SAMH Mental Health & Alcohol
Conference
Transforming the concept of
Dual Diagnosis to the concept
of Complex Needs
Dr Fraser Shaw
Consultant Psychiatrist in Addictions, West Dunbartonshire
Fraser.Shaw@ggc.scot.nhs.uk
What is ‘dual diagnosis’ or ‘comorbidity’?
Two overlapping but discernible subgroups of patients:• Those with a major substance misuse disorder and
another major psychiatric illness.
• Those who use alcohol and/or drugs in ways that
affect course and treatment of their mental illness.
(Guehaly, 1990)
Prevalence
Depends on who is asking, how, what, where etc!
• OPCS institutional survey, UK (Farrell et al 1998) - 7% of
those with schizophrenia reported ‘ever’ using drugs.
• Croydon, UK outpatients (Wright et al 2000) - 33% lifetime,
10% current prevalence of ‘substance misuse’ in cohort with
regular CMHT contact.
• Inner city USA inpatients (Brady et al 1991) 64% lifetime
prevalence of ‘substance abuse’.
Prevalence of Dual Diagnosis (The Royal College of Psychiatrists’ Research Unit)
Authors
Date
Location
Population
Lifetime rate of
substance use
Current rate of
substance use
Drake &
Wallach
1989
USA
Chronic Mental Health
Problems
32%
Regier et al.
1990
USA
Schizophrenia
47%
Barbee
1989
USA
All Patients
47%
Duke
1994
UK
Schizophrenia &
Alcohol
22%
36.6%
Menezes
1996
UK
Psychosis
32%
60%
Fowler
1998
Australia
Schizophrenia
27%
Scott
1999
UK
Psychosis
Cantwell
1999
UK
1st Episode Psychosis
Wright
2000
UK
Psychosis
37%
20% drugs
12% alcohol
33%
13%
• Bipolar disorder has the greatest risk of any Axis 1
disorder for substance misuse comorbidity.
• People with schizophrenia three times more likely than
those without to abuse alcohol, six times more likely to
abuse drugs.
• Comorbid schizophrenics have higher rates of inpatient
care and intensive crisis support.
“Mental disorder and substance
misuse sit on separate dimensions
each with its own continuum of
severity from mild to severe levels.”
Banerjee , Clancy and Crome (Eds), (2002)
The Royal College of Psychiatrists’ Research Unit
ASSESSMENT: SPECTRUM OF CO-MORBIDITY
Severity of problematic drug use
HIGH
Dependent drinker who
experiences increasing anxiety
Person with schizophrenia who
misuses Cannabis on a daily basis
to compensate for social isolation
Severity of mental illness
LOW
HIGH
Recreational misuser of dance
drugs who has begun to
struggle with low mood after
weekend use
Person with bi-polar disorder
whose occasional binge drinking
& experimental use of other
substances de-stabilises their
mental health
LOW
Adapted from DOH Dual Diagnosis Good Practice Guide
Available from www.doh.gov.uk/mentalhealth
Why is co-morbidity important?
Vulnerability:
•
•
•
•
•
•
Homelessness or
unstable housing
Interpersonal conflict
and family problems
Violence
Victim of crime
History of sexual,
physical and/or
emotional abuse
Suicide and self-harm
•
•
•
•
•
Poor compliance with
medication
Treatment recidivism
Poor prognosis of
mental health problems
Increased criminal
justice system contact
Early mortality
(Drake et al.,1998; Drake et al., 2001; Banerjee et al. (Eds.), 2002)
Integrated treatment
•
Presents fewer hurdles to treatment access
for patients with co-morbidity
•
Better retention in treatment
•
Potential to reduce substance misuse and
attain remission
•
Improved psychological functioning
(Drake et al., 1998, Drake & Mueser, 2000; Mueser et al., 1998).
Components of effective integrated
treatment approaches
•
Close monitoring
•
Case management
•
Assertive outreach
•
Comprehensive treatment
•
Stepped Care
•
Motivation based intervention
•
Longitudinal perspective
(Drake et al., 1993; Mueser & Drake, 2003)
Comorbidity, Dual Diagnosis (blah blah.....)
Transform to:-
- Complex needs
- Recovery Agenda
Complex Needs
•
Mental health problems
•
Substance misuse problems
•
Traumatic brain injury/head in jury
•
Learning disability
•
Literacy and communication skills
•
Personality disorder
•
History of trauma
Complex Needs II
•
Attention deficit hyperactivity disorder
•
Chronic pain
•
Sleep disorders
•
Homelessness
•
Involvement with criminal justice system
Complex Needs III
Alcohol use:
•
In a general UK population, 40% said alcohol made them feel
less anxious, 26% said less depressed.
•
Up to 65% of suicides have been linked to excessive alcohol
use.
•
Specific anxiety disorders and/or depression were found to be
related to frequent and/or heavy alcohol misuse in a primary care
setting.
•
Alcohol and/or drug misuse correlated with more frequent
hospitalisations for patients with schizophrenia.
Complex Needs IV
Benzodiazepine use:
•
Frequent accompaniment to alcohol misuse.
•
Anterograde amnesia associated with benzodiazepine use will impact
processing and retention of interventions.
•
Effectiveness of CBT-based interventions reduced with benzodiazepine
use.
•
Mounting evidence for persistent cognitive deficits in chronic
benzodiazepine use.
Other drug use:
•
Study of methadone maintenance patients found impairment across all
cognitive domains. Lifetime diagnosis of alcohol dependence, and
number of non-fatal heroin overdoses, were independent predictors.