# Presentation: 035240

## Co-occurring Disorders:The “Z-axis”Complexities of Co-Occurring Conditions ConferenceJune 2004Washington, DC

- Richard Saitz MD, MPH, FACP, FASAM
- Clinical Addiction Research and Education Unit
- Section of General Internal Medicine
- Center to Prevent Alcohol Problems Among Young People
- Boston University and Boston Medical Center

## Outline

- What we mean by comorbidity
- Conceptual framework
- Risk for co-occurring disorders
- Services not currently coordinated
- MH/SA impact care for chronic medical conditions
- Models of care for patients with co-occurring disorders
- Research directions

## Comorbidity

**Notes:**
Take a moment and think to yourself the first diagnosis or type of diagnosis that comes to mind when you see this word.
Raise your hand if the condition or type of condition you are thinking of is a mental health condition?  A substance dependence diagnosis?  A medical condition?
[consider asking audience if they are MH professional, Addiction professional, or a medical professional, primarily]
The definition of comorbidity depends on one’s perspective.  And that perspective is likely correlated with professional area of expertise.  And it implies there is a main or primary problem, and that other issues are just comorbid.
I first learned about comorbidity as a general medicine research fellow.  Then, I was taught research measures to account for medical comorbidity so that I could adjust for this nuisance when studying another medical diagnosis of interest.  As I focused more on alcohol-related research, I realized that many referred to alcohol dependence as a comorbidity, and that many alcohol research colleagues referred to psychiatric illness as comorbidity.
Frankly, as a primary care physician seeing patients who routinely had half a dozen or more diagnoses including medical, addiction and mental health problems, I was often confused by terminology like “dual diagnosis.” The term implied there were two diagnoses, which never seemed enough.  And dual diagnosis never included the medical diagnoses.  My patients, in primary care settings, all had “triple diagnosis,” at least. I had trouble finding special treatment programs that specialized in dual diagnosis, let alone triple or more. And The word Comorbidity also suggested one diagnosis was primary, the others comorbid. One could expect that patients and families would be even more confused by such professional perspectives.  Microsoft Word and Powerpoint spell checkers don’t even recognize the word comorbidity.  And Given these differing perspectives, it should be no surprise that appropriate management for anyone with anything other than a single diagnosis will be complicated and less effective than it could be.   Imagine my delight when I learned of SAMHSA’s report to Congress regarding the treatment of co-occurring disorders.  Let’s review the conceptual framework proposed therein.

## Case #1

- A 40 year old man is transferred from a group home to the general medical hospital with diabetic ketoacidosis; he stopped taking his antipsychotic. He refuses insulin because he believes it will harm him. After initial treatment he stabilizes but cannot return to his home because he won’t take insulin.  He is too medically complex for the psychiatric hospital and is declined by addictions treatment programs. He remains in the medical hospital where consultation for MH conditions is available.

**Notes:**
Welcome to my world

## Case #2

- A 54 year old man with Type 2 diabetes has alcohol dependence.  He has poor glycemic control and severe hypertriglyceridemia.  His alcohol use limits medication choices; he is on maximal doses of oral agents.  He takes his lipid lowering medication once instead of twice a day to avoid drinking and taking medication. He declines alcoholism treatment.

## Outline

- What we mean by comorbidity
**Conceptual framework**
- Risk for co-occurring disorders
- Services not currently coordinated
- MH/SA impact care for chronic medical conditions
- Models of care for patients with co-occurring disorders
- Research directions

## Service Coordination by Severity

| 

Addiction Specialty | 

 Hospital, Prison, ED |
| --- | --- |
| 

Primary Health |  

 Mental Health  
 Specialty |

- Alcohol, Tobacco & Other Drug Severity

- Mental Illness Severity

*Collaboration*

*Integration*

*Consultation*

*Adapted from SAMHSA 2002 Report to Congress on the Prevention and*
*Treatment of Co-occurring Substance Abuse and Mental Disorders*

**Notes:**
In this conceptual framework, drug severity is represented as increasing along the y axis, and mental illness severity increases along the x axis.  When both drug and mental illness problems are not severe, services for these problems are delivered in a primary health care setting with consultation as necessary.  When both drug and mental illness problems are severe, then care for the two is integrated in a specialty setting designed to care for such disorders together, or a more general setting designed to address urgent problems like a hospital or emergency department.  When the same severity exists but is limited to just one problem, addiction or mental health, the suggested setting is the specialty setting for that problem.  
Now I quote from the SAMHSA report to Congress describing this conceptual framework, it “displays the universe of individuals with co-occurring disorders.”
Friends, I believe I must be living in an alternate or parallel universe.  I would therefore like to propose expanding this universe to allow us to consider the patient with hypertension, diabetes, nicotine and alcohol dependence and depression who needs routine preventive care as well as specialty addictions and mental health care.

