Balance support
•
advocacy
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awareness •
winter 2012
A complicated
pairing For many people, dealing with concurrent disorders means facing substance addiction as well as another mental disorder
The nature of diagnosis
Why concurrent disorder diagnoses are so common and how they can mean better treatment options
Finding home
Resources available for those dealing with concurrent disorders
7 th An nu al
by
ou fT l Go
nt & Fly-Fishing De me a r rn
$114,000 raised!
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winter issue 2012
Publisher
Canadian Mental Health Association — Calgary Region in partnership with RedPoint Media Group Inc. General Manager
Angela Anderson
Managing Editor
Abby Miller
Editorial Committee
Science Advisor - Dr. David Hodgins, Angela Anderson, Lowri D'Sa, Trudy DeBecker, Dr. Deborah Dobson, Stephen Humphreys, Joan Landsiedel, Genevieve Roy, Geraldine Shklanka Creative Director
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Addressing the issues Services available for concurrent disorders. Message from the Executive Director
Resources Multiple meanings
There are several categories of and terms for concurrent disorders.
Traffic Coordinator
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Knowing More The nature of diagnosis How proper diagnosis of concurrent disorders can help you get the best treatment.
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Feature story A common, and complicated, pairing
Suite 400, 1202 Centre St. S.E. Calgary, Alberta, T2G 5A5 (403) 297-1700 info@cmha.calgary.ab.ca Balance magazine is published three times a year, with 11,000 copies distributed on newsstands throughout the city and 2,000 copies distributed by the Canadian Mental Health Association — Calgary Region. The information contained in this magazine is not intended to be a substitute for professional/medical advice. Always seek the advice of your physician or a qualified health professional before starting any new treatment. Statements, opinions and viewpoints expressed by the writers of this publication do not necessarily represent the views of the publisher. Copyright 2012 by RedPoint Media Group Inc. No part of this publication may be reproduced without the express written consent of the publisher.
Canadian Mental Health Association — Calgary Region Suite 400, 1202 Centre Street S.E. Calgary, AB T2G 5A5 Telephone: (403) 297-1700 Fax: (403) 270-3066
Dealing with substance addiction and another mental disorder.
12 14 p.
Community Update A place to call home Resources for people dealing with addiction and a mental disorder.
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Real people Finding her way Living, and thriving, with concurrent disorders.
Winter 2012 / Balance 3
Message from the Executive Director
issues Addressing the
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together. Strategic directions such as to build healthy and resilient communities, foster the development of healthy children, youth and families, and enhance community-based services really do hit the mark when it comes to what needs to be done in our province. The work of implementing these strategies is what needs to come next. In this issue of Balance, we focus on concurrent disorders, implications and lived experiences and touch on the complexity of the term. While we recognize this conversation involves much more than what this issue of the magazine could allow, let it be a starting place for conversation. Please enjoy this issue and let it bring some insight, education or just another perspective to your understanding of mental health. Photo by Alix Broadway
O
ur vision at Canadian Mental Health Association – Calgary Region is “Mentally healthy people in a healthy society.” We strive to achieve this vision every day through our programs and service delivery, health promotion, awareness initiatives, and by looking at the community and assessing opportunities where we can help. Our programs and services provide support for those living with mental disorders in the community, and that includes those who have been diagnosed with concurrent disorders. The facts are clear: One in five Canadians will experience a mental disorder in their lifetime, and everyone else either has a friend, family member or colleague that will be affected. The statistics around substance abuse are similar. This is no coincidence. The two are often connected. Alberta Health Services' Creating Connections: Alberta’s Addiction and Mental Health Strategy, released in September 2011, outlines a direction for success when dealing with both addiction and mental health
Examining the situation and services available for dealing with concurrent disorders.
Dan Delaloye Executive Director Canadian Mental Health Association – Calgary Region
Letters to Balance We invite you to send us a letter with your feedback or comments, article ideas or to share your personal experience with a mental health issue.
4 Balance / winter 2012
Send your letters to info@cmha.calgary.ab.ca. Select letters will appear online on the Canadian Mental Health Association — Calgary Region website.
