6^th International Conference on Dual Diagnosis Disorders September 11-12, 2019 Singapore

\r\n A mental illness is a disease that causes mild to severe disturbances in thought and/or behaviour, resulting in an inability to cope with life’s ordinary demands and routines.

\r\n There are more than 200 classified forms of mental illness. Some of the more common disorders are depression, bipolar disorder, dementia, schizophrenia and anxiety disorders.  Symptoms may include changes in mood, personality, personal habits and/or social withdrawal.

\r\n Mental health problems may be related to excessive stress due to a particular situation or series of events. As with cancer, diabetes and heart disease, mental illnesses are often physical as well as emotional and psychological. Mental illnesses may be caused by a reaction to environmental stresses, genetic factors, biochemical imbalances, or a combination of these. With proper care and treatment many individuals learn to cope or recover from a mental illness or emotional disorder.

\r\n Additionally, mental illness and substance use interact to make each diagnosis worse and to have serious, adverse effects on many areas of functioning, including work, relationships, health, and safety.

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\r\n Substance use disorders, which are defined as mild, moderate, or severe to indicate the level of severity, which is determined by the number of diagnostic criteria met by an individual. Substance use disorders occur when the recurrent use of alcohol and/or drugs causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home. According to the DSM-5, a diagnosis of substance use disorder is based on evidence of impaired control, social impairment, risky use, and pharmacological criteria.

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\r\n Bipolar disorder requires treatment of depressive and manic or hypomanic episodes together with long-term treatment to prevent future episodes, both syndromal and sub-syndromal. In recent years the importance of long-term treatment (that is, maintenance treatment) has been emphasised by several guidelines. The need for maintenance treatment is supported by the desire to prevent the costs of future episodes, that is, the intangible suffering to patients and their families and the economic burden of direct and indirect costs. In addition maintenance treatment may reduce long-term impairment associated with the bipolar disorder. There is evidence that functional impairment in patients who have recovered from acute episodes and are asymptomatic is related to the number of previous depressive episodes. The tendency for episodes to become more frequent with time also supports the rationale for maintenance treatment.

\r\n In the last decade, evidence from RCTs has accumulated regarding the effectiveness of several ‘new’ agents in the treatment of bipolar disorder. These include valproate (in various forms), lamotrigine and various atypical antipsychotics. The active control arms in several such studies have provided further evidence for the efficacy of ‘older’ treatments, in particular haloperidol (a conventional antipsychotic) in the treatment of mania and lithium in the prophylaxis of mania.

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\r\n The co-occurrence of a severe mental illness and a substance abuse or dependence disorder is common enough to be considered the expectation more than the exception. Substance use disorders can occur at any phase of mental illness.

\r\n Causes of this comorbidity may include self-medication, genetic vulnerability, environment or lifestyle, underlying shared origins, and/or a common neural substrate. The consequences of dual diagnosis include poor medication compliance, physical comorbidities, poor health, poor self-care, increased risk of suicide or risky behaviour, and even possible incarceration.. Screening, assessment, and integrated treatment plans for dual diagnosis to address both the substance use disorder and the mental illness are strongly recommended.

\r\n The strongest associations involve externalizing mental disorders and alcohol-drug dependence. Mental disorders are associated with alcohol-drug use, problems among users, dependence among problem users, and persistence among people with lifetime dependence. These dual diagnoses are associated with severity and persistence of both mental and alcohol-drug disorders. A wider range of mental disorders is associated with nicotine dependence. Prospective studies confirm this temporal order, although significant predictive associations are reciprocal. Analyses comparing active and remitted mental disorders suggest that some primary mental disorders are markers and others are causal risk factors for secondary substance disorders. Epidemiologic research can be used to help target and evaluate interventions aimed at preventing secondary substance use disorders by treating early-onset primary mental disorders.

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\r\n Psychosis is a brain-based condition that is made better or worse by environmental factors - like drug use and stress.

\r\n Schizophrenia is a serious disorder which affects how a person thinks, feels and acts. Someone with schizophrenia may have difficulty distinguishing between what is real and what is imaginary; may be unresponsive or withdrawn; and may have difficulty expressing normal emotions in social situations.

\r\n One frequently cited statistic is that 1% of the population is diagnosed with Schizophrenia in their lifetime, but actually 3.5% of the population experiences psychosis.  Hearing voices and seeing things that aren’t there are more common than we think. While these experiences can be scary and confusing, it is possible to recover and getting better, especially when we tackle issues early

\r\n Scientists recognize that the disorder tends to run in families and that a person inherits a tendency to develop the disease. Similar to some other genetically-related illnesses, schizophrenia may appear when the body undergoes hormonal and physical changes (like those that occur during puberty in the teen and young adult years) or after dealing with highly stressful situations.