## Service Coordination by Severity

- Alcohol, Tobacco
- & Other
- Drug Severity

- Mental Illness Severity

*Collaboration*

*Integration*
- Hospital, ED

- Medical Severity

*The*
*“**Z-axis”*

- Medical Specialty

| Addiction Specialty | 
 |
| --- | --- |
|  |  

 Mental Health  
 Specialty |

*Consultation*

- Primary Health

**Notes:**
With this z axis, I am not proposing a new paradigm; I leave that as a research agenda for us.  I have simply added an axis on which to consider how to integrate medical care along with addiction and mental health care.  Medical severity increases along this axis, and as with the other axes, if a severe problem exists with minimal or no severity in the other dimensions, a medical specialty treatment setting might be the best setting.  Service delivery coordination options can remain, in order of increasing complexity and formality, consultation, collaboration, and integration, though given the three dimensional complexity of the model, the emphasis for most patients triply diagnosed may need to be on a new or newly conceptualized care setting or settings that through collaboration can address all three areas, with occasional need for more specialized urgent care settings, and the option for consultation alone when that suffices.
My guess, and I emphasize that this is speculation that will require empirical study, is that the model that best balances effectiveness and cost and ease of implementation now that I have added a z-axis, will look most like collaboration.
For the remainder of my time I’d like to highlight some data that support the existence of the z-axis and how it can be addressed by health services delivery models.

## Outline

- What we mean by comorbidity
- Conceptual framework
**Risk for co-occurring disorders**
- Services not currently coordinated
- MH/SA impact care for chronic medical conditions
- Models of care for patients with co-occurring disorders
- Research directions

## Alcohol-related Emergency and Hospital Utilization, US

- Emergency
- 29 visits/1000 persons each year
- 8% of all ED visits
- Hospital
- 7.4% of acute admissions to short-stay, non-Federal general hospitals
- 1.8 million hospitalizations per year

*McDonald AJ et al. Arch Intern Med 2004; 164: 531 - 537.*
*Smothers BA et al. Arch Intern Med 2003; 163: 713 - 719.*

**Notes:**
National Hospital Ambulatory Medical Care Survey for 1992 through 2000

Very likely an underestimate since dependent on coded diagnoses by MDs and then recorded by hosp staff for survey

Hospital
Current dependence 1994, by interview
Multistage probability sample, 2040 patients, 90 hospitals

## Alcohol-related Diagnoses, AAFs<1

- Pulmonary and other respiratory tuberculosis 		0.25
- Malignant neoplasm of lip, oral cavity, and pharynx 	0.50 Malignant neoplasm of esophagus			0.75
- Malignant neoplasm of stomach 				0.20
- Malignant neoplasm of liver and intrahepatic bile ducts0.15
- Malignant neoplasm of larynx 				0.50
- Diabetes mellitus 						0.05
- Essential hypertension 					0.076
- Cerebrovascular disease 					0.065
- Pneumonia and influenza 					0.05
- Diseases of esophagus, stomach, and duodenum 	0.10
- Cirrhosis of liver without mention of alcohol 		0.50
- Biliary cirrhosis 						0.50
- Acute pancreatitis 						0.42
- Chronic pancreatitis 					0.60

**Notes:**
Don’t need to review well-known medical complex of alc and drugs like endocarditis and cirrhosis and HIV

Make point re common chronic med illnesses

## Medical Disorders More Common in Patients with Substance Use Disorder, Psychotic Disorder, and Both

- Diabetes
- Hypertension
- Heart Disease*
- Asthma*
- Gastrointestinal Disorders*
- Skin Infections*
- Malignant Neoplasms
- Acute Respiratory Disorders*

- *highest risk in those with both
*Dickey B et al.  Psych Services 2002;53(7):861-7.*

