Depression & Alcohol Black Dog Institute Mission: To advance - PowerPoint PPT Presentation

Depression & Alcohol

Black Dog Institute Mission: To advance the understanding and management of the mood disorders through Clinical  Research Services Research  Clinical Services  Community Support Community Support  Education Education The Institute is partially funded by NSW Ministry of Health and philanthropic 2 support. No pharmaceutical companies have input to the program.

Learning Objectives By the completion of this module you will be able to:  Discuss the epidemiology of co-morbid depression and problem alcohol use  Assess the impact of alcohol use in patients with depression  Diagnose alcohol use disorders  Incorporate the use of pharmacological and psychological treatments in the management of co-morbid depression and alcohol use disorders  Refer to appropriate services and resources, both online and in the community, to assist people with co-morbid depression and alcohol use disorders 3

Men, alcohol and depression  In 2011-12 almost three times as many men than women aged 18 years and over consumed alcohol in quantities that posed a health risk over their lifetime  Men are more likely to engage in externalising behaviours such as substance use in response to negative events especially when depressed  At least one-quarter of all suicides in Australia record alcohol dependence as a causal factor (Begg et al. 2007).  One psychological autopsy study found evidence of an alcohol disorder in 68% of male suicides and 29% of female suicides (Kolves et al. 2006). 4

Alan (aged 48) and GP Clip 1 – Alan and GP As you watch this consultation note down:  Any information that Alan reveals that you think is significant  Any questions or comments the GP makes that you think are significant 5

Alan Before we discuss a “diagnosis” for Alan:  What would be your reaction to Alan’s presentation?  What would be your concerns about his presentation? 6

History What other questions would you like to ask?  Suicide risk  Risk of harm to others  Use of other drugs (e.g. benzos)  Past and present medical history  Personal psychiatric history  Family psychiatric history cont... 7

History  Nutrition and exercise status  Has Alan ceased drinking in the past – how did he manage to do this? How long?  Any withdrawal syndrome (esp. symptoms of complicated withdrawal)  What would Alan like to do about his drinking? 8

Investigations Would you perform any investigations? If so, which investigations ?  FBC (MCV - Mean (Red Blood)Cell Volume - is increased in 20-30% of heavy drinkers in the community)  LFTs (GGT is increased in 30-50% of heavy drinkers in the community)  TSH B1/folate 9

Differential Diagnosis (i) What does Alan think is going on for him? (ii) What is the differential diagnosis for Alan? (iii) What domains of Alan’s life are affected by his alcohol use and low mood? (iv) How would you describe Alan’s alcohol use pattern? 10

Terminology: In the past (i) ICD 10: - Non- dependent:  Hazardous - at risk of harm  Risky – causing actual harm - Alcohol dependence (ii) DSM IV: - Alcohol Abuse - Alcohol Dependence 11

Terminology: DSM 5 DSM 5 has a single diagnosis of Alcohol Use Disorder with severity rankings of Mild/Moderate/ Severe 12

Severity What factors would determine severity?  Frequency  Quantity  Duration  Inability to control  Impact of current use on domains of life From the history alone, how would you rate the severity of Alan’s alcohol use disorder? 13

Screening Tools Are there any screening instruments you would use for Alan?  DASS 21  AUDIT (Alcohol Use Disorders Identification Kit) (ten items)  AUDIT C (three items) Let’s look at the AUDIT scale Alan has completed in your workbook 14

AUDIT scoring  8 -12 : = hazardous/harmful drinking  13 or more: = alcohol dependence in DSM IV terminology Alan’s score of 19 on the 10 item AUDIT indicates moderately severe alcohol use disorder 15

AUDIT C Audit C uses first 3 questions only  Cut off for alcohol misuse: 3 for women; 4 for men  A total of 5 or more indicates high risk drinking 16

Epidemiology A Alcohol use in Australia: Table 1: Alcohol use disorders in Australians aged 14 years or older Lifetime prevalence Alcohol use 87.9%* Risky drinking 20.1%* Alcohol abuse (DSM-IV) 18.3%# Alcohol dependence 3.9%# * Adapted from 2010 National Drug Strategy Household Survey report. #National Survey of Mental Health and Wellbeing, Teesson et al, 2010 17

