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Concurrent disorders

In Canada, concurrent disorders describe the situation in which a person has both a mental health disorder and a substance use disorder.

A person with a mental disorder has a higher risk of developing a substance use disorder, and a person with a substance use disorder has an increased chance of developing a mental health disorder at the same time.

The interactions between these two disorders can worsen the course of both.

Who is affected?

  • 7 million adults have concurrent disorders. This does not mean that one caused the other and it can be difficult to determine which came first.
  • Of the 20.3 million adults with substance use disorders, 37.9% also had mental illnesses.
  • Among the 42.1 million adults with mental illness, 18.2% also had substance use disorders.

There are many effective treatments for both mental and substance use disorders. A comprehensive treatment approach will address both disorders at the same time.

Not everyone gets the treatment they need:

  • 5% of those with co-occurring conditions received neither mental health care not substance use treatment.
  • 5% of those with co-occurring conditions received mental health care only.
  • 1% of those with co-occurring conditions received both mental health care and substance use treatment.
  • 9% of those with co-occurring conditions received substance use treatment only.

Data show high rates of comorbid substance use disorders and anxiety disorders (generalized anxiety disorder, panic disorder, and post-traumatic stress disorder). Substance use disorders also co-occur at high prevalence with mental disorders, such as depression and bipolar disorder, attention-deficit hyperactivity disorder (ADHD), psychotic illness, borderline personality disorder, and antisocial personality disorder.

Patients with schizophrenia have higher rates of alcohol, tobacco, and drug use disorders than the general population.  the overlap is especially pronounced with serious mental illness. Serious mental illnesses include major depression, schizophrenia, and bipolar disorder, and other mental disorders that cause serious impairment. Around 1 in 4 individuals with SMI also have a SUD.

For more information about finding treatment or yourself or a loved one, visit, drugabuse.gov/related-topics/treatment.

References

Han B, Compton WM, Blanco C, Colpe LJ. Prevalence, Treatment, And Unmet Treatment Needs Of US Adults With Mental Health And Substance Use Disorders. Health Aff Proj Hope. 2017;36(10):1739-1747. doi:10.1377/hlthaff.2017.0584

Acute Stress Disorder

Serves to identify those who are having substantial difficulties soon after a trauma. the diagnostic criteria include the three core problems also seen in PTSD, namely intrusive symptoms: (nightmares flashbacks) avoidance of remainders of the trauma (avoiding thoughts, feelings, conversations, activities, places, people) and hyperarousal (hypervigilance, exaggerated startle response, irritability, poor concentration, motor restlessness).

For acute stress disorder to be diagnosed, the problems noted above must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning or impairs the individual’s ability to pursue some necessary task, such as obtaining necessary assistance or mobilizing personal resources by telling family members about the traumatic experience.

The acute stress disorder symptoms are present for less than a month and emphasize dissociative symptoms (depersonalization and dissociative amnesia).

 

Differential diagnosis: PTSD 

Symptoms also cannot  be the result of substance use or abuse (e.g., alcohol, drugs, & medications ), caused by or an exacerbation of a general or pre-existing medical condition, and cannot be explained by a brief psychotic disorder.

Diagnostic tools:

  • Acute Stress Disorders Interview (Structured Interview).
  • Acute stress Disorder Scale (Self Report).

 

Treatment:       

  • Psychotherapy
  • Cognitive Behavior Therapy
  • Exposure Based Therapies
  • EMDR

Pharmacological:

  • Antidepressants
  • Selective Serotonin Reuptake Inhibitor (SSRI)
  • Benzodiazepines

Bereavement

Bereavement is the state of loss when someone close to an individual has died. Feelings of bereavement can also accompany other losses, such as the decline of one’s health or the health of a close other, or the end of an important relationship.

 

Symptoms

People experience bereavement in various ways, with different thoughts or feelings during the process. People may feel shocked, sad, angry, scared, or anxious. Some feel numb or have a hard time feeling emotions at all. The grieving person may experience feelings of guilt, “I should have…”, “I could have…”, or “I wish I had…” Emotions may be very intense, mood swings. At times, many people even feel relief or peace after a loss. These are all normal reactions to loss. In normal grief, symptoms will occur less often and will feel less severe as time passes (symptoms lessen between six months and two years after the loss).

 

Causes

The reaction to loss is influenced by the circumstances surrounding it and one’s relationship to the deceased.

