Centre for Brain and Mental Health ResearchUniversity of Newcastle, AUSTRALIA

APSAD Skills-based Workshop:Managing mental health issues in

AOD settingsAmanda Baker

Amanda.Baker@newcastle.edu.au

Overview

• Brief introduction

• Key features of mental health issues

• A useful model of care • PsyCheck exercise (Lee et al 2007)

• Goals from today

Centre for Brain and Mental Health ResearchUniversity of Newcastle, AUSTRALIA

References

Key features

Kavanagh, D.J., Mueser, K.T. & Baker, A. (2003) Management of comorbidity. In M. Teesson & H. Proudfoot (Eds.) Comorbid mental disorders and substance use disorders. Canberra: Commonwealth of Australia.

www.nationaldrugstrategy.gov.au/publications/index.htm

References

Assessment

Dawe, S. et al. (2002). Review of diagnostic and screening instruments for alcohol and other drug use and other psychiatric disorders (2nd ed). Canberra: Commonwealth of Australia.

www.nationaldrugstrategy.gov.au/publications/index.htm

References

Innovations in treatment

A. Baker & R. Velleman (2007) Clinical Handbook of Co-existing Mental Health and Drug and Alcohol Problems. London: Brunner-Routledge.

References

Training

Lee, N. et al. (2007) PsyCheck: Responding to mental health issues within alcohol and drug treatment. Canberra, ACT: Commonwealth of Australia

Introduction: group activity

• What mental health issues are common in the setting in which you work?

• What are the advantages & disadvantages of addressing the mental health issues issues?

• What barriers are there to addressing mental health issues?

• How important is it to address mental health issues?

(10 minutes)

What mental health issues are we talking about?

• Multiple, co-existing conditions• No typical presentation• Anxiety & depression very common • May meet criteria for DSM• However, co-existing issues/problems may

be present and impact on client functioning and other domains

10 key features

1. Frequencies are high2. Highest risk vs highest frequency3. Greatest health impact is from tobacco4. Higher rates in treatment settings5. Correlates may differ across substances6. Co-existing problems = poorer outcomes7. Variety of causal relationships

(Kavanagh et al 2003)

Models

(i) MH problems led to D&A problems

(ii) D&A problems led to MH problems

(iii)Bidirectional models: multiple different factors trigger both

(iv) Common factor model: one or more factors independently increase the risk of both

(v) Two conditions unrelated

(Kavanagh et al 2003)

10 key features (cont’d)

8. Different intervention structures for different subgroups (psychosis – integrated; ?anxiety & depression)

9. A set of interventions required rather than a single intervention format

10. Comorbidity is under-serviced (Kavanagh et al 2003)

Who’s responsibility is it to address mental health issues?

Who is responsible?

Clinicians’ responsibility to work towards generation of commitment to change co-existing problems of substance use and mental disorder

Exclusion of people using substances or with unstable mental health symptoms from treatment abrogates responsibility for eliciting motivation and assisting the person in the hardest stages of change

(Kavanagh & Connolly, 2007)

What Works for You?• Working individually complete the worksheet,

identifying which models you have an affinity with

• Then circle the main model you work with

• Now find someone else in the room that uses a DIFFERENT model to the one you typically work with and discuss with your partner– Why you use this model/strategies you do?– How you know it’s working ?

• Group discussion

Mod

ule

2

Stepped Care Model

• Tiered interventions• Recommended for:

Depression (Scogin et al, 03)

Anxiety (Baillie & Rapee, 04)

Alcohol (Sobell & Sobell, 00)

Smoking (Smith et al, 01)

Heroin (King et al, 2002)

Stepped care

• Advantages– Facilitate a larger number into treatment– Low-cost, least intrusive and simple first

interventions as a first step maximises treatment resources

– Sufficient to improve motivation, engagement & some mental health symptoms

Stepped care

• Competent assessment – suicidality, risk of harm to others,

intoxication, possible withdrawal effects, accommodation requirements, mental health and other comorbidity

