rawatan klien dua diagnosis (psikiatrik semasa...

RAWATAN KLIEN DUAL DIAGNOSIS (PSIKIATRIK SEMASA DETOKSIFIKASI)

DR OMAR ALI Pakar Perunding Psikiatri

Hospital Sultanah Bahiyah

BENGKEL RAWATAN DETOKSIFIKASI MENGGUNAKAN UBAT UBATAN

10 HB SEPTEMBER 2013 PLAK SG PETANI

What is Dual Diagnosis?

Dual diagnosis exists where

alcohol or drug problem and

an emotional/another mental health (psychiatric) problem

Also known as Co-morbidity

Co-occuring disorders

Substance Abuse and Mental Illness

A “dual diagnosis” occurs when an individual is affected by both

chemical dependency and mental illness.

Both illnesses may affect a person physically, socially, psychologically, and

spiritually.

Each illness has symptoms that interfere with a person’s ability to function

effectively.

The illnesses may affect each other, and each disorder predisposes to

relapse in the other disease. At times the symptoms can overlap and

even mask as each other, making treatment and diagnosis difficult.

To fully recover, a person needs to treat/address both disorders.

How Common Is Dual Diagnosis?

37% of people abusing alcohol 53% people abusing other drugs

Have at least one serious mental illness.

29% of people diagnosed as mentally ill, abuse either alcohol or drugs. American Medical Association

74% of users of drug services 85% of users of alcohol services

experienced mental health problems.

44% of mental health service users reported drug use. UK Dept. of Health

Sains Malaysiana 42(3)(2013): 417–421

Psychiatric Comorbidity Among Community-based, Treatment Seeking Opioid Dependents in Klang Valley

(Komorbiditi Penyakit Psikiatri dalam Kalangan Penagih yang Bergantung pada Opioid di Lembah Kelang)

AzLin Baharudin*, Lotfi Anuar, Suriati Saini, Osman Che Bakar, Rosdinom Razali & Nik Ruzyanei NiK Jaafar

• 204 penagih

• 43.6% - penagih opioid ini mempunyai komorbiditi psikiatri.

– Kemurungan 32.6%,

– disthiamia 23.6%

– Panik 14.6%.

Sains Malaysiana 42(3)(2013): 417–421

Psychiatric Comorbidity Among Community-based, Treatment Seeking Opioid Dependents in Klang Valley

• Komorbiditi psikiatri didapati siknifikan (p<0.05) – penyalahgunaan pelbagai jenis dadah, – sejarah dijatuhi hukuman mahkamah – sejarah penyakit psikiatri dalam kalangan ahli

keluarga.

Kajian • peratusan komorbiditi psikiatri adalah tinggi. • amat penting komorbiditi psikiatri dikaji dan intervensi awal penting

untuk kumpulan pesakit ini

Contoh Client / Pesakit

• Tajuddin

• Rafizi

• Nizam

• See Leng

Kekangan / Masalah pesakit Dual Diagnosis mendapat rawatan

• Pusat Rawatan Penagihan (Addiction Treatment Centres) tidak terima “penagih yang ada masalah mental” – Nanti buat kacau

– Agresif – tidak dengar arahan

– Bahayakan diri sendiri – ‘gantung diri’ – siapa nak jawab ?

– Tiada ubat mental

– Tiada Nurse / MA , tiada doktor

– “arahan dari atasan...”

Siapa yang nak terima ?

Polis ?

Swasta ? INABAH ? Rawatan Traditional ?

Kekangan / Masalah pesakit Dual Diagnosis mendapat rawatan

• Mesti “dry” atau Urine negatif ; baru boleh terima / masuk Addiction Rehab. – Tak boleh berhenti “ dadah / minum alkohol “ sebab – Stress , Anxiety

– Minum arak untuk ‘kurangkan keresahan / tak boleh tidur’

– Ambil ‘ice’ – self-treatment Kemurungan .

• Sukar untuk Pulih sepenuhnya

Why is dual diagnosis a problem?

