A focused introduction to the importance of underpinning that a comprehensive understanding of a person’s behavioural, mental and emotional health issues, requires an understanding of the person, their environment and needs.

1. Dr C Mouton
MBChB, FCPsychSA, KNMG Psychiatrist
Medical Director Triora
c.mouton@triora.com
Co-occurring Disorders:
The Rule, Not The Exception
iCAAD Amsterdam November 2018

2. Disclosure
(Potential) conflict of interest None
Relevant relations with industry None
Sponsoring or research money
Honorarium or financial payments
Shareholder
Other
None
None
None
None

3. Definition of addiction (1)
 Addiction is a primary, chronic disease of brain reward,
motivation, memory and related circuitry. Dysfunction in these
circuits leads to characteristic biological, psychological, social
and spiritual manifestations. This is reflected in an individual
pathologically pursuing reward and/or relief by substance use
and other behaviors.
https://www.asam.org/resources/definition-of-addiction

4. Definition of addiction (2)
 Addiction is characterized by inability to consistently abstain,
impairment in behavioral control, craving, diminished
recognition of significant problems with one’s behaviors and
interpersonal relationships, and a dysfunctional emotional
response. Like other chronic diseases, addiction often involves
cycles of relapse and remission. Without treatment or
engagement in recovery activities, addiction is progressive and
can result in disability or premature death.
https://www.asam.org/resources/definition-of-addiction

6. Dual Disorders / Dual Diagnosis
 Dual disorders - Mental illness and substance abuse
occurring together in the same person
 Comorbidity - Two (or more) co-occurring
disorders / dysfunctions
 Co-occurrence - Two “things” happening at the
same time
© 2018 Constant Mouton

7. Co-occurring Disorders (COD)
 Makes room for more disorders
 Includes medical and other disorders, associated with
the addiction
 Doesn’t focus on morbidity
 More accurate overall than other terms
© 2018 Constant Mouton

8. Numbers and concepts

9. How frequently does it occur?
 Lifetime prevalence of mood disorders 20,1%
 Lifetime prevalence of anxiety disorders 19,6%
 Lifetime prevalence of ADHD 9,2%
 Lifetime prevalence of any mental illness 42,7%
 Lifetime prev.: substance related disorders 19,1%
 Lifetime prev: SUD in severe mental illness 40% - 60%
 Pts in addiction units with mental illness 60% - 80%
De Graaf et al, NEMESIS-2

10. How frequently does it occur?
 Schizophrenia also with SUD 47%
 Bipolar also with SUD 52% - 56%
 Depression also with SUD 19% - 27%
 ADHD also with SUD 20% - 25%
 Anxiety disorders also with SUD 24% - 35%
 Post Traumatic Stress Disorder also with SUD 22% - 43%
 Personality Disorders also with SUD 44%
(Alcohol)
NIDA

11. How frequently does it occur?
 Lifetime prevalence: any other psychiatric disorder 97%
 + alcohol use disorder 75%
 + drug use 40%
 Personality disorders > 60%
 Mood disorders ~ 50%
 Anxiety disorders > 40%
 Pathological Gambling Disorder
Kesser RC, (2008) Petry (2005)

13.  Experimental
 To feel good
Why do people start using?
 To feel better
 To do better

15.  Primary mental illness leading to addiction
 Self medicating psychiatric symptoms (e.g. Anxiety)
 Self medicating side effects
 Schizophrenia: nicotine use  decreased S/E of Rx and (-) symptoms
 Mental illness itself can trigger or worsen addiction
 Mania: increased impulsivity  increase risk of use/relapse
 Panic: alcohol relieves symptoms  impulsivity other addiction
 Prescribing addictive medicine
What is the interaction in Co-occurring Disorders?
© 2018 Constant Mouton

16.  Primary addiction leads to a psychiatric sequelae
 Intoxication can cause symptoms of mental illness (Delirium)
 Substance use can unmask underlying mental illness
(Psychosis)
 No clear evidence if substance use cause mental illness as
such
 Cannabis – inducing first psychosis
 Substance use can worsen existing mental illness
What is the interaction in Co-occurring Disorders?
© 2018 Constant Mouton

17.  Unrelated primary diagnosis (Two or more separate
diagnoses, unrelated, might interact)
 Common aetiology
 Bio-psycho-social factors lead to both conditions e.g.
 Family dysfunction leading to addiction
 Conduct disorder leading to addiction
 Shared genetic risk e.g. ADHD and addiction have
shared genomes involved
What is the interaction in Co-occurring Disorders?
© 2018 Constant Mouton