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\r\n Addiction is a condition that results when a person ingests a substance (for example, alcohol, cocaine, nicotine) or engages in an activity such as gambling, sex, shopping that can be pleasurable but the continuation of which becomes compulsive and interferes with ordinary responsibilities and concerns, such as work, relationships, or health. People who have developed an addiction may not be aware that their behaviour is out of control and causing problems for themselves and others. This is a biological state in which the body adapts to the presence of a drug so that drug no longer has the same effect, otherwise known as tolerance. Another form of physical addiction is the phenomenon of overreaction by the brain to drugs (or to cues associated with the drugs).

\r\n The vulnerability of the nervous system to both temporary changes and permanent damage from a wide variety of agents is increasingly evident. For thousands of years humans have searched out agents that affect the nervous system. Many people today are regular users of alcohol, caffeine, or other agents designed to affect the nervous system. Industrialization ushered in an era of rapid development of new chemicals, often accompanied by human exposure that we learned, sometimes through tragic experience, can irreparably damage the nervous system. No one can reach his or her full genetic potential with a damaged nervous system. As a consequence, neurotoxicology developed as a discipline in the 1970s to advance our understanding of the effects of chemicals on the nervous system.

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\r\n Depression (major depressive disorder) is a common and serious medical illness that negatively affects how the person feel the way you think and how you act. Fortunately, it is also treatable. Depression causes feelings of sadness and/or a loss of interest in activities once enjoyed. It can lead to a variety of emotional and physical problems and can decrease a person’s ability to function at work and at home

\r\n Anxiety is an emotion characterized by feelings of tension, worried thoughts and physical changes like increased blood pressure.

\r\n People with anxiety disorders usually have recurring intrusive thoughts or concerns. They may avoid certain situations out of worry. They may also have physical symptoms such as sweating, trembling, dizziness or a rapid heartbeat.

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\r\n BPD is a serious mental illness characterized by pervasive instability in moods, interpersonal relationships, self-image, and behaviour.

\r\n BPD, originally thought to be at the "border" of psychosis and neurosis, suffer from difficulties with emotion regulation. While less well known than schizophrenia or bipolar disorder, BPD affects two percent of adults. People with BPD exhibit high rates of self-injurious behaviour, such as cutting and, in severe cases, significant rates of suicide attempts and completed suicide. Impairment from BPD and suicide risk are greatest in the young-adult years and tend to decrease with age. BPD is more common in females than in males, with 75 percent of cases diagnosed among women.

\r\n People with borderline personality disorder often need extensive mental health services and account for 20 percent of psychiatric hospitalizations. Yet, with help, many improve over time and are eventually able to lead productive lives.

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\r\n Pharmacological management of both the psychiatric and the substance use disorder is an important foundation of the treatment of clients with co-occurring severe mental illness and substance use disorder. In all of the above psychosocial studies, clients in psychosocial treatment research also received medication management, which was rarely accounted for in analyses. Research on the effects of medications themselves, however, is in its infancy. Thus far research suggests two main points. First, medications shown to be effective for the treatment of alcohol disorders in the general population, such as disulfuram and naltrexone, are probably effective also in clients with serious mental illness Second, some medications that treat the mental illness may lead to reduction in the severity of the substance use disorder.

\r\n Antidepressants appear to reduce not only symptoms of depression but also alcohol use in clients with major depression and alcohol disorder Mood stabilizers are active not only on mania but also on alcohol use in clients with bipolar disorder and comorbid alcohol dependence Typical antipsychotics improve the symptoms of schizophrenia but have little effect on co-occurring substance use. Most of the newer (atypical) antipsychotics are equally effective as the typical antipsychotics in improving schizophrenia symptoms and may offer some benefit in reducing craving or substance use, but research is preliminary Clozapine is clearly the most powerful drug in treating schizophrenia symptoms and, at least in quasi-experimental studies, appears to be at the same time the most effective antipsychotic medication in relation to substance use.

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\r\n Pharmacological management of both the psychiatric and the substance use disorder is an important foundation of the treatment of clients with co-occurring severe mental illness and substance use disorder. In all of the above psychosocial studies, clients in psychosocial treatment research also received medication management, which was rarely accounted for in analyses. Research on the effects of medications themselves, however, is in its infancy. Thus far research suggests two main points. First, medications shown to be effective for the treatment of alcohol disorders in the general population, such as disulfuram and naltrexone, are probably effective also in clients with serious mental illness Second, some medications that treat the mental illness may lead to reduction in the severity of the substance use disorder.

\r\n Antidepressants appear to reduce not only symptoms of depression but also alcohol use in clients with major depression and alcohol disorder Mood stabilizers are active not only on mania but also on alcohol use in clients with bipolar disorder and comorbid alcohol dependence Typical antipsychotics improve the symptoms of schizophrenia but have little effect on co-occurring substance use. Most of the newer (atypical) antipsychotics are equally effective as the typical antipsychotics in improving schizophrenia symptoms and may offer some benefit in reducing craving or substance use, but research is preliminary Clozapine is clearly the most powerful drug in treating schizophrenia symptoms and, at least in quasi-experimental studies, appears to be at the same time the most effective antipsychotic medication in relation to substance use.