Alcohol Depression B Alcohol use and Depression: Prolonged heavy drinking:  80% depressive symptoms  30-40% major depression  5-10% depression persisting weeks after abstinence 18

Epidemiology C Other co-morbidities: Very high incidence of anxiety disorders in alcohol use disorder 1. Complex trauma 2. Other substance abuse 3. D Depression and alcohol use:  In the 2000 National Survey of Mental Health and Wellbeing, around 17% of those with depression met criteria for an alcohol use disorder (12 month) 19

Primacy Which is Alan’s primary disorder? Is this important?  Although establishing the primary disorder can be helpful in terms of management decisions and prognosis, in practice it is often not possible to determine primacy  Where possible a period of 3-4 weeks abstinence can help ascertain if anxiety and depression are predominantly alcohol related  Uncertainty regarding primacy need not preclude effective treatment  The focus is best shifted to a model that views the conditions as 20 concurrent with an integrated treatment approach

Back to Alan A. What would Alan be expecting from this consultation? B. What would you hope to achieve in this consultation? C. How would you explain to Alan your assessment of his situation so far? 21

Psycho-education What psycho-educational messages would you impart at this stage?  Safe drinking guidelines  Symptoms of depression  Impact of alcohol intake on mood  Impact of low mood on alcohol intake  Effective treatment is available  Change is possible  Alcohol withdrawal syndrome  Role of good nutrition, esp. thiamine 22

Fostering hope  People with co-morbid depression and alcohol use disorder can benefit from brief and simple interventions  Patients and clinicians can hold attitudes of hopelessness around change and recovery which may discourage active engagement in treatment  Creating a dialogue of hope and positivity can help counter these attitudes 23

Arranging follow-up When would you see Alan again? Is there anything you could ask Alan to do between visits? Why would keeping a diary be useful? What would you want him to record ?  Looking at best mood and worst mood, strongest cravings and least cravings and starting to make links between these  Can start with simple task such as rating mood and number of drinks and slowly include other observations How would you “sell” Alan the idea of charting his mood and drinking for the week? 24

Alcohol & Mood Diary Best / Mood Cravings ETOH Day Time Situation Worst 1 - 10 1 - 10 Use Best Monday Worst Best Tuesday Worst Best Wednesday Worst Best Thursday Worst Best Friday Worst Best Saturday Worst Best Sunday 25 Worst

Next Visit One week later Alan has returned. His blood tests revealed an elevated GGT (150) and an MCV of 101 He has completed his mood/drink diary What are your thoughts looking at Alan’s mood/ drink diary? 26

Motivation  What would be Alan’s level of motivation to address his alcohol and mood issues?  What is important to Alan and could underpin his motivation to change? 27

Stages of change What are the stages of change?  Pre-contemplation  Contemplation  Preparation  Action  Maintenance 28

Stages of Change  What is the significance of the stage of change? Although a person’s stage of change has not be shown to be predictive of treatment outcomes it can provide a useful information in terms of management planning  How could you enhance Alan’s motivation for change? Motivational Interviewing 29

Eliciting Pros and cons: (i) Alcohol:  What do you like about drinking?  What don’t you like about drinking?  What do you like about the idea of quitting?  What don’t you like about the idea of quitting? 30

Eliciting Pros and cons: (ii) Depression  What is good about leaving the depression as it is?  What is not so good?  What would be good about treating and recovering from the depression?  What would be not so good? 31

MHTP for Alan  Alan has indicated he is not yet ready to give up alcohol but may consider reducing his intake  He agrees to complete a Mental Health Treatment Plan together with the GP and accept a referral to a psychologist under the Better Access program 32

Skills Practice In pairs:  GP and Alan are completing the Mental Health Treatment Plan together.  In this skills practice the GP works collaboratively with Alan to decide:  Patient needs/main issues – What are the problem issues for Alan?  Goals – What are Alan’s goals for treatment? 33