*Please include your name and contact information in your letter. Your name will only appear online with your permission. Note that letters may be condensed for space.
Resources
Multiple meanings There are several categories of and terms for concurrent disorders, and defining the issue can be the first step to seeking treatment. By Angela Anderson
+
Mental disorder substance abuse When someone is diagnosed with a mental disorder, such as depression or bipolar disorder, and they also experience substance abuse issues, they can be diagnosed with what is known most commonly as a concurrent disorder. According to the Centre for Addiction and Mental Health, concurrent disorders can be divided into five categories:
1 2 3 4 5
Mood and anxiety disorder plus substance use Severe and persistent mental health disorder plus substance use Personality disorder plus substance use Eating disorder plus substance use
Wordplay Other terms for concurrent disorders include co-occurring disorders or co-morbidity. In the United States, the terms “dual diagnosis” or “dual disorder” may be used. In some cases, any of these terms may also be used to describe someone with two diagnosed mental disorders, or a mental disorder and a physical disorder occurring simultaneously. While several terms are commonly used, the Diagnostic and Statistical Manual of Mental Disorders only refers to these types of situations in specific form. For example, if an individual has a mood
disorder that is judged to be due to the physiological effects of a substance, they can be technically diagnosed with Substance-Induced Mood Disorder. Similarly, if someone is experiencing a mental disorder such as anxiety disorder because of a physical condition, they can be diagnosed with Anxiety Disorder Due to a General Medical Condition. In this issue of Balance, and also to elaborate on the most common use of the term, our focus is on substance abuse and a mental disorder occurring simultaneously.
Mental disorder, such as gambling, plus substance use
Other types of concurrent disorders Sometimes, if a person is diagnosed with two simultaneously occurring disorders, whether substance abuse and a mental disorder, two mental disorders, or a mental disorder and a physical disorder, the term “concurrent disorder” may be used.
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Where to go for more information Canadian Mental Health Association www.cmha.ca, (403) 297-1700 Centre for Addiction and Mental Health www.camh.net, 1-800-463-6273 Winter 2012 / Balance 5
Knowing More By Vanessa Annand
The nature of
diagnosis A dual diagnosis means more effective treatment options, not a more serious problem.
6 Balance / winter 2012
Knowing More
T
he term “concurrent disorders,” or “dual diagnosis,” means more than one disorder at work in the same person — like a substance abuse disorder and another mental health disorder. But “more than one” doesn't equate to “more severe” or “more insurmountable.” It may just mean “more tools” — tools that can aid and hasten recovery. Helena Myllykoski, an associate professor in the School of Nursing at Mount Royal University, says, “If you have a concurrent disorder, it doesn't mean you're sicker. Addictions sometimes make the disorder experience more, well, complicated. Not worse or better. Just complicated.” That complexity requires an expert eye to determine if two or more discrete disorders are present. Dr. Nady el-Guebaly, an international expert in addiction psychiatry, says there are three primary factors he looks at when diagnosing concurrent disorders. His first task is to get to the bottom of a murky chicken/egg query: which symptoms showed up first? “We look at [a patient's] history. We try to go back a bit and figure out whether or not the depression happened first, or the substance dependence happened first,” says Dr. el-Guebaly. The next history Dr. el-Guebaly examines is the family one. For example, a significant history of mood disorders in a patient's family history means the patient is more likely to have that sort of disorder. Finally, he finds out whether or not there have been attempts at stopping the substance abuse in the past. If so, why didn't they work? Someone with only a substance abuse disorder might feel depressed during periods of withdrawal, but after three or four weeks, they tend to feel better. Someone who has both a substance abuse disorder and a mood disorder like major affective disorder (MAD),
however, may feel even worse after that three-week reprieve from alcohol. This might compel them to revisit their abusive drinking. If the first step is untangling the symptoms and naming the concurrent disorders, the next step is bringing those disorders together again and ensuring they aren't treated in isolation. Concurrent disorders call for concurrent treatments. Thankfully, Alberta has moved away from what Myllykoski calls “siloing” — pushing people into either addictions treatments or mental disorder treatments with little regard for how one might affect the other. “You don't want uncoordinated care. You don't want people to bounce between sub-
in Canada? That, says Dr. el-Guebaly, is difficult to say. Determining prevalence depends not only upon correct individual diagnoses, but also upon the inclusiveness of nation-wide studies. A commonly cited figure for the percentage of Canadians that have concurrent disorders is 1.7 per cent, a statistic that was published in the December 2008 issue of The Canadian Journal of Psychiatry. But in a paper that Dr. el-Guebaly co-authored for the September 2008 issue of the same publication, it was noted that “most household surveys do not include the necessary probe questions to determine whether symptoms are substanceinduced or part of an independent disorder.”
