ASSESSMENT, DIAGNOSIS AND TREATMENT

1
ASSESSMENT, DIAGNOSIS AND TREATMENT

• PLANNING FOR THE PATIENT WITH MULTIPLE DIAGNOSES

2
DUAL DIAGNOSIS

• THE CO-EXISTENCE OF A MAJOR MENTAL DISORDER AND A
  SUBSTANCE ABUSE DISORDER

3
TRIPLE DIAGNOSIS

• HIV ()
• MAJOR MENTAL DISORDER
• SUBSTANCE ABUSE

4
LIFETIME PREVALENCE RATES (ECA, 1990)

• NON-SUBSTANCE ABUSE MENTAL DISORDERS-22.5
• ALCOHOL ABUSE/DEPENDENCE-13.5
• OTHER DRUG ABUSE/DEPENDENCE-6.1

5
RATES OF CONCURRENCE (ECA, 1990)

• MENTAL DISORDER-29 SUBSTANCE ABUSE
• ALCOHOL ABUSE/DEPENDENCE (ALCOHOLISM)-37 MENTAL
  DISORDER
• OTHER DRUG ABUSE/DEPENDENCE-51 MENTAL DISORDER

6
SAN MATEO COUNTY MENTAL HEALTH SYSTEM

• 10,431 UNDUPLICATED CLIENTS,
• JULY 96-JUNE1997
• 40 WERE DUALLY DIAGNOSED
• 4,272 (41) WERE SERIOUSLY MENTALLY ILL
• 50 WERE DUALLY DIAGNOSED

7
NATIONAL COMORBIDITY STUDY (REIGER, et. al., 1990)

• 55 OF CASES OF ALCOHOL DEPENDENCE HAD AT LEAST
  ONE MENTAL DISORDER
• 69 OF CASES OF DRUG DEPENDENCE HAD AT LEAST ONE
  MENTAL DISORDER
• 34 OF MENTALLY ILL HAD SUBSTANCE ABUSE PROBLEM

8
PABLOS PREVALENCE RATES (SAN FRANCISCO HOMELESS
POPULATION)

• MAJOR MENTAL ILLNESS 60-80
• EQUALLY DIVIDED BETWEEN SUBSTANCE-INDUCED AND
  PRE-EXISTING MENTAL ILLNESS
• SUBSTANCE ABUSE 99.99
• NICOTINEALCOHOLMJ
• STIMULANTS (SPEEDgtCOCAINE)
• OPIATES

9
INCIDENCE OF MENTAL ILLNESS AND SUBSTANCE ABUSE
AMONG THE HOMELESS

• SUBSTANCE ABUSE 52-66
• MENTAL ILLNESS 22
• MENTALLY ILL WITH SUBSTANCE ABUSE PROBLEM 77
• SUBSTANCE ABUSERS WITH MENTAL ILLNESS NO
  ACCURATE DATA AVAILABLE, BUT I SUSPECT 50-70

10
REASONS FOR CONCURRENCE

• MENTAL ILLNESS DOES NOT PREVENT SUBSTANCE ABUSE
• SUBSTANCE-INDUCED MENTAL ILLNESS
• SELF-MEDICATION
• SUBSTANCE USE INCEASING SOCIABILITY
• SUBSTANCE USE RELIEVING UNPLEASANT MEDICATION
  EFFECTS

11
BARRIERS TO PROVIDING RATIONAL TREATMENT

• IMPEDIMENTS WITHIN THE MENTAL HEALTH SYSTEM
• IMPEDIMENTS WITHIN THE SUBSTANCE ABUSE TREATMENT
  SYSTEM
• THE NEED FOR A NEW APPROACH, CREATING A HYBRID
  SYSTEM

12
MODEL SYSTEM

• CENTRALIZED INTAKE
• STANDARDIZED ASSESSMENT PROCESS
• PHYSICAL EXAMINATION
• DISEASE SCREENING
• TB
• HIV
• HEPATITIS

13
MODEL SYSTEM

• PATIENT SPECIFIC MEDICAL CARE
• DETOXIFICATION
• ABSCESS CARE
• HEALTH CARE MAINTENANCE
• SUBSTANCE ABUSE SCREENING
• PSYCHOSOCIAL SCREENING
• PSYCHIATRIC SCREENING

