Substance Misuse and Mental Health

1. Substance Misuse and Mental Health Manchester Mental Health & Social Care Trust

2. Aims & Objectives • Aims: To raise awareness of issues of drug use and SMI on 1st onset psychosis • Objectives: To introduce – • Different drugs and their effects • How drugs interact with psychosis • How this affects young people with a vulnerability to psychosis

3. Group Exercise • As a large group, list all the drugs, legal or otherwise that you are aware of. • Discuss what kind of drugs they are and how they affect people • Consider specifically how these effects might be similar to, or might affect, psychotic symptoms

4. Depressants • Alcohol • Benzodiazepines • Solvents and gases • GHB (gammahydroxybutyrate)

5. Effects of Depressants • Relieves tension and anxiety • Impairs the efficiency of mental and physical functioning • Decreases self control • Causes ‘drunkenness’ behaviour and aggression • Causes drowsiness, sleep and in some cases unconsciousness • Tolerance to these drugs is often developed causing a physical dependence - alcohol

6. Drugs that reduce pain • Opiates – heroin , morphine , opium • Opioids - codeine • Narcotic Analgesics - percadine

7. Effects of Opiates • Reduces sensitivity to and the emotional reaction of pain • Induces a feeling of warmth and contentment • Higher doses can cause sedation, stupor, sleep and unconsciousness • Tolerance and physical dependence can be caused with repeated doses

8. Stimulants • Amphetamines • Cocaine • Caffeine • Tobacco • Anabolic Steroids • Alkyl Nitrates • Hallucinogenic amphetamines (Ecstasy) • Khat

9. Effects of Stimulants • Increased alertness • Diminished fatigue • Delays sleep • Increases the perceived ability to perform physical tasks • Nervousness and anxiety (except tobacco) • Temporary psychotic states (except tobacco and caffeine)

10. Anabolic steroids Amyl Nitrates Increased aggression and sex drive Diminished sexual characteristics in both men and women Rushing effect as blood vessels dilate Headaches, vomiting Excessive use leads to severe vomiting and unconsciousness causing fatalities Idiosyncratic effects

11. Hallucinogenic Amphetamines – ‘E’ Feelings of empathy with others Some forms – mild hallucinations / visual distortions Increased energy Idiosyncratic Effects

12. Drugs that alter perception • LSD • Hallucinogenic mushrooms • Cannabis • DMT • Ketamine

13. Effects of LSD, Mushrooms, Cannabis • Heightened sensory experiences • Elevation of mood • Minimal risk of physical dependency • Pseudo hallucinations • Relaxation, drowsiness (cannabis)

14. Cannabis & psychosis • People with a vulnerability to psychosis can be extremely sensitive to the effects of cannabis • Many young people smoke cannabis. Peer pressure means that it is often difficult for someone to refuse it when offered despite knowing that it makes them feel paranoid etc • The links between cannabis and psychosis are still being explored but some studies seem to show a correlation, especially if started at an early age

15. Effects of DMT • Short lived 30-60 minutes • intoxication • hallucinations • disorientated or anxious

16. Effects of Ketamine • Exhilaration • Nausea • Numbness • Visual distortions • Strong doses >hallucinations / unconsciousness • Anxiety • Muscle spasms • Paranoia • Inability to feel / avoid pain

17. Standardised Classification of Schizophrenia • Hearing voices spoken aloud • Third person hallucinations • Hallucinations in the form of commentary • Somatic delusions • Thought Withdrawal of insertion • Thought Broadcasting • Delusional Perception • Feelings or actions experienced as made or influenced by others

18. Stress-vulnerability Model(Zubin and Spring, 1977)

19. The Stress-vulnerability Model(Brabban & Turkington 2002)

20. The ‘super-sensitivity’ model • Some people seem to be ‘super-sensitive’ to the effects of different types of drugs (think of examples among your own friends!) • For some, this sensitivity manifests itself in the development of psychotic symptoms (Holland 2002) • Even quite small amounts of substances can have significant effects on some people • This ‘super-sensitivity’ can be very harmful for them and upsetting for their families

21. Stress Vulnerability • Focuses on the existing levels of vulnerability to psychosis • Symptoms may be exacerbated by either general stress and/or acute stress • Increase in symptoms is likely to impact on a number of areas: personal, social and family

22. Group Exercise Within your groups using the case study provided • Identify the stresses likely to be exacerbating Sue's symptoms. • List these and then feed back as a large group

23. Problems in Defining Dual Diagnosis • Medicalisation of human activity • Imprecise term • Encourages pessimistic prognoses • Used to describe other co-morbidity

24. Prevalence • 74.5% of users of drug services and 85.5% of users of alcohol services experience mental health problems • 67.6% of drug treatment users and 80.6% of alcohol treatment users had depression and/or anxiety • 26.9% of drug treatment users and 46.8% of alcohol treatment users suffered from severe depression • The figures are 19% and 32.3% for severe anxiety • 7.9% of drug treatment users and 19.4% of alcohol treatment users have a psychosis

25. ‘Dual diagnosis’ & Young People • Young people are more likely to be exposed to drug use by their peers • Late adolescence is a time of changing stress for everyone • We also know that late adolescence is a high risk time for psychosis

26. ‘Dual Diagnosis’ & Young People • Some studies have shown a link between cannabis use and psychosis, though this is a controversial area (Arseneault et al 2004) • Helping young people with a vulnerability to psychosis to make informed decisions about their drug use can be very helpful in controlling illness