• Historically addiction seen as – Moral issue

– Form of mania

– Disease

• Addiction and mental health services separate

• AA/rehab centres: bias against medication

Dual Diagnosis Problems

• “76% of services failing to offer a specific service for people with dual diagnosis

• Dual Diagnosis not clearly understood or formally recognised

• Service models used aligned to organisations rather than complex needs of people with dual diagnosis”

“Mental health & addiction services and the management of dual diagnosis in Ireland”

National Advisory Committee on Drugs 2004.”

Diagnosis #1:

MENTAL ILLNESS

What is Mental Illness:

Mental Illness Facts

• Mental illnesses are medical conditions that disrupt

– a person’s thinking,

– feeling, mood,

– ability to relate to others, and daily functioning.

• Just as diabetes is a disorder of the pancreas, mental illnesses are

medical conditions that often result in a diminished capacity for

coping with the ordinary demands of life.

Serious mental illnesses

Include:

• major depression

• schizophrenia

• bipolar disorder

• obsessive compulsive disorder (OCD)

• panic disorder

• post traumatic stress disorder (PTSD)

• borderline personality disorder

DSM-5 – diagnostic criteria and codes

1. Neurodevelopmental disorders

2. Schizophrenia spectrum and other psychotic disorders

3. Bipolar and related disorders

4. Depressive disorders

5. Anxiety disorders

6. Obsessive-compulsive and related disorders

7. Trauma- and stressor-related disorders

8. Dissociative disorders

9. Somatic symptom and related disorders

10. Feeding and eating disordersdisorders

11. Sexual dysfunctionsGender dysphoria

12. Disruptive, impulse-control, and conduct disorders

13. Substance-related and addictive disorde

14. rNeurocognitive disorders

15. Paraphilic disorders

In Addition to Medication Treatment

• Psychosocial treatment such as – cognitive behavioral therapy,

– interpersonal therapy,

– peer support groups,

– and other community services can also be components of a treatment plan that assist with recovery.

– The availability of transportation, diet, exercise, sleep, friends, and meaningful paid or volunteer activities contribute to overall health and wellness, including mental illness recovery.

Diagnosis Specific Signs and

Symptoms

Major Depression

• Dysphoric mood

• At least 4 of the following

– Changes in appetite and sleep patterns, agitation, loss

of interest in pleasurable activities, fatigue,

worthlessness, guilt, inability to concentrate,

ruminating negative thoughts, feeling helpless and

hopeless, recurrent thoughts of death

Signs and Symptoms of Depression

• Tearful

• Changes in sleeping patterns

• suicidal ideation

• changes in appetite

• loss of pleasure

• isolation

• sudden outburst of anger

• Difficulty concentrating

• Ruminating thoughts

• Feeling helpless

• Feeling hopeless

• Feeling like life is not worth living

• Ruminating on negative thoughts

• Emotional numbness

Signs and Symptoms of Depression

Bipolar Disorder

• Bipolar disorder, also known as manic depression, is a brain

disorder that causes unusual shifts in a person's mood, energy, and

ability to function. Different from the normal ups and downs that

everyone goes through, the symptoms of bipolar disorder are

severe. They can result in damaged relationships, poor job or school

performance and even suicide.

Bipolar Disorder: Manic

• One of more distinct period with a predominantly elevate,

expansive or irritable mood

• Duration of at least one week during which most of the time at

least 3 have been present

• Increase in activity, hyper verbal or pressured speech, flights of

ideas, grandiosity, decreased need for help, distractibility,

buying sprees, sexual indiscretions, foolish business

investments, reckless driving

Personality Disorders

• Each of us has a personality or group of characteristics

(traits) which influence the way we think, feel & behave and

makes us a unique individual.

• Someone may be described as having a 'personality disorder'

if their personal characteristics cause regular and long term

problems in the way they cope with life and interact with

other people. Some people with these disorders never come

into contact with the mental health services.

• APA: “when personality traits are inflexible and maladaptive

and cause either significant impairment in social or

occupational functioning or subjective distress.”


• Approximately 10-13% of the population have

a personality disorder. Personality disorders

are more common in younger age groups

(25-44 year age group) and are equally

distributed between males and females.