 

Losing a partner or spouse:

The surviving partner may have to deal with a multitude of decisions regarding funeral arrangements, finances, and more, at what feels like the worst possible time to have to deal with such matters. The bereaved partner may also have to explain the death to children and help them through their grief.

The death of one’s child, regardless of the cause of death or the age of the child, is an emotionally devastating event that can overwhelm a parent. “A child’s death arouses an overwhelming sense of injustice for lost potential, unfulfilled dreams, and senseless suffering. Parents may even feel responsible for the child’s death. They may also feel that they have lost a vital part of their own identity.”

The death of a mother or father can have a deep impact no matter what age a person is when it occurs. The specifics of how one grieves will depend on several personal factors, including one’s relationship with the parent, religious beliefs, previous experience with death, and whether one believes it was “time” for the parent to die. The loss of a parent may also mean the loss of a lifelong friend, counselor, and adviser. Therefore, the bereaved person may suddenly feel very much alone, even with the support of other family and friends.

 

A Loss Due to Suicide

It can be more difficult than dealing with other losses because of the feelings of shame, guilt, rejection that are often experienced. In addition, the stigma attached to deaths by suicide can increase the bereaved person’s sense of isolation and vulnerability.

 

Anticipatory Grief

When someone’s death is expected, those close to that person may experience anticipatory grief. “Like grief that occurs after the death of a loved one,” It can involve symptoms of depression, increased concern for the dying person, and emotional preparation for the death.

 

Treatment

Grief is painful and exhausting. But working through sorrow and allowing themselves to express such feelings can help a bereaved person recover.

Identifying the emotions connected to the loss, helping the bereaved become able to live independently, and illuminating the bereaved person’s ways of coping with the loss.

The American Psychological Association identifies several actions that bereaved people can take, that may help them cope:

  1. talking about the death with others
  2. accepting the normal feelings that come with loss
  3. minding one’s own health and eating well
  4. celebrating the life of the deceased person.

 

Pathological Grief:

Grief can be complicated when the loss is sudden or unexpected. It can often be , frightening when the loss is the result of an accident, disaster, or the result of a crime. Other factors also play a role. A person’s experience of mental illness, lack of personal and social supports, and difficult personal relationships can also affect the impact of grief. These are generally depressed patients who have not shown improvement with antidepressant drugs, and at times present with other psychiatric conditions.

 

Loss occurs in many ways:

  • Real loss when a significant person is lost.
  • Threatened losses are situations where we deal with impending loss.
  • Symbolic losses are the loss of an ideal, belief, way of life, or country.
  • Loss of physical strength, disease, or surgical procedures resulting in amputation are major losses. In pathological mourning “the individual has been unable to come to terms with the loss, either to acknowledge it consciously, or to give up yearning for the person”

 

Clinical Manifestations

These patients had “difficulty in accepting the fact that the lost person was dead”, and they expressed “ideas of guilt and self blame” and a painful feeling of emotional loss and emptiness. Also frequently seen was “hostility towards others associated with the loss”. Hostility is pathological if the person withdraws socially and avoids family members.

 

Characteristics of Those Suffering Pathological Grief

Self detrimental behavior and lost social interaction. lacking initiative and being indecisive and restless. They look to others for direction and want to be included in social activities; when they are, they feel grateful. However, they are apathetic and cannot make up their minds to do anything on their own.

 

Nothing brings satisfaction, and it appears that they carry out many daily routines out of habit. Patients may show self punitive behavior without being aware of guilt feelings. Such people may give away belongings, be lured into foolish financial dealings and act stupidly, damaging their reputations and losing their friends or professional status.

Drug dependency can develop to ward off painful awareness of the loss. In reality the loss is too difficult to accept; a pathological mourner can achieve chemical relief. Individuals suffering pathological grief have a high morbidity rate and increased rates of physical disease and death.

Suicide

If you have thoughts of suicide

At times, people with complicated grief may consider suicide. If you’re thinking about suicide, talk to someone you trust. If you think you may act on suicidal feelings, call 911 or your local emergency services number right away.

