TIPS and TOPICS
Vol 1, No.2
May 2003

In this issue
– SAVVY
– SKILLS
– SOUL
– STUMP the SHRINK
– Until next time

WELCOME!

Welcome back to this second edition of TIPS and TOPICS.

The response to the first edition was very positive and satisfying. If you are receiving TIPS and TOPICS for the first time, thanks for signing up along with over a hundred of your colleagues. For a few of you with whom I have had professional contact in the past, I took the liberty of sending this along to you this month. If you would like to keep receiving it, I’ll be happy to send it. But if you are overwhelmed with information already and would rather not receive TIPS and TOPICS free each month, then I totally understand if you unsubscribe (see Unsubscribe link at the very end).

Thanks to all of you who wrote and expressed appreciation and gave feedback. It seems TIPS and TOPICS has already filled a need for many of you. I hope this edition will also be as useful to many.

SAVVY

Over the past month, I was asked to consult about two patients. Between them, both had been hospitalized in acute care medical and psychiatric units five times in the past six months. They were admitted for depression, suicidal feelings and ideation. One had a serious overdose and one even had electroconvulsive therapy (ECT). Alcohol and cocaine were the drugs involved. One of the consultation questions asked of me was this: What should be the focus of treatment given the patient’s poor follow through with treatment, “denial”, and multiple readmissions in a period of months?

In both cases, the substance dependence was correctly recognized as an important element in the patient’s history and treatment needs. However, in both cases, the clinician’s major emphasis was on the mental health problems – partly because those were the most acute presenting symptoms. Very little assessment of the substance use was done to tease apart to what degree the psychiatric symptoms were a result of the addiction problem; or to what degree the symptoms were truly a co-occurring disorder. Both programs were not very savvy about addiction treatment, let alone integrated dual diagnosis treatment.

Tips:

• If a person is suffering from depression or any other psychiatric presentation, and is actively using alcohol and/or other drugs, specific assessment of both the mental health and substance use is needed. Is there a mental health problem where substance use may be attempts to self medicate the psychiatric disorder? Is this a substance use disorder in which the mental health symptoms are a result of addiction illness? Or is it a true dual diagnosis?
• It is necessary to understand the difference between Substance Use Disorders and Substance-Induced Disorders. They are both under the category of Substance-Related Disorders (See DSM-IV Text Revision, 2000). This can help tease apart some of these assessment dilemmas.
• If a person is in an early stage of readiness to change (notice I am downplaying the use of the term “denial”) and demonstrates ambivalence or lack of understanding about addiction, this is an active treatment issue. It is not a reason to exclude a person from treatment, or to provide only passive education about addiction.

SKILLS

Given the prevalence of co-occurring mental and substance-related disorders (dual diagnosis) it is good that both mental health and addiction treatment clinicians are so much more aware about dual diagnosis. However, awareness without clinical savvy can lead to knee-jerk over-reactions. Addiction treatment professionals too quickly can refer a client for a psychiatric evaluation without taking even a little time for more careful assessment and gathering of history data. Mental health professionals similarly can often rush to medicate symptoms before determining if they are looking at a substance-induced disorder or a true dual diagnosis.

Tips:

• A Substance-Induced Mood Disorder, for example, “is distinguished from a primary Mood Disorder by considering the onset, course, and other factors. Substance-Induced Mood Disorders arise only in association with intoxication or withdrawal states, whereas primary Mood Disorders may precede the onset of substance use or may occur in periods of sustained abstinence.” (Page 405 DSM-IV Text Revision)
• Take the history and timelines to check the relationship between substance use and addiction problems and the appearance of mental health problems. Not all mood swings are Bipolar Disorder – it could be that the person is using uppers and downers, stimulants and depressant substances. Not all heavy drinking is alcoholic drinking – it may be that the client is drinking at night until he passes out, in an attempt to deal with the severe insomnia of Major Depression.
• Even after four weeks following detox, people can still have problems with depression, anxiety and mood swings etc. While we want to give people the benefit of medication if necessary, there is also a period of psychosocial adjustment after detox. If an individual has few (if any) positive recovery tools to deal with stress or discomfort- (e.g. dealing with cravings or mood swings) mental health symptoms can still be present after detox. These symptoms may be a part of normal addiction recovery and not positive proof that a co-occurring mental disorder exists.