19. Untreated Co-occurring Disorders
 Addiction predicts worse outcome for mental illness
 Mental illness predicts worse outcome for addiction
 Negative effect on treatment
 Non-response or poor response to regular treatment
 More frequently non-compliant
 Increased hospital admission rates
 Increased suicidality rate
 Increase overall health cost
© 2018 Constant Mouton

20. Untreated Co-occurring Disorders
 Higher rate of homelessness
 Higher unemployment rate
 More family problems
 Legal problems / arrest more likely / frequent
 Negative effect on psychosocial functioning
 Medical problems
 Higher HIV, Hepatitis and STD rate
 Higher mortality rate
© 2018 Constant Mouton

21. Untreated Co-occurring Disorders
 More stigma within health sector
 Less qualified staff to treat both disorders
 More problems getting care / treatment
 Lower availability of dual disorder facilities
 Poor accessibility to health services
© 2018 Constant Mouton

22. Assessment

23. Assessment – the bare minimum
 Biographical assessment incl. family history (Lifespan + genogram)
 Complete addiction history
 Complete medical and psychiatric history (symptom clusters)
 Trauma history (physical / emotional / ACE)
 Functioning (QOL, different life domains)
 First the big picture, then treatment strategy
 Screening tools are not diagnostic
 Assess safety
© 2018 Constant Mouton

24. Genogram
© 2018 Constant Mouton

25. Bio-psycho-social model
Biological Psychological Social
•Genetic predisposition
•Physical development
•Intelligence
•Temperament
•Medical comorbidity
•Personality structure
•Self-esteem
•Insight
•Defense mechanisms
•Patterns of cognition
•Responses to stressors
•Trauma history
•ACE (Adverse Childhood
Events)
•Coping strategies
•Peer relationships
•Family constellation
•Transitions within the
family (ARISE)
•Work environment
•Ethnic influences
•Socioeconomic issues
•Culture
•Religion
© 2018 Constant Mouton

26. Predisposing factors:
“What made me VULNERABLE in
the first place?”
Protective factors:
“Which positive things do I have
going for me?” RESILIENCE
Precipitating factors:
“What TRIGGERED the most recent
episode?”
Perpetuating factors:
Things that keep the problems
going on / keeps me from
recovery (RELAPSE)
Problems/diagnoses:
GOALS
The Big Picture (Dynamic approach)
© 2018 Constant Mouton

27. Diagnosis – some aspects
 Does it matter?
 Only diagnose if you are trained to do so
 Be careful with sharing provisional / differential diagnoses
 Stay clear of lay diagnoses
 Questionnaires are never diagnostic
 Capture the Big Picture
 Psychodynamic diagnosis
 DSM-5 / ICD

28. Treatment

29. GOAL of treatment is RECOVERY

30. Recovery from the patients perspective
 Feeling supported by family and peers and being able to
participate in the community - BEING CONNECTED
 Holistic and individualized treatment approach, seeing
the person “behind the symptoms” – INDIVIDUALIZED
TREATMENT/ SHARED DECISION MAKING
De Ruysscher C, et al.. The Concept of Recovery as Experienced by Persons with Dual Diagnosis: A Systematic Review
of Qualitative Research From a First-Person Perspective. J Dual Diagn. 2017 Jul 12:1-16.

31. Recovery from the patients perspective
 Having personal beliefs, such as fostering feelings of
hope, building a new sense of identity, gaining
ownership over one's life, and finding support in
spirituality – SPIRITUALITY
 Importance of meaningful activities that structure one's
life and give one motivation to carry on -
MEANINGFULLNESS
De Ruysscher C, et al.. The Concept of Recovery as Experienced by Persons with Dual Diagnosis: A Systematic Review
of Qualitative Research From a First-Person Perspective. J Dual Diagn. 2017 Jul 12:1-16.