**Notes:**
Admin Data from MA DMA
Cross sectional observ design
26,332 Medicaid beneficiaries 18-64 yrs old
11,185 rx’d for mental illness—schizophrenia, bipolar d/o or other psychotic d/o
12 mo prev rates and then LR to estimate effect of SA d/o (Alc or drug ICD9) and Mental illness on risk for having a medical disorder (8 selected conditions or groups of conditions).
Those with severe mental illness had higher age and sex adjusted risk.  Those with both SA and Mental Illness had the highest risk for the 5 starred d/o’s

## Comorbidity in a Detoxification Sample

- 470 adults with no primary medical care in a short-term residential detoxification unit, mean age 36
- 47% had chronic medical illness
- 90% had CES-D score >16
- 70% reported moderate to severe pain at least intermittently during 2 years of follow-up
- Intermittent pain associated with relapse (OR 2.0)
- Persistent pain associated with relapse (OR 5.2)

*DeAlba I et al. **Am J Addictions 2004;13:33-45.*
*Larson MJ et al. CPDD Abstract 2004.*
*Saitz R et al. **HSR 2004;39(3):587-606.*

**Notes:**
Alcohol, heroin or cocaine as 1st or 2nd drug of choice
Asthma, COPD, HTN, Liver, seizures arthritis top 5
Relapse=alc to intox or use of drug past 30 days

## Mertens JR et al. Arch Intern Med 2003; 163: 2511 - 2517. 

| Med/Psych DX | % of AOD Pts | % of Controls |
| --- | --- | --- |
| Acid-related | 5.5 | 2.1 |
| Arthritis | 3.9 | 1.3 |
| Asthma | 6.8 | 2.6 |
| COPD | 0.7 | 0.1 |
| Headache | 9.2 | 3.8 |
| Hypertension | 7.2 | 3.4 |
| Low back pain | 11.2 | 5.8 |
| Injury/OD | 25.6 | 12.1 |
| Depression | 28.5 | 2.7 |
| Anxiety disorder | 16.9 | 2.2 |
| Major psychosis | 6.6 | 0.4 |
| Liver cirrhosis | 0.7 | 0.1 |
| Hepatitis C | 0.7 | 0.2 |

*Mertens JR et al. Arch Intern Med 2003; 163: 2511 - 2517. *

**Notes:**
All are stat signif diff in cond LR vs  3690 Matched controls (on age, sex and length of plan enrollment).
747 Pts in SA treat (alcohol, marijuana, cocaine, stimulants, narcotics) in an HMO c/w Pats in same HMO w/o SA

## Outline

- What we mean by comorbidity
- Conceptual framework
- Risk for co-occurring disorders
**Services not currently coordinated**
- MH/SA impact care for chronic medical conditions
- Models of care for patients with co-occurring disorders
- Research directions

## Patients in Addiction Treatment not Receiving Medical Care, and Vice Versa

- Of 5,824 adults entering addiction treatment in Massachusetts, 41% had no physician
- Prior substance abuse treatment or mental health treatment were not associated with having a physician
- Of those with a primary care physician, 45% reported the physician unaware of their addiction

*Saitz R et al. Substance Abuse  1997;18:187-195.*
*Saitz R et al. **Am J Drug Alcohol Abuse 1997;23:343-354.** *

## Patients with Severe Mental IllnessWhere are they? Medical Care

*Bosworth HB et al.  Psych Services 2004 June;55:708-10.*

|  | Median Outpatient Visits |  |
| --- | --- | --- |
|  | Psychiatric | Medical |
| AUD
No AUD | 5
9 | 10
15 |
| IDU
No IDU | 9
7 | 18
13 |
| Cocaine
No cocaine | 6
8 | 12
14 |

**Notes:**
396 veterans hospitalized for schizophrenia, bipolar disorder, PTSD (severe mental illness) and followed for 12 months.  

