MENTAL HEALTH & Substance MENTAL HEALTH & Substance AbuseAbuse

Concurrent DisordersConcurrent DisordersSWRK 2083SWRK 2083

Keith Cameron, M.A., M.B.A.Keith Cameron, M.A., M.B.A.

AgendaAgendaWeek 1Week 1

IntroductionIntroduction Course Outline & Administrative Course Outline & Administrative

Issues Issues Introduction to Concurrent DisordersIntroduction to Concurrent Disorders Definition of Key TermDefinition of Key Term Clinical ComplexityClinical Complexity

Class practical exercisesClass practical exercises

IntroductionIntroduction Keith Cameron, M.A., M.B.A.Keith Cameron, M.A., M.B.A.

Contact InformationContact Information Kcameron75@gKcameron75@gmail.commail.com

No contact at the CollegeNo contact at the College

Web site:Web site: http://http://www.cameke.pbworks.comwww.cameke.pbworks.com

It is your responsibility to access the web-site for It is your responsibility to access the web-site for power point presentationspower point presentations

They will be posted by the end of the day on the Tuesday prior to class I will not be bringing copies to class Other information may be posted that is FYI only but may be beneficial in

assignments or the test

Course OutlineCourse OutlineEVALUATION SYSTEM:EVALUATION SYSTEM: Week 3 – Multiple Choice Quiz (20%)Week 3 – Multiple Choice Quiz (20%)

Open book and work in pairsOpen book and work in pairs Week 4 – Small Group Work – 3 maximum (30%)Week 4 – Small Group Work – 3 maximum (30%) Week 7 – Final Multiple Choice (40%)Week 7 – Final Multiple Choice (40%) Attendance (10%)Attendance (10%)

Those that have been granted job status will be prorated out of 90Those that have been granted job status will be prorated out of 90

Religious holidays. It is the student’s responsibility to Religious holidays. It is the student’s responsibility to discuss this issue with your professor at least discuss this issue with your professor at least one weekone week before the holiday.before the holiday.

Students registered with Disability Services are required Students registered with Disability Services are required

to supply confirming documentation to the professor and to supply confirming documentation to the professor and inform him/her of any plans to write tests in private inform him/her of any plans to write tests in private

It is your responsibility to read and It is your responsibility to read and understand the course outline. Ask if understand the course outline. Ask if you are not sureyou are not sure

Course OutlineCourse Outline – Cont’d– Cont’d

ASSIGNMENT POLICY: PLS. READ CAREFULLY!ASSIGNMENT POLICY: PLS. READ CAREFULLY! Group work is submitted at the end of class. Group work is submitted at the end of class. If 1 assignment is missedIf 1 assignment is missed

You must contact the professor You must contact the professor on the day of the on the day of the assignment at the latestassignment at the latest ( no documentation is required)( no documentation is required)

by emailby email If you have contacted the professor, only then will be If you have contacted the professor, only then will be

eligible for a make up after the final test on week 7eligible for a make up after the final test on week 7 If you miss a second assignment:If you miss a second assignment:

You must contact the professor on the day of the You must contact the professor on the day of the assignment and must provide documentation within one assignment and must provide documentation within one week to access any accommodation week to access any accommodation

Groups will consist of 3 membersGroups will consist of 3 members Each member is to participate in written responseEach member is to participate in written response Members are expected to participate equally and remain until Members are expected to participate equally and remain until

the work is completed.the work is completed. Groups who sign in a missing group participant will be liable for Groups who sign in a missing group participant will be liable for

sanctions as a whole ( i.e. 0 on that assignment)sanctions as a whole ( i.e. 0 on that assignment) To view George Brown College policies go to To view George Brown College policies go to

www.gbrownc.on.ca/policieswww.gbrownc.on.ca/policies

General CommentsGeneral Comments Please ask questionsPlease ask questions

If you don’t know others also don’t knowIf you don’t know others also don’t know It is your right to have explanations and clarificationsIt is your right to have explanations and clarifications Very often there are not right and wrong answersVery often there are not right and wrong answers

