Strategies for Effective Case-Planning in Clients with

Co-Occurring Mental Illness and Substance Use Disorders

Christina M. Delos Reyes, MDChief Clinical OfficerADAMHS Board of Cuyahoga County

Ohio Justice Alliance for Community Corrections

Conference

October 10, 2013

www.centerforebp.case.edu

Learning Objectives

Overview of mental illnesses and addiction Strategic approach to clients with co-occurring

mental illness and substance use disorders Principles of differential diagnosis to understand

client non-adherence and resistance to change How to write an effective case-plan, which takes into

account individual client needs and goals

The Human Brain

Most complex organ in the body Different brain areas control different things:

– Brain stem critical life functions such as heart rate, breathing, sleeping, etc.

– Limbic system reward circuit (ability to feel pleasure), perception of emotions, motivation, etc.

– Cerebral cortex sensory processing, thinking, planning, solving problems, making decisions, etc

What Is Mental Illness?

Mental illness or a mental disorder is a diagnosable condition that:– Affects a person’s thinking, emotional state, and

behavior– Disrupts the person’s ability to

Work Carry out daily activities Engage in satisfying relationships

Prevalence of Mental Illness

U.S. Adults with a Mental Disorder in Any One Year

Type of Mental Disorder % Adults Anxiety disorder 18.1 Major depressive disorder 6.7 Substance use disorder 3.8 Bipolar disorder 2.6 Eating disorders 2.1 Schizophrenia 1.1Any mental disorder 26.2

Mood Disorders

Types of Mood Disorders– Major depressive disorder– Bipolar I disorder– Bipolar II disorder– Dysthymia– Postpartum depression– Seasonal depression

Depression vs. Major Depressive Disorder

What Is Depression?– Everyday blues, sadness or a short-term depressed mood

is common– Many individuals may cope with these feelings without

significant impact on their everyday life.

Episodes of Major Depressive Disorder – last for at least 2 weeks– affect a person’s emotions, thinking, behavior, and physical

well-being– Ability to work and have satisfying relationships

Signs and Symptoms of Depression: Emotions

Sadness Anxiety Guilt Anger Mood swings Lack of emotional responsiveness Feelings of helplessness/hopelessness Irritability

Signs and Symptoms of Depression:Thoughts

Frequent self-criticism Self-blame Pessimism Impaired memory and concentration Indecisiveness and confusion Tendency to believe others see you in a

negative light Thoughts of death and suicide

Signs and Symptoms of Depression: Behaviors

Crying spells Withdrawal from others Neglect of responsibilities Loss of interest in personal appearance Loss of motivation Slow movement Use of drugs and alcohol

Signs and Symptoms of Depression: Physical

Fatigue/lack of energy Sleeping too much or too little Overeating or loss of appetite Weight loss or gain Constipation Headaches Irregular menstrual cycle Loss of sexual desire Unexplained aches and pains

Some Risk Factors for Depression

Distressing and uncontrollable event

Exposure to stressful life events

Difficult childhood Ongoing stress and anxiety Another mental illness Previous episode of

depression Family history More sensitive emotional

nature

Illness that is life threatening, chronic, or associated with pain

Medical conditions Side effects of medication Recent childbirth Premenstrual changes in

hormone levels Lack of exposure to bright

light in winter Chemical (neurotransmitter)

imbalance Substance misuse

Bipolar Disorder: Symptoms of Mania

Increased energy and over activity Need less sleep than usual Elated mood or severe irritability Rapid thinking and speech Lack of inhibitions Grandiose delusions Lack of insight

What is Psychosis?

Condition in which a person has lost some contact with reality

A person may have severe disturbances in thinking, emotion, and behavior

Usually occurs in episodes –not a constant or static condition

Psychotic disorders are not as common as depression and anxiety disorders

Psychotic Disorders

Types of Disorders in Which Psychosis Occurs– Schizophrenia– Schizoaffective disorder– Bipolar disorder– Psychotic depression– Drug-induced psychosis

Risk Factors for Psychotic Disorders

Genetic factors Biochemistry Stress Alcohol and Drug Use Other factors

Characteristics of Schizophrenia

Delusions Hallucinations Thinking difficulties Loss of drive Blunted emotions Social withdrawal

Anxiety Disorders

Anxiety disorders differ from normal stress and anxiety

An anxiety disorder is more severe, lasts longer and interferes with work, regular activities and relationships

Anxiety can range in severity from mild uneasiness to a panic attack or a flashback

Often co-occurs with mood disorders and substance use

Types of Anxiety Disorders

– Generalized Anxiety Disorder Persistent, overwhelming and unfounded anxiety/worry accompanied by

multiple physical and psychological symptoms

– Panic Disorder Recurring panic attacks & persistent worry about possibility of a future attack

– Phobic Disorders Avoids or restricts activities due to fear of specific objects/situations