• Prominent characteristics

– Tx of problematic relationships

– Blames difficulties on others or bad fortune

– Doesn’t learn from mistakes

– Generate and perpetuate existing problems

– Lack of control over emotions

– Distorted thinking

Types of Personality Disorders

Divided into 3 Clusters:

A) odd/eccentric : paranoid, schizoid

B) dramatic/erratic: antisocial, borderline,

histrionic, narcissistic

C) anxious/inhibited: dependent, avoidant,

obsessive-compulsive

Antisocial Personality Disorder

• Current age of at least 18

• Onset before 15 as indicated by 3 or more:

– Truancy, expulsion, delinquency, running away

from home, arrested, persistent lying, repeated

sexual intercourse, repeated drunkenness or

substance abuse, thefts, vandalism, low school

grades, chronic violations of home rules, initiation

of fights


• At least 4 of the following since age 18:

– Inability to sustain consistent work behavior

– Lack of ability to function as a responsible parent

– Failure to accept social norms with respect to lawful

behavior

– Inability to maintain enduring attachment to a sexual

partner


• Irritability and aggressiveness

• Failure to honor financial obligations

• Failure to plan ahead or impulsivity

• Disregard for the truth

• Recklessness

• A pattern of continuous antisocial behavior in which

the rights of others are violated

Borderline Personality Disorder

• At least 5 of the following:

– Impulsivity or unpredictability in at least 2 areas that are

potentially self damaging-Spending, sex, gambling, shoplifting,

AOD use, etc

– A pattern of unstable and intense interpersonal relationships

– Inappropriate, intense anger or lack of control over anger

– Identity disturbances

– Affective instability

– Intolerance of being alone

– Physical self damaging acts

– Chronic feelings of emptiness and boredom

The Good News About Mental Illness:

• Is that recovery is possible.

• Mental illnesses can affect persons of any age, race, religion, or

income.

• Mental illnesses are not the result of personal weakness, lack of

character, or poor upbringing.

• Most people diagnosed with a serious mental illness can experience

relief from their symptoms by actively participating in an individual

treatment plan.

Diagnosis #2:

SUBSTANCE ABUSE

Addiction = A Dog with a Bone

It never wants to let go.

It bugs you until it gets

what you want.

It never forgets

when/where it is used to

getting its bone.

It thinks it’s going to get a

bone anytime I do anything

that reminds it of the bone.

Co-Occurring Risk Factors

• Childhood risk factors such as poverty, family discord, and pre

and postnatal complications appear to be implicated in both

mental illness and substance use.

• Between 51 and 97 percent of women with serious mental

illness have been physically or sexually abused.

• 41 to 71 percent of women treated for alcohol or drug use report

being sexually abused.

Stigmas

• Alcohol and drug abuse have many negative

connotations in our society.

• For many, drug abuse is perceived to result from

lack of willpower, laziness, or selfishness.

• Sadly, these erroneous perceptions also extend

to a group extremely vulnerable to drug abuse –

people with mental disorders.

Relationship between Substance Abuse and

Mental Illness

• Those with a mental disorder can be very sensitive to the effects of drug abuse; not only can it be easier to abuse drugs, it can also be harder to quit.

• Like the rest of the population, a person with a mental disorder is more likely to abuse drugs if there is a family history of alcohol and drug abuse.

• Environmental factors such as peer pressure, location, and the availability of the drug also contribute to a pattern of drug abuse in the mentally ill.

Relationship between Substance

Abuse and Mental Illness, cont.

• Drug use can interfere with prescribed medication,

increase symptoms of a mental condition, and

increase relapse risk.

• Having difficulty developing social relationships,

some people find themselves more easily accepted by

groups whose social activity is based on drug use.

• Some believe that an identity based on drug

addiction/alcoholism is more acceptable than one

based on mental illness.

