11118 Dennis McChargue PhD About This Series Core Topics for Behavioral Health Providers BHECNs webinar series designed to educate behavioral health trainees and providers about practical topics in behavioral health ID: 727810
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Slide1
Inform Your Practice: An Evidence-Based Approach for Clients with Dual Diagnosis
11/1/18
Dennis McChargue,
PhDSlide2
About This Series: Core Topics for Behavioral Health Providers
BHECN's webinar series designed to educate behavioral health trainees and providers about practical topics in behavioral health
Expert presenters provide a mixture of principles and case based application
All webinars are free of chargeSlide3
Core Topics for Behavioral Health ProvidersInform Your Practice: An Evidence-Based Approach for Clients with Dual Diagnosis
CID 39840
November 1, 2018
Target Audience:
Providers and trainees from the following fields: Physicians, psychologists, advanced practice providers, nurse, licensed mental health therapists, and social workers.
Educational Objectives:
1. Explain the prevalence and etiology of substance users with co-occurring mental health problems
2. Discuss difficulties in and approaches to accurately diagnose co-occurring disorders
3. Identify treatment approaches for those who have co-occurring disorders.Slide4
Requirements for Successful CompletionIn order to receive continuing education credits or contact hours, you must:Sign into Go to Webinar
and attend the entire
learning activity
Complete the online evaluation by signing in to
My Account
at
www.unmc.edu/cce
Go to Evaluate a Course/Print Certificate
Use
CME Activity Code
39840
Save and print your certificate. Retain for future documentation. Certificates are available up to
6
0-days
post activity upon completion of the evaluation and attestation.Slide5
CREDITThe University of Nebraska Medical Center, Center for Continuing Education is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The University of Nebraska Medical Center, Center for Continuing Education designates this live activity for a maximum of 2.0
AMA PRA Category 1 Credit
™. Physicians should claim only the credit commensurate with the extent of their participation in the activity
.
The University of Nebraska Medical Center College of Nursing Continuing Nursing Education is accredited with distinction as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. This activity is provided for
2.0
contact hour under ANCC criteria.
This
activity has been planned and implemented in accordance with the accreditation requirements and policies of the American Nurses Credentialing Center’s Commission on Accreditation (ANCC) through the joint
providership
of the University of Nebraska Medical Center College of Nursing Continuing Nursing Education (UNMC CON CNE) (provider
), University
of Nebraska Medical Center, Center for Continuing Education
(UNMC CCE), and Behavioral Health Education Center of Nebraska (BHECN).
This program meets the criteria of an approved continuing education program for Licensed Mental Health Providers
.
This program meets the criteria of an approved continuing education program for Social Work.Slide6
DISCLOSURE DECLARATIONAs a provider accredited by ACCME, the University of Nebraska Medical Center, Center for Continuing Education, the University of Nebraska Medical Center, College of Nursing Continuing Nursing Education, and the American Nurses Credentialing Center’s Commission on Accreditation must ensure balance, objectivity, independence, and scientific rigor in its educational activities. Faculty are encouraged to provide a balanced view of therapeutic options by utilizing either generic names or the trade names of several to ensure impartiality.
All speakers, planning committee members and others in a position to control continuing medical education content participating in a University of Nebraska Medical Center, Center for Continuing Education, University of Nebraska Medical Center, College of Nursing Continuing Nursing Education, and American Nurses Credentialing Center’s Commission on Accreditation activity are required to disclose relationships with commercial interests. A commercial interest is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. Disclosure of these commitments and/or relationships is included in these course materials so that participants in the activity may formulate their own judgments in interpreting its content and evaluating its recommendations.
This activity may include presentations in which faculty may discuss off-label and/or investigational use of pharmaceuticals or instruments not yet FDA-approved. Participants should note that the use of products outside currently FDA-approved labeling should be considered experimental and are advised to consult current prescribing information for FDA-approved indications.
All materials are included with the permission of the authors. The opinions expressed are those of the authors and are not to be construed as those of the University of Nebraska Medical Center, Center for Continuing Education, University of Nebraska Medical Center, College of Nursing Continuing Nursing Education, or American Nurses Credentialing Center’s Commission on Accreditation.Slide7
FACULTY AND PLANNING COMMITTEE DISCLOSURESAll faculty and planning committee members have no financial relationships to disclose.
Heidi Keeler, PhD, RN
Assistant Professor
College of Nursing-Omaha Division
Director, Continuing Nursing Education
Director, Office of Community Engagement
University of Nebraska Medical Center
Howard Liu, MD
Associate Professor
Department of Psychiatry
Director, Behavioral Health Education Center of Nebraska
University of Nebraska Medical Center
Dennis
McChargue
, PhD
Associate Professor
Department of Psychology
University of Nebraska-Lincoln
Brenda Ram, CMP, CHCP
Interim Director, Educational Programs
Center for Continuing Education
University of Nebraska Medical CenterSlide8
The Behavioral Health Education Center of Nebraska (BHECN), pronounced “beacon”, was established in 2009 by a legislative bill to address the shortage of behavioral health professionals in rural and underserved areas of the state. unmc.edu/bhecn
MISSION: BHECN is dedicated to improving access to behavioral health care across the state of Nebraska by developing a skilled and passionate workforce.
