Comorbidity Detection of Comorbidity What are the barriers

Comorbidity

Detection of Comorbidity • What are the barriers to GPs asking about AOD-related issues? • What are the barriers to GPs asking about mental health issues? • What prevents patients from raising these issues with their GP? • How can these problems be overcome? Comorbidity

Comorbidity “. . . is a theoretical concept that refers to having more than one disorder at various times. It indicates vulnerability to illness and points to disability and higher need to use health services. ” “The coexistence of [both] conditions…is a particular challenge for clinicians as the two. . . combine to produce substantially poorer health and greater impairment of function than would normally be attributed to either on its own…” Andrews et al. (1999, p. 19); Mc. Cabe & Holmwood (2003, p. 5) Comorbidity

“Regardless of whether the substance use and mental health issues are primary, secondary or independent of each other, they become intrinsically connected over time and result in a worsening clinical picture. ” Mc. Cabe & Holmwood (2003, p. 27) Comorbidity

Of the 25% of adults who experience a mental health problem in any one year, the majority will have a concurrent AOD-related problem. Comorbidity

Comorbid Affective, Anxiety and Substance Use Disorders (Australian Males, 1999) Substance Use 1. 4 8. 3 Anxiety 3. 6 0. 8 0. 6 1. 3 Affective 1. 4 Teesson and Burns (2001, p. 8) Comorbidity

Comorbid Affective, Anxiety and Substance Use Disorders (Australian Females, 1999) Anxiety 3. 1 7. 3 Affective 3. 2 0. 8 0. 9 0. 3 Substance Use 2. 4 Teesson and Burns (2001, p. 8) Comorbidity

“The problem with GPs is that they are in an ideal position to do everything!” As GPs see 85% of the population each year, GPs are well placed to offer: – early detection and accurate diagnosis of comorbidity – information and treatment options – brief interventions (for those with low disability) – referral and coordinated care – medical treatment for health issues – family support – long-term monitoring and follow-up. Comorbidity

A Vital Role for the GP • GPs can readily detect coexisting problems early • There is evidence that GPs can successfully contribute to the management of these cases with good outcomes • Resourcing is an issue for most public health services, so opportunistic GP intervention is often crucial • Many GPs feel there are barriers to managing comorbidity including lack of training and time, inadequate back-up. Comorbidity

Detection GPs routinely need to ask about both mental health and AOD issues since: • only 50% of depressed individuals tend to raise the issue of depression with their GPs, and • only 10% of those with AOD-related problems raise the issue with their GP. If one problem is revealed, always ask about the other Comorbidity

Comorbidity • GPs see many comorbid cases, and are often the first or only point of contact with health services • Around a quarter of those with a mental health problem in a 12 month period will have a coexisting AOD-related problem • Nearly half the women and a third of men with mental health problems will have an alcohol use disorder • Between a quarter and a third of those who have ever had a psychotic episode will have had an alcohol and/or cannabis problem / dependence. Comorbidity

Why Such a High Rate? • High-risk use of AODs can precipitate or exacerbate mental health problems: – psychosis in the mentally vulnerable (esp. from cannabis and stimulants) – depression (esp. from alcohol) – anxiety / social and phobia / panic attacks (esp. alcohol & benzodiazepines) • Shared underlying causes / antecedents – genetics – environmental influences • ‘Self-medication’ hypothesis (controversial). Problematic AOD use and mental health problems share many antecedents. Comorbidity

Some Comorbid Associations • Increased rates of violence (perpetrator and victims) • Homelessness • Poor treatment compliance • Reduced or potentiated effect of medication • Slower recovery from AOD-related problems • Higher suicide rates. Comorbidity

Courtesy of Dr. John Sherman, St. Kilda Medical Centre Comorbidity

Courtesy of Dr. John Sherman, St. Kilda Medical Centre Comorbidity

Suicide and AOD Use • Psychoactive drugs are present at autopsy in 30 – 50% of suicides • Intoxication predisposes to suicide in those at risk by: – disinhibiting usual constraints on the person – providing ‘courage’ – clouding judgement and the ability to see alternatives – deepening mood or worsening psychosis – misadventure. Comorbidity

Screening & Assessment (1) • Screen for high-risk AOD use in those presenting with mental health problems and vice versa • Which came first? – do the mental health symptoms persist after withdrawal & during periods of prolonged abstinence? – is there a family history of mental health problems and/or AOD dependence? – did the symptoms of the mental health problems predate problematic AOD use? Comorbidity

