatment program characteristics may be more advantageous because of the emphasis on individualized and specific levels of intensity of treatment “(McLellan, 1993) M Rus-Makovec 11 EFTC 2007 Research on effectiveness of addiction treatment programme • Patients (n = 622) were included in the study consecutively after the admission • Group 1 (n = 347 at the beginning) was supposed to be followed – at the beginning – at the end of intensive treatment programme – 3, 6, 12 and 24 months after discharge from the intensive treatment programme • Group 2 (n = 275 at the beginning) was supposed to be followed – at the beginning – at the end of intensive treatment programme – 24 months after discharge from the intensive treatment program M Rus-Makovec 11 EFTC 2007 • Independent variables – – – – – – Demographic variables Co morbidity Treatment context (in- & out-patient) After-care treatment Social support in treatment Time stage in treatment process • Treatment success critheria / dependent variables – Abstinence (sobriety) – Self-evaluation of mental health, physical health, financial status, relations with important others, quality of life – Changes in marital status / partnership – Changes in employment status M Rus-Makovec 11 EFTC 2007 • Abstinence / sobriety rate after intensive treatment discharge – 3 months (n = 213): 85 % abstinent – 6 months (n = 177): 84 % abstinent – 12 months (n = 116): abstinent 86 % – 24 months (n = 213): abstinent 80 % • Included in some form of after-care – 3 months: 60 % – 6 months: 61 % – 12 months: 59 % – 24 months: 58 % M Rus-Makovec 11 EFTC 2007 The most frequent co-occurent diagnoses • After at least 1 months of sobriety the co-occurrence syndromes are diagnosed, avoiding those anxiousdepressive symptoms as after-end-of-drinking-cessation should be diagnosed as comorbide/co-ocurrent category • Depression 19.8 % • Anxiety disorders 11 % • Personal disorders 20.9 % • Benzodiazepine dependency 19 % • Nicotine dependency 62.2 % M Rus-Makovec 11 EFTC 2007 Comorbide diagnoses and abstinence – no significant risk found (2, p) • • The finding is explained by their inclusion in proper modality of after-care treatment, combining psychotherapy and pharmacotherapy. The only vulneralibility regarding length of abstinence was found in smokers at 6 months (x = 5.9 (1), p = 0.015): smokers showed greater percent of probability to relapse than non-smokers at that time of evaluation. 3m 6m 12 m 24 m Depression 0.35 0.792 0.08 0.767 0.89 0.345 0.50 0.480 Anxiety 0.13 0.714 0.17 0.673 3.0 0.081 1.9 0.163 Personal disorder 0.84 0.357 0.004 0.951 1.9 0.162 1.1 0.302 M Rus-Makovec 11 EFTC 2007 Accurracy of diagnosis of main comorbide disorders in % - too strict and especially underdiagnosed anxiety states • The quality of diagnosing was controlled by Mini International Neuropsychiatric Interview instrument (MINI) rutine MINI Depression Disthymia 19.8 21.4 11.4 Anxiety disorder Panic Generalised PTSD 11 6.4 16.4 3.6 M Rus-Makovec 11 EFTC 2007 At the beginning of intense treatment n = 517 - 0.29 0.000 At the end of intense treatment n = 427 - 0.25 0.000 3 months aftre discage n = 204 - 0.39 0.000 6 months after discharge n = 167 - 0.33 0.000 12 months after discharge n = 108 - 0.23 0.018 24 months after discharge - 0.38 0.000 n = 209 M Rus-Makovec 11 EFTC 2007 Correlations (r, p) between selfevaluations of psychological health and n of psychiatric diagnoses Problems found in diagnostic procedure • Dual diagnosis syndromes are hidden behind drug addiction symptoms • Vice versa, alcohol addiction (also in the early recovery) can mimic almost all psychiatric symptomes • In the beginning of treatment addicted patients can be more prone to defensive attitude and denial instead to good therapeutic alliance • Often neuro-cognitive impairment is under-estimated • Alcohol / drugs can force numbing or dissociative reactions after trauma causing cognitive and emotional distortions of experience – F.e. patient with trauma experience can also be prone to manipulation M Rus-Makovec 11 EFTC 2007 Integrated treatment • In last years it became apparent that some people can not process stable recovery without concurrently addressing co-occurrent states and psychological trauma dynamics – before we waited first to stable abstinence before addressing trauma issue, which sometimes never come – secondly, it was learned that concurrent treatment did not result in more relapses (Carruth, Burke 2006). M Rus-Makovec 11 EFTC 2007 • Psychiatric context can offer concurrent treatment for alcohol / drugs addiction and severe co-occurrent mental symptoms including complex symptoms of psychological trauma because of their broad base of clinicians, experienced in addiction, psychiatric and psychotherapeutic fields • Need for new paradigm in addiction as well in psychiatric context? M Rus-Makovec 11 EFTC 2007 Structure of professional and non-professional cooperation in alcohol addiction problem in SI Psychiatry • Detoxification • Dual diagnoses Social Service GP Somatic hospitals •“ordinary” • family medicine Clients/patients directly Addiction psychiatrist • mental out-patient clinics • psychiatric hospital in-patient treatment day hospital Non-institutional help • AA • Self-help groups •… out-patient treatment After-care (institutional) - »clubs« of treated A - group therapy - family therapy M Rus-Makovec 11 EFTC 2007 - individual psychotherapy Not to miss opportunity for efficient help … • … because of the way we construct our knowledge: we use knowledge that informs us about the territory of our work – we include and exclude what we are trying to think about and “know” • … disciplinarity as a form of knowledge and the dynamics of oppositionality and competition … (Flaskas 2003) Meta – knowledge: if we construct our knowledge in systemic way, then we can get pieces of puzzles about phenomena of addiction together M Rus-Makovec 11 EFTC 2007