14
STANDARDIZED ASSESSMENT PROCESS

• ADDICTION SEVERITY INDEX (ASI)
• DRUG
• ALCOHOL
• MEDICAL
• EMPLOYMENT
• LEGAL
• FAMILY
• PSYCHOLOGICAL

15
STANDARDIZED ASSESSMENT PROCESS

• ASAM (AMERICAN SOCIETY OF ADDICTION MEDICINE)
  TREATMENT CRITERIA
• INPATIENT
• MED/PSYCH
• MINNESOTA MODEL
• RESIDENTIAL
• THERAPEUTIC COMMUNITIES
• SOCIAL MODEL RECOVERY HOMES

16
ASAM TREATMENT CRITERIA

• OUTPATIENT TREATMENT
• LEVEL 1 (lt9 HOURS/WEEK)
• LEVEL 2 (gt9HOURS/WEEK)
• DAY TREATMENT
• PARTIAL HOSPITALIZATION

17
SUBSTANCE ABUSE REVIEW

• ADDICTION
• DEPENDENCE
• TOLERANCE
• CROSS TOLERANCE
• HALF-LIFE (T1/2)

18
SUBSTANCE ABUSE REVIEW

• ROUTES OF DRUG ADMINISTRATION
• PO
• PR
• INTRANASAL
• IV
• IM
• INHALATION (SMOKING)

19
SUBSTANCE ABUSE

• PERSISTENT PATTERN OF SUBSTANCE USE THAT RESULTS
  IN SUBSTANCE-RELATED PROBLEMS

20
MODELS OF SUBSTANCE ABUSE

• PROHIBITIONIST
• SOCIAL
• MORAL
• PSYCHOLOGICAL
• DISEASE

21
DISEASE MODEL

• ETIOLOGY
• SIGNS/SYMPTOMS NATURAL COURSE
• CULTURALLY INTERCHANGEABLE
• TREATMENT

22
ALCOHOLISM

• ETIOLOGY BIOLOGICAL, CULTURAL/BEHAVIORAL,
  PSYCHOLOGICAL
• SYMPTOMS ALCOHOL RELATED PROBLEMS NATURAL
  COURSE
• CULTURALLY INTERCHANGEABLE
• TREATMENT ABSTINENCE

23
NATURAL COURSE OF ALCOHOLISM
24
CNS DEPRESSANTS (MINOR TRANQUILZERS)

• BENZODIAZEPINE/BARBITURATES
• ANTI-ANXIETY
• SEDATIVE-HYPNOTICS
• ALCOHOL
• OLDIES BUT GOODIES
• CHLORAL HYDRATE
• ETHCHLORVYNOL
• MEPROBAMATE
• METHAQUALONE

25
CNS STIMULANTS

• COCAINE
• SMOKABLE COCAINE CRACK
• METHAMPHETAMINE (SPEED)
• SMOKABLE SPEED ICE

26
OPIATES

• NATURAL OPIUM, MORPHINE, CODEINE
• SEMI-SYNTHETIC HEROIN, HYDROMORPHONE (DILAUDID),
  OXYCODONE (PERCODAN)
• SYNTHETIC PROPOXYPHENE (DARVON), MEPREIDINE
  (DEMORAL), DOLOPHINE (METHADONE)

27
HALLUCINOGENS

• CANNABINOLS
• LSD
• MESCALINE (PEYOTE)
• PSILOCYBIN (MUSHROOMS)
• ECSTASY (MDMA)
• PCP (ANGEL DUST)

28
MENTAL ILLNESS REVIEW

• MEDICAL MODEL
• HISTORY
• PHYSICAL EXAMINATION
• MENTAL STATUS EXAMINATION
• LABORATORY STUDIES, ETC
• DIAGNOSIS

29
DSM-IV MULTIAXIAL ASSESSMENT

• AXIS I MAJOR MENTAL ILLNESS
• SUBSTANCE RELATED DISORDERS
• AXIS II PERSONALITY DISORDERS
• MENTAL RETARDATION
• AXIS III GENERAL MEDICAL PROBLEMS
• AXIS IV PSYCHOSOCIAL/ENVIRONMENTAL
• PROBLEMS
• AXIS V GLOBAL ASSESSMENT OF
• FUNCTIONING