Because I say it doesn’t mean it is rightBecause I say it doesn’t mean it is right

I would request that any backbench talking be done outside I would request that any backbench talking be done outside the classthe class This is disturbing to me and the rest of the classThis is disturbing to me and the rest of the class I will not talk above other peopleI will not talk above other people

Turn cell phones offTurn cell phones off If there is an emergency call awaiting let me knowIf there is an emergency call awaiting let me know

Keep assignments including scantrons in case of a Keep assignments including scantrons in case of a discrepancy in marks. No marks will changed discrepancy in marks. No marks will changed without this back-up supportwithout this back-up support

A Few PointersA Few Pointers

ReadingsReadings Reading package available at CollegeReading package available at College Note that when you first open “Health Note that when you first open “Health

Canada” document it is in Roman Canada” document it is in Roman numerals – keep scrolling down until you numerals – keep scrolling down until you get to the page numbersget to the page numbers

Note page number on the document will not Note page number on the document will not correspond to the scroll down pages on the correspond to the scroll down pages on the leftleft

Mental Illness..................S. Abuse: Mental Illness..................S. Abuse: How we define themHow we define them

Context of BehaviourContext of Behaviour Social DevianceSocial Deviance Persistence of Persistence of

maladaptive maladaptive behavioursbehaviours

Subjective distressSubjective distress SeveritySeverity Impact on Impact on

functioningfunctioning

ToleranceTolerance Withdrawal symptomsWithdrawal symptoms Need more, same effectNeed more, same effect Persistent drive for Persistent drive for

substance, or failure to substance, or failure to cut backcut back

Time spent getting itTime spent getting it Reduce social/work Reduce social/work

activitiesactivities Use despite health/social Use despite health/social

problemsproblems

Some Themes for the CourseSome Themes for the Course

ComplexityComplexity Numerous MH disorders combined with different disordersNumerous MH disorders combined with different disorders Age/demographicsAge/demographics

Assessing Concurrent Disorders (CD)Assessing Concurrent Disorders (CD) What came first?What came first? What do we treat?What do we treat?

TreatmentTreatment What came first?What came first? What do we treat firstWhat do we treat first

Causes of CDCauses of CD What went wrong in childhood?What went wrong in childhood?

FocusFocus Mood + AlcoholMood + Alcohol Anxiety + AlcoholAnxiety + Alcohol Psychosis & CannabisPsychosis & Cannabis

DefinitionDefinition

What is your understanding of What is your understanding of the termthe term Concurrent Disorders Concurrent Disorders

What it is not!What it is not!

What do We Mean by What do We Mean by Concurrent Disorders?Concurrent Disorders?

At least one mental health disorder as At least one mental health disorder as defined by DSM-IVdefined by DSM-IV

Plus substance abuse or dependence as Plus substance abuse or dependence as defined by DSM-IVdefined by DSM-IV

Multi combinations and variations, Multi combinations and variations, including multi-morbidityincluding multi-morbidity Across drugsAcross drugs Across mental disordersAcross mental disorders Demographics/cultural groupsDemographics/cultural groups

Abuse vs. Dependence

Substance abuse is a pattern of drug, alcohol or other substance use that creates many adverse results from its continual use. The characteristics of abuse are a failure to carry out obligations at home or work, continual use under circumstances that present a hazard (such as driving a car), and legal problems such as arrests. Use of the drug is persistent despite personal problems caused by the effects of the substance on self or others.

Substance dependence has been defined medically as a group of behavioural and physiological symptoms that indicate the continual, compulsive use of a substance in self-administered doses despite the problems related to the use of this substance. Sometimes increased amounts are needed to achieve the desired effect or level of intoxication. Consequently the patient's tolerance for the drug increases. Withdrawal is a physiological and psychological change that occurs when the body's concentration of the substance declines in a person who has been a heavy user.

