Treatment of Addiction and Co-occurent Mental Problems: The Power of Interdisciplinary Knowledge

1. Treatment of Addiction and Co-occurent Mental Problems: The Power of Interdisciplinary Knowledge Maja Rus Makovec University Psychiatric Hospital Ljubljana Chair of Psychiatry, Medical Faculty Ljubljana M Rus-Makovec 11 EFTC 2007

2. How people change their behavior? Can we agree: • People have their own way how they can learn (develop, change …): pressure, support, alone, in group, …; capacity for self-treatment • Their capacity for change differs in time (“it was not the right time”) • People are specific mixture of sources of power and vulnerabilities, yet there are some universal features for change • Addicted people differ: special heterogeneity of legal drugs addiction • Equifinality of legal drug (alcohol) addiction: there can be different pathways to similar condition M Rus-Makovec 11 EFTC 2007

3. Bio-psycho-social model of addiction • State-of-art: do not stop at the level of brain neurotransmitter biochemistry but to place a person’s mental dysfunction manifesting itself in their human suffering and certain behavior into the person’s psycho-social context (Eisenberg, 1999). • Addicted person: does not want to change or can not because of biological or other obstacles? Who or what is responsible for change? • In western culture learning “per partes” is favoured (Bateson): different levels of experience are rarely co-constructed – “to fell in love” with one’s own experience M Rus-Makovec 11 EFTC 2007

4. “What everybody in addiction professional community should know about co-occurrent mental problems” • Following co-occurent metal problems with mainly or partly neurobiological basis can severly damage addicted persons’ ability for psycho-social change (and are not only a construct): • neuro-cognitive impairment of working memory • restrict abilities to receive, encode and integrate the newly introduced information • dual diagnosis of serious mental disorder (as depression, anxiety, psychosis …) • trauma experience • personal development resulting in serious personal or relational disorder (developmental trauma) M Rus-Makovec 11 EFTC 2007

5. What to do with information about co-occurent problems? • To help patients with co-occurent mental problems efficiently - need for • More patience • More time • More interdisciplinary cooperation • To have realistic goals of treatment M Rus-Makovec 11 EFTC 2007

6. Different levels of interactions between drug and other mental disorder (co-occurent, dual diagnosis, comorbide state …) • Drug or end of drug use can induce depression • Popular theory about drug use as secondary to an “underlying depressive disorder” • Two mental problems independently at the same time • Each mental problem worsen the other • Addiction can be extremely dramatic per se and without co-occurrent disorders • Addiction can be less dramatic in appearance but more reluctant to change because of co-occurrent disorders M Rus-Makovec 11 EFTC 2007

7. Major consequences of comorbidity • At least one-half of the patients in psychiatric and substance use treatment with comorbid disorder (Regier et al. 1990, Kessler et al. 1994) • Higher service utilization … • More severe symptoms … • Greater functional disability (Bijl, Ravelli, 2000) M Rus-Makovec 11 EFTC 2007

8. One of many perspectives on addiction: • “Altered and and damaged neurochemistry underlies (their) tragic vulnerability …– the addicts have to struggle with powerful midbraincircuits (Dackis, Gold, 1998) • Such perspective counters the notion about “lack of will power”: surprising, empowering, respect- and hope-introducing fact is, that so many addicted people challenge their biology efficiently because of right motivation and support • Some addicted people have such an enormous obstacle of co-occurent mental problems, that they need special help and special context of treatment to reach their human capacity for change M Rus-Makovec 11 EFTC 2007

9. Center for Alcohol Addiction Treatment of University Psychiatric Hospital Ljubljana • Started in 1970 with phylosophy of therapeutic community, now-a-day “addiction psychiatry – psychotherapy” orientation with some aspects of TC • 33 slots in inpatient and 30 slots in outpatient treatment for patients with alcohol and benzodiazepine addiction, in last year some patients with previous experience of TC • After-care: cca 300 visits per month • Abstinence-based programme: predominantly psychosocial interventions combining with pharmacologic agents for dual diagnosis M Rus-Makovec 11 EFTC 2007

10. Indications for admission are severe psychosocial or psychiatric conseqences of addiction or difficulties / inability to attain abstinency despite previous attempts. • Population of patients is not preselected. • Treatment offers (mainly) group psychotherapy and individual interventions. Heterogenous groups • The program is encouraging admission of patients with co-occurrent mental (psychiatric) disorders • Patients with severe impairment in neuropsychological functioning ordinary can not follow the program, as well as acutely suicidal or psychotic patients without long-term stable remission M Rus-Makovec 11 EFTC 2007

11. Intensive treatment is conceptualised as: • 1st part: in-patient setting • 2nd part: out-patient setting (day-hospital). • Active participation of important others is stressed as the essential part of the programme. • After-care recovery is strongly recommended • If comorbide disorders or/and severe interpersonal problems are identified during the intensive treatment period, psychotherapy (individual, couple, family therapy) or psychiatric care is offered to the patients after discharge M Rus-Makovec 11 EFTC 2007

