1. Workshop What do mental health workers need to know? June 2006 Gary Croton Eastern Hume Dual Diagnosis Service Dual Diagnosis introduction for mental health workers

2. Prevalence Harms Demand Policy This presentation…. Potential Terminology Definitions DDx cohorts Making sense of it Relai’/ps b/t the disorders What is DDx? Why does it matter?

3. What is DDx?

4. Terminology ‘ Dual Diagnosis’ ‘Comorbidity’ ‘Co-occurring Disorders’ definition: co-occurrence of any Mental Health Disorder with any Substance Use Disorder Other terms: ‘Concurrent disorders’….. ‘MICA’….. ‘MISA’…. ‘CAMI’…. ‘SAMI’…. ‘MISUD’….. c.f. ‘dual disability’: people with both intellectual disability and mental illness Definitions

5. DDx cohorts Great variety in… Combinations of disorders Severity of disorders Treatment needs

6. Common dual diagnosis presentations 1. To Primary Care / General Practice Depression with alcohol abuse or dependence Early psychosis with cannabis abuse or dependence Anxiety with alcohol abuse or dependence DDx cohorts

7. Common dual diagnosis presentations 2. To an AT&OD treatment agency Alcohol dependence with anxiety &/or depression symptoms or disorder Amphetamine abuse with paranoid symptoms Opiate abuse or dependence with personality disorder DDx cohorts

8. Common dual diagnosis presentations 3. To an Mental Health treatment agency Schizophrenia with alcohol, cannabis or polydrug abuse or dependence Personality disorder with episodic polydrug abuse Mood disorder with stimulant or depressant abuse or dependence DDx cohorts

9. DDx cohorts - Organic mental disorders -Disorders with childhood/ adol’nce onset - Disorders of Psyc’al develop’nt Disorders of personality - Neurotic disorders - Mood disorders - Schizophrenia & delusional disorders - Multiple drug use - Volatile solvents - Tobacco - Hallucinogens - Other stimulants - Cocaine - Sedatives or hypnotics - Cannabinoids - Opioids - Alcohol - Acute intoxication - Harmful use - Dependence syndrome - Withdrawal state - Withdrawal state with delirium MENTAL DISORDER CLINICAL STATE SUBSTANCE ICD-10 combinations of disorders

10. How do I make sense of it? DDx cohorts

11. Tier 1 Lo MH & or Lo SUD with or without COD Tier 2 Hi SUD with or without MH Specialist mental health Clinical & PDRSS Specialist AT&OD Possibly PMH teams Primary Care General Practice Community Health DDx cohorts How do I make sense of it? Tier 3 Hi MH with or without SUD Victorian DHS Policy: Dual Diagnosis Key directions and priorities for service development March 2006

12. 4 models: 1.Common risk factors: - Genetic risk factors - Trauma - Poor cognitive functioning 2. MH causes SUD 3. SUD causes MH 4. Bi- directional - MHD ↑ vulnerability to SUD - Self medication - ↓ dysphoria - Super sensitivity - Amphetamine psychosis - Cannabis psychosis? - Ongoing interaction Relationships b/t the disorders

13. What maintains the comorbidity is the most relevant to treatment Relationships b/t the disorders More than 1 model may apply at different times

14. Why does DDx matter?

15. Prevalence Co-occurring disorders are common in the general population Key messages In treatment populations co-occurring disorders are the expectation not the exception Having 1 of the disorders substantially increases your risk of also developing the other disorder Prevalence of particular combinations of disorders varies with different treatment settings

16. Prevalence General Population Mental Health General Practice AT&OD treatment

17. Prevalence General Population Alcohol dependent: 4.5 x more likely to also have an Affective disorder 4.4 x more likely to also have an Anxiety disorder Cannabis dependent: 4.3 x more likely to also have an Anxiety disorder Tobacco users 2.2 x more likely to also have an Affective disorder 2.4 x more likely to also have an Anxiety disorder. Australian population / any 12-month period Anxiety Disorder: 9.7%, Substance Use Disorder: 7.7% Mood Disorder: 5.8% 1 in 4 with one of the disorders also had one of the other disorders!! 1997 NSMHW

18. Prevalence General Practice Hickie et al, 2001 study: (n=46,515) Comorbidity of common mental disorders & alcohol or other substance misuse in Australian general practice Prevalence of mental health &/or substance use amongst persons attending General Practice Co-occurring mental disorders & substance misuse in patients attending General Practice 56% 12%

19. Prevalence AT&OD treatment Depression &/or Anxiety Disorder Weaver et al, 2002 (UK) Alcohol service users: (n = 62) Drug Service users: (n= 216) Personality Disorder Psychotic Disorder 2 or more psych. disorders 55% 19% 53% 81% Psychotic Disorder Depression or Anxiety Disorder alone Personality Disorder Depression & Anxiety Disorder 8% 36% 37% 68% No MH disorder MH disorder No MH disorder MH disorder 85% 75% 15% 25%

20. Mental Health Prevalence Vic MH Branch 2002 - 24hr census Clinical sample: 45% reported alcohol or drug abuse/ dependence (possible underestimate). - Cannabis abuse/dependence = 37% of all comorbidity - Alcohol abuse/dependence = 31% - Amphetamine abuse/ dependence = 10%.

