RAWATAN KLIEN DUA DIAGNOSIS (PSIKIATRIK SEMASA DETOKSIFIKASI)

DR OMAR ALI Pakar Perunding Psikiatri Hospital Sultanah Bahiyah

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 or co-occurring disorder 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 persons 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): 417421

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% daripada kumpulan penagih opioid ini mempunyai komorbiditi psikiatri.
Penyakit Kemurungan 32.6%, penyakit disthiamia pada 23.6% penyakit Panik pada 14.6%.

Sains Malaysiana 42(3)(2013): 417421

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

Komorbiditi psikiatri didapati mempunyai perbezaan siknifikan (p<0.05)

penyalahgunaan pelbagai jenis dadah, sejarah dijatuhi hukuman mahkamah sejarah penyakit psikiatri dalam kalangan ahli keluarga.

Kajian ini menunjukkan peratusan komorbiditi psikiatri adalah tinggi. Ini memperlihatkan bahawa amat penting komorbiditi psikiatri dikaji dan intervensi awal penting untuk kumpulan pesakit ini

So what?
Must be dry to access most addiction rehab services Cant get dry because of mental health issue e.g. anxiety-self medicate e.g. drink to reduce anxiety Addiction Treatment centres dont assess for other mental health problems Reduces chances of long term recovery

Contoh Client / Pesakit

DIN
Zahari Nizam

See Leng
Zul Mr x

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 persons 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

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

Signs and Symptoms of Depression

Difficulty concentrating
Ruminating thoughts Feeling helpless

Feeling hopeless
Feeling like life is not worth living Ruminating on negative thoughts Emotional numbness

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.

Personality Disorders
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.

Personality Disorders
Prominent characteristics
Tx of problematic relationships Blames difficulties on others or bad fortune

Doesnt 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

Antisocial Personality Disorder

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

Antisocial Personality Disorder

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 its going to get a bone anytime I do anything that reminds it of the bone.

Substance Abuse and Mental Illness = Co-Occurring Disorder

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 badfeelings, 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 substancerelated disorders. DDC programs can meet such patients 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.)

PSYCHOPHARMACOLOGY PRACTICE GUIDELINES

DUAL PRIMARY TREATMENT PSYCHOPHARM FOR MI Atypicals (?) and clozapine for psychosis LiCO3 vs newer generation mood stabilizers Any non-tricyclic antidepressant, particularly SSRI, SNRI

PSYCHOPHARMACOLOGY PRACTICE GUIDELINES

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