– Post-Traumatic Stress Disorder & Acute Stress Disorder Anxiety after experiencing a distressing or catastrophic event

– Obsessive-Compulsive Disorder Obsessive thoughts & behaviors accompanying anxiety

Prevalence of Anxiety Disorders

U.S. Adults with an Anxiety Disorder in Any One Year

Type of Anxiety Disorder % Adults

Specific phobia 8.7 Social phobia 6.8 Post–traumatic stress disorder 3.5 Generalized anxiety disorder 3.1 Panic disorder 2.7 Obsessive–compulsive disorder 1.0 Agoraphobia (without panic) 0.8Any anxiety disorder 18.1

Signs and Symptoms of Anxiety: Physical

Cardiovascular:pounding heart, chest pain, rapid heartbeat, blushing

Respiratory: fast breathing, shortness of breath Neurological: dizziness, headache, sweating,

tingling, numbness Gastrointestinal: choking, dry mouth, stomach

pains, nausea, vomiting, diarrhea Musculoskeletal: muscle aches and pains

(especially neck, shoulders and back), restlessness, tremors and shaking, inability to relax

Signs and Symptoms of Anxiety:Psychological and Behavioral

Psychological– Unrealistic or excessive fear and worry (about past and

future events), mind racing or going blank, decreased concentration and memory, indecisiveness, irritability, impatience, anger, confusion, restlessness or feeling “on edge” or nervous, fatigue, sleep disturbance, vivid dreams

Behavioral– Avoidance of situations, obsessive or compulsive behavior,

distress in social situations, phobic behavior

Symptoms of a Panic Attack

– Palpitations, pounding heart, or rapid heart rate

– Chest pain or discomfort– Sweating – Chills or hot flashes– Trembling and shaking– Numbness or tingling– Shortness of breath,

sensations of choking or smothering

– Dizziness, light-headedness, feeling faint, unsteady

– Abdominal distress or nausea

– Feelings of unreality– Feelings of being

detached from oneself– Fear of losing control or

going crazy– Fear of dying

Risk Factors for Anxiety Disorders

People who are more likely to react with anxiety when they feel threatened are those who:

– Have a more sensitive emotional nature– Have a history of anxiety in childhood or adolescence– Are female– Abuse alcohol– Experience a traumatic event

Medical conditions or side effects of some prescription medications

Intoxication or withdrawal from alcohol, cocaine, sedatives, and anti-anxiety medications

Substance Use Disorders

The use of alcohol or drugs does not necessarily mean a person has a substance use disorder

Substances affect a person’s brain in different ways, and people may use alcohol or drugs because of these effects.

Substance use disorders may be characterized as mild, moderate, or severe

– “Mild” corresponds to the old concept of Substance ABUSE– “Moderate/severe” corresponds to the old concept of

Substance DEPENDENCE

Substance Use Disorders

Deciding to start drugs and Deciding to start drugs and experimentation with drugs experimentation with drugs are are preventable behaviorspreventable behaviors

Drug Addiction is a Drug Addiction is a treatable treatable brain diseasebrain disease

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Explanatory Models of Addiction

Moral wrong Spiritual empty Psychological impulse control Behavioral habit Medical disease

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Medical model of addiction

Sick person seeking wellness SUDs as chronic diseases

– Biological basis– Identifiable signs and symptoms– Predictable course and outcome

Treatment improves outcomes Lack of treatment may lead to morbidity and

mortality

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Medical model of addiction

A chronic relapsing disease of the brain– Drugs change brain structure and function– Brain changes can be long lasting and lead to

harmful behaviors

Characterized by compulsive drug seeking and use despite harmful consequences

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Facts About Substance Use Disorders

Lifetime Prevalence is 13-14% (1 in 8)– U.S. adults who have a SUD in their lifetime

Annual Prevalence is 3.8% – U.S. adults who have a SUD in any given year

Alcohol use disorders are three times as common as drug use disorders

75% of people who develop substance use disorders do so by age 27

Substance use disorders can co-occur with almost any mental illness

Signs and Symptoms of Substance Use Disorders

Increased use over time Increased tolerance for the substance Difficulty controlling use Symptoms of withdrawal Preoccupation with the substance Giving up important activities (work, social, family,

etc.) Continued use even after recognizing problems with

substance use

Commonly Used Substances

Alcohol Tobacco Marijuana Heroin (and other opioids) Sedatives and tranquilizers Cocaine Amphetamines and Methamphetamines Ecstasy and other hallucinogens Inhalants

Drug Use Disorders in the United States, 2001-2003

National Epidemiologic Survey on Alcohol and Related Conditions, 2004

Risk Factors for Substance Use Disorders

Availability and tolerance of the substance in society

Learning Social factors Genetic predisposition Sensitivity to the substance Other mental health problems

Does relapse = treatment failure?

