1. CUBE assessment with dual diagnosis patients Olli Kampman Adjunct Professor, Univ Tampere, Medical School, Dept of Psychiatry

2. Dual diagnosis, DD Severe mental disorder (sch, bipolar disorder, severe depression, comorbidity) + at least substance dependency Different determinations, lack of constant terminology

3. Why new assessment method? Need for categorising the DD problem Epidemiological numbers are varying Treatment is not currently based on diagnoses The problem is not recognised or no treatment is available for DD patients Difficult to assess outcome Increasing stigma around the DD problem A comprehensive problem which is more than a sum of ingredients Etc..

4. Cube assessment method Three dimensions: mental disorder, substance abuse, level of functioning Brief and simple assessment Gains information for prognosis evaluation Recognising risks (continuous or habitual problem drinking, social problems, increasing psychic symptoms, poor functioning) Indicator of recovery: follow-up e.g. between 3-6 months

5. Cube model and SUD intervention

6. Cube sub-scores A. Substance abuse: 0/1 B. Mental disorder: 0/1 C. Level of functioning: 0/1 Total risk score 0-3; treatment option depends on this Kampman, Lassila SLL 2007:47

7. Cube (3-dimensional assessment) ScorePrimary intervention 0-1FRAMES 2-3Motivational interview CRA, CRAFT 1 2 3 Psychotic disorder Other Severe Mild to moderate Mental disorder Level of functioning Substance abuse Good Poor 2 2 1 1 0

8. Cube sub-scores (0) A.Substance abuse: Non-complicated dependency no more than 2 yrs B.Mental disorder: Non-psychotic disorder C.Level of functioning: GAF >50

9. Screening of substance abuse: AUDIT

10. Assessment The severity of substance abuse is assessed, if AUDIT score at least 11 A.Substance abuse=0 1.Solely alcohol use (or any other single substance use) 2. Problem within dependency level (and the use at most 3 days/week) 3. Continuous problem less than 2 yrs All above criteria must be fulfilled, otherwise the severity of substance abuse=1

11. Assessment B.Mental disorder (last month) Other than psychotic=0 (depression, anxiety disorder, personality disorders, co-morbidity) Psychotic=1 (schizofrenia, bipolar disorder, other)

12. Assessment C.Level of functioning (last month) 1.GAF>50=0 2.GAF<50=1 GAF? Category 50-41: Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job)

13. 91 - 100 Superior functioning in a wide range of activities, life's problems never seem to get out of hand, is sought out by others because of his or her many positive qualities. No symptoms. 81 - 90 Absent or minimal symptoms (e.g., mild anxiety before an exam), good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns (e.g., an occasional argument with family members). 71 - 80 If symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). 61 - 70 Some mild symptoms (e.g., depressed mood and mild insomnia) OR some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. 51 - 60 Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). 41 - 50 Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). 31 - 40 Some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) OR major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). 21 - 30 Behavior is considerably influenced by delusions or hallucinations OR serious impairment, in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) OR inability to function in almost all areas (e.g., stays in bed all day, no job, home, or friends) 11 - 20 Some danger of hurting self or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement) OR occasionally fails to maintain minimal personal hygiene (e.g., smears feces) OR gross impairment in communication (e.g., largely incoherent or mute). 1 - 10 Persistent danger of severely hurting self or others (e.g., recurrent violence) OR persistent inability to maintain minimal personal hygiene OR serious suicidal act with clear expectation of death.

14. 0 1

15. Assessment and follow-up date 1date 2date 3date 4 A. Substance abuse1100 B.Mental disorder0000 C. Level of functioning1110 Total 2210

16. Cube (3-dimensional assessment) ScorePrimary intervention 0-1FRAMES 2-3Motivational interview CRA, CRAFT 1 2 3 Psychotic disorder Other Severe Mild to moderate Mental disorder Level of functioning Substance abuse Good Poor 2 2 1 1 0

17. Cube model and SUD intervention

18. Assessment and follow-up date 1date 2date 3date 4 A. Substance abuse1100 B.Mental disorder0000 C. Level of functioning1110 Total 2210

19. Cube assessment in Lahti area Local nursing staff participating in regional DD education Five units in SU and psychiatric services (in- and outpatient units) Inclusion criteria mental disorder + harmful SU, consecutive patients during spring 2009 No patient identification, questions to staff Aim: testing validity and usefulness of the Cube assessment

20. Cube assessment in Lahti area: results Patients, n=85, men 2/3, 42±14 yrs. 55% psych. treatm., 45% SU services 45% multiple SU Duration of SUD 17±11v. In 50% dg psychosis (F2), 1/3 mood disorders Cube score (n): 1 (7)2 (30)3 (48) Time used with assessment: 7±3 min. Perceived difficulty of assessment (0-100 VAS): 34±13

21. Cube assessment in Lahti area: results SU duration associated with Cube score (group 2 < 3) Time used with assessment related to Cube score, equally difficult in gr. 2 and 3

22. Prevalence of DD in Ostrobothnia district MHS case count in January 2008 All units in SO (outpatient care 14 days, hospital 28 days) GAF assessment after 6 months according to information in patient records N=1219 (appr. 2/3 of outpatient visits/ hospitalisation periods) AUDIT ≥ 8, n=322

23. Prevalence of DD in Ostrobothnia DiagnosesN (%) Psychoses (F2 + bipolar + psychotic depression) 113 (35.1) Depression (primary dg, non-psychotic)138 (42.9) Current or earlier diagnosis of SUD90 (28.0) Any other substance than alcohol use during last 12 months (self-report) 26 (8.3)

24. Prevalence of DD in Ostrobothnia AUDIT-scoreN (%) 8-1095 (29.5%) 11-15102 (31.7%) 16-2061 (18.9%) yli 2064 (19.9%)

25. Prevalence of DD in Ostrobothnia GAF 50 or belowGAF over 50 N=136 (42.2%)N=186 (57.8%) Psychosis N=79 (58.1%) Psychosis N=32 (17.2%) Depression N=43 (31.6%) Depression N=95 (51.1%) Anxiety disorders N=6 (4.4%) Anxiety disorders N=25 (13.4%)

26. Cube: conclusion Simplifying complex problem Suitable for clinical use Differentiates between psychotic and non- psychotic DD-patients Time of assessment increases with more severe problems, but is still easy Duration of SUD problem is closely connected with the total score