32. Quadrants of Minkhoff
Implication for specific treatment
© 2018 Constant Mouton

33. Sequential treatment
© 2018 Constant Mouton

34. Sequential treatment
© 2018 Constant Mouton

35. Integrated Dual Disorder Treatment
© 2018 Constant Mouton

36.  Same team
 Same location
 Same time
 More effective than parallel treatment
 At least ten studies show integrated treatment is more
effective than traditional sequential treatment
Drake et al, Schiz Bulletin 1998; Drake et al, Psych Services 2001 for summaries
Integrated Dual Disorder Treatment

37.  Multidisciplinary Team
 Stage-Wise Interventions (stages of change, stages of
treatment)
 Access to Comprehensive Services (e.g., residential, etc.)
 Time-Unlimited Services Assertive Outreach
 Motivational Interventions (And invitational interventions,
ARISE?)
 Substance Abuse Counseling
Drake et al, Schiz Bulletin 1998; Drake et al, Psych Services 2001 for summaries
Integrated Dual Disorder Treatment

38.  Group Treatment
 Family Participation
 Participation in Alcohol & Drug Self-Help Groups
 Pharmacological Treatment
 Interventions to Promote Health
 Secondary Interventions for Treatment of Non- Responders
Drake et al, Schiz Bulletin 1998; Drake et al, Psych Services 2001 for summaries
Integrated Dual Disorder Treatment

39. Collaborative Care

40. UBUNTU - “I am because we are”

41. Mental Health Law Addiction Psychiatrist Person Of Medical Social Recovery Psychologist
Nurse Enforcement Counsellor Concern Doctor Work Specialists

42. Transitional Field Map
Landau-°©‐Stanton, J. and Clements, C. (1993) AIDS, health and mental health: a primary sourcebook. New York: Brunner/Mazel.

43. Strength in Numbers
PoC
 Individual
 Biological
 Psychological
© 2018 Constant Mouton

44. Strength in Numbers
PoC
Psychiatrist
Psychologist
Counsellor
Social Work MH Nurse
Art TherapistPhysical Therapy
 Individual
 Biological
 Psychological
 Ancillary/Professional
(traditional)
© 2018 Constant Mouton

45. Strength in Numbers
PoC
Psychiatrist
PsychologistCounsellor
Social Work MH Nurse
Sponsor
Self-help Coach
GP
Interventionist
Recovery Coach
Art TherapistPhysical Therapy
Pharmacist
Dentist
 Individual
 Biological
 Psychological
 Ancillary/Professional
(extensive)
© 2018 Constant Mouton

46. Strength in Numbers
PoC
Psychiatrist
PsychologistCounsellor
Social Work MH Nurse
Sponsor
Self-help Coach
GP
Interventionist
Recovery Coach
Art TherapistPhysical Therapy
Pharmacist
Dentist
Partner
Brother
Son Sister in Law
Uncle
Niece
 Individual
 Biological
 Psychological
 Family/Intimate
 Ancillary/Professional
© 2018 Constant Mouton

47. Strength in Numbers
PoC
Psychiatrist
PsychologistCounsellor
Social Work MH Nurse
Sponsor
Self-help Coach
GP
Interventionist
Recovery Coach
Art TherapistPhysical Therapy
Pharmacist
Dentist
Partner
Brother
Son Sister in Law
Uncle
Niece
Colleague
Friend Neighbour
TeacherBaker
Friend
 Individual
 Biological
 Psychological
 Family/Intimate
 Extended natural
 Ancillary/Professional
© 2018 Constant Mouton

48. Strength in Numbers
PoC
Psychiatrist
PsychologistCounsellor
Social Work MH Nurse
Sponsor
Self-help Coach
GP
Interventionist
Recovery Coach
Art TherapistPhysical Therapy
Pharmacist
Dentist
Partner
Brother
Son Sister in Law
Uncle
Niece
Colleague
Friend Neighbour
TeacherBaker
Friend
Religious Leader
Community Leader
Spiritual Guide
Cultural Leader
Community projects
Self Help groups
Community
Group
 Individual
 Biological
 Psychological
 Family/Intimate
 Extended natural
 Ancillary/Professional
 Cultural / Community
 Spiritual
© 2018 Constant Mouton

49. Key factors for Collaborative Care
 Coordination and Case Management
 Refer as necessary
 Stay in your own lane… ;-)
 Respect privacy (share only what is necessary)
 Involve the PoC in all steps (Shared Decision Making)
 All efforts should be towards recovery (shared
therapeutic goal)
© 2018 Constant Mouton

50. Key factors for Collaborative Care
 It’s both/and not either/or (inclusive, not exclusive)
 Trust within team
 Communication and Respect
 5 professionals = 1 relative (don’t forget the family!)
 Ethics apply to everyone!
 Privacy and Autonomy of the PoC should be guaranteed
© 2018 Constant Mouton

52. Dr C Mouton
MBChB, FCPsychSA, KNMG Psychiatrist
Medical Director Triora
c.mouton@triora.com
Thank You