MENTAL HEALTH & Substance Abuse
Concurrent Disorders
SWRK 2083
Keith Cameron, M.A., M.B.A.
Agenda
Week 1
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Introduction
Course Outline & Administrative Issues
Introduction to Concurrent Disorders
Definition of Key Term
Clinical Complexity
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Class practical exercises
Introduction
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Keith Cameron, M.A., M.B.A.
Contact Information
 Kcameron75@gmail.com
 No contact at the College
Web site:
 http://www.cameke.pbworks.com
It is your responsibility to access the web-site for power
point presentations
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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 Outline
EVALUATION SYSTEM:
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Week 3 – Multiple Choice Quiz (20%)
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Week 4 – Small Group Work – 3 maximum (30%)
Week 7 – Final Multiple Choice (40%)
Attendance (10%)
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Open book and work in pairs
Those that have been granted job status will be prorated out of 90
Religious holidays. It is the student’s responsibility to discuss
this issue with your professor at least one week before the
holiday.
Students registered with Disability Services are required to
supply confirming documentation to the professor and inform
him/her of any plans to write tests in private
 It
is your responsibility to read and
understand the course outline. Ask if you
are not sure
Course Outline
– Cont’d
ASSIGNMENT POLICY: PLS. READ CAREFULLY!
 Group work is submitted at the end of class.
 If 1 assignment is missed
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You must contact the professor
at the latest ( no documentation is required)
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by email
If you have contacted the professor, only then will be eligible
for a make up after the final test on week 7
If you miss a second assignment:
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on the day of the assignment
You must contact the professor on the day of the assignment and
must provide documentation within one week to access any
accommodation
Groups will consist of 3 members
Each member is to participate in written response
Members are expected to participate equally and remain until the work is
completed.
Groups who sign in a missing group participant will be liable for sanctions
as a whole ( i.e. 0 on that assignment)
To view George Brown College policies go to www.gbrownc.on.ca/policies
General Comments
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Please ask questions
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If you don’t know others also don’t know
It is your right to have explanations and clarifications
Very often there are not right and wrong answers
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I would request that any backbench talking be done outside the
class
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This is disturbing to me and the rest of the class
I will not talk above other people
Turn cell phones off
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Because I say it doesn’t mean it is right
If there is an emergency call awaiting let me know
Keep assignments including scantrons in case of a
discrepancy in marks. No marks will changed without this
back-up support
A Few Pointers
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Readings
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Reading package available at College
Note that when you first open “Health
Canada” document it is in Roman numerals –
keep scrolling down until you get to the page
numbers
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Note page number on the document will not
correspond to the scroll down pages on the left
Mental Illness..................S. Abuse:
How we define them
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Context of Behaviour
Social Deviance
Persistence of
maladaptive
behaviours
Subjective distress
Severity
Impact on functioning
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Tolerance
Withdrawal symptoms
Need more, same effect
Persistent drive for
substance, or failure to
cut back
Time spent getting it
Reduce social/work
activities
Use despite health/social
problems
Some Themes for the Course
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Complexity
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Assessing Concurrent Disorders (CD)
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What came first?
What do we treat first
Causes of CD
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What came first?
What do we treat?
Treatment
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Numerous MH disorders combined with different disorders
Age/demographics
What went wrong in childhood?
Focus
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Mood + Alcohol
Anxiety + Alcohol
Psychosis & Cannabis
Definition
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What is your understanding of the
term Concurrent Disorders
What it is not!
What do We Mean by Concurrent
Disorders?
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At least one mental health disorder as defined
by DSM-IV
Plus substance abuse or dependence as defined
by DSM-IV
Multi combinations and variations, including
multi-morbidity
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Across drugs
Across mental disorders
Demographics/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 Canada
(Similar in the USA)
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“A combination of
mental/emotional/psychiatric problems
with the abuse of alcohol and/or other
psychoactive drugs…any combination of
mental health and substance use
disorders, as defined in DSM IV.”
(Cooper & Calderwood
in readings)
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In definition, the DSM–IV is used as the
tool for diagnosis (Axis 1 & 2)
Some Terms
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CAMI: chemically abusing – mentally ill
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MICA: Mentally ill – chemically abusing
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SAMI: Substance abusing – mentally ill
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Co-occurring (the US)
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‘Double-jeopardy’
What is a Dual Disorder??
Not Dual Disorders
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People with MH + Substance abuse may
have more than 2 disorders
Dual Disorders
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In Canada, refers to Developmental Delay & a
Mental Health issue
Concurrent Disorders
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In Canada, captures complexity of substance
abuse with mh
Prevalence Data
From Journal of American Medical Association
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Large overlap: between substance use and
mental health disorders
Most clients who actually seek treatment
have a concurrent disorder
Some Stats
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50% of seriously mentally ill affected by
substance abuse
90% of mentally ill smoke heavily
77% of those treated for alcohol-related
disorders have experienced at least one
other psychiatric disorder in their lifetimes.
