Evaluating & Managing The Dual Diagnosis Patient Peter A. DeMaria, Jr.., M.D., FASAM Coordinator of Psychiatric Services Tuttleman Counseling Services Clinical Associate Professor of Psychiatry & Behavioral Sciences Department of Psychiatry & Behavioral Sciences Temple University School of Medicine Philadelphia, Pennsylvania

Case Study A Anne is a 19 year old student who tells you that she has been diagnosed with ADHD, anorexia nervosa, depression, borderline personality disorder and alcoholism. She is prescribed methylphenidate (Concerta), citalopram (Celexa), quetiapine (Seroquel) and alprazolam (Xanax). She recently had a relationship break-up. She feels her depression is getting worse and she has started to drink again. She appears of average height and weight.

Case Study B Brian is a 20 year old student who complains of problems with concentration and focus. He finds that he forgets to do important things; this forgetfulness has caused problems with his schoolwork and in his relationship with his GF. He has a well documented ADHD history and would like to restart his stimulant. He reports that he likes to party with his friends on the weekends and smokes MJ during the week to help him relax and sleep.

Case Study C Bill is a 21 year old student who presents stating that he has mood swings and can’t sleep. He has a history of binge alcohol and cocaine use, but says he hasn’t had any cocaine in a month.

Presenting Psychiatric Symptoms Dual Diagnosis 6/4/2010 Presenting Psychiatric Symptoms Anxiety Depression Insomnia Psychotic symptoms Disruptive behavior Peter A. DeMaria, Jr., M.D., FASAM

Causes of Psychiatric Symptoms Dual Diagnosis 6/4/2010 Causes of Psychiatric Symptoms Drug intoxication or withdrawal states Medical illness Psychiatric comorbidity Peter A. DeMaria, Jr., M.D., FASAM

The Challenge Mental Illness Dual Diagnosis Substance Use Disorder

Definition of Addictive Disease Addiction is a primary, chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. The disease is often progressive and fatal. It is characterized by continuous or episodic impaired control over drinking or drug use, preoccupation with alcohol or drugs, use of alcohol or drugs despite adverse consequences, and distortion in thinking, most notably denial. (Adapted from the NCADD and ASAM Definition of Alcoholism.)

Chronic Disease Model Prototypes: CAD, HTN, DM Development and course reflect an interplay of genetic vulnerability, pathophysiology, and personal behaviors Treatment focuses on management not cure Goals include highest quality of life Patient must take an active role in treatment Compliance is frequently an issue

Substance Use Is a Spectrum Disorder Abstinence Experimentation Substance abuse Substance dependence

Lifetime Prevalence of Comorbidity - ECA Date Mental Disorders, 22.5% Comorbidity = 29% Alcohol = 22% Other drug = 15% Alcohol Disorder, 13.5% Comorbidity = 45% Psychiatric - 37% Other drug = 22% Other Drug Disorder = 6.1% Comorbidity = 72% Psychiatric = 53% Alcohol = 47% JAMA 264(19):2511-2518,1990

Epidemiology of Dual Diagnosis ECA Study: Alcoholics have 1.5 - 2 x higher incidence of depression than general population Alcoholics: At intake 70% have moderate to severe depression 4 - 6 weeks after detox 10-20% had major depression Psychiatric inpatients at McLean Hospital: 60% of males and 40% of females met criteria for alcohol or drug abuse or dependence

Epidemiology of Dual Diagnosis Cocaine addicts at McLean Hospital: 27% had affective illness. Opiate addicts: 54% had lifetime incidence and 24% had current episode of major depression. 15.2% of respondents in the NCS who had ADHD met criteria for any substance use disorder (3 x the rate of respondents without ADHD).

The Biopsychosocial Spiritual Orientation Biological Spiritual Social Psychological

The Biopsychosocial Spiritual Orientation Biological Genetics Health issues Brain chemistry Social Living unit Relationships Work/school Cultural factors Spiritual Organizing principles Morals/ethics Psychological Self esteem Identity Object relations Drives/defenses/ conflicts Developmental history Trauma/abuse Personality traits Relationships

“Dual diagnosis is an expectation, not an exception.” -Dr. Kenneth Minkoff www.kenminkoff.com

The Four Quadrant Model for Co-Occurring Disorders Both High Severity Mental Illness Low Severity Substance Use Disorder High Severity Both Low Severity A guide to treatment planning.