27. Detection of Substance Misuse • The cost of non detection • Misdiagnosis • Missed opportunity to engage • Suboptimal pharmocotherapy • Missed detoxification/rehabilitation • Inappropriate referral

28. SUBSTANCE MISUSE HIV, Hepatitis B and C Acquisitive crime Non-acquisitive crime Poorer general health Lowering socio-economic status SERIOUS MENTAL ILLNESS Significant levels of mental impairment / distress Poorer general health Lower socio-economic status Poor social function and integration Harmful Events and Outcomes

29. Harmful Events & Outcomes in Dual Diagnosis COMBINED CONDITIONS • HIV, Hepatitis B and C infection • Acquisitive / non acquisitive crime • Markedly poor general health • Markedly poor social and economic standing • Markedly impaired mental health • Significant isolation from sources of support

30. Group Exercise • In small groups try to identify the potential harm or risks that might be associated with Sue’s substance use • Discuss these as large group

31. Detection of Substance Misuse • Aim is to identify • Substance Dependence • Substance Abuse • Harmful effects of Substance Use • Difficulties in detection/assessment • Concealment/poor eliciting • Intoxication mimics psychosis • Minimisation by staff and clients • Communication and perceptual disturbance

32. Those who are most at risk ! • Young males • Family history of substance use disorder • Homelessness • Disruptive behaviour • Isolation and poor familial relationships • Repeated hospitalisation • Legal problems • Physical presentation • At risk occupations

33. Assessment • Screening - CAGE,MAST, DAST, • Self report • Reports from carers, family and friends • Observation -behaviour and physical, mental state • Triggers, effects and consequences • Social function (Mueser et al 1995) • SATS – to measure willingness to change

34. Focus on • Nature of problematic use • Factors associated with maintenance of problematic substance using behaviours • Attitude towards substance use and treatment

35. Assessment Focus • Description • times, duration, frequency,quantity, severity of effects, developmental use history • Psychological • relaxed, excited, psychosis • Physiological • tolerance, dependency, withdrawal, • Cognitive • positive and negative drug expectancies

36. Assessment Focus • Behavioural • interpersonal coping strategies, communication • Environmental • social context of use, peer pressure • Clients’ level of motivation • Clients’ participation in treatment • past or present • Conditions associated with problematic use

37. Group Exercise • Identify the questions you would ask Sue and those who are close to her to assess her substance use • Write these down and share with the large group

38. STAGE DEFINITION GOAL Engagement Client does not have regular contact with clinician To establish a working goal with the client Persuasion Client has regular contact with clinician, but does not want to work on reducing substance use To develop the client's awareness that substance use is a problem and generate motivation to change Active Treatment Client is motivated to reduce substance use as indicated by reduction in substance use for at least 1 month but less than 6 To help the client further reduce substance use and, if possible, attain abstinence Relapse Prevention Client has not experienced problems related to substance use for at least 6 months (or is abstinent) To maintain awareness that relapse could happen and to extend recovery to other areas e.g., social, relationships, work)

39. Model of change (Prochaska and DiClemente 1982) Stability Making changes Keeping it going Planning change Relapse Thinking about change Not thinking about change

40. Motivational Interviewing The Client Stage & Therapist Task Not thinking about change (Precontemplation) • Be empathic • Raise the issue - record, monitor • Increase the clients perception of risks and problems (pros and cons) • Provide information (leaflets etc) • Education about illness and management • Convince client that clinician has something to offer - instil hope • Help resolve a pressing problem

41. Motivational Interviewing The Client Stage & Therapist Task Thinking about Change (Contemplation) • Tip the balance - (Pros and cons) • Provide information • Monitoring (Keep diary) • Evoke reasons to change, risks of not changing; strengthen the clients self efficacy for change of current behaviour • Consider barriers to change • Educate about effects of substance misuse on mental illness • Explore how substance abuse may interfere with meeting other goals

42. Motivational Interviewing The Client Stage & Therapist Task Preparing to Change (Preparation) • Help client set goals • Action Planning • Explore barriers

43. Motivational Interviewing The Client Stage & Therapist Task Making changes (Action) • Encourage and support is essential • Developing the use of problem solving such as: • Refusing offers to use substances • Avoiding high risk situations • Developing alternative leisure activities • Structuring daily time

44. Motivational Interviewing The Client Stage & Therapist Task Keeping it Going (Maintenance) • Encourage the evaluation of the decision to change • Review progress made by young person and risk factors associated with relapse of substance misuse • Diary • Rewards • Identification of High risk situations and solutions • Help enhance other areas of clients functioning -relationship skills, work or education, self care, independent living skills, leisure activities

45. Motivational Interviewing The Client Stage & Therapist Task Relapse • Re-engage • Review pro’s and con’s of change • Support • Explore options • Review goals

46. Group Exercise • Identify which stage Sue is at using the model depicting the cycle of change • Which behaviours have assisted you to come to this conclusion? • Which interventions would you engage Sue in at this stage?

47. Conclusion • Drugs and alcohol are freely available and often used by young people • Effects on people with vulnerability to psychosis can be profound (super-sensitivity model) • However, if the young person decides to control their drug/alcohol use, their mental health can improve. • There are ways of working with them that can support them