M Rus-Makovec 11 EFTC 2007 Treatment of Addiction and Co-occurent Mental Problems: The Power of...

M Rus-Makovec 11 EFTC 2007

Treatment of Addiction and Co-occurent Mental Problems: The Power of Interdisciplinary Knowledge

Maja Rus MakovecUniversity Psychiatric Hospital Ljubljana

Chair of Psychiatry, Medical Faculty Ljubljana


How people change their behavior? Can we agree:

– People have their own way how they can learn (develop, change …): pressure, support, alone, in group, …; capacity for self-treatment

– Their capacity for change differs in time (“it was not the right time”)

– People are specific mixture of sources of power and vulnerabilities, yet there are some universal features for change

– Addicted people differ: special heterogeneity of legal drugs addiction

– Equifinality of legal drug (alcohol) addiction: there can be different pathways to similar condition


Bio-psycho-social model of addiction

• State-of-art: do not stop at the level of brain neurotransmitter biochemistry but to place a person’s mental dysfunction manifesting itself in their human suffering and certain behavior into the person’s psycho-social context (Eisenberg, 1999).

• Addicted person: does not want to change or can not because of biological or other obstacles? Who or what is responsible for change?

• In western culture learning “per partes” is favoured (Bateson): different levels of experience are rarely co-constructed – “to fell in love” with one’s own experience


“What everybody in addiction professional community should know about co-occurrent mental problems”

• Following co-occurent metal problems with mainly or partly neurobiological basis can severly damage addicted persons’ ability for psycho-social change (and are not only a construct): – neuro-cognitive impairment of working memory

• restrict abilities to receive, encode and integrate the newly introduced information

– dual diagnosis of serious mental disorder (as depression, anxiety, psychosis …)

– trauma experience– personal development resulting in serious personal or

relational disorder (developmental trauma)


What to do with information about co-occurent problems?

• To help patients with co-occurent mental problems efficiently - need for – More patience– More time– More interdisciplinary cooperation

– To have realistic goals of treatment


Different levels of interactions between drug and other mental disorder (co-occurent, dual diagnosis, comorbide

state …)

• Drug or end of drug use can induce depression• Popular theory about drug use as secondary to an

“underlying depressive disorder”• Two mental problems independently at the same time• Each mental problem worsen the other

• Addiction can be extremely dramatic per se and without co-occurrent disorders

• Addiction can be less dramatic in appearance but more reluctant to change because of co-occurrent disorders


Major consequences of comorbidity

• At least one-half of the patients in psychiatric and substance use treatment with comorbid disorder (Regier et al. 1990, Kessler et al. 1994)

• Higher service utilization …

• More severe symptoms …

• Greater functional disability (Bijl, Ravelli, 2000)


One of many perspectives on addiction:

• “Altered and and damaged neurochemistry underlies (their) tragic vulnerability …– the addicts have to struggle with powerful midbraincircuits (Dackis, Gold, 1998)

• Such perspective counters the notion about “lack of will power”: surprising, empowering, respect- and hope-introducing fact is, that so many addicted people challenge their biology efficiently because of right motivation and support

• Some addicted people have such an enormous obstacle of co-occurent mental problems, that they need special help and special context of treatment to reach their human capacity for change


Center for Alcohol Addiction Treatment of University Psychiatric Hospital Ljubljana

• Started in 1970 with phylosophy of therapeutic community, now-a-day “addiction psychiatry – psychotherapy” orientation with some aspects of TC

• 33 slots in inpatient and 30 slots in outpatient treatment for patients with alcohol and benzodiazepine addiction, in last year some patients with previous experience of TC

• After-care: cca 300 visits per month

• Abstinence-based programme: predominantly psychosocial interventions combining with pharmacologic agents for dual diagnosis


• Indications for admission are severe psychosocial or psychiatric conseqences of addiction or difficulties / inability to attain abstinency despite previous attempts.

• Population of patients is not preselected. • Treatment offers (mainly) group psychotherapy and

individual interventions. Heterogenous groups • The program is encouraging admission of patients with

co-occurrent mental (psychiatric) disorders • Patients with severe impairment in neuropsychological

functioning ordinary can not follow the program, as well as acutely suicidal or psychotic patients without long-term stable remission


• Intensive treatment is conceptualised as:– 1st part: in-patient setting– 2nd part: out-patient setting (day-hospital).

• Active participation of important others is stressed as the essential part of the programme.