About BHECN Slide9
Attendees are mutedTo ask a question, please type it in to the “Questions” box in your GoToWebinar control panel Slides are available to download in “Handouts” section of control panel
Please complete survey after the webinar
AnnouncementsSlide10
Click the link to view a recording of today's webinar and information on future webinarshttps://www.unmc.edu/bhecn/education/online-training/core-topics-webinars.html
Recording availableSlide11
Dr. Dennis McChargue
Dr.
Dennis McChargue, associate professor of Psychology at the University of Nebraska-LincolnSlide12
Inform Your Practice: An Evidence-Based Approach for Clients with Dual Diagnosis
Dennis
McChargue
, PhD
Associate Professor
Department of PsychologySlide13
PrevalenceEtiologyDifferential DiagnosisTreatment Models
Dual DiagnosisSlide14
Prevalence
NSDUH, 2005; SAMHSA, 2015
8.9 Million
Sample: 24.6 Million with MHSlide15
6 of of 10 people with SUD also suffer from another formof mental illness (NIDA, 2007)
Prevalence Slide16
ComponentsSubstance Use and Mental Health ProblemsOccurring in the same personSimultaneously or sequentially
Interactive Effect
Both affect…
Course
Prognosis
…of Both
NIDA, 2009
Definition Slide17
III
Substance
Use
Tx
IV
Emergency Room Crises
I
General Health Care Setting
II
Mental Health Provider
Quadrant Model of entry
Substance Severity
Mental Health SeveritySlide18
Etiology Slide19
Temporal Priority
and Age of
ONset
Whitbeck
, Yu,
McChargue
& Crawford, 2009
Kaplan- Meier Age of Onset Curves WHO, 2000
Course of illness more chronic than single disorder.Slide20
Etiological explanations
1. Self-MediationSlide21
Etiological explanations
2. Biological mechanisms
CNS Drugs. 2016 Dec;28(12):1115-26.
Methamphetamine Psychosis: Epidemiology and Management.
Glasner
-Edwards & Mooney LJ.
…approximately 40% of MA users affected… psychotic symptoms include hallucinations, ideas of reference and paranoid delusions…can recur and persist.Slide22
Etiological explanations
3. Genetic/Environmental
Arch Gen Psychiatry. 2003 60(9):929-37.
The Structure of Genetic and Environmental Risk Factors for Common Psychiatric and Substance Use Disorders in Men and Women.
Kendler KS, Prescott CA & Myers J et al.,
…across 5600 twin pairs…pattern of lifetime comorbidity…results largely from the effects of genetic risk factors.
(Brady & Sinha, 2005)Slide23
MH/SUD Specific Pairings
Depression
Social Anxiety
OCD
GAD
PTSD
Hallucinogens
Psychostimulants
Depressants
Opioids
Bipolar
Psychotic-SpectrumSlide24
Dual Diagnosis
Common Pairings
Anxiety
Hallucinogens
Psychostimulants
Depressants
Opioids
Mood
Psychotic-
Spectrum
Severity = Degree of UseSlide25
Differential Diagnosing/Early DetectionTailoring Treatment
Pairing IssuesSlide26
Differential diagnosis Slide27
Differential Diagnosing Slide28
Differential Diagnosing Slide29
Differential Diagnosing
Anxiety
Alcohol
DepressionSlide30
Differential Diagnosing
Main IssuesSlide31
Prog Neuropsychopharmacol Biol Psychiatry. 2011
Comparisons of methamphetamine psychotic and schizophrenic symptoms: A differential item functioning analysis.
Srisurapanont
M
,
Arunpongpaisal
S
,
Wada K
,
Marsden J
,
Ali R
,
Kongsakon
R
.
FINDINS: The results suggest that, at the same level of syndrome severity (i.e., negative, positive, and anxiety/depression syndromes), the severity of psychotic symptoms, including the negative ones, observed in MA psychotic and schizophrenic patients are almost the same.
Addiction. 2006 Oct;101(10):1473-8.
The prevalence of psychotic symptoms among methamphetamine users.
McKetin
R
,
McLaren J
,
Lubman
DI
,
Hides L
.
FINDINGS: Thirteen per cent of participants screened positive for psychosis, and 23% had experienced a clinically significant symptom of suspiciousness, unusual thought content or hallucinations in the past year. Dependent methamphetamine users were three times more likely to have experienced psychotic symptoms than their non-dependent counterparts, even after adjusting for history of schizophrenia and other psychotic disorders.
Drug Alcohol Rev. 2010 Jul;29(4):456-61.Long-term outcomes in methamphetamine psychosis patients after first hospitalisation.Kittirattanapaiboon
P, Mahatnirunkul S, Booncharoen H, Thummawomg P, Dumrongchai U, Chutha W.Of those, 39.2% were re-hospitalised and 38% were given a diagnosis of schizophrenia due to persistent psychosis.Slide32
Differential Diagnosing
Process
Screening
Diagnostic
Differential
Etiologic/
DevelopmentalSlide33
DASS: (42 items)http://www2.psy.unsw.edu.au/groups/dass/BSI-18
https://
pearsonassess.ca
/
haiweb
/cultures/
en
-ca/Products/
Product+Detail.htm?CS_ProductID
=BSI-18&CS_Category=
psychological-biopsychosocial&CS_Catalog
=TPC-
CACatalog
PCL-C (17 items)
Weathers, F.W.,
Huska
, J.A., Keane, T.M.