Theories of Dual-Diagnosis

• Self-medication theory: Substances are selectively used in service of alleviating symptoms of mental illness (i.e. stimulant abuse employed to counter the sedative effects of anti-psychotic medications)

• Alleviation of dysphoria: mental illness creates dysphoria

(feeling bad) and this dysphoria leads to drug use to mitigate the experience of these unpleasant feelings

• Multiple risk: In addition to the alleviation of bad-feelings, there are additional risks such as: social isolation, poverty, lack of daily structure, residing in areas with drug availability, history of traumatic events

Some Key Factors

• Studies in the UK and United States have indicated that individuals with dual-diagnosis have a number of difficulties and poorer outcomes including:

– Increased severity of symptoms and relapse

– More frequent inpatient hospital admissions

– Higher treatment costs

– Increased hostility and involvement with the legal system

Key Factors Continued

• Increase likelihood of suicide

• Increased rate of homelessness and insecure housing

• Increased risk of HIV infection

• Family problems or intimate relationships

Ciri-ciri Relapse

Rasmussen (2000) ada menggariskan ciri-ciri relapse ialah

– perubahan dalaman individu seperi – peningkatan stress, – perubahan pemikiran,perasaan dan tingkah laku;menafikan tentang rasa kebimbangan yang dialami; – menghindari dan mempertahan diri sendiri bahawa tidak relapse sebaliknya memfokuskan kepada orang

lain, – bersifat defensive, – bersifat kompulsif,berkelakuan impulsive

•

krisis lanjutan seperti melihat remeh sesuatu masalah,perasaan yang tertekan, – perancangan masa hadapan yang lemah dan gagal; – berfikiran bahawa semua perkara tidak dapat diselesaikan – bertindak secara tidak matang untuk tujuan bergenbira atau berseronok.

Individu juga berasa keliru dan memberi reaksi yang berlebihan kesan daripada tidak dapat berfikir dengan jelas,

– tidak dapat mengurus perasaan dan emosi , – sukar untuk mengingati sesuatu,berasa keliru. – tidak dapat mengawal stres dan menjadi mudah marah.

Ciri-ciri Relapse

• kemurungan (depression)

– tabiat makan yang luar biasa (tidak lalu atau terlalu banyak makan), – kurang bersemangat untuk mengambil sesuatu tindakan, – sukar untuk tidur, – terjejas aktiviti harian – mengalamisuatu tempoh tekanan yang agak lama.

• Individu yang relapse juga akan kehilangan kawalan kerana memendam perasaan, – berasa tidak mampu dan tidak berguna, – menolak pertolongan, – melanggari program pemulihan,melanggar nilai – nilai diri, – hilang keyakinan diri,marah tanpa sebab,suka bersendirian,kecewa

• mengalami tekanan.

• Ciri-ciri terakhir ialah individu mula relapse dengan mengambil dadah akibatnya berperasaan kecewa,hilang kawalan diri dan kehidupan serta kemerosotan tahap kesihatan.

PENCEGAHAN DADAH MELALUI RAWATAN

Pendekatan farmakologi Pendekatan farmakologi bergantung kepada ubat-ubatan atau dadah untuk menyekat kesan euforik, ataupun mengurangkan kegianan serta slmptom putus dadah (withdrawl symptoms) semasa dadah digunakan

methadone, - Naltrexone, buprenorphine, ubat-ubatan juga digunakan dalam proses detoksifikasi dengan tujuan untuk

mengawal kegianan. dadah digunakan bagi mengurangkan masalah dual-diagnosis seperti

kemurungan atau skizofrenia. prevalen salah guna bahan dalam kalangan kes mental seperti ini

mencapai 50 peratus.

The Four Quadrant Model

• The Four Quadrant Model is a viable mechanism

for categorizing individuals with co-occurring

disorders for the purpose of service planning

and system responsibility.

Sub-Groups of Dual Diagnosis Client

Types

Psychiatric High

Substance High

Serious & persistent mental illness

with substance dependence

Psychiatric Low

Substance High

Substance dependence with some

psychiatric complications

Psychiatric High

Substance Low

Serious and persistent mental

illness with substance abuse

Psychiatric Low

Substance Low

Mild psychopathology with

substance abuse

“Treatment” Continued

Parallel: These intervention approaches focus on both substance abuse and mental illness treatment at the same time

Integrated: Treatments are delivered at the same time (like the parallel approach) but are coordinated by the same staff team members in the same treatment setting

Specific approaches with in these 3 philosophies include: Biological: This is the psychotropic medication arm of

treatment and can be effective toward managing symptoms of mental illness which in turn can facilitate treatment of substance misuse

“Treatment” Continued • Social and Psychological: This is a broad spectrum

term used to describe therapeutic techniques such as:

• Motivational Interviewing: Engaging in supportive and directed conversation about individuals behaviors and patterns that are designed to increase intrinsic motivation to change

• Cognitive Behavioral: weakening connections between life stressors and reactive/habitual responses that are negative and destructive.