Screening & Assessment (2) • How are the mental health problems and AOD use impacting on each other? • How are the problems impacting on the patient’s broad psychosocial functioning? (Inquire as for any mental health and AOD assessment) • Multiple reviews may be required if the clinical presentation fluctuates • Where managed withdrawal is indicated, facilitate ongoing review, and engage the patient in the care plan. Comorbidity

To Improve Assessment Accuracy • Assess when psychologically stable (not withdrawing) • Use self-report plus other information (family, bloods, urine tests etc. ) • Assure confidentiality • Evaluate reasons for possible inaccuracies and address these • Use simple, direct, open-ended questions and clear time frames • Routinely asking about drug use normalises use therefore increases likelihood of genuine response • Repeat over time if possible. Comorbidity

A Suitable Approach Requires • An accurate assessment of both problems • A focus on patient difficulties rather than a diagnosis • Good patient–GP rapport (esp. knowledge of patient) to identify recreational drug effects on clinical presentations, and assist self-report accuracy • GPs to recognise the many valid reasons that people have for using psychoactive drugs • Awareness of potential interactions between drug use and mental health problems to ensure treatment is appropriate and effective. Comorbidity

Management of Comorbidity • Based on patient’s ‘readiness to change’ • Aim to increase awareness of the impact of each problem • Involve family / carers • Withdrawal management may assist long-term engagement in care • Include: – information provision – structured problem-solving – motivational interviewing – brief behavioural or cognitive approaches. Comorbidity

A Behavioural Approach to Intervention Behavioural Symptom Checklist • Loss of motivation • Apathy and indifference • Decreased productivity • Difficulty problem-solving • Social withdrawal • Difficulty setting goals • Impaired ability to make decisions. Comorbidity

Pharmacological Approaches • Avoid using drugs of dependence (e. g. , methadone, buprenorphine) unless they are part of your treatment plan • Only short-term use of (longer acting) BZDs • To identify cause of symptoms, consider role of: – prescribed medications – other drug use – drug interactions • ‘Drug-seeking’ behaviour may necessitate a limited prescribing plan. Comorbidity

Time Frames for Symptom Abatement with Abstinence • Depression and anxiety due to alcohol dependence: 4– 6 weeks (maybe longer) • Psychosis due to amphetamines and/or cannabis: 7– 10 days • Prolonged symptoms beyond these periods suggest an underlying mental health problem. Comorbidity

Engaging the Patient • A non-confrontational approach is essential to retain the patient in treatment – a demanding approach can be stressful and exacerbate mental health problems • Discuss problem definition and negotiate management options with the patient • May require assertive care and involuntary management to protect the patient or others • Try to engage in the long term. Comorbidity

Shared Care • Integrated ‘shared care’ is essential: – patients tend to move between services (different services may fulfil different patient needs) – a range of skills and approaches is required to meet the multiple needs of these patients – involve supportive family / friends and carers whenever possible • Referral is essential if: – at risk of harm to self or others – florid symptoms require psychiatric intervention – withdrawal is likely to be complicated – lifestyle remains chaotic – patient has poor psychosocial support. Comorbidity

Structured Management (1) • Attend to both disorders concurrently (‘integrated treatment’) – do not prioritise one at the expense of the other • Attempt to enhance motivation with a simplified form of motivational interviewing: – reasons for use, relationship between use and mental health problems, concerns about use – difficult if lifestyle is unlikely to improve after ceasing high-risk AOD use. Comorbidity

Structured Management (2) • Set small, highly achievable goals • Take a structured problem-solving and skills-enhancement approach • Harm reduction is a priority – this population is at high risk of: – contracting blood-borne viruses – poor nutrition – accidents. Recognise that few patients will desire abstinence. Comorbidity

Prescribing • Prescribe medication cautiously (assume some AOD use will persist, with a risk of adverse interactions) • Medication is generally less effective in treating mental health problems if high-risk AOD use persists • Anticraving medication can be considered. Comorbidity

Longer-term Management • Psychological interventions are often not as effective, or may be totally ineffective esp. in the short term, when high-risk AOD use persists • Accept multiple lapses in AOD use in this group as the norm: – relapse hotlines and support are essential • Long-term support often required: – actively encourage suitable accommodation, nutrition, social supports. Comorbidity

Referral Consider referral when: – self-harm or risk to others is present – acute exacerbation of mental disorder occurs – drug dependence with major associated problems (legal, health, social) is present – complicated withdrawal is anticipated. Develop links between mental health and local AOD services (where they exist) Comorbidity