PCL-C for DSM-IV
. Boston: National Center for PTSD – Behavioral Science Division, 1991.
Stage of Change (19 items)
http://casaa.unm.edu/inst/SOCRATESv8.pdf
Differential Diagnosing
ScreeningSlide34
Structured Clinical Interview for DSM-IVMINI International Neuropsychiatric Interview
Addiction Severity Index
Differential Diagnosing
Diagnostic
(
Cosci
& Fava, 2011)Slide35
Differential Diagnosing
Macro Mechanisms
Macro
Emotional
Emotional/Experiential Avoidance
Specific Mood
Alexithymia
Anhedonia
Distress Tolerance
Cognitive
Rumination
Executive Functioning Challenges
Rigid ThinkingSlide36
Differential Diagnosing
Etiologic/
Developmental
Substance Use
Age 15-16 |18-21| 21-28 |…..
Mental Health
Depression
Daily Alcohol Use
Events
Use
Drop College
DUI
Depression
Probation/
Tx
Eval
Lost Job
Dep
F
Hx
Ethol
African Am
MaleSlide37
Differential Diagnosing
Key Questions
Process
Core
Which symptoms appear core to each diagnosis?
What information is needed to minimize the potential for mislabeling core symptoms?
Are there cultural or gender factors to consider?
Common/Overlapping
Which sxs appear better accounted for by X disorder vs. Y disorder?Slide38
Differential Diagnosing
Questions?
?Slide39
Single Model of CareTreating the mental health problem assumes the substance use problems disappearsDe-emphasizes the nature of addictionSequential Model of Care
Treats on disorder at a time
Doesn’t facilitate simultaneous utilization of both mental health and addiction services
Assumes having on disorder active while treating other
Treatment ModelsSlide40
Parallel Model of CareTwo treatment facilities treating a different problem without coordinationIntegrated Model of CareTx team address both MH and SUD.
Requires collaboration among MH and SUD providers.
Requires continuing formal interaction and cooperation in ongoing assess and
tx
.
Treatment ModelsSlide41
Integrative strategies
Treatment Planning Exercise (4-5 goals)
Providers: MH outpatient/SUD halfway house
Patient
41
yr
old; African American male; multiple DUIs; probation; unemployed
Alcohol Dependence (abstinent 6 months)
Hx
of 6 prior treatments
Longest abstinence 8 months
History of Social Anxiety and Depression
Active symptoms of MDD and Social Anxiety Disorder
Symptoms have increased across 6 monthsSlide42
Etiologic
Substance Use
Age 15-16 |18-21| 21-28 |….. | 41
Mental Health
Depression
Daily Alcohol Use
Events
Use
Drop College
DUI
Depression
Probation/
Tx
Lost Job
Dep
DUIs
4
Txs
Dep
/Anxiety
Dep
/Anxiety
Episodic Daily UseSlide43
Integrative Tx Planning
Patient Education
Educates about the multiple disorders
Brings insight into how each disorder influences the other
Education about the etiological processes specific to the individual
Education about interactive prognosisSlide44
Integrative Tx Planning
Substance Stabilization/Relapse Prevention
Includes specific language about mental health triggers/influences
Recovery Reinforcement
Sober support
Social network
Physical and Mental Well-being
Academic/EmploymentSlide45
Integrative
tx
planning
Mental Health Stabilization/Relapse Prevention
Includes language about substance triggers/influences
Mental Health Interventions
Specific to Disorder
Risk Management
Substance, Suicide, Violence,
De-compensationSlide46
Integrative
tx
planning
Simple Example (1-2 month in
tx
)
Goal 1: Continued education about how Hank’s mental health has influence his substance use (MH provider or DC)
Goal 2: Develop insight and coping strategies associated with relapse risk. (SUD provider)
Goal 3: Develop insight into how mental health symptoms function as a trigger to use (MH provider)
Goal 4: Develop emotion regulation coping strategies that assist in coping with both substance and mental health. (provider specific)
Goal 5: Monitor and assist client in managing substance use and mental health risks (provider specific)Slide47
Integrative strategies
Additional Strategies/Recommendations
Beware of Compensatory Behavior
Utilize treatments that affect both first
Specific Disorders
Social Anxiety
(if pre-existing before substance onset) utilize group treatment as exposure
PTSD
exposure doesn’t necessarily prompt relapse, if in controlled environmentSlide48
Integrative
strategies
Pharmacology Concerns
Beware of prescription seeking behavior
ADHD/PSYCHOSTIMULANT
Psychostimulant meds
PTSD/OPIOID
Benzodiazepine
Beware of medications for diagnoses that were misdiagnosed.
Collaboration with Medication Provider EssentialSlide49
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