• Self-Help Groups: This includes many 12-step groups that can instill peer support and self-discipline

AOS Programs

• Programs that offer Addiction-Only Services

Some addiction treatment programs cannot accommodate

patients with psychiatric illnesses that require ongoing

treatment, however stable the illness and however well

functioning the individual. Such programs are said to provide

Addiction-Only Services

DDC Programs

• Dual Diagnosis Capable (DDC) Programs

Dual Diagnosis Capable (DDC) programs routinely accept

individuals who have co-occurring mental and substance-

related disorders. DDC programs can meet such patient’s needs

so long as their psychiatric disorders are sufficiently stabilized

and the individuals are capable of independent functioning to

such a degree that their mental disorders do not interfere with

participation in addiction treatment.

DDE Programs

• Dual Diagnosis Enhanced (DDE) Programs

DDE programs can accommodate individuals with dual

diagnoses who may be unstable or disabled to such an extent

that specific psychiatric and mental health support. monitoring

and accommodation are necessary in order for the individual to

participate in addiction treatment. Such patients are not so

acute or impaired as to present a severe danger to self or

others, nor do they require 24-hour, intensive psychiatric

supervision.

The ideal Client & professionals can see and access holistic service

The reality

Strategies for

Psychopharmacology with

Persons who have

Co-Occurring Disorders

PSYCHOPHARMACOLOGY PRACTICE GUIDELINES

DUAL PRIMARY TREATMENT

• ADDICTION PSYCHOPHARM

• Disulfiram

• Naltrexone

• Acamprosate

• Bupropion, Varenicline

• Opiate Maintenance

• Mood stabilizers?

• Others? (Baclofen, etc.)


DUAL PRIMARY TREATMENT

• PSYCHOPHARM FOR MI

• Atypicals (?) and clozapine for psychosis

• LiCO3 vs newer generation mood stabilizers

• Any non-tricyclic antidepressant, particularly SSRI, SNRI


DUAL PRIMARY TREATMENT • PSYCHOPHARM FOR MI

• Anxiolytics: clonidine, SSRIs, SNRIs, topiramate,

other mood stabilizers, atypicals (short-term),

• ADHD: Atomoxetine is probably first line. Bupropion, clonidine, SSRIs, tricyclics, then

sustained release stimulants.

SAFETY • Acute medical detoxification should follow same

established protocols as for individuals with addiction only.

• Maintain reasonable non-addictive psychotropics during detoxification

• For acute behavioral stabilization, use whatever medications are necessary (including benzodiazepines) to prevent harm.

• APAKAH PRINSIP ASAS RAWATAN PENAGIHAN DADAH YANG BERKESAN? • Prinsip asas rawatan penagihan dadah yang berkesan adalah:

1. Tiada rawatan tunggal sesuai untuk semua individu klien. 2. Rawatan dan pemulihan perlulah mengikut keperluan klien yang unik. 3. Kemudahan rawatan perlu sentiasa ada (tersedia). 4. Rancangan pemulihan perlu dinilai dan dikaji semula dari masa ke masa. 5. Klien hendaklah berada dalam tempoh rawatan yang mencukupi. 6. Kaunseling dan terapi tingkahlaku merupakan komponen yang kritikal dan berkesan dalam rawatan. 7. Ubat-ubatan boleh membantu rawatan penagih dadah. 8. Dual-diagnosis perlu untuk penagih bermasalah psikiatri. 9. Detoksifikasi penting untuk menghilangkan kegianan. 10. Motivasi dalaman dan luaran boleh membantu pemulihan. 11. Status kepulihan klien perlu dipantau. 12. Pengesanan HIV dan penyakit kronik perlu dibuat. 13. Sistem sokongan sosial perlu untuk mengekalkan kepulihan

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