## Outline

- What we mean by comorbidity
- Conceptual framework
- Risk for co-occurring disorders
- Services not currently coordinated
**MH/SA impact care for chronic medical conditions**
- Models of care for patients with co-occurring disorders
- Research directions

## Quality of Diabetes Care

|  | % with retina exam |
| --- | --- |
| No mental disorder | 71 |
| Psychiatric disorder | 71 |
| Substance disorder | 64 |
| “Dual diagnosis” | 68 |

*Desai MM et al. Am J Psychiatry 2002;159(9): 1584-90.*

**Notes:**
38,020 veterans with at least 3 outpatient visits. Chart abstracted quality data and administrative data

Approximately a quarter of the sample had a diagnosed mental disorder (23.7% with psychiatric disorder only, 1.3% with substance use disorder only, and 2.6% with a dual diagnosis). Overall rates of receipt for the indicators were higher than national benchmarks for all patient subgroups, ranging from 70.8% for retina examination to 95.0% for foot inspection. Rates for both retina examination and foot sensory examination differed significantly by mental health status, mainly because of lower rates among those with a substance use disorder. The associations remained significant in multivariate generalized estimating equation analyses that controlled for demographic characteristics, health status, use of medical services, and hospital-level characteristics. 

## Alcohol Use and Incident Diabetic Retinopathy

| 2 Studies | RR (95% CI) |
| --- | --- |
| +0.5 drinks/day
   Younger onset
   Older onset | 
2.09 (0.04-4.07)
0.75 (0.40-1.42) |
| >1.9 drinks/day | 2.25 (1.15-4.42) |

*Howard AA et al.  Ann Intern Med. 2004;140(3):211–219.** *

**Notes:**
Systematic review identified 2 studies

Population based sample (fundus photography) 436 younger/193 olderadjusted for age, sex, glycemic control
Men (296) from a diabetes clinic (direct ophthalmoscopy) adjusted for duration of DM, glycemic control and erectile dysfunction

The results for progression of retinopathy were similar to the incidence results in the population-based study (top row). 

## Catheterization and Revascularization after Myocardial Infarction

|  | CATH           PTCA         CABG
Adjusted Relative Risk |  |  |
| --- | --- | --- | --- |
| Mental disorder
    Schizophrenia
    Affective
    Substance Use | 0.72
    0.41
    0.65
    0.78 | 0.75
    0.55
    0.51
    0.58 | 0.68
    0.27
    0.63
    0.80 |
| No mental disorder | 1 | 1 | 1 |

*Druss BG et al. JAMA 2000; 283: 506 - 511.*

**Notes:**
No assoc between MH/SA and revasc in those who received cath, and no impact on mortality

## Influence of Mental Health and Addictions on Hepatitis C Therapy

- 154 patients with HIV, alcohol abuse, hepatitis C
- 81 (53%) had contraindications to interferon
- 52 heavy drinking
- 15 had CD4<100
- 14 IDU with needle sharing
- 14 decompensated liver disease
- 13 recent suicidal ideation
- 54 (35%) had lesser contraindications to interferon
- 47 had significant depressive symptoms
- 8 Had CD4 100-200
- 7 were drinking alcohol (“moderate amounts”)
- 7 IDU

*Nunes et al. Abstract at CPDD 2004*

**Notes:**
+HCV +RNA

25 had 1 or more contraind
14 had 1 or more lesser contraind
Only 19 (12%) had no contraindications to ifn rx
And this list does not address whether they were suitable for rx from a liver dx (bx) perspective 
Eligibility for treatment

## Substance use, Depressive symptoms, and HIV Outcomes

- Prospective cohort study of 350 adults with HIV and alcohol problems
- Depressive symptoms and substance use were associated with worse adherence
- Substance use was associated with less HIV viral load suppression
- Substance abuse treatment
- reduced the odds of ED utilization (AOR 0.5)
- increased the odds of HAART for HIV (AOR 1.70)
- not associated with 30-day HAART adherence or HIV viral load suppression

*Palepu A et al.  J Subst Abuse Treat 2003;25:37-42 and Palepu et al. Addiction 2004;99:361-8*

**Notes:**
Adjusted for age, sex, race, homelessness, self help use, injection drug use, and ADS
HIV ALC cohort
SA Treatment was: any of the following in the past 6 months: 4 weeks in a half-way house or residential facility; 4 visits to a substance abuse counselor or mental health professional; or participation in any methadone maintenance program (self-report)

## Major Depression in Patients with Myocardial Infarction

|  | Six-month Mortality
Adjusted Hazard Ratio (95% CI) |
| --- | --- |
| Depression | 4.29 (3.14-5.44) |

***Frasure-Smith N et al. JAMA 1993;270(15):1819-1825***

**Notes:**
222 MI patients, assessed for Major Depressive episode at baseline and followed thereafter.
control for left ventricular dysfunction (Killip class) and previous MI, the multivariate significant predictors of mortality in the data set
All mortality in the cohort was cardiac