Definition in CanadaDefinition in Canada(Similar in the USA)(Similar in the USA)

““A combination of A combination of mental/emotional/psychiatric mental/emotional/psychiatric problems with the abuse of alcohol problems with the abuse of alcohol and/or other psychoactive drugs…and/or other psychoactive drugs…any combination of mental health any combination of mental health and substance use disorders, as and substance use disorders, as defined in DSM IV.” defined in DSM IV.” (Cooper & Calderwood in readings)(Cooper & Calderwood in readings)

In definition, the DSM–IV is used as In definition, the DSM–IV is used as the tool for diagnosis the tool for diagnosis (Axis 1 & 2)(Axis 1 & 2)

Some TermsSome Terms

CAMI: chemically abusing – mentally illCAMI: chemically abusing – mentally ill

MICA: Mentally ill – chemically abusingMICA: Mentally ill – chemically abusing

SAMI: Substance abusing – mentally illSAMI: Substance abusing – mentally ill

Co-occurring (the US)Co-occurring (the US)

‘‘Double-jeopardy’Double-jeopardy’

What is a Dual Disorder??What is a Dual Disorder??

Not Dual DisordersNot Dual Disorders

People with MH + Substance abuse People with MH + Substance abuse may have more than 2 disordersmay have more than 2 disorders

Dual Disorders Dual Disorders In Canada, refers to Developmental In Canada, refers to Developmental

Delay & a Mental Health issue Delay & a Mental Health issue Concurrent DisordersConcurrent Disorders

In Canada, captures complexity of In Canada, captures complexity of substance abuse with mhsubstance abuse with mh

Prevalence DataPrevalence Data From Journal of American Medical AssociationFrom Journal of American Medical Association

Large overlap: between substance Large overlap: between substance use and mental health disordersuse and mental health disorders

Most clients who actually seek Most clients who actually seek treatment have a concurrent disordertreatment have a concurrent disorder

Some StatsSome Stats

50% of seriously mentally ill affected 50% of seriously mentally ill affected by substance abuseby substance abuse

90% of mentally ill smoke heavily90% of mentally ill smoke heavily

77% of those treated for alcohol-77% of those treated for alcohol-related disorders have experienced at related disorders have experienced at least one other psychiatric disorder in least one other psychiatric disorder in their lifetimes.their lifetimes.

Some SpecificsSome Specifics

SchizophreniaSchizophrenia 47% also have a substance abuse disorder, 47% also have a substance abuse disorder,

which is 4x the risk of the general which is 4x the risk of the general populationpopulation

Bipolar DisorderBipolar Disorder 61% also had a substance abuse disorder 61% also had a substance abuse disorder

which is 5x the risk of the general which is 5x the risk of the general populationpopulation

Specific RisksSpecific Risks

Compared to general population the Compared to general population the lifetime risk for developing alcohol lifetime risk for developing alcohol dependence is:dependence is: 21 times higher for Antisocial Personality21 times higher for Antisocial Personality 6 timers higher for those with Mania6 timers higher for those with Mania 4x higher for those with schizophrenia4x higher for those with schizophrenia 2x higher for those with panic disorder, 2x higher for those with panic disorder,

major depression, & OCDmajor depression, & OCD

Most Common Most Common CombinationsCombinations

SpecificallySpecifically

Mood Disorder plus Alcohol Mood Disorder plus Alcohol

Anxiety Disorder plus AlcoholAnxiety Disorder plus Alcohol

Five Most Common GroupingsFive Most Common Groupings(Health Canada)(Health Canada)

1.1. Substance Use + Mood & Anxiety Substance Use + Mood & Anxiety DisordersDisorders

2.2. Substance Use + Severe & Substance Use + Severe & Persistent MHPersistent MH

3.3. Substance Use & Personality Substance Use & Personality DisordersDisorders

4.4. Substance Use + Eating DisordersSubstance Use + Eating Disorders5.5. Other Substance Use & MHOther Substance Use & MH