30
MENTAL STATUS EXAMINATION

• APPEARANCE
• BEHAVIOR
• SENSORIUM
• ORIENTATION
• SPEECH
• AFFECT
• MOOD

• THOUGHT PROCESS
• THOUGHT CONTENT
• COGNITIVE EXAM
• SUICIDE
• HOMICIDE
• JUDGMENT
• INSIGHT

31
PSYCHIATRIC DISORDERS

• PSYCHOTIC DISORDERS
• AFFECTIVE DISORDERS
• ANXIETY DISORDERS
• HIV () CONDITIONS
• PERSONALITY DISORDERS

32
PSYCHOTIC DISORDERS

• SUBSTANCE-INDUCED
• DUE TO MEDICAL CONDITION
• BRIEF PSYCHOTIC DISORDER
• SCHIZOPHRENIFORM DISORDER
• SCHIZOPHRENIA
• DELUSIONAL DISORDER
• NOT OTHERWISE SPECIFIED

33
AFFECTIVE DISORDERS

• SUBSTANCE-INDUCED
• DUE TO MEDICAL CONDITION
• MAJOR DEPRESSIVE DISORDER
• DYSTHYMIC DISORDER
• ADJUSTMENTT DISORDER
• BIPOLAR DISORDER
• CYCLOTHYMIC DISORDER
• SCHIZOAFFECTIVE DISORDER

34
ANXIETY DISORDERS

• SUBSTANCE-INDUCED
• DUE TO MEDICAL CONDITION
• POST TRAUMATIC STRESS DISORDER
• PANIC DISORDER WITH/WITHOUT AGORAPHOBIA
• OBSESSIVE COMPULSIVE DISORDER
• GENERALIZED ANXIETY DISORDER
• ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (AD/HD)

35
HIV PSYCHIATRIC CONDITIONS

• PSYCHIATRIC CONDITIONS THAT PRE-DATE HIV ()
• PSYCHOLOGICAL RESPONSE TO A TERMINAL DIAGNOSIS
• VIRAL-INDUCED CONDITIONS
• PSYCHOTIC
• AFFECTIVE
• ANXIETY
• DEMENTIA

36
PERSONALITY DISORDERS

• LITTLE OR NO ABILITY FOR EMPATHY
• UTILIZE PRIMITIVE DEFENSES
• SPLITTING
• PROJECTION
• ANTISOCIAL PERSONALITY DISORDER, NOT AMENABLE FOR
  TREATMENT!
• MUST BE DISTINGUISED FROM ADULT, LEARNED,
  ANTISOCIAL BEHAVIOR

37
SUBSTANCE-INDUCED MENTAL DISORDERS

• INTOXICATION
• WITHDRAWAL SYNDROMES
• ABSTINENCE SYNDROMES

38
ALCOHOL-INDUCED MENTAL ILLNESS

• IMPULSE CONTROL PROBLEMS
• VIOLENCE, SUICIDE, UNSAFE SEX, HIGH RISK BEHAVIOR
• SLEEP DISTURBANCE
• ANXIETY
• DEPRESSION
• PSYCHOSIS
• DEMENTIA

39
STIMULANT-INDUCED MENTAL ILLNESS

• IMPULSE CONTROL PROBLEMS
• VIOLENCE, UNSAFE SEX, HIGH RISK BEHAVIOR
• MANIA
• PANIC DISORDER
• DEPRESSION
• ANXIETY
• PSYCHOSIS
• COGNITIVE IMPAIRMENT

40
MARIJUANA-INDUCEDMENTAL ILLNESS

• DELIRIUM MEMORY PROBLEMS, DIFFICULTY WITH
  MULTI-STEP TASKING
• PSYCHOSIS
• PANIC DISORDER
• AMOTIVALTIONAL SYNDROME (?)

