Co-occurring Addictive and Psychiatric Disorders: A Practice-Based Handbook from a European Perspective

398 Pages·2015·4.23 MB·English

by  Geert Dom

Co-occurring
Addictive and
Psychiatric Disorders
A Practice-Based Handbook
from a European Perspective
Geert Dom
Franz Moggi
Editors
123
Co-occurring Addictive and Psychiatric
Disorders
ThiSisaFMBlankPage
Geert Dom (cid:129) Franz Moggi
Editors
Co-occurring Addictive
and Psychiatric Disorders
A Practice-Based Handbook from
a European Perspective
Editors
GeertDom FranzMoggi
CollaborativeAntwerpPsychiatric ClinicalPsychologicalServiceandDepartment
ResearchInstitute(CAPRI) ofPsychotherapy
AntwerpUniversityHospital(UZA) UniversityHospitalofPsychiatry
AntwerpUniversity(UA) UniversityofBern
Antwerp,Belgium Bern
and Switzerland
PsychiatricCenterAlexianBrothers
Boechout
Belgium
ISBN978-3-642-45374-8 ISBN978-3-642-45375-5(eBook)
DOI10.1007/978-3-642-45375-5
SpringerHeidelbergNewYorkDordrechtLondon
LibraryofCongressControlNumber:2014956662
#Springer-VerlagBerlinHeidelberg2015
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In honor of and gratitude to all patients and
their families, who have shared some of their
pathway to recovery with me.
Geert Dom
DedicatedtoMarina,Anna-Chatrina,Nicolo,
Laura, David, and Nikola.
Franz Moggi
ThiSisaFMBlankPage
Introduction to Dual Disorders: Co-occurrence
of Psychiatric and Addictive Disorders
General Context
DualDisorders(dualdiagnosis)aredefinedastheco-occurrenceofapsychoactive
substanceusedisorder(ornon-substance-relatedaddiction)andanotherpsychiatric
disorderinthesameindividual(WHO2010).Theprevalenceofpatientswithdual
disorders is high and is suspected to rise. This accounts for general population
samples, but is most evident within patients who present for treatment for either
addictive or mental health problems. In recent European studies, the high preva-
lence of psychiatric comorbidity was a remarkably stable finding across very
different regions (e.g., Southern and Nordic European countries), despite large
differences in types of substances of abuse, severity, and routes of drug use
(Reissner et al. 2012). Inversely, among patients presenting with a mental health
disorder, a high prevalence of substance use disorder comorbidity can be found
(European Monitoring Centre for Drugs and Drug Addiction, EMCDDA 2013).
ConsistentwiththeseEuropeanstudies,resultsfromtheUSNationalComorbidity
Survey(NCS)indicatethatabouthalfoftheindividualswhosufferfromapsychi-
atric disorder will develop a substance use disorder (SUD) sometime in their life
(Kessler 2004) and that 15 % of them will do so within one year (Kessler
etal.1996).
Patients with dual disorders comprise a disproportionately large part of the
disease burden and mortality compared to other single mental health conditions.
Indeed, most of these patients can be described as individuals with multiple
problemswhoareatahighriskforavarietyofdetrimentaloutcomesinallpossible
domains(e.g.,social,legal,mental,andphysicalhealthoutcomes).
In addition to their complexity, treatment compliance and effectiveness for
patients with dual disorders are generally poorer when compared with other, less
complex,patientswithasingledisorder.Thismayinpartberelatedtotheproblems
in care delivery for patients with dual disorders. At the heart of this issue is the
traditional split between treatment for addictions and mental health care, a para-
digm that is still highly influential in many European countries. Of note, mental
health and addiction care organizations are very diverse across Europe. Great
differencesexist betweencountriesandeven betweendifferent regions within the
same country. This is true for models of care, resources, methods of working or
vii
viii IntroductiontoDualDisorders:Co-occurrenceofPsychiatricandAddictiveDisorders
training, and most importantly, the collaboration between addiction and
psychiatriccare.
Overall,thereisagreatneedtoimprovethecareforpatientswithdualdisorders.
In 2013, Europe introduced the European Mental Health Action Plan. If one
compares the current, actual levels of care currently offered with the objectives
proposedinthisActionPlan(Table1),patientswithdualdisordersclearlydonot
reach these targets. Specifically, domains such as accessibility and specific
competencies(objective3),provisionofjointmentalandsomatichealth(objective
5), and coordination of services (objective 6) are critically underdeveloped for
patientswithdualdisorders,evencomparedwithotherpatienttypes.
Table1 ObjectivesoftheEuropeanMentalHealthActionPlan(2013)
Objective1:Everyonehasanequalopportunitytorealizementalwell-beingthroughouttheir
lifespan,particularlythosewhoaremostvulnerableoratrisk
Objective2:Peoplewithmentalhealthproblemsarecitizenswhosehumanrightsarefully
valued,respected,andpromoted
Objective3:Mentalhealthservicesareaccessible,competent,affordable,andavailableinthe
communityaccordingtoneed