“If you have a concurrent disorder, it doesn't mean you're sicker. Addictions sometimes make the disorder experience more complicated. Not worse or better. Just complicated.” stance treatments and mental health treatments. You want them to be part of the treatment plan, and the best way to do that is to say, 'You know what? You're a whole person,'” she says. Myllykoski describes treatment today as “filling the toolbox” with treatments that can be effective for both disorders. Think of group therapy as a wrench, or pharmacotherapy as a handful of nails. Concurrent disorders don't necessarily call for a plethora of pills. In fact, Dr. el-Guebaly says that the opposite may be true. If someone is misdiagnosed with only a single disorder, they may be prescribed more drugs — and the wrong ones — than if they are correctly diagnosed with concurrent disorders. Myllykoski says concurrent disorder diagnoses are becoming more common, and that's a good thing: the more prevalent the diagnosis, the less stigmatized it will be. So how prevalent are concurrent disorders
The figures for the percentage of Americans with concurrent disorders tend to be higher, but Dr. el-Guebaly thinks that if a new Canadian study were commissioned using polling methods similar to the U.S. ones, our rates would be more in line with U.S. numbers. If Dr. el-Guebaly is correct, then concurrent disorders are even more common in Canada than we've believed up to this point. He stresses that it's not the numbers that count, though; it's the people. “At the end of the day, these are all statistics, right? When we talk to people, we don't talk about statistics. We talk about them. The good news is that they are being diagnosed. It's much better than being in the dark.”
Winter 2012 / Balance 7
Feature Story By Roberta McDonald
A common, and complicated,
8 Balance / winter 2012
Feature Story
pairing For many people, dealing with concurrent disorders means facing substance addiction as well as another mental disorder.
Z
oltan had a promising journalism career and an active social life when he began experiencing paralyzing panic attacks in his 20s. He began using a plethora of anti-depressants while self-medicating with alcohol and, in just five years, his life completely deteriorated. “I had an anxiety disorder in my early 20s. I was drinking anyway. I progressed from social drinking to medicated drinking. I was on different SSRIs like Prozac and Paxil, and the anxiety meds Ativan. None of them were very effective because I would drink,” he says. “My life was completely unmanageable. I had been to three or four mental health and addiction clinics. Detox seven times. I had been in the emergency room countless times. The cycle kept going and going.”