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\r\n Down syndrome is a genetic disorder and the most common autosomal chromosome abnormality in humans, where extra genetic material from chromosome 21 is transferred to a newly formed embryo. These extra genes and DNA cause changes in development of the embryo and foetus resulting in physical and mental abnormalities. Each patient is unique and there can be great variability in the severity of symptoms.

\r\n Normally, the human body has 23 pairs of chromosomes called autosomes and two sex chromosomes allosomes. At conception, a new cell is formed that receives one copy of each chromosome from the sperm and one copy from the egg. The new cell divides and multiplies to form an embryo and ultimately a foetus and new human. Each cell contains the exact same genetic material as the original 48 chromosomes, carrying the same genes and DNA.

\r\n In patients with Down syndrome, an error occurs in the coming together of chromosome 21. The extra genetic material is responsible for the developmental abnormalities that occur. Instead of 46 chromosomes plus two sex chromosomes, there are 47.

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\r\n Addiction can occur in many forms. Often, it is assumed that physical dependence characterized by withdrawal symptoms is required in order for someone to be diagnosed with an addiction disorder, but the fact is that behavioural addiction can occur with all the negative consequences in a person’s life minus the physical issues faced by people who compulsively engage in drug and alcohol abuse. It is the compulsive nature of the behaviour that is often indicative of a behavioural addiction, or process addiction, in an individual. The compulsion to continually engage in an activity or behaviour despite the negative impact on the person’s ability to remain mentally and/or physically healthy and functional in the home and community defines behavioural addiction. The person may find the behaviour rewarding psychologically or get a “high” while engaged in the activity but may later feel guilt, remorse, or even overwhelmed by the consequences of that continued choice. Unfortunately, as is common for all who struggle with addiction, people living with behavioural addictions are unable to stop engaging in the behaviour for any length of time without treatment and intervention.

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\r\n There are two types of elderly addicts: those who become addicted to drugs or alcohol before age 65, termed “early-onset addicts”, and those who do so after age 65, termed “late-onset addicts.” Early-onset addicts are those who have abused drugs and alcohol throughout their lifetime, becoming dependent and addicted to illicit substances at a younger age and perpetuating this addiction as age advances. This group of elderly addicts is thought to make up two-thirds of the geriatric alcoholic population and may have more physical and psychiatric issues than late-onset addicts, according to the Psychiatric Times.

\r\n The New York Times further publishes that between 14 and 20 percent of the elderly population have suffered from either a mental health disorder, substance abuse disorder, or both, according to a national survey in 2010. Mental illness often co-occurs with substance abuse. Those diagnosed with a mood disorder may be twice as likely to also battle a drug abuse disorder, NIDA reports. In fact, psychiatric disorders and substance abuse may occur as often as between 21 and 66 percent of the time. As we age, physical and mental capacities may deteriorate further blurring the lines between substance dependence and mental illness.

\r\n Stressful life changes that often occur as we age may increase the incidence of drug or alcohol abuse, which can develop into a late-onset addiction. For instance, as age advances, loved ones or significant others may pass away, living situations can change, retirement begins, and physical maladies may increase. Drinking or using drugs may begin as a method of coping with these difficult psychological and physical changes.

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\r\n Clinicians from both drug and alcohol services and mental health services have long recognized that neither service area provides adequate clinical care to those clients who have a dual diagnosis of substance abuse and mental illness. It is now more than 10 years since a ground-breaking Australian study recognized this. To ascertain whether there has been improvement in the service management of clients who have a dual diagnosis, and to determine the best practice interventions in the area of mental health nursing, we undertook a review of the literature. The databases CINAHL, MEDLINE, PsycARTICLES and PsychINFO were searched and 185 articles met the inclusion criteria. From this review, it seems that gaps still remain in the provision of services and that mental health nurses might be best placed to provide integrated care to those clients who have a dual diagnosis and present to mental health services. This requires mental health nurses to have skills in substance use detection and knowledge of potential care implications for the client in the context of their substance use.

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\r\n The comorbid psychiatric conditions were equally represented, with schizophrenia, bipolar I disorder, psychotic disorder, and posttraumatic stress disorder and borderline personality disorder as the most common disorders. All patients presented substance use disorders, with alcohol abuse (71.4%) and cocaine abuse (42.9%) as the most prevalent ones. During a severe dual pathology program, it was noted that a considerable number of severe dual pathology cases first become noticed at an emergency mental health unit. The patient's cooperation while in the ER is essential for detecting undiagnosed dual-pathology cases or managing clinical decompensation episodes in these patients. The use of inhaled loxapine might be of a great help to attain this goal. Although our data refer to a limited number of cases, this case series represents the overall clinical practice and demonstrates the effectiveness of inhaled loxapine for agitation in dual patients who are seen at a hospital. Afterward, an adequate management of the comorbid disorders with the available integrated resources would be necessary to improve treatment adherence and outcome in patients with dual diagnosis.

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