12. Team need to negotiate how to combine the focus • on behavioural changes (“rehabilitation”, normative part of approach) and • non-directive encouragement for increasing autonomy of patients, attainment of insight and cultivation of the patient / therapist relationship • “Matching comorbid psychiatric severity in substance-related disorders to treatment program characteristics may be more advantageous because of the emphasis on individualized and specific levels of intensity of treatment “(McLellan, 1993) M Rus-Makovec 11 EFTC 2007

13. Research on effectiveness of addiction treatment programme • Patients (n = 622) were included in the study consecutively after the admission • Group 1 (n = 347 at the beginning) was supposed to be followed • at the beginning • at the end of intensive treatment programme • 3, 6, 12 and 24 months after discharge from the intensive treatment programme • Group 2 (n = 275 at the beginning) was supposed to be followed • at the beginning • at the end of intensive treatment programme • 24 months after discharge from the intensive treatment program M Rus-Makovec 11 EFTC 2007

14. Independent variables • Demographic variables • Co morbidity • Treatment context (in- & out-patient) • After-care treatment • Social support in treatment • Time stage in treatment process • Treatment success critheria / dependent variables • Abstinence (sobriety) • Self-evaluation of mental health, physical health, financial status, relations with important others, quality of life • Changes in marital status / partnership • Changes in employment status M Rus-Makovec 11 EFTC 2007

15. Abstinence / sobriety rate after intensive treatment discharge • 3 months (n = 213): 85 % abstinent • 6 months (n = 177): 84 % abstinent • 12 months (n = 116): abstinent 86 % • 24 months (n = 213): abstinent 80 % • Included in some form of after-care • 3 months: 60 % • 6 months: 61 % • 12 months: 59 % • 24 months: 58 % M Rus-Makovec 11 EFTC 2007

16. The most frequent co-occurent diagnoses • After at least 1 months of sobriety the co-occurrence syndromes are diagnosed, avoiding those anxious-depressive symptoms as after-end-of-drinking-cessation should be diagnosed as comorbide/co-ocurrent category • Depression 19.8 % • Anxiety disorders 11 % • Personal disorders 20.9 % • Benzodiazepine dependency 19 % • Nicotine dependency 62.2 % M Rus-Makovec 11 EFTC 2007

17. Comorbide diagnoses and abstinence – no significant risk found (2, p) • The finding is explained by their inclusion in proper modality of after-care treatment, combining psychotherapy and pharmacotherapy. • The only vulneralibility regarding length of abstinence was found in smokersat 6 months (x = 5.9 (1), p = 0.015): smokers showed greater percent of probability to relapse than non-smokers at that time of evaluation. M Rus-Makovec 11 EFTC 2007

18. Accurracy of diagnosis of main comorbide disorders in % - too strict and especially underdiagnosed anxiety states • The quality of diagnosing was controlled by Mini International Neuropsychiatric Interview instrument (MINI) M Rus-Makovec 11 EFTC 2007

19. Correlations (r, p) between self-evaluations of psychological health and n of psychiatric diagnoses M Rus-Makovec 11 EFTC 2007

20. Problems found in diagnostic procedure • Dual diagnosis syndromes are hidden behind drug addiction symptoms • Vice versa, alcohol addiction (also in the early recovery) can mimic almost all psychiatric symptomes • In the beginning of treatment addicted patients can be more prone to defensive attitude and denial instead to good therapeutic alliance • Often neuro-cognitive impairment is under-estimated • Alcohol / drugs can force numbing or dissociative reactions after trauma causing cognitive and emotional distortions of experience • F.e. patient with trauma experience can also be prone to manipulation M Rus-Makovec 11 EFTC 2007

21. Integrated treatment • In last years it became apparent that some people can not process stable recovery without concurrently addressing co-occurrent states and psychological trauma dynamics • before we waited first to stable abstinence before addressing trauma issue, which sometimes never come • secondly, it was learned that concurrent treatment did not result in more relapses (Carruth, Burke 2006). M Rus-Makovec 11 EFTC 2007

22. Psychiatric context can offer concurrent treatment for alcohol / drugs addiction and severe co-occurrent mental symptoms including complex symptoms of psychological trauma because of their broad base of clinicians, experienced in addiction, psychiatric and psychotherapeutic fields • Need for new paradigm in addiction as well in psychiatric context? M Rus-Makovec 11 EFTC 2007

23. Psychiatry • Detoxification • Dual diagnoses Social Service Somatic hospitals • GP • “ordinary” • family medicine Clients/patients directly • Addiction psychiatrist • mental out-patient clinics • psychiatric hospital in-patient treatment day hospital out-patient treatment • Non-institutional help • AA • Self-help groups • … After-care (institutional) - »clubs« of treated A - group therapy - family therapy - individual psychotherapy Structure of professional and non-professional cooperation in alcohol addiction problem in SI M Rus-Makovec 11 EFTC 2007

24. Not to miss opportunity for efficient help … • … because of the way we construct our knowledge: we use knowledge that informs us about the territory of our work – we include and exclude what we are trying to think about and “know” • … disciplinarity as a form of knowledge and the dynamics of oppositionality and competition … (Flaskas 2003) Meta – knowledge: if we construct our knowledge in systemic way, then we can get pieces of puzzles about phenomena of addiction together M Rus-Makovec 11 EFTC 2007