• After-care recovery is strongly recommended • If comorbide disorders or/and severe interpersonal

problems are identified during the intensive treatment period, psychotherapy (individual, couple, family therapy) or psychiatric care is offered to the patients after discharge


• Team need to negotiate how to combine the focus – on behavioural changes (“rehabilitation”,

normative part of approach) and – non-directive encouragement for increasing

autonomy of patients, attainment of insight and cultivation of the patient / therapist relationship

• “Matching comorbid psychiatric severity in substance-related disorders to treatment program characteristics may be more advantageous because of the emphasis on individualized and specific levels of intensity of treatment “(McLellan, 1993)


Research on effectiveness of addiction treatment programme

• Patients (n = 622) were included in the study consecutively after the admission

• Group 1 (n = 347 at the beginning) was supposed to be followed – at the beginning– at the end of intensive treatment programme– 3, 6, 12 and 24 months after discharge from the intensive

treatment programme

• Group 2 (n = 275 at the beginning) was supposed to be followed– at the beginning– at the end of intensive treatment programme– 24 months after discharge from the intensive treatment program


• Independent variables– Demographic variables – Co morbidity– Treatment context (in- & out-patient)– After-care treatment– Social support in treatment– Time stage in treatment process

• Treatment success critheria / dependent variables– Abstinence (sobriety)– Self-evaluation of mental health, physical health,

financial status, relations with important others, quality of life

– Changes in marital status / partnership– Changes in employment status


• Abstinence / sobriety rate after intensive treatment discharge– 3 months (n = 213): 85 % abstinent– 6 months (n = 177): 84 % abstinent– 12 months (n = 116): abstinent 86 %– 24 months (n = 213): abstinent 80 %

• Included in some form of after-care– 3 months: 60 %– 6 months: 61 %– 12 months: 59 %– 24 months: 58 %


The most frequent co-occurent diagnoses

• After at least 1 months of sobriety the co-occurrence syndromes are diagnosed, avoiding those anxious-depressive symptoms as after-end-of-drinking-cessation should be diagnosed as comorbide/co-ocurrent category

• Depression 19.8 %• Anxiety disorders 11 %

• Personal disorders 20.9 %

• Benzodiazepine dependency 19 %• Nicotine dependency 62.2 %


Comorbide diagnoses and abstinence – no significant risk

found (2, p) • The finding is explained by their inclusion in proper modality of after-care

treatment, combining psychotherapy and pharmacotherapy. • The only vulneralibility regarding length of abstinence was found in smokers at 6

months (x = 5.9 (1), p = 0.015): smokers showed greater percent of probability to relapse than non-smokers at that time of evaluation.

3m 6m 12 m 24 m

Depression 0.35

0.792

0.08

0.767

0.89

0.345

0.50

0.480

Anxiety 0.13

0.714

0.17

0.673

3.0

0.081

1.9

0.163

Personal disorder

0.84

0.357

0.004

0.951

1.9

0.162

1.1

0.302


Accurracy of diagnosis of main comorbide disorders in % - too strict

and especially underdiagnosed anxiety states

• The quality of diagnosing was controlled by Mini International Neuropsychiatric Interview instrument (MINI)

rutine MINI

Depression

Disthymia

19.8 21.4

11.4

Anxiety disorder

Panic

Generalised

PTSD

11

6.4

16.4

3.6


Correlations (r, p) between self-evaluations of

psychological health and n of psychiatric

diagnoses

At the beginning of intense treatment

n = 517

- 0.29

0.000

At the end of intense treatment

n = 427

- 0.25

0.000

3 months aftre discage

n = 204

- 0.39

0.000

6 months after discharge

n = 167

- 0.33

0.000


n = 108

- 0.23

0.018


n = 209 - 0.38

0.000


Problems found in diagnostic procedure

• Dual diagnosis syndromes are hidden behind drug addiction symptoms

• Vice versa, alcohol addiction (also in the early recovery) can mimic almost all psychiatric symptomes

• In the beginning of treatment addicted patients can be more prone to defensive attitude and denial instead to good therapeutic alliance

• Often neuro-cognitive impairment is under-estimated • Alcohol / drugs can force numbing or dissociative

reactions after trauma causing cognitive and emotional distortions of experience– F.e. patient with trauma experience can also be prone to

manipulation


Integrated treatment

• In last years it became apparent that some people can not process stable recovery without concurrently addressing co-occurrent states and psychological trauma dynamics

– before we waited first to stable abstinence before addressing trauma issue, which sometimes never come

– secondly, it was learned that concurrent treatment did not result in more relapses (Carruth, Burke 2006).


• Psychiatric context can offer concurrent treatment for alcohol / drugs addiction and severe co-occurrent mental symptoms including complex symptoms of psychological trauma because of their broad base of clinicians, experienced in addiction, psychiatric and psychotherapeutic fields

• Need for new paradigm in addiction as well in psychiatric context?


Structure of professional and non-professional cooperation in alcohol addiction problem in SI

Social Service

GP•“ordinary”• family medicine

Psychiatry• Detoxification• Dual diagnoses

Somatic hospitals

Clients/patientsdirectly

Addiction psychiatrist• mental out-patient clinics• psychiatric hospital

in-patient treatment day hospital

out-patient treatment

Non-institutional help• AA• Self-help groups• …

After-care (institutional)- »clubs« of treated A- group therapy- family therapy- individual psychotherapy


Not to miss opportunity for efficient help …

• … because of the way we construct our knowledge: we use knowledge that informs us about the territory of our work – we include and exclude what we are trying to think about and “know”

• … disciplinarity as a form of knowledge and the dynamics of oppositionality and competition … (Flaskas 2003)

Meta – knowledge: if we construct our knowledge in systemic way, then we can get pieces of puzzles about

phenomena of addiction together

M Rus-Makovec 11 EFTC 2007 Treatment of Addiction and Co-occurent Mental Problems: The Power of...

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