41
SUBSTANCE USE AS AN ATTEMPT AT SELF-MEDICATION

• MAJOR DEPRESSIVE DISORDER
• SPEED
• OPIATES
• ANXIETY DISORDERS
• MINOR TRANQUILIZERS
• MJ
• OPIATES

42
SELF-MEDICATION

• ATTENTION-DEFICIT/HYPERACTIVITY DISORDER
• MINOR TRANQUILIZERS
• MJ
• OPIATES
• SPEED
• SCHIZOPHRENIA
• STIMULANTS
• OPIATES

43
SELF-MEDICATION

• BIPOLAR DISORDER
• MINOR TRANQUILIZERS
• MJ
• OPIATES
• SPEED (FOR DEPRESSIVE CYCLE)

44
DIAGNOSTIC STRATEGY

• ASSESS HEALTH STATUS
• ASSESS DEGREE OF SUBSTANCE USE
• ASSESS MENTAL HEALTH STATUS
• ATTEMPT TO DETERMINE CAUSE/EFFECT
• HIV-INDUCED
• SUBSTANCE-INDUCED
• PRE-EXISTING MENTAL ILLNESS
• ALL OF THE ABOVE

45
TREATMENT CONSIDERATIONS

• INTERVENTION STRATEGIES
• STAGES OF CHANGE EVALUATION
• TREATMENT MATCHING
• ACHIEVING ABSTINENCE (0-6 MONTHS)
• MAINTAINING ABSTINENCE (6-24 MONTHS)
• LIFELONG ABSTINENCE

46
ACHIEVING ABSTINENCE

• DETOXIFY, IF NECESSARY
• ASSESS/TREAT PSYCHIATRIC DISORDER, IF PRESENT
• MOTIVATIONAL INTERVIEWING
• SUPPORTIVE PSYCHOTHERAPY
• RELAPSE PREVENTION
• MEDICATION SUPPORT
• SOCIAL SUPPORTS
• PEER SUPPORT GROUPS (I.E. 12 STEP)

47
SUPPORTIVE PSYCHOTHERAPY

• ABSTINENCE PSYCHOTHERAPY
• PSYCHO-EDUCATION
• MEDICATION COMPLIANCE
• AVOIDANCE OF ALL SUBSTANCES

48
RELAPSE PREVENTION

• RELAPSE IS A PROCESS
• IDENTIFIABLE TRIGGERS
• PRESDICTABLE SET OF THOUGHTS, FEELINGS AND
  BEHAVIORS
• NEED TO IDENTIFY THE RELAPSE PROCESS AND
  INSTITUTE ALTERNATE BEHAVIORS

49
MAINTAINING ABSTINENCE

• SUPPORTIVE PSYCHOTHERAPY-PSYCHODYNAMICALLY
  ORIENTED PSYCHOTHERAPY (IF CLINICALLY INDICATED)
• TAPER SUPPORTIVE MEASURES AS INDICATED
• INCREASE INTENSITY OF TREATMENT AT TIMES OF
  POTENTIAL RELAPSE

50
LIFELONG ABSTINENCE

• PSYCHODYNAMICALLY ORIENTED PSYCHOTHERAPY (IF
  CLINICALLY INDICATED)
• INCREASE INTENSITY OF TREATMENT AT TIMES OF
  POTENTIAL RELAPSE

51
OPIATE REPLACEMENT THERAPY

• METHADONE MAINTENANCE DRUG REPLACEMENT THERAPY
  WITH A LONG ACTING, ORALLY ADMINISTERED
  MEDICATION THAT IS REPLACING A SHORT ACTING,
  ILLICIT, INTRAVENOUSLY ADMINISTERED OPIATE

52
HARM REDUCTION

• PUBLIC HEALTH EFFORTS THAT ARE AIMED AT REDUCING
  THE INHERENT RISKS ASSOCIATED WITH SUBSTANCE USE
• HARM REDUCTION EXAMPLES
• DESIGNATED DRIVER PROGRAMS
• NEEDLE EXCHANGE
• METHADONE MAINTENANCE