Objective4:Peopleareentitledtorespectful,safe,andeffectivetreatment
Objective5:Healthsystemsprovidegoodphysicalandmentalhealthcareforall
Objective6:Mentalhealthsystemsworkinwell-coordinatedpartnershipswithothersectors
Objective7:Mentalhealthgovernanceanddeliveryaredrivenbygoodinformationand
knowledge
Helping to improve treatment standards, and ultimately, the quality of life for
patients with dual disorders is at the heart of this book. We specifically focus on
Europeancontributionsfortworeasons.First,itisnoteworthythatthebulkofboth
research and clinical textbooks originate from the USA. Indeed, there is no
Europeancountrythatspendsmoremoneyonmentalhealthandaddictionresearch
than the USA. Consequently, more than two-thirds of all papers in scientific
journalsonaddictions,includingthoseoncomorbidity,areofUSorigin(Bramness
et al. 2014). Thus, a European-grounded dual disorder textbook might provide an
importantandcomplementaryadditiontotheexistingworks.
Second,inspiteofthehighqualityoftheUSscientificandclinicalcontributions,
an important question remains whether these findings can be implemented seam-
lessly into the broad variety of European contexts. Indeed, within Europe many
differences exist in patient characteristics (and types of drugs used), organization
andfinancingofcare,attitudestowardpatientswithdualdisorders,andalsolevels
of stigmatization. Although US models are currently used frequently as the basis
when developing treatment programs for patients with dual disorders, more and
more interesting models are developed within many European settings, with each
model providing their own emphases to take into account the cultural and local
conditions.Inaddition,withinthebroaderEuropeanpsychiatryandmentalhealth
field, there is currently a powerful trend toward developing more homogeneity in
standards and quality of care, training, and curriculum requirements, and joining
research efforts. Many European organizations actively work toward better
IntroductiontoDualDisorders:Co-occurrenceofPsychiatricandAddictiveDisorders ix
integration and harmonization. This accounts both for psychiatry (e.g., European
Psychiatric Association, EPA, www.europsy.net) and addiction care (e.g.,
European Federation of Addiction Societies, www.eufas.net). The editors and the
contributorsofthisbookhopethatthiseditionwillbeasignificantcontributionto
shared knowledge and increased awareness throughout the various European
countries and will help to promote a European network of interested individuals
andorganizationsthattakethecareforpatientswithdualdisorderstoheart.
Clinical and Research Problems
Fromaclinicalperspective,itisimportanttoknowwhetherandhowtwoormore
disorders are etiologically related toeach otherbecause there are implications for
treatment. For example, in the Environment Catchment Area Study (Regier
et al. 1990), the authors found arisk close to30 times higher for individualswith
Antisocial Personality Disorder (ASPD) to have any SUD sometime in their
lifetime; but for individuals with anxiety disorders, only about a twofold higher
risk for a SUD. Thus, it is questionable whether ASPD and SUD are comorbid
disorders or only a single disorder where substance abuse is one of its criteria. In
contrast,the“comorbidity”ofanxietydisordersandSUDisnotnecessarilyadual
disorder, but rather anxiety symptoms could be a consequence of intoxication or
substancewithdrawal and,assuch, couldbeasubstance-inducedanxietydisorder
with corresponding implications for treatment. There is certainly more than one
valid etiological model for dual disorders, as well as several models for specific
comorbiditiesofpsychiatricandsubstanceusedisorders.Theseareincludedinthe
chaptersonspecificdualdisordersinthisvolume.
Even for experienced professionals, there are many difficulties in the clinical
assessment of symptoms and making a diagnosis. Clinicians basically need to
evaluatefirstlywhetherthereareenoughsymptomswithsufficientseveritypresent
fortwoormoredisorders(i.e.,meetthecriteriaofadiagnosis),secondlywhether
thesymptomsaresubstanceinducedorindependentofaSUD,andthirdlywhether
thereareinteractionprocessesbetweenthetwo(ormore)disorders.However,often
it is not possible to observe patients in a stable psychiatric state while abstaining
from substance use for a sufficient period of time to answer these three well-
founded questions; thus, diagnoses are often tentative, and as a consequence,
treatmentispronetoerrors.
Thetreatmentofpatientswithdualdisordershasbeencalleda“missionimpos-
sible” for some time (Chow et al. 2012). Nowadays, integrated treatments are
acceptedasthefirstchoiceoftreatmentforpatientswithdualdisorders.Treatment
is characterized by the enhancement of motivation to behavioral change and
adherencetothetreatment;theconcurrentintegrationofeffectivepharmacological
andpsychosocialinterventionsforboththepsychiatricdisorderandthesubstance