Addressing psychosocial needs

1. Addressing psychosocial needs Marta Torrens Institut d’Atenció Psiquiàtrica i Addiccions IMIM-Hospital del Mar Universidad Autònoma de Barcelona EMCDDA Identifying Europe’s information needs for effective drug policy Lisbon, 6-8 May 2009

2. Outline • Addiction and psychosocial needs: the concomitant psychiatric disorders • Epidemiology of other concomitant psychiatric disorders among drug addicts • Effectiveness of treatment • Conclusions

3. Epidemiology of psychiatric comorbidity in drug abusers Relevance of psychiatric comorbidity in drug abusers Treatment of psychiatric comorbidity in drug abusers • More emergency admissionsCurran 2003; Martín-Santos 2006 • Higher prevalence of suicide Appleby 2000; Aharonovich 2002 • Increased rates of medical comorbidity (risk behaviours and related infections: HIV & HCV) King et al, 2000; Carey et al, 2001; Rosenberg et al, 2001; Dickey et al, 2002 • More risk of relapse following drug abuse treatment: Brown et al, 2004; Compton et al, 2003; McLellan et al, 1983; Rounsaville et al, 1986; 1982; Shanahan et al, 2005 Increased psychopathological & medical severity

4. Relevance of psychiatric comorbidity in drug abusers Treatment of psychiatric comorbidity in drug abusers • Increased rates of childhood and adult physical and sexual abuse Grice et al, 1995; Jarvis & Copeland, 1997; Kang et al et al, 1999 • Higher unemployment and homelessness rates Caton et al, 1994, Vazquez et al, 1997 • Greater incident of violent or criminal behaviour Abram and Teplin 1991; Cuffel et al, 1994; Swartz et al, 1998, Soyka 2000 Increased psychopathological, medical & social severity

5. Epidemiology of psychiatric comorbidity in drug abusers Prevalence: 15-80% • What population? • General population • Primary care/ Mental health services/ Substance abuse facilities • Substance abusers non-seeking treatment • When? • Past month, 6 months, 12 months, lifetime • How? • Diagnostic criteria, Diagnostic instruments

6. Evolution of diagnostic concepts

7. General population studies ECA Epidemiological Cathment Area Study ; NCS National Comorbidity Study; NLAES National Longitudinal Alcohol Epidemiologic Survey; NHE&W National Household Survey in England & Wales; ICPE International Consortium in Psychiatric Epidemiology; ANSMH&WB National Survey of Mental Health and Well Being ; NESARC National Comorbidity Survey of Alcoholism and Related Conditions; NCS-R National Comorbidity Survey Replication

8. General population studies: main results • Extensive co-occurrence among Mood, Anxiety and Substance Use Disorder (SUD) • Mood/SUD > Anxiety/SUD • Risk of Mood and Anxiety Disorders greater for Substance Dependence than for Substance Abuse • Gender differences: female more comorbidity than male • Comorbidity occurs across cultures

9. Substance Abuse Services: lifetime prevalence (%)

10. Substance abuse services: lifetime prevalence (%)

11. Substance Abuse services: Main results • Psychiatric comorbidity is frequent in treatment-seeking substance abusers: 40-60% • The most prevalent co-morbid diagnoses are: • Mood disorders (Major Depression) • Anxiety disorders (Panic) • Antisocial Personality disorder

12. Epidemiology of psychiatric comorbidity in drug abusers Prevalence: 15-80% • What population? • General population • Primary care/ Mental health services/ Substance abuse facilities • Substance abusers non-seeking treatment • When? • Past month, 6 months, 12 months, lifetime • How? • Diagnostic criteria, Diagnostic instruments • Where? • Availability and accessibility to treatment • Availability and accessibility to licit and illicit drugs (epidemic) • Other inter-current events (i.e. HIV infection)

13. Barcelona: 2001-2005 Lifetime prevalence of psychiatic comorbidity in substance abusers ? • Population? Substance abuse facilities Substance users not seeking treatment • When? Lifetime • How? DSM-IV criteria mean PRISM • Where? Availability and accessibility to treatment Availability and accessibility to licit and illicit drugs (epidemic) Other inter-current events (i.e. HIV infection, HCV)

14. Lifetime prevalence of psychiatric comorbidity in SA: Barcelona 2001-05 At street N=650 Seeking Drug treatment 67 Rodriguez-Llera et al, 2006; Nocon et al 2007; Herrero et al, 2008; Astals et al, 2008; Martin-Santos et al, at submission