## Treating Major Depression in Patients with Myocardial Infarction

- Randomized, clinical trial
- 2,481 men and women hospitalized with MI and depression (75%) or lower perceived social support (25%)
- CBT and group therapy for 6 months
- Results:
- Improvements in depressive symptoms and perceived social support
- No difference in 24% death or recurrent MI

**Notes:**
Improvements in control group limited major differences in psychosocial symptoms
May need larger studies to look for smaller effects (power was to detect a 30% reduction in mortality) or better interventions 

## Outline

- What we mean by comorbidity
- Conceptual framework
- Risk for co-occurring disorders
- Services not currently coordinated
- MH/SA impact care for chronic medical conditions
**Models of care for patients with co-occurring disorders**
- Research directions

## The “teachable moment”

- Definition: naturally occurring health events thought to motivate individuals to spontaneously adopt risk-reducing health behaviors
- Smoking cessation
- Pregnancy, hospitalization and disease diagnosis, high (10-78%)
- Clinic visits (2-10%) consistently lower

*McBride CM et al. Health Educ Res 2003;18(2):156-70 *

**Notes:**

Perhaps we can take advantage of co-occurring conditions
Review article
Similar to situation of alcohol intervention for alcohol related trauma, or perhaps in medical hospital settings.

## Integrated Primary Care and Addiction Treatment

- Overall sample: trend towards higher costs and no difference in abstinence
- Subgroup with substance abuse-related medical or psychiatric conditions
- --More likely to be abstinent in integrated care
-    group (69% vs. 55%, p=0.006)

*Weisner C et al. JAMA 2001;286:1715-23.*

**Notes:**
592 patients in a chemical dependency program assigned to receive primary medical care on-site at the addiction treatment program, or, to separate “as usual” care

Incremental cost-effectiveness ratio $1581 per additional abstinent case

## Integrated Medical and Alcoholism Care

- Randomized trial of a thorough multidisciplinary evaluation, and care plan (N=101)
- Monthly primary care visits to review drinking and medical problems
- Mental health, social services and more intensive alcohol treatment on site
- 2-year results:
- 30-day abstinence increased from 47% to 74%
- Mortality decreased from 30% to 19%

*Willenbring ML & Olson DH. Arch Intern Med 1999;159:1946-52*
*Willenbring ML et al. J Stud Alcohol. 1995;56:337-343 *

**Notes:**
In a randomized trial in a special alcohol clinic for veterans, (Willenbring et. al., 1995) the integrated care group was more likely to be abstinent (74% vs 49% 30-day abstinence) than a usual care group (Willenbring and Olson, 1999). The study intervention was [focused on alcoholism but included substantial attention to comorbidity.  The intervention was an initial thorough inpatient evaluation by a multidisciplinary team who developed a care plan to reduce alcohol severity and remission of related medical conditions, monthly primary care visits to review drinking and medical problems at a frequency indicated by clinical status, and feedback of blood test results to encourage abstinence.  Mental health and social services and more intensive alcohol treatment were provided on-site when necessary.] Patients were contacted when they missed appointments. 

...care plan to reduce alcohol severity and achieve remission of medical conditions 

## Potential Impact of Buprenorphine Treatment in Primary Care

- Initial experience with 37 patients (30 max. at any one time). Median age 31.
- 68% had no previous primary medical care
- 59% had medical comorbidity
- 43% had Hepatitis C (a quarter of these diagnosed at entry)
- 54% had psychiatric comorbidity (80% with no psychiatric care)
- 86% retained in care 4 months

*Alford DP et al.  SGIM Abstract 2004.*

**Notes:**
%
Depression 49
Anxiety 14
PTSD 12
Bipolar 3

## What is Primary Care?

- Integrated and accessible health services provided by primary care clinicians (generally MD, NP, PA)
- Addresses the majority of health care needs
- Sustained personal relationship between patient and clinician
- Does not consider mental health separately from physical health
- Intrinsic to PC are opportunities to promote health and prevent disease

*Institute of Medicine.  Primary Care: America’s Health in a New Era. National Academy Press, Washington, DC. 1996.*

**Notes:**
Is PC a way to address....

Potential of primary care, collaboration integration, probably not realized yet (old fashioned model of lone MD vs more current approach w/teams (Grumbach and Bodenheimer JAMA 2004;291:1246-51