Key to PractitionersKey to Practitioners

Only a minority of substance abusers Only a minority of substance abusers and those with mental health and those with mental health problems reach out for help….but…problems reach out for help….but…

“…“…those in the general population those in the general population with concurrent disorders present the with concurrent disorders present the highest probability of seeking highest probability of seeking treatment.” Kesslertreatment.” Kessler

Key----Key----

US StudyUS Study: Respondents with alcohol : Respondents with alcohol use disorders were five times as use disorders were five times as likely to see help when they also had likely to see help when they also had a mental health problem.a mental health problem. ““Those who seek help are the most Those who seek help are the most

severe cases in the general population…severe cases in the general population…and are more often readmitted to and are more often readmitted to treatment.” treatment.”

““Intersectionality:Intersectionality:” ”

‘‘The experience of living with The experience of living with multiple stigmatized multiple stigmatized

identities, facing multiple identities, facing multiple layers of discrimination.’layers of discrimination.’

Article: “Multiple Identities, Article: “Multiple Identities, Multiple Barriers”: U. Multiple Barriers”: U.

ChandraseskeraChandraseskera

Complexity = Multiple Complexity = Multiple Identities Identities

Each with its own unique issues…Each with its own unique issues…

S AbuseM Illness

LGBTQLGBTQPeople of ColorPeople of Color

ClassClass

New Canadian

New Canadian

Gender

Consequences of Having a Consequences of Having a Concurrent DisorderConcurrent Disorder

Statistically, clients have a greater propensity for Statistically, clients have a greater propensity for violence, medication non-compliance, and failure violence, medication non-compliance, and failure to respond to treatment…compared with clients to respond to treatment…compared with clients with substance abuse only or mental illness onlywith substance abuse only or mental illness only

““These consumers are in and out of hospitals and These consumers are in and out of hospitals and treatment programs without lasting success.” treatment programs without lasting success.” (NAMI)(NAMI)

Treatment takes longer to workTreatment takes longer to work

Consequences ---Consequences ---

‘‘Downward Drift’: Downward Drift’:

Mental illness lands clients in poor Mental illness lands clients in poor housing, in neighborhoods where housing, in neighborhoods where drug use prevails…inability to form drug use prevails…inability to form social relationships, isolation can social relationships, isolation can lead to joining the drug sub-culturelead to joining the drug sub-culture

Consequences ---Consequences ---

Leads to homelessness or jail: Leads to homelessness or jail: Half of the mentally ill homeless have Half of the mentally ill homeless have

substance abuse problems substance abuse problems 31% a concurrent disorder31% a concurrent disorder

16% of prison inmates have concurrent 16% of prison inmates have concurrent disordersdisorders

Leads to overall poorer physical health Leads to overall poorer physical health and greater chance of relapseand greater chance of relapse““these consumers are in and out of hospital and these consumers are in and out of hospital and

treatment programs without lasting success.”treatment programs without lasting success.” (Nami)(Nami)

Services lack integrationServices lack integration

““Often only one of the disorders is Often only one of the disorders is identified. If both are recognized, the identified. If both are recognized, the individual may bounce back and individual may bounce back and forth between services, or be refused forth between services, or be refused service by one of them….Fragmented service by one of them….Fragmented and uncoordinated services create a and uncoordinated services create a service gap for persons with co-service gap for persons with co-occurring disorders.” (NAMI)occurring disorders.” (NAMI)

Why CD Clients Quit Why CD Clients Quit TreatmentTreatment

Enter treatment in crisis or chronic stateEnter treatment in crisis or chronic state Therapeutic alliance tougher to establishTherapeutic alliance tougher to establish Treatment streams not integrated (one Treatment streams not integrated (one

disorder recognized)disorder recognized) Clients need longer-term treatment that Clients need longer-term treatment that

many agencies do not offermany agencies do not offer Pattern of failed relationships, abuse: Pattern of failed relationships, abuse:

attachment issuesattachment issues

Double StigmaDouble Stigma

Is it better to be drug user or a mental Is it better to be drug user or a mental health consumer?health consumer?