If you want to learn more about these assessment dilemmas, you can check out the Home Study Course: “Dilemmas in Dual Diagnosis Assessment, Engagement and Treatment“at Professional Psych Seminars, www.psych sem.com.

SOUL

I am writing this section on Mother’s Day at 6:30 AM in a basic, but comfortable tent cabin in Yosemite National Park. What a privilege to be able to drive under four hours to such a place of astounding beauty. But last night, in an incongruous juxtaposition of experiences (sorry for the fancy words) we were in a lodge lounge packed with people cheering on the Sacramento Kings in the NBA Playoffs. If you are not a basketball fan, you would not know that the Sacramento fans are the most loyal and noisy fans in the USA. The Kings lost in double overtime. The prospects look bleak. Chris Webber, the King’s star player, is out for the rest of the playoffs with a torn cartilage in his left knee.

Two games ago, the Kings looked on track to take it all and win the championship this year. Frank Sinatra said it all in his gritty song “That’s Life” – “riding high in April, shot down in May”. In those final minutes of the game, the battle with the Dallas Mavericks seesawed between victory and defeat. Participating in the emotion and passion in the room, you would have thought the most important event in the world was a basketball game. Many of you didn’t even know the game was on, couldn’t care less and won’t ever care.

Outside, the sky is perfectly blue; the air crisp and clear; the sheer granite rocks tower all around us. One can look across the meadow to see Yosemite Falls pounding over the rock face. Half Dome stands huge, tall and impressive. Beside Yosemite’s picture-postcard beauty, we are here to meet up with our college freshman son on a geology class field trip. He gets to hike this grand National Park for two days- and for college credit!

In my view, there’s nothing wrong with the emotion and passion of a tight playoff game. And in the battles over budget cuts, competing theories of treatment, and advocacy for our various rights and noble initiatives, there’s nothing wrong with emotion and passion. But budgets come and go. Theories and rights rise and fall in importance, and basketball games will be forgotten next week. The grandeur of Yosemite, the emotion and passion around our mother and family remain way beyond April and May. I remind myself and perhaps you too, about priorities, perspective and permanence. What really is important? What do you really want for you, your family and the people we serve?

STUMP the SHRINK

Question:

Dr. Mee-Lee:
“I am reviewing a document and they have used the term “substance related” disorder and said they got it from the ASAM material. Is that the official new term? I had just heard two weeks ago that the term was “substance use” disorder. I have been in the field 22 years and have been through a number of these changes and don’t like the former term as it seems to refer to “related” disorders but not necessarily inclusive of substance use directly. Please advise if you have any insight to the “official” terminology. Thanks!”
Jane (real person, but not real name)

Answer:

Dear Jane:
“As regards the term “substance-related disorders”, we are using the language of DSM -IV. Substance-Related Disorders are made up of two categories: Substance Use Disorders (Substance Abuse and Substance Dependence); and Substance-Induced Disorders (Substance Intoxication and Substance Withdrawal and a whole host of other Substance Induced Disorders like Alcohol Induced Depression; or Amphetamine Induced Psychosis etc.) So it depends on the patient and their presentation as to what their diagnosis is. In the ASAM Patient Placement Criteria, we use all of the terms depending on what the history and assessment reveals. In other words, the term “substance-related disorders” is not replacing substance use disorders. ” Substance-Related Disorders” is the overarching DSM-IV chapter for both addiction disorders and for psychiatric disorders induced by substances. These substance-induced disorders are psychiatric disorders that are “related” to the substance, but are not the specific addiction or Substance Use Disorder (Abuse or Dependence). Check out the DSM and it should make sense, but let me know if not.”

Until next time

I would welcome any Success Stories on implementing any of the TIPS and TOPICS, or any questions to Stump the Shrink! Send those along. Just tell me how much identifying data you are comfortable with my sharing in this ezine. All the best until next time.

David.