21. Severely mentally ill: More frequent relapse and hospitalisation Greater housing difficulties & homelessness Violence and exploitation Forensic involvement: Wallace, Mullen and Burgess (2004). - persons with schizophrenia committed 8 x the # of offences as non-schizophrenia matched control group - much higher rates of criminal conviction for persons with schizophrenia with substance abuse than for those without substance abuse problems (68.1% versus 11.7%). Physical disorders Increased treatment costs Carer trauma & loss Blood-borne infections Suicide risk Unemployment / work instability / poverty Harms

22. Demand 2006 Senate Mental Health Inquiry submissions & reports 2003 ‘Out of Hospital, Out of Mind’ 2 top priorities: - Implementation of earlier intervention strategies - Attention to the overlap between mental health & drug & alcohol abuse SANE Mental Health Report card 2004 ‘There are no coherent national strategies covering key issues such as dual diagnosis’ 2005 ‘Not for service’

23. Policy Policy: March 2006 Forum April 2006 1. Dual diagnosis is systematically identified and responded to in a timely evidence-based manner as core business in both mental health and d & a services. Dual Diagnosis: Key directions and priorities for service development Victorian MH & DP&S Branches 2. Staff in mental health and d&a services are dual diagnosis capable (have the necessary knowledge and skills to provide integrated responses to people with dual diagnosis). 5 mandated service development outcomes:

24. Policy 3. Specialist mental health and d&a services develop partnerships for the provision of integrated treatment and care. (No wrong door service system) Dual Diagnosis: Key directions and priorities for service development Victorian MH & DP&S Branches 5. Consumers and carers are involved in the planning and evaluation of service responses. 5 mandated service development outcomes: 4. Client outcomes and service responsiveness to dual diagnosis clients are monitored and regularly reviewed

25. Policy Commonwealth / State COAG: 2006/07 budget: $21.6 mill: campaign alerting community to links b/t illicit drug use & mental health. Federal initiatives $73.9 mill : training/ resources to assist AT&OD workers to provide effective Rx National Comorbidity Initiative ADGP – Managing the mix – primary care initiative National Youth Mental Health Foundation

26. Potential Improving our recognition of and response to co- occurring SUDs will improve the effectiveness of our treatment of mental health disorders

27. References Andrews, G., Hall, W., Teesson, M., Henderson, S. (1999). National survey of mental health and wellbeing: Report 2: The mental health of Australians. Canberra, Department of Health and Aged Care Croton, G. (2005): Australian treatment system’s recognition of and response to co-occurring mental health & substance use disorders Senate Mental Health Inquiry Submission Degenhardt, L., Hall, W., Lynskey, M (2001) Alcohol, cannabis and tobacco use among Australians: a comparison of their associations with other drug use and use disorders, affective and anxiety disorders and psychosis. Addiction 96, 1603-1614.

28. References Groom et al, (2003), ‘Out of Hospital, Out of Mind' Mental Health Council of Australia Hickie, I, Koschera, A, Davenport, T., Naismith, S., Scott, E. Comorbidity of common mental disorders and alcohol or other substance misuse in Australian general practice. Med J Aust. 2001 Jul 16; 175 Suppl: S31-6. Mental Health Council of Australia, (2005) Not For Service: Experiences of Injustice and Despair in Mental Health Care in Australia, Canberra SANE (2004) SANE Mental Health Report 2004

29. References Victorian DHS: Dual Diagnosis: Key directions and priorities for service development. Draft policy version March 2006 Wallace, C., Mullen, P., Burgess, P. (2004). Criminal offending in Schizophrenia over a 25-year period marked by deinstitutionalisation and increasing prevalence of comorbid substance use disorders. Am J Psychiatry 161:4, April 2004. Weaver, T., Madden, P., Charles, V. (2003) Comorbidity of substance misuse and mental illness in community mental health and substance misuse services. BJPsychiatry, 183 304-313 WHO International Statistical Classification of Diseases and Related Health Problems 10th Revision Version for 2006

30. Resources / More info Dual Diagnosis Australia & NZ / Co-occurring disorders roundup www.dualdiagnosis.org.auwww.dualdiagnosis.org.au National Comorbidity Initiative http://www.health.gov.au/internet/wcms/publishing.nsf/Content/healt h-pubhlth-strateg-comorbidity-index.htm http://www.health.gov.au/internet/wcms/publishing.nsf/Content/healt h-pubhlth-strateg-comorbidity-index.htm Managing the Mix http://www.adgp.com.au/site/index.cfm?display=4614 http://www.adgp.com.au/site/index.cfm?display=4614 CCISC model / Drs Ken Minkoff & Christie Cline http://www.kenminkoff.com/index.html http://www.zialogic.org/ TIP 42: Substance Abuse Treatment for Persons With Co-Occurring Disorders http://store.health.org/catalog/ProductDetails.aspx?ProductID=1697 9 http://store.health.org/catalog/ProductDetails.aspx?ProductID=1697 9