2. 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

6. 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)

7. 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’.

8. Prevalence of Dual Diagnosis (The Royal College of Psychiatrists’ Research Unit) AuthorsDateLocationPopulation Lifetime rate of substance use Current rate of substance use Drake & Wallach 1989USA Chronic Mental Health Problems 32% Regier et al. 1990USASchizophrenia47% Barbee1989USA All Patients 47% Duke1994UK Schizophrenia & Alcohol 22%36.6% Menezes1996UKPsychosis32%60% Fowler1998AustraliaSchizophrenia27% Scott1999UKPsychosis Cantwell1999UK 1 st Episode Psychosis 37% 20% drugs 12% alcohol Wright2000UKPsychosis33%13%

9. 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.

10. “Mental disorder and substance misuse sit on separate dimensions each with its own continuum of severity from mild to severe levels.” “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

11. Severity of problematic drug use Severity of mental illness ASSESSMENT: SPECTRUM OF CO-MORBIDITY Adapted from DOH Dual Diagnosis Good Practice Guide Available from www.doh.gov.uk/mentalhealth

12. Why is co-morbidity important? Homelessness or unstable housing Homelessness or unstable housing Interpersonal conflict and family problems Interpersonal conflict and family problems Violence Violence Victim of crime Victim of crime History of sexual, physical and/or emotional abuse History of sexual, physical and/or emotional abuse Suicide and self-harm Suicide and self-harm Poor compliance with medication Poor compliance with medication Treatment recidivism Treatment recidivism Poor prognosis of mental health problems Poor prognosis of mental health problems Increased criminal justice system contact Increased criminal justice system contact Early mortality Early mortality (Drake et al.,1998; Drake et al., 2001; Banerjee et al. (Eds.), 2002) Vulnerability:

13. Integrated treatment Presents fewer hurdles to treatment access for patients with co-morbidity Presents fewer hurdles to treatment access for patients with co-morbidity Better retention in treatment Better retention in treatment Potential to reduce substance misuse and attain remission Potential to reduce substance misuse and attain remission Improved psychological functioning Improved psychological functioning (Drake et al., 1998, Drake & Mueser, 2000; Mueser et al., 1998).

14. Components of effective integrated treatment approaches Close monitoring Close monitoring Case management Case management Assertive outreach Assertive outreach Comprehensive treatment Comprehensive treatment Stepped Care Stepped Care Motivation based intervention Motivation based intervention Longitudinal perspective Longitudinal perspective (Drake et al., 1993; Mueser & Drake, 2003)

15. Comorbidity, Dual Diagnosis (blah blah.....) Transform to:- - Complex needs - Recovery Agenda

16. Complex Needs Mental health problems Mental health problems Substance misuse problems Substance misuse problems Traumatic brain injury/head in jury Traumatic brain injury/head in jury Learning disability Learning disability Literacy and communication skills Literacy and communication skills Personality disorder Personality disorder History of trauma History of trauma

17. Complex Needs II Attention deficit hyperactivity disorder Attention deficit hyperactivity disorder Chronic pain Chronic pain Sleep disorders Sleep disorders Homelessness Homelessness Involvement with criminal justice system Involvement with criminal justice system

18. Complex Needs III Alcohol use: In a general UK population, 40% said alcohol made them feel less anxious, 26% said less depressed. 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. 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. 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. Alcohol and/or drug misuse correlated with more frequent hospitalisations for patients with schizophrenia.

19. Complex Needs IV Benzodiazepine use: Frequent accompaniment to alcohol misuse. Frequent accompaniment to alcohol misuse. Anterograde amnesia associated with benzodiazepine use will impact processing and retention of interventions. Anterograde amnesia associated with benzodiazepine use will impact processing and retention of interventions. Effectiveness of CBT-based interventions reduced with benzodiazepine use. Effectiveness of CBT-based interventions reduced with benzodiazepine use. Mounting evidence for persistent cognitive deficits in chronic 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. 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.