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Co-Occurring Disorders Current Evidence Based Treatments
Dr. Dawn-Elise Snipes
Objectives
~ Review current research on evidence based and promising practices for Co-Occurring Disorders
Intro
~ Most people with addictions also have other co-occurring issues
~ Mood disorders
~ Pain
~ PTSD
~ Effective treatment requires concurrent treatment of all presenting biopsychosocial issues
CBT
~ Cognitive Behavioral Therapy
~ Addiction
~ Anxiety
~ Dementia
~ Depression
~ Eating Disorders
~ Insomnia
~ OCD
~ Schizophrenia focuses on motivational enhancement for agreed recovery goals, appropriate use of coping skills, working with symptoms, understanding experience of psychosis, strengthening adaptive view of self, personal/emotional issues or comorbid disorders, relapse prevention, and family or social reintegration.
Mindfulness Based Interventions
~ MBIs consistently outperform active control conditions, such as health education, relaxation training, and supportive psychotherapy.
~ Mindfulness treatments were shown, in general, to have similar effectiveness with first-line psychological (and psychiatric) interventions for children and adults when compared directly and superior to waitlist and control conditions with relatively little variation across disorders
~ mindfulness was equivalent or superior to other active treatments for addictions, smoking, depression, pain, and weight/eating
Relaxation Therapies
~ Relaxation therapies use physiologic techniques (e.g., deep breathing or progressive muscle relaxation) to regulate the sympathetic/parasympathetic balance and reduce symptoms of arousal seen in chronic pain
~ Biofeedback was associated with pain reduction, reduced depression, disability, and muscle tension and improved coping in chronic musculoskeletal pain, headache and fibromyalgia
Virtual Reality
~ Through cognitive training, sensory immersion and social skill training, rehabilitation through VR therapies helps patients improve QoL
~ VR assisted burn and nonburn wound care reduced opioid need by 39% compared to no VR, while levels of pain and anxiety were similar
~ In people with dementia, VR may provide enjoyable, leisurely activities that may promote QoL and psychological well-being
~ Depression and suicidality are characterized by excessive negative imagery and impoverished positive imagery. One study of 79 people positive mood and well-being increased significantly post-VR-intervention (Edge of the Present-EOTP). Hopelessness scores and negative mood decreased, and sense of presence was high
~ Anxiety and phobias: Exposure/guided rehearsal/efficacy
~ PTSD
Transcranial Direct Current Stimulation
~ Transcranial direct current stimulation (tDCS) is a non-invasive neuromodulatory technique
~ Multiple factors can alter tDCS after-effects, including the polarity, duration, and frequency of stimulation; current density (i.e., current intensity/electrode surface area); stimulation/return electrode locations; neuroanatomy; underlying pathology/state; and co-administered drugs/treatments
Transcranial Direct Current Stimulation
~ Recurrent pain leads to maladaptive neuroplasticity. tDCS probably effective in reducing neuropathic, fibromyalgia, migraine, post-operative pain
~ tDCS may benefit motor function and likely improves cognition in people with Parkinson’s
~ tDCS improves motor rehabilitation in chronic and subacute stroke
~ tDCS is effective in treating depression in MDD without drug resistance
~ tDCS is probably effective for reducing auditory hallucinations in schizophrenia
~ tDCS probably effective in decreasing relapses or craving in alcohol addiction
Nutritional Interventions
~ Vitamins, minerals and several phytonutrients influence the expression of Brain Derived Neurotropic Factor (BDNF) and serve as modifiable determinants of systemic inflammation
~ 13 main nutrients implicated in the pathophysiology of depression and systemic inflammation include: Folate, iron, long chain omega-3 fatty acids, magnesium, potassium, selenium, thiamine, vitamin A, vitamin B6, vitamin B12, vitamin C, vitamin D and zinc.
~ Symptoms associated with deficiencies, especially when subclinical, are nonspecific and include fatigue, irritability, aches and pains, decreased immune function and heart palpitations
Nutritional Interventions
~ 47% of studies that found a positive impact of a dietary intervention
~ Gut health is increasingly understood as critical for brain health. Along with being nutrient-dense sources of vitamins and minerals, two components of plants are relevant to mental health, but not well represented in the literature: fiber (feeds gut bacteria) and phytonutrients (antioxidants)
~ Vitamin D is deficiency is associated with pain and is correlated with muscle fatigue
~ Skin pigmentation, obesity, northern latitudes and poor diet lead to Vitamin D deficiencies.
Sleep
~ Sleeplessness has been shown to induce a generalized state of hyperalgesia, anxiety and depression
~ Extended sleeplessness is associated with HPA-Axis dysfunction
~ There are common neurobiological processes in sleep disturbances, addiction and mood disorders which may reflect neurobiological dysfunction and may not spontaneously recover leading to an increased risk of relapse
~ Sleep hygiene interventions, sleep studies and multidisciplinary intervention can be useful.
Acupuncture
~ A systematic review with meta-analysis of acupuncture analgesia in the emergency setting found acupuncture “provided statistically significant, clinically meaningful, and improved levels of patient satisfaction with respect to pain relief in the emergency setting
~ In meta-analysis of 17,922 patients using acupuncture therapy for chronic musculoskeletal pain , osteoarthritis, headache and migraine, acupuncture was significantly better than both placebo and usual care. 90%of acupuncture benefit persisted at 12 months
Massage
~ Single dose of massage therapy provided significant improvement in post-operative pain and anxiety compared to active comparators in surgical pain populations
~ Manual therapy including massage was effective for pain, stiffness and physical function in chronic pain
Bright Light Therapy
~ Dosing: intensities of 5,000–10,000 lx, measured at the level of the eyes, and a therapeutic distance of 60–80 cm from the light box for 30 minutes
~ Seasonal Affective Disorder
~ Potentially effective at improving both disordered-eating behavior (binge and night eating) and mood
~ Parkinson’s BLT significantly improves motor dysfunction including rigidity, tremor, nocturnal movements and postural imbalance; depression and anxiety; sleep dysfunction including insomnia, excessive daytime sleepiness and overall fragmentation of sleep/wake cycle
Bright Light Therapy
~ Bipolar disorder BLT significantly reduced the severity of depression and patients who were not on psychotropic drugs revealed significantly decreased disease severity (pregnancy/postpartum??)
~ Cautions:
~ Evening administration of BLT can increase the incidence of sleep disturbances
~ People who are bipolar may switch to hypomania during therapy
~ Suicidality may sporadically occur early in the treatment course
~ Menstrual irregularities have been reported
Summary
~ CBT and Mindfulness are still the gold standard to address the cognitive and HPA-Axis aspects of a variety of disorders
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