## Receipt of Primary Care Improves Addiction Severity

*Saitz et al. Submitted.*

**Notes:**
Prosp cohort, 470 adults in detox alc/her or cocaine

Predicted means from multiple regression models.  Adjusted for interview number, randomization group, age, sex, ethnicity, homelessness, health insurance, mental and physical health, baseline alcohol and drug severity, motivation to change use, use of self-help or addiction specialty treatment.  *Alcohol was the first or second substance of choice.  **Another drug was the first or second substance of choice.
47% had med comorb, 90% elev CES-D

## Care for People with Drug Abuse or Dependence

|  | Hospitalization
(AOR, 95% CI) |
| --- | --- |
| HIV
   Regular drug care
   Regular med care
   Both | 
0.85 (0.76-0.96)
0.82 (0.74-0.91)
0.76 (0.67-0.85) |
| Non-HIV
   Regular drug care
   Regular med care
   Both | 
0.71 (0.66-0.76)
0.91 (0.86-0.95)
0.73 (0.68-0.79) |

*Laine C et al. JAMA, May 2001; 285: 2355 - 2362. *

**Notes:**

Retrospective cohort of admin claims data from NY medicaid program
Hosp in 1997 as predicted by care in 1996
11 556 human immunodeficiency virus (HIV)-positive and 46 687 HIV-negative drug users
regular drug abuse care ( 6 months in 1 program), regular medical care (>35% of care from 1 clinic, group practice, or individual physician), both, or neither

Effects seen for all types of hosps EXCEPT drug abuse hosps (alcohol, medical, mental health)
Adjusted for age, sex, residence, comorbidity, HIV conditions, hosp days in baseline year, substance abuse conditions

## Chronic Disease Management

- 1,801 older adults with depression or dysthymia in 18 primary care clinics
- Mean 3 chronic conditions
- 20 minute educational video, booklet, visit with nurse or psychologist case manager in primary care, with medical and psychiatric consultation as needed
- Results: Significant reduction in depressive symptoms, functional impairment, and *arthritis pain and functional outcomes* (for the 1001 with arthritis)

*Lin EHB et al. JAMA 2003; 290: 2428 - 2429 *
*Unützer J et al.  JAMA 2002; 288: 2836 - 2845*

**Notes:**
 In a large randomized trial, 1,801 depressed older adults were identified by referral or screening at one of 18 primary care clinics nationwide (Unutzer et. al., 2002). Excluded bipolar, psychosis or CAGE 2+.  CDM (collaborative care mgt, care mgt) intervention patients received a 20-minute educational video and booklet about depression and a visit with a trained depression nurse or psychologist case manager in primary care.  Patients underwent medical and psychosocial assessment and were asked their treatment preferences.  The CDM program included a psychiatrist and medical doctor (primary care depression expert) who met with the team to develop care plans.  The case manager worked with primary care physicians to facilitate the treatment plan, and referred patients to medical and social services as clinically indicated.  The team suggested either antidepressant medication (80% had 1 trial of medication), or brief psychotherapy adapted for the primary care setting delivered by the case manager (30% received this counseling).   Unlike the more familiar efficacy study, this effectiveness design offered services tailored to patients’ needs and preferences rather than attempting to provide a specific treatment to all subjects regardless of preference or need (see 4.1).  Patients were contacted by phone (mean 6 times) or visited the clinic every other week (mean 9 visits).  When symptoms persisted, the team, including the specialist (psychiatrist) intervened.  [The depression CDM intervention included focus on a medical condition if the patient wished.] Compared with ‘usual care,’ CDM patients were more likely to receive depression treatments and they had a significant reduction in depressive symptoms and functional impairment.  [The depression CDM intervention also improved arthritis pain and functional outcomes (Lin et. al., 2003). CDM interventions focus on a disease but attend to comorbidity, and a major strength and promise of such interventions is improvement in the disease of focus as well as comorbidities.] 