• Brief psychoeducation/mi, progress monitored

• Increase intensity of treatment or change focus of treatment (Sobell & Sobell, 2000)

Stepped care

• Flexible treatment plan– Guided by client progress and functioning– Rather than predetermined set of symptoms or

characteristics– So far virtually impossible to predict who with

coexisting problems will respond

• Common in clinical practice: regular, thorough assessment

Stepped care recommendations

• Step 1 (assessment/minimal intervention)– Screening, assessment, feedback and self-help

• AOD, mh, medical, QoL, current stressors, readiness to change

• Feedback • Self-help material• Refer on if necessary

Stepped care recommendations

• Step 2 (brief interventions, integrated psychoeducation, motivational interviewing)

• Assess (eg, 1-month later)• Continue monitoring or if not responded,

offer more

Stepped care recommendations

• Step 3– Monitor, intensive integrated CBT intervention– Could include pharmacotherapy and longer

psychosocial treatment

Integrated CBT recommended

• Various MH & D&A problems:– Anxiety (Baillie & Sannibale)

– Depression (Kay-Lambkin et al)

– Psychosis (Barrowclough et al)

– Bipolar (Whicher & Abou-Saleh)

– Eating disorders (Coelho et al)

– Personality disorder (McGovern et al)

– Learning difficulties (Barter)

Baker & Velleman, 2007

Further intervention

• Steps 4, 5 6 etc: – Longer-term, more intensive interventions– More specific interventions (eg, trauma,

relationship counselling)– Can transfer to monitoring and crisis

roundabouts at any time

PsyCheck as an example

• PsyCheck Screening Tool– The PsyCheck Mental health Screen for AOD

clients– Suicide/Self-harm risk assessment– Self-Reporting Questionnaire (SRQ)

Lee et al 2007

Interpreting the PsyCheck Screening Tool

• Intervention or further assessment is required if– The client reaches 5 or more on the SRQ– The client is at risk of suicide/self-harm– The client has a mental health history

• Consider– Readiness to change– Current symptoms Lee et al 2007

Mod

ule

1

SRQ Interpretation Lee et al 2007Total Score Interpretation Action

0 No symptoms present. Re-screen using the PsyCheck after 4 weeks

1-4 Some symptoms of depression, anxiety and/or somatic complaints indicated.

Offer Session 1

Re-screen after 4 weeks

Provide self-help material

5

or above

Considerable symptoms of depression, anxiety and/or somatic complaints indicated

Offer Sessions 1-4

Re-screen after 4

If no improvement after re-screening, consider referral

Mod

ule

1

Evidenced Based Practice Lee et al 2007

• Best evidence for CBT compared to other types of therapies– Most high level research (RCTs) and the most

positive research– Effective for a wide range of mental health

problems including AOD, anxiety and depression

BUT

Whatever framework you use, you can create your own evidence through measuring individual outcomes – CBT emphasises this

Mod

ule

2

Assessment, Formulation and Treatment Planning Lee et al 2007

ScreeningCognitive

Behavioural Assessment

Case formulation

Treatment Plan

AOD Assessment

Mod

ule

3

A Snapshot: Practice Guidelines Lee et al 2007

Session 1

Psychoeducatio

n

Session 2

Identifying unhelpful thoughts

Session 3

Managing unhelpful thoughts

Session 4

Relapse prevention

•Present case formulation to client

•Provide info on symptoms

•Explain CBT

•Homework

•Links between thoughts & feelings

•Identifying unhelpful thoughts

•Homework

•Challenging unhelpful thoughts

•Homework

•Identifying triggers

•Identify early warning signs

•Breaking the rule effect

•Termination

•Rescreening

Mod

ule

4

Conclusions

• Screening & assess MH & AOD issues

• Consider a stepped care approach

• PsyCheck may help guide you

• Provide integrated interventions where necessary

Your Goal

What small goal can you set after attending this brief workshop?

(eg, reading, discussion with colleagues, try some mental health screening instruments,

link up with a psychologist)