NO! Relapse is likely, and is a part of the chronic nature of the disease

Relapse rates for drug addiction are similar to relapse rates in other chronic diseases– 40-60% relapse rate for addiction in 1 yr period

Relapse often indicates that treatment needs to be reinstated, adjusted, or changed to an alternate form

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Comparison of Addiction to Other Chronic Diseases

Med compliance

Required hospital stay annually

Follow diet & behavior

change

DM I <60 % ~40 % <30 %

HTN <40 % ~60 % <30 %

Asthma <40 % ~60 % <30 %

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Addiction and Mental Illness

Co-exist commonly Mental illness may precede addiction Drug use and abuse may trigger or worsen

mental illness in vulnerable individuals

Prevalence of substance use disorders in mental illness

0

10

20

30

40

50

60

% of respondents

with substance use disorder

Gen pop Schiz Bipolar Maj dep OCD Panic

Regier et al., JAMA, 1990

A complex relationship…

Substance use and mental illness may co-occur by coincidence

Substance use may cause or increase severity of mental illness

Mental illness may cause or increase severity of substance use

Both conditions may be caused by a third condition Substance use and withdrawal may mimic symptoms

of mental illness

Strategic Approach to Dual Disorders: Decreasing resistance & Increasing Engagement

1. Question & Answer

2. Expert

3. Information Overload

4. Labeling

5. Blaming/shaming

6. Demanding change

1. Ask and Listen

2. Shared Responsibility

3. Check Understanding

4. Person-Centered

5. Acceptance of Person

6. Change is the Person’s Decision

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Common Traps & How to Avoid Them

Question & Answer

Asking a series of close-ended questions can lead to:

Restricted information

Frustration

Defensiveness

Passivity

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Solution: Ask and Listen

Use open-ended questions Some closed questions, as needed Yields more information Communicates understanding Doesn’t necessarily take more time People feel heard and engaged in their

care

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Expert

Provider telling person what to do can lead to:

Passivity

Half-hearted commitments

Verbalized “compliance”50

Solution: Shared Responsibility

Ask permission to share information Avoid jargon Acknowledge person’s expertise Information sharing - a two way street Offer options/choices

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Information Overload

Providing too much information at one time can lead the person to:

Feel overwhelmedBe unable to act Stop listening Not absorb Information

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Solution: Check Understanding

Share small amounts of information

Stop and check understanding before offering further information

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Labeling

Referring to person as their condition or in negative terms can lead to:

Barriers in relationship

Resistance (people don’t like labels)

Dissatisfaction with provider

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Solution: Person-Centered

Be person-centered Seek to understand the person’s

experience Treat person with respect Address person according to their

preference View person as capable

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Blaming/Shaming

Criticizing person for behavior that may be worsening their health condition can lead to:

Defensiveness

Not feeling empowered

Decreased motivation to change

Increase in unhealthy behavior56

Solution: Acceptance of Person

Acceptance of the person Learn what matters to the person Acknowledge behavior change is hard Repeated attempts at change are normal Affirm small change efforts

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Demanding Change

Attempting to force behavior change can lead to:

Resistance

Creates a power struggle nobody wins!

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Solution: Change is the Person’s Decision

It’s the Person’s Decision Choice and control belongs to the person View person as capable Express optimism about ability to change Create opportunities for person to voice

need for change Be a resource

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Differential Diagnosis of Difficult Behavior

Mental illness symptoms Addiction symptoms

– intoxication, withdrawal, codependency Antisocial traits Medication side effects Other undiagnosed/untreated medical illness Reaction to remote or recent trauma Other reasons? …or a combination…

Case-Planning Areas of Emphasis

SUBSTANCE ABUSE MENTAL HEALTH PHYSICAL HEALTH HOUSING CRIMINAL THOUGHTS CRIMINAL PEERS / FRIENDS FAMILY / SOCIAL SUPPORT EDU / EMPL / FINANCIAL LEISURE / RECREATION

Case-planning Examples

Summary

Overview of mental illnesses and substance use disorders

Six strategies for increasing engagement and six traps to avoid

Differential diagnosis of difficult behavior

Effective case planning for co-occurring disorders

Resources

National Institute on Mental Health website: http://www.nimh.nih.gov

National Institute on Drug Abuse website: http://www.nida.nih.gov

National Alliance on Mental Illness website: http://www.nami.org

Mental Health First Aid website: http://www.thenationalcouncil.org/cs/about_the_program

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Contact Information

Christina M. Delos Reyes, MDChief Clinical Officer

Alcohol, Drug Addiction, and Mental Health Services [ADAMHS] Board of Cuyahoga County

2012 West 25th Street, Cleveland, Ohio 44113Phone 216-241-3400 Fax 216-241-0805

delosreyes@adamhscc.org

Medical ConsultantCenter for Evidence Based Practices at Case

http://www.centerforebp.case.edu