## Outline

- What we mean by comorbidity
- Conceptual framework
- Risk for co-occurring disorders
- Services not currently coordinated
- MH/SA impact care for chronic medical conditions
- Models of care for patients with co-occurring disorders
**Research directions**

## Research Agenda

- Prevalence of co-occurring MH/SA disorders and medical disorders
- Impact of one medical/MH/SA disorder on the incidence, severity, quality of care and health outcomes of others
- Development and testing of new models of care that
- bring needed care to the patient with “triple diagnosis”
- can address comorbidity in the face of varied levels of severity of comorbidities
- Identify and overcome barriers to implementation

**Notes:**
...disorder, in various health care delivery settings
...disorders, like hypertension, heart failure, asthma, heart disease, diabetes, and ways to improve care
...MH/SA, and ways to improve care
...diagnosis” such as collaborative care bringing MH/SA services into general medical care settings, and medical care to patients in MH/SA treatment settings
Health care teams as is almost natural in pc practice JAMA 2004;291:1246-51  Grumbach and Bodenheimer

## Thank You for Your Attention

## Extra Slides

## Alcohol-related diagnosesAAFs=1

- Alcoholic psychoses
- Alcohol dependence syndrome
- Nondependent abuse of alcohol
- Alcoholic polyneuropathy
- Alcoholic cardiomyopathy
- Alcoholic gastritis
- Alcoholic fatty liver
- Acute alcoholic hepatitis
- Alcoholic cirrhosis of liver
- Alcoholic liver damage, unspecified
- Excessive blood level of alcohol
- Accidental poisoning by ethyl alcohol, not elsewhere specified

**Notes:**
ICD-9 code dxs

## Cardiac Catheterization after Myocardial Infarction

|  | Unadjusted Proportion (%) | Adjusted Relative Risk |
| --- | --- | --- |
| Mental disorder
    Schizophrenia
    Affective
    Substance Use | 32
    22
    33
    41 | 0.72
    0.41
    0.65
    0.78 |
| No mental disorder | 44 | Reference |

*Druss BG et al. JAMA 2000; 283: 506 - 511.*

**Notes:**
5365 adults with mental disorder c/w 108,288 without, after acute MI (heart attack)
FFS Medicare (age >=65), national sample of claims, principal Dx MI in acute care hosp
Adjusted for demographics, cardiac risk factors and history, severity of MI at presentation, and hospital characteristics including availability of technology

(less likely to be adm to hosp with tech)(Ors transf to RR by methods of Zhang and Yu)

## Revascularization after Myocardial Infarction

|  | PTCA |  | CABG |  |
| --- | --- | --- | --- | --- |
|  | Unadj. % | Adj. RR | Unadj. % | Adj. RR |
| Mental disorder
    Schizophrenia
    Affective
    Substance Use | 12
    9
    9
    12 | 0.75
    0.55
    0.51
    0.58 | 8
    4
    8
    11 | 0.68
    0.27
    0.63
    0.80 |
| No mental disorder | 17 | Ref | 13 | Ref |

**Notes:**
No assoc between MH/SA and revasc in those who received cath, and no impact on mortality

## Preventive Care: Mammography

- Older women with schizophrenia
- 62% in past 2 years
- Age-matched controls
- 86% in past 2 years

*Dickerson FB et al.  Psych Services 2002;53:882-4.*

**Notes:**
Age 40-70
62% of 43 women

## Alcohol Use and Diabetes

- Incident diabetes
- 18 prospective cohort studies: U-shaped relationship
- Glycemic control
- 6 experimental studies of up to 6 drinks given to 5-20 subjects with diabetes
- 3 found decreases in serum glucose
- 3 found no difference each
- Diabetes medications
- In 2 studies, immediate glycemic response to 3-drink challenge did not differ
- 23 subjects taking troglitazone or placebo
- 50 subjects before and after sulfonylurea

*Howard AA et al.  Ann Intern Med. 2004;140(3):211–219.** *

**Notes:**
Systematic review
18 prospective cohort studies, most of fair (as dist fr good) methodologic quality.  In general, those that looked found a U-shaped rel with moderate drinking having lowest and heavy or non-drinking having the higher risks for diabetes.  But studies had many limitations including nonstandard screening measures for DM, alcohol measure at baseline only, and variable ways of categorizing consumption and failure to adjust for important confounders of the relationship. (opportunity for further research)
Glycemic control—experimental studies; none in clinical practice and clinical management of diabetes (eg effects on adherence, etc)
Meds: 2 small experimental studies in patients with type 2 diabetes.  4 hrs post alcohol, 6 hrs post alcohol in sulfonylurea study.   Troglit for 42-45 days, sulfonylurea for 10 days