Some Specifics
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Schizophrenia
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47% also have a substance abuse disorder,
which is 4x the risk of the general population
Bipolar Disorder
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61% also had a substance abuse disorder
which is 5x the risk of the general population
Specific Risks
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Compared to general population the
lifetime risk for developing alcohol
dependence is:
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21 times higher for Antisocial Personality
6 timers higher for those with Mania
4x higher for those with schizophrenia
2x higher for those with panic disorder, major
depression, & OCD
Most Common Combinations
Specifically
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Mood Disorder plus Alcohol
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Anxiety Disorder plus Alcohol
Five Most Common Groupings
(Health Canada)
4.
Substance
Disorders
Substance
Substance
Substance
5.
Other Substance Use & MH
1.
2.
3.
Use + Mood & Anxiety
Use + Severe & Persistent MH
Use & Personality Disorders
Use + Eating Disorders
Key to Practitioners
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Only a minority of substance abusers and
those with mental health problems reach
out for help….but…
“…those in the general population with
concurrent disorders present the highest
probability of seeking treatment.” Kessler
Key---
US Study: Respondents with alcohol use
disorders were five times as likely to see
help when they also had a mental health
problem.
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“Those who seek help are the most severe
cases in the general population…and are more
often readmitted to treatment.”
Article: “Multiple Identities, Multiple
Barriers”: U. Chandraseskera
“Intersectionality:”
‘The experience of living with
multiple stigmatized identities,
facing multiple layers of
discrimination.’
Complexity = Multiple Identities
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Each with its own unique issues…
S Abuse
M Illness
Class
New
Canadian
Gender
LGBTQ
People of Color
Consequences of Having a Concurrent
Disorder
Statistically, clients have a greater propensity for violence,
medication non-compliance, and failure to respond to
treatment…compared with clients with substance abuse
only or mental illness only
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“These consumers are in and out of hospitals and
treatment programs without lasting success.” (NAMI)
Treatment takes longer to work
Consequences --
‘Downward Drift’:
Mental illness lands clients in poor
housing, in neighborhoods where drug use
prevails…inability to form social
relationships, isolation can lead to joining
the drug sub-culture
Consequences --
Leads to homelessness or jail:
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Half of the mentally ill homeless have substance
abuse problems
31% a concurrent disorder
16% of prison inmates have concurrent
disorders
Leads to overall poorer physical health and
greater chance of relapse
“these consumers are in and out of hospital and
treatment programs without lasting success.” (Nami)
Services lack integration
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“Often only one of the disorders is
identified. If both are recognized, the
individual may bounce back and forth
between services, or be refused service by
one of them….Fragmented and
uncoordinated services create a service
gap for persons with co-occurring
disorders.” (NAMI)
Why CD Clients Quit Treatment
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Enter treatment in crisis or chronic state
Therapeutic alliance tougher to establish
Treatment streams not integrated (one
disorder recognized)
Clients need longer-term treatment that
many agencies do not offer
Pattern of failed relationships, abuse:
attachment issues
Double Stigma
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Is it better to be drug user or a mental health
consumer?
Mental Health
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Becoming less stigmatized
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More education
Better outcomes
Addictions
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Still seen as a moral failure
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Judged more harshly
Internalized Stigma
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Addiction: harsh judgment by our culture
creates more durable internal stigma
Beliefs: I’m a loser, I’m a bad person, I
don’t deserve help, I don’t deserve love
1+1 = more than 2
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Substances make MH
problems worse
Substances mimic or
hide MH problems
Substances used to
relieve MH symptoms
(Self-medication)
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Substances can make
MH meds less
effective
Substances can lead
to clients forgetting to
take MH meds
Relapse with one
triggers symptoms of
other problem
Consequences for Treatment
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Overall, poor outcomes: chronic course
Poor physical health
High relapse rates
‘Recidivism’
So: clients more likely to seek help, and
also to quit help
Treatment
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“Co-existing mental disorders increase the
probability of abandoning treatment
prematurely.”
 WHY?
How Many Concurrent
Combinations Are There?
Bio-Psycho Social Model
Review
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A framework that incorporates the
NATURE vs. NURTURE controversy
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Examines the positive strengths of the consumer
Recognizes the biological predisposition of mental
illnesses & addictions
Recognizes the negative and positive elements in the
environment
Organizes information in a way that can be
communicated and include the consumer in decision
making
Recognizes the importance of the consumer in the
treatment process
Group Assignment
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As a group list your experience the last time
you drank a lot of alcohol?
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Biological/Psychological/Social-Spiritual +
Behavioural
Biological
Psychological
Social
Behavioural
List Features of Depression
Consider such things as thinking, judgment, inherited vulnerability,
depressed CNS, memory, social functioning, mood
Biological
Psychological
Social
Behavioural
Alcohol Abuse vs. Depression
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How do we distinguish depression and alcohol
abuse?
Does alcohol abuse mask depression?
Which came first?
Does one cause the other?
Are they both hereditary or environmental?
Common pathway
Assessment is challenging
Add Other Factors That May Affect
Assessment and Treatment