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Copyright Alcohol Medical Scholars Program 1
Integrated Treatment of Co-Occurring Integrated Treatment of Co-Occurring Mental Illness (MI) and Substance Use Mental Illness (MI) and Substance Use
Disorders (SUD)Disorders (SUD)
Krishna Balachandra, M.D., FRCPC Krishna Balachandra, M.D., FRCPC
Concurrent Disorders Program Concurrent Disorders Program
University of Western OntarioUniversity of Western Ontario
Copyright Alcohol Medical Scholars Program 2
Co-Occurring Disorders Co-Occurring Disorders (COD)(COD)
~50% Serious disorders have SUD~50% Serious disorders have SUD
Physicians inadequately trained in SUDPhysicians inadequately trained in SUD
Pts with COD Pts with COD suboptimal care suboptimal care
Pts with COD at Pts with COD at risk risk
Copyright Alcohol Medical Scholars Program 3
DefinitionsDefinitions
Mental disordersMental disorders
Substance abuse ≥ 1 ofSubstance abuse ≥ 1 of
Obligations Obligations
Hazardous useHazardous use
Legal Legal
Interpersonal Interpersonal
problemsproblems
Substance dependence ≥ Substance dependence ≥ 3 of3 of ToleranceTolerance WithdrawalWithdrawal Amounts/timeAmounts/time CutCut TimeTime ActivitiesActivities Physical/psychological Physical/psychological
problemsproblems
Copyright Alcohol Medical Scholars Program 4
Co-Occurring DisordersCo-Occurring Disorders
Mental IllnessSubstance Use Disorder
COD
Copyright Alcohol Medical Scholars Program 5
This Lecture ReviewsThis Lecture Reviews
EpidemiologyEpidemiology
EtiologyEtiology
Treatment overallTreatment overall
Relevance of integrated treatmentRelevance of integrated treatment
Copyright Alcohol Medical Scholars Program 6
Epidemiology of CODEpidemiology of COD
SUD AUD DUD
17
Copyright Alcohol Medical Scholars Program 7
SUD
Epidemiology of CODEpidemiology of COD
Bipolar
3-5 X’s
AUD DUD
17
56
Copyright Alcohol Medical Scholars Program 8
Epidemiology of CODEpidemiology of COD
ASPD
5-7 X’s
SUD AUD DUD
17
56
83
Copyright Alcohol Medical Scholars Program 9
Etiology of CODEtiology of CODCommon VulnerabilityCommon Vulnerability
Common genesCommon genes Twin study of AUD + DepressionTwin study of AUD + Depression
ASPDASPD
Common physiology in bothCommon physiology in both HPA axis HPA axis
Hippocampus/frontal cortexHippocampus/frontal cortex
Cannabinoid, dopamine receptorsCannabinoid, dopamine receptors
Copyright Alcohol Medical Scholars Program 10
Etiology of CODEtiology of CODSUD as Response to MISUD as Response to MI
SymptomsSymptoms
Social skillsSocial skills
Medication side effectsMedication side effects
Mental Illness Substance Use Disorder
Copyright Alcohol Medical Scholars Program 11
Etiology of CODEtiology of CODMI as Response to SUDMI as Response to SUD
Cannabis use Cannabis use ↑ rates of ↑ rates of psychosispsychosis
Meta-analysis supports Meta-analysis supports ↑ risk↑ risk
Possible genetic mechanismPossible genetic mechanism
Mental IllnessSubstance Use Disorder
Copyright Alcohol Medical Scholars Program 12
We Have ReviewedWe Have Reviewed
Epidemiology Epidemiology
Etiology Etiology
Treatment overallTreatment overall
Relevance of integrated treatmentRelevance of integrated treatment
Copyright Alcohol Medical Scholars Program 13
Treatment StrategiesTreatment Strategies
AdvantagesAdvantages DisadvantagesDisadvantages
Sequential RxSequential Rx ++ ++++++++++
Parallel Rx Parallel Rx ++ ++++++ ++++
Integrated Rx Integrated Rx +++ +++++ ++
Copyright Alcohol Medical Scholars Program 14
Integrated TreatmentIntegrated Treatment
Simultaneous treatmentSimultaneous treatment
Consistency of location and providers Consistency of location and providers
AdvantagesAdvantages
DisadvantagesDisadvantages
Copyright Alcohol Medical Scholars Program 15
Integrated Rx: Clinical CaseIntegrated Rx: Clinical Case
27 M, Bipolar, Alc dep27 M, Bipolar, Alc dep
++ ER visits++ ER visits
No show apptsNo show appts
Frustrated docsFrustrated docs
Legal chargesLegal charges
HomelessHomeless
Copyright Alcohol Medical Scholars Program 16
Principles of Integrated RxPrinciples of Integrated Rx
““No wrong door”No wrong door”
Shared decision makingShared decision making
ComprehensivenessComprehensiveness
AssertivenessAssertiveness
Copyright Alcohol Medical Scholars Program 17
Principles of Integrated RxPrinciples of Integrated Rx
Negative consequencesNegative consequences
Time unlimitedTime unlimited
Multiple therapiesMultiple therapies
Cultural sensitivityCultural sensitivity
Copyright Alcohol Medical Scholars Program 18
Principles of Integrated RxPrinciples of Integrated Rx
Motivation based treatmentMotivation based treatment
