Co-occurring Addictive and Psychiatric Disorders: A Practice-Based Handbook from a European Perspective PDF
Preview Co-occurring Addictive and Psychiatric Disorders: A Practice-Based Handbook from a European Perspective
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 Thisworkissubjecttocopyright.AllrightsarereservedbythePublisher,whetherthewholeorpart of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation,broadcasting,reproductiononmicrofilmsorinanyotherphysicalway,andtransmissionor informationstorageandretrieval,electronicadaptation,computersoftware,orbysimilarordissimilar methodologynowknownorhereafterdeveloped.Exemptedfromthislegalreservationarebriefexcerpts inconnectionwithreviewsorscholarlyanalysisormaterialsuppliedspecificallyforthepurposeofbeing enteredandexecutedonacomputersystem,forexclusiveusebythepurchaserofthework.Duplication ofthispublicationorpartsthereofispermittedonlyundertheprovisionsoftheCopyrightLawofthe Publisher’s location, in its current version, and permission for use must always be obtained from Springer.PermissionsforusemaybeobtainedthroughRightsLinkattheCopyrightClearanceCenter. ViolationsareliabletoprosecutionundertherespectiveCopyrightLaw. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publicationdoesnotimply,evenintheabsenceofaspecificstatement,thatsuchnamesareexempt fromtherelevantprotectivelawsandregulationsandthereforefreeforgeneraluse. While the advice and information in this book are believed to be true and accurate at the date of publication,neithertheauthorsnortheeditorsnorthepublishercanacceptanylegalresponsibilityfor anyerrorsoromissionsthatmaybemade.Thepublishermakesnowarranty,expressorimplied,with respecttothematerialcontainedherein. Printedonacid-freepaper SpringerispartofSpringerScience+BusinessMedia(www.springer.com) 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
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