When he presented at the emergency room 12 years ago, he was in the clutches of chronic alcoholism. His liver protruded from his gaunt frame and the doctor told him he wouldn’t survive the year. It wasn’t until he admitted he had an addiction that he was able to get help through a 12-step program. Dealing with a concurrent mental health disorder and addiction can be overwhelming and baffling. According to a report released by the Calgary Addiction Centre (a treatment, research and education program operating under Alberta Health Services), the number of people dealing with substance abuse and a concurrent mental health disorder ranges from 70 to 80 per cent. Dr. Ronald Lim works with clients at the Claresholm Centre for Mental Health and Addictions and the Foothills Addiction Centre. He sees patients from across the social spectrum with wide-ranging addictions and mental health concerns. “A lot of people think they’re two different issues, addictions and mental health issues. But in reality, they’re very interrelated,” he
Winter 2012 / Balance 9
Feature Story
says. According to Dr. Lim, people diagnosed with a mental disorder, such as depression, anxiety or attention deficit hyperactivity disorder, have a high risk of developing concurrent addiction issues. Many people, like Zoltan, may find their way to addiction as a coping method for their mental disorder. But there are other ways these two mental health issues (substance abuse is a men-
tal disorder in itself) can present themselves in one person. The ecosystem of the brain is instantly and dramatically impacted by drugs. For example, if someone is suffering from depression and a shortage of dopamine, cocaine can flood the brain with the chemical, giving users an instant, albeit fleeting sense of well-being. For someone with anxiety, marijuana can create a feeling of
Local Resources for Concurrent Disorders Education and peer support are often instrumental in recovery, and Calgary has several agencies and support options available. Canadian Mental Health Association — Calgary Region Offers a wide variety of programs for those diagnosed with mental disorders, and their families. From peer support and goal-based individual programs to family support and education, they are dedicated to helping those with mental disorders maintain a high quality of life in the community.www.cmha.calgary.ab.ca Organization for Bipolar Affective Disorders The OBAD site provides listings of Calgary and area support meetings and an Ask an Expert section with e-mails addresses of psychiatrists and psychologists specializing in mood disorders. The e-book A Guide to Recovery is available for download. www.obad.ca Calgary Association of Self Help Offers social, recreational, and creative services in a safe and welcoming environment. www.calgaryselfhelp.com, (403) 266-8711 Calgary Addiction Centre Assessment of concurrent mental health and addiction and comprehensive treatment options. The website includes a podcast series on relevant topics and current information. www.addictioncentre.ca, (403) 944-2025 Claresholm Centre for Mental Health and Addictions Ninety-day in-patient program for individuals coping with concurrent mental health and addictions. A physician’s referral is required. www.claresholmcentre.com Alcoholics Anonymous Calgary Twelve-step program for people on the path to freedom from alcohol with meetings available throughout the city and at various times of the day and evening. www.calgaryaa.org, (403) 777-1212 Narcotics Anonymous Calgary Provides peer support and meetings during the day and evening for individuals coping with narcotics addictions. www.canaacna.org Depression and Anxiety Peer Support Under the stewardship of Dr. Alan Eastman, this group aims to provide a non-judgmental and upbeat environment for anyone grappling with depression and anxiety. daaps.webs.com, (403) 454-2887 Centre for Addiction and Mental Health A national program that provides links to success stories and videos of notable Canadians who have overcome mental illness and addictions. www.camh.net
10 Balance / winter 2012
calm. For an individual coping with post-traumatic stress disorder, alcohol may seem like an easy fix, but since it’s a depressant, the long-terms effects can be devastating. The relief created by the drugs is not curative, and not long-lasting. Alternatively, some drug use can lead to psychosis. Alcohol has been shown to increase risk of mental disorders, especially in men. Recently, a connection has been found between marijuana use in teenagers and schizophrenia diagnoses later in life. Anthony Banka, supervising counsellor at the Calgary Drop-In Centre, says the centre has seen an increase in clients struggling with mental disorders and addictions, in part due to cutbacks to mental health programs. Each case varies, but he notes the number of individuals experiencing psychotic episodes complicated by potent marijuana use has increased noticeably. Thirty per cent of the centre’s clients report having a severe mental illness and 70 per cent report chronic and/or acute addictions. But mental disorders and addictions aren’t confined to the marginalized. Mental illness strikes one in four Albertans. “Mental health issues are not bound by social-economic restraints,” says Dr. Shervin Vakili, a psychologist specializing in addictions, anxiety and depression. “What we see is people manifesting in different ways depending on the resources they have. If you have access to resources, be they public or private, you get better care.” Dr. Vakili notes that the stigma associated with mental disorders often delays treatment, as individuals balk at telling family and colleagues about their affliction. Lack of education about the perils of drug use is often the largest barrier in seeking treatment, particularly in adolescents. Dr. Vakili adds that this is especially the case when it comes to marijuana. In addition, since substance abuse can sometimes mask other symptoms of a mental disorder, many people do not find they receive the best or most effective treatment possible even once they do seek help. “When somebody has an addiction, everybody tends to jump on that. You’re an addict, that’s what’s going on with your life, that’s the problem. They often miss underlying issues,” says Dr. Vakili.
