SUBSTANCE ABUSE AND MENTAL ILLNESS:

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SUBSTANCE ABUSE AND MENTAL ILLNESS

• WHY WE NEED TO WORK TOGETHER AS WE LOOK TO THE
  FUTURE
• BARBARA SULLIVAN, Ph.D.
• UTAH ADDICTION CENTER
• UNIVERSITY OF UTAH

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Why we cannot afford to ignore substance abuse
in patients with mental illness

• Overlapping developmental, environmental, and
  genetic vulnerabilities
• Drugs can trigger mental disorders in those that
  are vulnerable and can exacerbate their course
• Patients with mental illness are at greater
  risk for substance abuse
• Drugs contribute significantly to the morbidity
  and mortality of patients with mental illness

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Prevalence of Drug Disorders (other than nicotine)
Prevalence of Nicotine Addiction
40
35
30
Percent
25
Percent
20
15
10
5
0
Mania
Depression
Social Phobia
Any Mood Disorder
Generalized Anxiety
Any Anxiety Disorder
Panic w/ Agoraphobia
Panic w/out Agoraphobia
General public
Schizophrenia
Depression
General public
Conway et al., J Clin Psychiatry, February 2006.
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Addictive and Mental Disorders Commonly Co-Exist
Comorbid Disorders
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Age at Which Marijuana Use Is First Initiated
80 70 60 50 40 30 20 10 0
Drug Abuse
Child lt12
Teen 12-17
Young Adult 18-25
Adult gt25
Source Gfroerer, JC et al., SMA 02-3711, OA,
SAMHSA Data from National Survey of Drug Use
and Health.
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Adolescent Cannabis Use Effects Adult Psychosis
in Individuals with Variations in the COMT Gene
20
no adolescent cannabis use
adolescent cannabis use
15
with schizophreniform disorder at age 26
10
5
0
Met/Met
Val/Met
Val/Val
COMT genotype
Source Caspi, A. et al. Biol. Psychiatry, 57
1117-1127 2005.
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Adolescent Exposure to Cannabinoids Alters the
Response of VTA Dopamine Neurons to Drugs of Abuse
Early exposure to cannabinoids renders DA cells
more reactive which could trigger a psychotic
episode in a vulnerable individual
Source Pistis, M. et al., Biol Psychiatry, 56
86-94, 2004.
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Depression Ratings for Baseline Weeks 1 2 of
A Quit Attempt in Depressed and Non-Depressed
Women Smokers
Non-Depressed Depressed
Source Pomerleau, CS et al., Journal of
Addictive Diseases, 20(10, pp. 73-80, 2001.
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Comorbidity with Mental Illness
i.e gt 80 Schizophrenics Smoke
Schizophrenics have Fewer ?7 AChR in Hippocampus
mRNA Levels of ?7 AChR are Lower in
Schizophrenics
control subjects
schizophrenic patients
Perl, O. et al., FASEBJ, 17, 2003
Nicotine normalizes a sensory gating abnormality
defect found in most schizophrenics
Freedman et al., Biol Psych, 38, 22-23, 1995
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Two Independent Systems

• The mental health and substance abuse treatment
  systems operate independently of one another, as
  separate cultures, each with its own treatment
  philosophies, administrative structures, and
  funding mechanisms.
• (NASMHPD-NASADAD National Dialogue, 1999)

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Existing Common Practices

• Independent Systems Result in Clients Being
• Treated for one disorder without regard for the
  other
• Bounced based on changing dominant symptoms
• Lost Through the Cracks

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Substance Abuse

• A maladaptive pattern of substance use leading to
  clinically significant impairment or distress
• failure to fulfill obligations at work, school or
  home
• use in situations in which it is physically
  hazardous
• use-related legal problems
• persistent or recurrent social or interpersonal
  problems caused or exacerbated by the effects of
  the substance

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Substance Dependence

• A maladaptive pattern of substance use leading to
  clinically significant impairment or distress
• tolerance
• withdrawal
• taken in larger amounts or over a longer period
  than was intended
• persistent desire or unsuccessful efforts to cut
  down/control use
• spending a great deal of time obtaining, using,
  or recovering
• important social, occupational or recreational
  activities abandoned or reduced because of
  substance use
• continued use despite persistent /recurrent
  physical or psychological problem substance is
  likely to cause or exacerbate

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Mental Disorder

• Clinically significant emotional, behavioral or
  psychological syndrome or pattern that results in
  a range of distress and life impairment

