Module 4: Interaction of

Objectives To be aware of the possible reasons why dual diagnosis occurs To be aware of the specific effects of substances on mental health To be aware of how substance use affects prescribed psychiatric medications

Dual Diagnosis Capabilities Education and Health Promotion: Be able to offer basic but accurate and up to date information and advice about effects of substances on mental and physical health and vice versa. Dual Diagnosis Capability 8 level

Possible links between mental health and substance use Common Causal factor: An underlying factor that increases likelihood of developing both a substance use disorder and mental illness e.g. past trauma or a genetic predisposition. Mental Illness leads to substance use. People with mental illness are more likely to develop substance use problem than those in general population. For example, mental illness may lead to the use of substances as a coping strategy or self-medication. Substance use causes mental illness. Heavy substance use clearly leads to temporary states that mimic psychosis (drug induced psychosis) and/or lead to problems such as depression. Bi-Directional Theory. Mental health symptoms and substance use affect the course of each other in a constantly evolving spiral.

Alcohol and mental health Most commonly used drug by those with mental health problems Depression Anxiety and paranoia Morbid jealousy Delerium Tremens (confusion and psychosis) Organic brain damage For people with schizophrenia –May increase psychotic symptoms –Reduces effectiveness of psychiatric medication

Cannabis and Mental Health Second most commonly used drug by those with mental health problems. In any user cannabis use can cause anxiety, panic attacks, and extreme, but short lived paranoia. Temporary cannabis psychosis Some evidence that regular cannabis use is a contributing factor to the onset of schizophrenia: –cannabis use in teenage years is a predictor of future mental illness. –The earlier a person begins smoking and the heavier they smoke, the greater the risk of future development of schizophrenia. –This effect seems to be stronger in individuals who have other vulnerability factors (Arseneault et al, 2004). People with schizophrenia who smoked cannabis were more likely to relapse quicker and have worse symptoms than those who didn’t use cannabis. (Linszen et al 1994)

Cocaine and Mental Health Less commonly used, mostly urban areas. Cocaine increases levels of dopamine in the brain. (Dopamine-chemical messenger in the brain; high levels have been associated with psychotic symptoms). Even people without a history of psychosis can experience a transient but severe psychosis (“drug- induced psychosis”). Cocaine use in people with schizophrenia seems to increase both severity of symptoms and likelihood of psychiatric relapse when compared to non-drug using people. Can exacerbate or induce a depressive illness as it may deplete natural serotonin levels over time. (Serotonin is the chemical messenger in the brain that is reduced in people with depression)

Opiates and Mental Health Less than 10% of people with schizophrenia use opiates: –relapse of psychotic symptoms commonly occurs during or immediately after withdrawal of opiate or substitute (methadone). –Opiates have mild antipsychotic effects, and therefore use may mask psychosis. –People with acute psychosis should not undergo a rapid detoxification of opiates; the focus of care should be on the stabilisation of their mental state and substitute opioid prescribing (Royal College of Psychiatrists, 2002). Opiates: more commonly used by people who also have depression, anxiety, and/or personality disorders rather than psychotic illness.

Anti-depressants and Substance use Alcohol will reduce effectiveness of anti- depressants- is it worth prescribing? Mono oxidase inhibitors are contraindicated with stimulants such as amphetamines (hypertensive crisis) drinking increases risk of impulsive self- harm therefore avoid “toxic” anti- depressants such as tricyclics

Anti-psychotics and Substance Use People with dual diagnosis are at greater risk of extrapyramidal side- effects and tardive dyskinesia (movement disorders). People who use drugs and alcohol have worse outcomes on typical antipsychotics (e.g. chlorpromazine) Atypicals prefered due to low profile of EPSE (e.g. Olanzapine) Alcohol and other drugs may reduce plasma level of antipsychotic (may need higher dose) Antipsychotics may help provide a level of protection from adverse effects of substances by blocking dopamine receptors No need to discontinue anti-psychotics even if person regularly uses drugs. However, substance use mixed with anti-psychotics may cause drop in blood pressure, increased sedation, and high temperatures so regular health monitoring is vital.

Benzodiazepines and Substance Use Benzodiazepines (tranquillisers) such as diazepam are highly addictive and very difficult to withdraw from. High doses of benzo’s act like alcohol leading to paranoia, disinhibition and aggression. They interact with other depressants (alcohol, heroin etc) increasing sedative effect and toxicity If mixed with depressants, can lead to accidental overdose and death. Have a high “street value”. Prescription of benzo’s should be for short term (2 weeks) treatment for anxiety only.