EngagementEngagement
PersuasionPersuasion
Active treatmentActive treatment
Maintenance/Relapse preventionMaintenance/Relapse prevention
Copyright Alcohol Medical Scholars Program 19
Integrated TreatmentIntegrated TreatmentEngagementEngagement
Goal: Establish working relationshipGoal: Establish working relationship
OutreachOutreach
Practical assistancePractical assistance
E.g. housingE.g. housing
Crisis interventionCrisis intervention
Copyright Alcohol Medical Scholars Program 20
Integrated TreatmentIntegrated TreatmentEngagement Engagement
Support + assistance to social networkSupport + assistance to social network
Stabilize medical/psychiatric illnessStabilize medical/psychiatric illness
Address legal issuesAddress legal issues
Family visitsFamily visits
Close monitoringClose monitoring
Copyright Alcohol Medical Scholars Program 21
Integrated Treatment Integrated Treatment PersuasionPersuasion
Goal: Goal: awareness of problem awareness of problem
Individual + family educationIndividual + family education
Groups to discuss pros/cons of usingGroups to discuss pros/cons of using
Non substance social skillsNon substance social skills
Copyright Alcohol Medical Scholars Program 22
Integrated Treatment Integrated Treatment PersuasionPersuasion
Structured activityStructured activity
E.g. supported employmentE.g. supported employment
Social + rec activitiesSocial + rec activities
““Damp” housingDamp” housing
Psychiatric stabilizationPsychiatric stabilization
Copyright Alcohol Medical Scholars Program 23
Integrated Rx: Clinical CaseIntegrated Rx: Clinical Case
27 M, Bipolar, Alc dep27 M, Bipolar, Alc dep
ER visitsER visits
Keeps apptsKeeps appts
Happier docsHappier docs
Legal assistanceLegal assistance
HousingHousing
Alcohol use continuesAlcohol use continues
Copyright Alcohol Medical Scholars Program 24
Integrated Treatment Integrated Treatment Active RxActive Rx
Goal: Goal: substance use substance use
Strategies to Strategies to substance usesubstance use
Social skillsSocial skills
E.g. refusal skillsE.g. refusal skills
Self help groupsSelf help groups
E.g. “Double Trouble”E.g. “Double Trouble”
Copyright Alcohol Medical Scholars Program 25
Integrated Treatment Integrated Treatment Active RxActive Rx
Individual psychotherapyIndividual psychotherapy
Substitute activitiesSubstitute activities
Meds Meds Substance use (e.g. disulfiram, naltrexone)Substance use (e.g. disulfiram, naltrexone)
““Dry” housingDry” housing
Stress/coping skillsStress/coping skills
Copyright Alcohol Medical Scholars Program 26
Goal: maintain and extend recoveryGoal: maintain and extend recovery
Social skillsSocial skills
E.g. interpersonal relationshipsE.g. interpersonal relationships
Problem solvingProblem solving
E.g. new ways to cope E.g. new ways to cope
Integrated Treatment Integrated Treatment Maintenance/Relapse PreventionMaintenance/Relapse Prevention
Copyright Alcohol Medical Scholars Program 27
Lifestyle improvementLifestyle improvement
E.g. smoking cessationE.g. smoking cessation
Independent housingIndependent housing
Role modelingRole modeling
E.g. leading groupsE.g. leading groups
Integrated Treatment Integrated Treatment Maintenance/Relapse PreventionMaintenance/Relapse Prevention
Copyright Alcohol Medical Scholars Program 28
Hank’s 12 step program
Copyright Alcohol Medical Scholars Program 29
Efficacy of Integrated RxEfficacy of Integrated Rx
RetentionRetention
55% Integrated Rx > 35% usual Rx 55% Integrated Rx > 35% usual Rx
Substance useSubstance use
40% Abstinence post Rx vs 2% baseline 40% Abstinence post Rx vs 2% baseline
60% Negative urine integrated Rx > 25% usual Rx 60% Negative urine integrated Rx > 25% usual Rx
Copyright Alcohol Medical Scholars Program 30
Efficacy of Integrated RxEfficacy of Integrated Rx
Financial stressFinancial stress
40% Employed vs 5% baseline40% Employed vs 5% baseline
60% Housing vs 50% baseline60% Housing vs 50% baseline
70% $ For basic needs > 45% usual Rx70% $ For basic needs > 45% usual Rx
6000 $/pt Criminal justice cost savings6000 $/pt Criminal justice cost savings
Copyright Alcohol Medical Scholars Program 31
Efficacy of Integrated RxEfficacy of Integrated Rx
HospitalizationHospitalization
7% Post-integrated Rx vs 30% pre Rx7% Post-integrated Rx vs 30% pre Rx
Rates of arrestRates of arrest
13% Post-integrated Rx vs 30% pre Rx13% Post-integrated Rx vs 30% pre Rx
Copyright Alcohol Medical Scholars Program 32
We Have ReviewedWe Have Reviewed
Epidemiology Epidemiology
Etiology Etiology
Treatment overall Treatment overall
Relevance of integrated treatment Relevance of integrated treatment