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Co-Occurring Disorders

• One or more mental disorders AND one or more
  disorders relating to alcohol and/or other drug
  use
• Disorders (mental and substance abuse) must be
  established independently

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Prevalence of Co-occurring Disorders
Mental Health Programs1
20 50
clients with substance use disorder
Source 1 Sacks et al. 1997 2 Kessler, R. et al.
1996 3SAMHSA, 2004
Drug Treatment Facilities1
50 75
clients with mental disorder
General Population (National Comorbidity Survey)
2
have mental disorder
of those with lifetime addictive disorder
50
50
have substance use disorder
of those withlifetime mental illness disorder
4.2 million with serious mental disorder and
co-occurring substance use disorder3
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Four QuadrantsService Coordination by Severity
Quadrant III Less severe mental disorder More
severe substance disorder
Quadrant IV More severe mental disorder More
severe substance disorder
Quadrant I Less severe mental disorder Less
severe substance disorder
Quadrant II More severe mental disorder Less
severe substance disorder
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Risks of Death by Injury Compared to Medicaid
Patients with Medical Treatment Only aged 18-64
in 1997-1998
Dickey, B. et al., J of Behavioral Health
Services and Research, 2004.
60 of injury deaths were by poisoning
(prescription drugs, over the counter, controlled
substances and street drugs).
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Overarching Principles

• Co-occurring disorders must be expected and
  clinical services should incorporate this
  assumption into all screening, assessment, and
  treatment planning
• Within the treatment context, both co-occurring
  disorders are considered primary
• Empathy, respect, and belief in the individuals
  capacity for recovery are fundamental provider
  attitudes
• Treatment should be individualized to accommodate
  the specific needs and personal goals of unique
  individuals in different stages of change.

COCE Leadership Training
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Practice Guidelines

• Employ a recovery perspective
• Adopt a multi-problem viewpoint
• Develop a phase approach to treatment
• Address real-life problems early in treatment
• Plan for cognitive and functional impairments
• Use support systems

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Essential Program Components

• Screening, Assessment, and Referral
• Psychiatric and Mental Health Consultation
• Prescribing Onsite Psychiatrist
• Medication and Medication Monitoring
• Psycho-educational Classes
• Dual Recovery Groups, (onsite)
• Dual Recovery Mutual Self-Help Groups (offsite)

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Consensus-Based Practices with Evidence Base in
Substance Abuse

• Motivational Enhancement Therapy
• Contingency Management
• Cognitive Behavioral Therapy
• Relapse Prevention
• Repetition and Skills Building
• Participation in Mutual Self-Help Groups
• Modified Therapeutic Communities (MTCs)

COCE Leadership Training
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Implementing New Practices
Key Components of Successful Implementation

• PRACTITIONERS
• Carefully Selected
• Trained
• Coached

• ORGANIZATIONS
• Support at the Highest Levels
• A Champion for the new Practice
• Necessary Infrastructure
• Skillful Supervision

• COMMUNITIES,
• CONSUMERS OTHER STAKEHOLDERS
• Strategy for involvement

• LOCAL, STATE, FEDERAL GOVERNMENTS
• Flexible environment through policies,
  regulations, funding

Adapted from Fixsen, D. L., Naoom, S. F.,
Blase, K. A., Friedman, R. M. Wallace, F.
(2005). Implementation Research A Synthesis of
the Literature. Tampa, FL University of South
Florida, Louis de la Parte Florida Mental Health
Institute, The National Implementation Research
Network (FMHI Publication 231).
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Levels of Program Capacity in Co-Occurring
Disorders
Fully Integrated COD Integrated
Beginning Addiction Only Tx
Intermediate COD Capable
Advanced COD Enhanced
Advanced COD Enhanced
Beginning Mental Health Only Tx
Intermediate COD Capable
Substance Abuse Tx
Mental Health Tx
More Tx for Mental Disorders
More Tx for Substance Abuse Disorders
COCE Leadership Training
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Comorbid Conditions Present A Variety of Unique
Treatment Challenges
Learning more about the similarities and
differences in their neurobiological, genetic
and environmental underpinnings will lead to
more targeted and effective treatment strategies

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ACKNOWLEDGMENTS

• National Institute on Drug Abuse
• SAMHSAs Co-Occurring Center for Excellence
  Leadership Training
• University of Utah Health Sciences
• State Division of Substance Abuse and Mental
  Health Services