Mental HealthMental Health Becoming less stigmatizedBecoming less stigmatized

More educationMore education Better outcomesBetter outcomes

AddictionsAddictions Still seen as a moral failureStill seen as a moral failure

Judged more harshlyJudged more harshly

Internalized StigmaInternalized Stigma

Addiction: harsh judgment by our Addiction: harsh judgment by our culture creates more durable internal culture creates more durable internal stigmastigma

Beliefs: I’m a loser, I’m a bad person, Beliefs: I’m a loser, I’m a bad person, I don’t deserve help, I don’t deserve I don’t deserve help, I don’t deserve lovelove

1+1 = more than 21+1 = more than 2

Substances make MH Substances make MH problems worseproblems worse

Substances mimic or Substances mimic or hide MH problemshide MH problems

Substances used to Substances used to relieve MH symptomsrelieve MH symptoms

(Self-medication)(Self-medication)

Substances can make Substances can make MH meds less effectiveMH meds less effective

Substances can lead Substances can lead to clients forgetting to to clients forgetting to take MH medstake MH meds

Relapse with one Relapse with one triggers symptoms of triggers symptoms of other problemother problem

Consequences for Consequences for TreatmentTreatment

Overall, poor outcomes: chronic Overall, poor outcomes: chronic coursecourse

Poor physical healthPoor physical health High relapse ratesHigh relapse rates ‘‘Recidivism’ Recidivism’ So: clients more likely to seek help, So: clients more likely to seek help,

and also to quit helpand also to quit help

TreatmentTreatment

““Co-existing mental disorders Co-existing mental disorders increase the probability of increase the probability of abandoning treatment prematurely.”abandoning treatment prematurely.”

WHY?WHY?

How Many Concurrent How Many Concurrent Combinations Are There?Combinations Are There?

Bio-Psycho Social ModelBio-Psycho Social ModelReviewReview

A framework that incorporates the A framework that incorporates the NATURE vs. NURTURE NATURE vs. NURTURE controversycontroversy

Examines the positive strengths of the consumerExamines the positive strengths of the consumer Recognizes the Recognizes the biologicalbiological predisposition of mental predisposition of mental

illnesses & addictionsillnesses & addictions Recognizes the negative and positive elements in Recognizes the negative and positive elements in

the the environmentenvironment Organizes information in a way that can be Organizes information in a way that can be

communicated and include the consumer in communicated and include the consumer in decision makingdecision making

Recognizes the importance of the consumer in Recognizes the importance of the consumer in the treatment processthe treatment process

Group AssignmentGroup Assignment

As a group list your experience the last As a group list your experience the last time you drank a lot of alcohol?time you drank a lot of alcohol? Biological/Psychological/Social-Spiritual + Biological/Psychological/Social-Spiritual +

BehaviouralBehavioural

BiologicalBiological PsychologicPsychologicalal

SocialSocial BehaviouralBehavioural

List Features of DepressionList Features of Depression

Consider such things as thinking, judgment, inherited Consider such things as thinking, judgment, inherited vulnerability, depressed CNS, memory, social functioning, vulnerability, depressed CNS, memory, social functioning, moodmood

BiologicalBiological PsychologicPsychologicalal

SocialSocial BehaviouralBehavioural

Alcohol Abuse vs. Alcohol Abuse vs. DepressionDepression

How do we distinguish depression and How do we distinguish depression and alcohol abuse?alcohol abuse?

Does alcohol abuse mask depression?Does alcohol abuse mask depression? Which came first?Which came first? Does one cause the other?Does one cause the other? Are they both hereditary or environmental?Are they both hereditary or environmental? Common pathwayCommon pathway Assessment is challengingAssessment is challenging

Add Other Factors That May Add Other Factors That May Affect Assessment and Affect Assessment and

TreatmentTreatment