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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