15. Lifetime prevalence of psychiatric comorbidity in SA Rodriguez-Llera 2006; Nocon 2007; Herrero 2008; Astals 2008; Martin-Santos at submission

16. Lifetime prevalence of DEPRESSION

17. Lifetime prevalence of ANXIETY

18. Lifetime prevalence of PSYCHOSIS

19. Epidemiology of psychiatric comorbidity: Summary • Psychiatric comorbidity is frequent among substance abusers: 40%-70% in both: treatment seeking and non-seeking, and in different main drug of abuse • Mood and anxiety are the most frequent Axis I comorbid disorders • Primary disorders are more frequent than induced • Small number of subjects with severe mental illness in substance abuse treatment centres

20. Treatment of psychiatric comorbidity in drug abusers • Where? • How?

21. Treatment of psychiatric comorbidity in drug abusers Treatment of psychiatric comorbidity in drug abusers Where? Networks General Health

22. Treatment of psychiatric comorbidity in drug abusers Treatment of psychiatric comorbidity in drug abusers Where? Networks General Health Mental Health

23. Treatment of psychiatric comorbidity in drug abusers Treatment of psychiatric comorbidity in drug abusers Where? Networks General Health Mental Health Drug Abuse

24. Treatment of psychiatric comorbidity in drug abusers Where? Acute Hospitalization Partial Hospitalization Open/Day Hospital Residential Treatment Mental Health Center Detoxification Unit Partial Hospitalization Therapeutic community Drug Abuse Center

25. Treatment of psychiatric comorbidity in drug abusers Where? Acute Hospitalization Partial Hospitalization Open/Day Hospital Residential Treatment Mental Health Center Psychiatric comorbidity Detoxification Unit Partial Hospitalization Therapeutic community Drug Abuse Center

26. Treatment of psychiatric comorbidity in drug abusers Where? Integrated Parallel Sequential

27. Treatment of psychiatric comorbidity in drug abusers How? • Pharmacological • Psychosocial

28. Treatment of psychiatric comorbidity in drug abusers Treatment of psychiatric comorbidity in drug abusers How? Pharmacological • Efficacy • Safety & tolerability • Abuse Liability • Interactions with substance of abuse

29. Treatment of psychiatric comorbidity in drug abusers Treatment of psychiatric comorbidity in drug abusers Depression • Efficacy • Medication effects are larger when Primary Major Depression rather than Substance-induced depression • SSRIs do not seem to offer significant advantages compared with tricyclic drugs (desipramine) Nunes & Levin 2004; Torrens 2005; • Safety • Risk of overdoses with tryciclics • Abuse Liability • Only amineptine and fentamine Haddad 1999; Jasinski 2008 • Interactions with substance of abuse • MAOIs + cocaine & stimulants: absolute contraindication

30. Treatment of psychiatric comorbidity in drug abusers Anxiety

31. Treatment of psychiatric comorbidity in drug abusers Anxiety Safety BZP:Risk of overdoses MAOIs: Absolute contraindication

32. Treatment of psychiatric comorbidity in drug abusers Treatment of psychiatric comorbidity in drug abusers Psychosis • Typical Antipsychotic: • Improvement of psychosis • Impairment of substance use • Atypical Antipsychotic: First election • Clozapine: • Improvement of psychotic symptoms • Decrease of substance use (nicotine, alcohol, other substances of abuse) • Olanzapine • Risperidone • Quetiapine • Aripripazole Brady 1990; Dixon 1991; McEvoy 1995; Green 2002; 2003; 2008,

33. Treatment of psychiatric comorbidity in drug abusers Treatment of psychiatric comorbidity in drug abusers How? Psychosocial • Interventions that show consistent positive effects on substance use disorder • group counseling, • contingency management • residential dual diagnosis treatment • Interventions with significant impacts on other areas of adjustment: • case management: enhances community retention • legal interventions: increase treatment participation Drake et al, 2008

34. Summary • Psychiatric comorbidity is frequent among substance abusers: 40%-70% in both: seeking and non-seeking treatment, and in different main drug of abuse • Mood and anxiety are the most frequent Axis I comorbid disorders • 35% to 70% of individuals with substance use disorder and mental health symptoms are not receiving any treatment

35. Conclusions Policy makers must guarantee services that: • Facilitate the access to appropriate treatment of substance abusers with other psychiatric comorbidity (in both mental health and drug abuse networks) • Provide diagnosis and treatment of other psychiatric comorbidity among substance abusers seeking treatment

36. Conclusions • More research is need to develop adequate treatments for treating concomitant psychiatric disorders in substance abusers • Services • Pharmacological • Psychosocial

37. Thank you for your attention !! T