Feature Story
“A lot of people think they’re two different issues, addictions and mental health issues. But in reality, they’re very interrelated.” When seeking treatment, Dr. Lim says a holistic approach is key: “If you don’t treat the mental health issue at the same time the addiction is treated, there will be relapses. Patients who have concurrent disorders, such as anxiety and depression as well as addictions, can often have very chaotic lives. We treat different aspects of the whole picture.” A chartered accountant who once worked in opulent boardrooms making deals worth millions, Jeremy* endured grinding bouts of chronic depression, exacerbated by a gambling addiction and alcohol. “My first addiction was work — a requirement
including an addiction. With a focused and sustained effort, an integrated, fulfilling and productive life is within reach. Zoltan says it took him several tries to find sobriety and the life skills he needed to address his anxiety. He’s been clean and free of attacks for 11 years. “Use whatever resources are out there. Don’t give up, and if you fail, try again. Just keep going,” he says. “It was a number of years for me, in and out of rehab. It wasn’t that I went once and it kicked in. It took a while.”
for most professionals. But the ghosts that will haunt me for life are gambling and alcohol. I discovered that the poker table was just a smaller version of a boardroom table,” he says. It wasn’t until 2006 at the age of 56, when he was diagnosed with bipolar type two disorder, that he began to regain clarity and a sense of purpose. With the support of a team of doctors and psychologists, proper medicine, and a holistic program of self-care, he has been able to again form healthy relationships with family and friends. There is hope for anyone enduring the pain and stigma of concurrent mental disorders,
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Winter 2012 / Balance 11
Community Update By Lynda Sea
home A place to call
When dealing with concurrent disorders, everyday matters like housing can become more complicated. But there are programs and resources that can help people address their addiction and mental disorder at the same time.
I
n 2008, approximately two per cent of Canadians (435,000 people) suffered from concurrent disorders. This rate is increasing and, even back then, was felt to be an underestimated statistic. Individuals with concurrent disorders have the added challenge of seeking treatment for both their mental health disorder and addictions, and doing so in the face of social stigma and navigating complex health services and
12 Balance / winter 2012
programs that may address one issue, but not the other. “At Hamilton House, my attitude is that concurrent disorders are the expectation, not the exception,” says Shannon Middlemiss, a registered nurse at Hamilton House, a postdischarge transitional group home program in Calgary, operated by Canadian Mental Health Association – Calgary Region and Alberta Health Services. “In the past, most centres and service pro-
viders in the community have been very fragmented in the care that they provided. It was ‘We’ll treat your mental health issue but not your addiction, so we can’t work with your depression until you’ve addressed your drinking problem.’ Or it was ‘We’ll treat your addiction but not your mental health issue.’ It was always one or the other.” Not only are people diagnosed with concurrent disorders dealing with non-centralized support services that can be much harder
Community Update
“A number of integrated programs work by addressing multiple needs including housing, employment, education and life skills.” to access, but even the resources that are in place pose large barriers. If a person has a substance abuse problem and is seeking housing, they may be denied because the programs are abstinence-based. When they seek help for the addiction, wait lists are long for many programs — anywhere from a few months to years — and there’s the chance they can relapse while waiting. Leslie Hill, Director of the Supportive Living Program with Canadian Mental Health Association — Calgary Region, says both clinical and community support needs to happen in tandem in order to affect long-term success when treating concurrent disorders. Practitioners agree that concurrent mental disorder and addiction problems need to be addressed at the same time to effectively treat both conditions. It’s important to distinguish whether certain behaviours or conditions are manifestations of the mental disorder or byproducts of substance abuse or withdrawal. In some cases, addictions to drugs and alcohol can create symptoms of a mental disorder, such as hallucination and anxiety, which can further complicate getting the proper treatment. “It can be difficult to tell if the symptoms that a person is experiencing are a result of their drug or alcohol abuse or if they’re a result of the mental disorder,” says Hill. “We do clients a poor service if we don’t address both problems at the same time,” says Middlemiss. A number of integrated programs that are most effective work by addressing multiple needs including housing, employ-
ment, education and life skills as well as offering support to manage substance addictions. “[Concurrent disorders] can interfere with employment so we talk about goals. If we are able to identify an addiction issue, we facilitate referrals to other agencies in the community, and treat in-house as need be,” she says. Hill adds that getting rid of the stigma around mental illness is a big step in encouraging individuals to seek help. “There also needs to be more collaboration between the mental health and addiction sectors so we can work together more frequently.”