Disorder Parallels Addiction Major Mental Illness A biological illness Heredity (in part) Chronic disease Incurable Leads to lack of control of behavior and emotions Positive & negative symptoms

Disorder Parallels Addiction Major Mental Illness Affects the whole family Progression of the disease without treatment Symptoms can be controlled with proper treatment Disease of denial Facing the disease can lead to depression & despair

Disorder Parallels Addiction Major Mental Illness Disease is often seen as a “moral issue” due to personal weakness rather than having biological causes Feelings of guilt and failure Feelings of shame and stigma Physical, mental, & spiritual disease

Screening-Assessment-Treatment High index of suspicion Screen everyone; revisit regularly Assess which Stage of Change Engage in treatment Use Motivational Interviewing techniques Use behavioral/contingency contacts Involve others Consult/Refer

Stages of Change Precontemplation Contemplation Preparation Action Maintenance

Differentiating Substance Related Disorders from Psychiatric Disorders Relationship of symptoms to drug use Which came first? Presence of symptoms during periods of sobriety Past treatment history Atypical presentation Poor or unpredictable response to treatment Family history-psychiatric or addiction Look for common co-morbidities: Bipolar disorder and alcoholism ADHD and substance abuse Cluster B personality traits/disorder

General Approach to the Dual Diagnosis Patient Comprehensive biopsychosocial spiritual assessment. Engage patient in treatment and develop a therapeutic relationship. Develop a treatment plan Addressing both psychiatric & addiction issues Assess response Adjust treatment plan

Treatment Planning Treatment planning must be individualized. The treatment plan must follow a careful assessment. The treatment plan is not static, it is dynamic and changes as the providers learns more and the patient changes with interventions. Develop a treatment team utilizing the expertise in other clinicians. Ensure regular and thorough communication between all treatment team members.

Possible Treatment Modalities Individual counseling/therapy (psychiatric/addiction) Group counseling/therapy (psychiatric/addiction) Self-help (12 step) programs Behavioral/contingency management Couple’s Therapy Family therapy Disability Resources & Services Involvement IOP/Partial hospitalization Inpatient psychiatric (dual diagnosis) hospitalization Psychotropic medication (psychiatric/addiction)

Issues Specific to College MH Practice Hospitalization necessary/indicated? Treat in-house or refer out? Is drug screening available? Must the student be clean for everything? If not, what is acceptable? What support is available on campus?

Pharmacotherapy of Addictive Disorders Detoxification Aversive agents Disulfiram (Antabuse) Anti-craving Agents Naltrexone (ReVia, Vivitrol) Acamprosate (Campral) Bupropion (Wellbutrin, Zyban) Varenicline (Chantix)

Pharmacotherapy of Addictive Disorders Maintenance pharmacotherapy Nicotine replacement therapy (NRT) Patch, gum, inhaler, lozenge Opioid maintenance pharmacotherapy Methadone Buprenorphine (Subutex/Suboxone)

General Approach to Psychopharmacology Use biopsychosocial spiritual model Avoid addictive substances (e.g. BZ) Treat psychiatric condition if it prevents engagement in addiction treatment. Avoid making psychiatric diagnosis and initiating medication until 2-4 weeks into abstinence from substances. Less is better

Case Study A Anne is a 19 year old student who tells you that she has been diagnosed with ADHD, anorexia nervosa, depression, borderline personality disorder and alcoholism. She is prescribed methylphenidate (Concerta), citalopram (Celexa), quetiapine (Seroquel) and alprazolam (Xanax). She recently had a relationship break-up. She feels her depression is getting worse and she has started to drink again. She appears of average height and weight.

Case Study B Brian is a 20 year old student who complains of problems with concentration and focus. He finds that he forgets to do important things; this forgetfulness has caused problems with his schoolwork and in his relationship with his GF. He has a well documented ADHD history and would like to restart his stimulant. He reports that he likes to party with his friends on the weekends and smokes MJ during the week to help him relax and sleep.

Case Study C Bill is a 21 year old student who presents stating that he has mood swings and can’t sleep. He has a history of binge alcohol and cocaine use, but says he hasn’t had any cocaine in a month.