Resources close to “home” In Alberta, there are a number of resources available that focus on concurrent disorders, including the alex's Pathways to Housing program. This health centre takes a multidisciplinary approach where a team of psychiatrists, nurses and outreach workers wrap community support around clients while they go through the process of obtaining and maintaining housing. Clients can have permanent housing without the prior requirement of treatment for addictions or health issues. Housing and treatment are separated, but clients have 24/7 access to intensive, individualized support and clinical services. At the Claresholm Centre for Mental Health and Addictions, patients with concurrent disorders can seek recovery in a residential environment. Patients with mental health issues, including mood disorders and substance
abuse, are assisted with education programs and treatment that increase their independence so they can manage their disorders. The centre also offers in-house treatment for addiction and pain management. In Ponoka, the Centennial Centre for Mental Health and Brain Injury was also designed specifically to help individuals with mental disorders and serious addictions. In addition to clinical treatment and psychotherapy, patients can also access education workshops and counselling. Middlemiss also points to the places such as Calgary Alpha House Society, which offers a safe place to detox from alcohol and drugs 24-hours a day and can refer people to additional resources. She also praises the Foothills Addiction Centre for its inclusivity. “The centre is more treatment-based to help individuals with withdrawal [from their substances], but they don’t exclude someone who has a mental health disorder,” says Middlemiss. “Substance abuse can impact mental health, and mental health can in turn cause someone to return to substance use and abuse,” she says. “We have to realize that the two intersect and are related to one another and do impact one another.”
Winter 2012 / Balance 13
Real People
way
Finding her
At only 21, and after years of addiction, Laura Zuk is living — and thriving — with concurrent disorders
As told to Abby Miller
I
t was never the drug specifically. When I was using, I would change drugs — I started with weed, went to crack. I did some acid and finally hit my bottom with inhalants. But my addiction was the obsession, and before the drugs it was self-harming. That’s how it went. When it wasn’t self-harming, it was drugs; when it wasn’t drugs, it was an eating disorder. Something to focus on that wasn’t how I was feeling. I started self-harming in Grade 9. My parents found out about it but initially let it slide. I think they hoped it was a phase, and for the most part I hid it well. I was a straight A student, I pushed myself really hard and so they weren’t concerned. I also started drinking in Grade 9. I started using drugs around the end of Grade 12, and it went downhill pretty quickly. I think the addiction was just to mask the depression and anxiety. It was the best way I knew how to cope. Of course it was destructive and I knew that, but I didn’t know how to deal with my emotions. My addiction took
some of the pain away from whatever I was dealing with at the time. I was still dealing with themood swings, and the anxiety and stuff like that, but it wasn’t so painful to deal with all the emotions when I always had the addiction to fall back on. Now I’m six months clean, and I’m really pretty stoked about that. It’s hard putting together clean time. When I first started going to 12-step pro-
maintain. And a lot of people have similar attitudes about depression, they have the “buck up” attitude. If I could take a magic pill and just have it go away, I would. But it’s not that easy. It’s something you have to work at and deal with, potentially for the rest of your life. But, at the same time, there are ways that you can learn to cope with it and live a “normal” life. This isn’t a death sentence — neither
When I first started going to 12-step programs, I didn’t think I’d be accepted because I have a mental health disorder, but they so often go together. So many people have both problems. People just don’t realize that.
14 Balance / winter 2012
grams, I didn’t think I’d be accepted because I have a mental health disorder, but they so often go together. So many people have both problems. People just don’t realize that. They look at addicts and say, “You just need to stop using,” but it’s not as simple as that. It’s hard to
addiction nor a mental health diagnosis is a death sentence. A lot of people feel like, “I’m doomed to be trapped in my own misery for the rest of my life,” and that is just not true. There are ways out.
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