Durham Region

Distress Centre Durham

Distress Line: 905-430-2522; 1-800-452-0688

Pride Line: 1-855-87PRIDE (77433)
Business Line: 905-430-3511
Website: www.distresscentredurham.com

Halton Region

Distress Centre Halton

Distress Lines:

Oakville: 905-849-4541

Burlington: 905-681-1488

North Halton: 905-877-1211

Website: www.dchalton.ca

Kingston

Telephone Aid Line Kingston (TALK)

Distress Line: 613-544-1771
Website: http://telephoneaidlinekingston.com/

Lanark, Leeds and Grenville Counties

Developmental Services Lanark Leeds Grenville

Distress Line: 1-800-465-4442
http://www.developmentalservices.com

London Middlesex

CMHA Middlesex

Distress Line: 519-601-8055 / 1-844-360-8055
Reach Out: 519-433-2023 / 1-866-933-2023

Website: https://cmhamiddlesex.ca/programs-services/support-line/

Niagara Region

Distress Centre Niagara

Distress Lines:

St Catharines, Niagara Falls & Area: 905-688-3711
Fort Erie Area: 905-382-0689
Grimsby, West Lincoln: 905-563-6674
Port Colborne, Wainfleet: 905-734-1212

Website: www.distresscentreniagara.com

Northern Ontario

Beendigen Inc (Talk 4 Healing)

Distress Line: 1-855-554-HEAL (4325)
Languages:

  • Offers services in English, Ojibway, Oji-Cree, and Cree

Website: http://www.talk4healing.com/

Nunavut / Kamatsiaqtut

Nunavut Kamatsiaqtut Helpline

Distress Line: 876-979-3333, or 800-265-3333
Website: http://www.nunavuthelpline.ca/

Ottawa & Region

Distress Centre Ottawa & Region

Ottawa Distress Line: 613-238-3311
Outaouais Distress Line: 1-866-676-1080
Champlain Mental Health Crisis Line: 1-866-996-0991
Mental Health Crisis Line Grey & Bruce: 1-877-470-5200
Frontenac Mental Health Crisis Line: 1-855-477-2963

Website: www.dcottawa.on.ca

Québec and Ontario

(French Speaking Only)

Tel-Aide Outaouais:

Distress Line (Gatineau): 819-775-3223
Distress Line (Ottawa): 613-741-6433
Toll Free: 1-800-567-9699
Website: www.telaideoutaouais.ca

Wellington and Dufferin Counties

Torchlight

Distress Line: 5 19-821-3760 or 1-888-821-3760
Crisis Line: 519-821-0140 or 1-877-822-0140
Website: http://torchlightcanada.org/

Windsor & Essex County

The Downtown Mission

Distress Line: 519-256-5000
Website: https://www.downtownmission.com/

Prevention

Getting counseling soon after a loss may help, especially for people at increased risk of developing complicated grief. In addition, caregivers providing end-of-life care for a loved one may benefit from counseling and support to help prepare for death and its emotional aftermath.

  • Talking about your grief and allowing yourself to cry also can help prevent you from getting stuck in your sadness.
  • Support. Family members, friends, social support groups and your faith community are all good options to help you work through your grief.
  • Bereavement counseling. Through early counseling after a loss, you can explore emotions surrounding your loss and learn healthy coping skills. This may help prevent negative thoughts and beliefs from gaining such a strong hold that they’re difficult to overcome.

Treatment

Psychiatrists can help people experiencing long-term disability, depression, or social isolation following the death of a loved one. Depending on the severity of major depression and disability associated with persistent complex bereavement or complicated grief, the psychiatrist may prescribe well-tested medication and/or psychotherapy.  The overall treatment goal is return-to-function following the loss.

Psychotherapy

Complicated Grief Treatment involves learn about complicated grief and how it’s treated, explore topics as grief reactions, complicated grief symptoms, adjusting to your loss and redefining your life goals, exploring and processing thoughts and emotions, improving coping skills, reducing feelings of blame and guilt.

Other types of psychotherapy can help you address other mental health conditions, such as depression or PTSD, which can occur along with complicated grief.

Medications

Antidepressants may be helpful in people who have clinical depression as well as complicated grief.

Post-Traumatic Stress Disorder (PTSD)

Treatment Psychotherapy:

Cognitive Behavior Therapy: involves confronting and modifying the distorted threat appraisal process and irrational beliefs about guilt.

Exposure Therapies: are effective in 60 -70% of patients, although may increase symptoms in some people.

Eye Movement Desensitization and Reprocessing (EMDR): has been shown in metanalysis to have efficacy similar to CBT.

 

Pharmacotherapy:

SSRIs are mainstay of treatment, helping between 40-85% of the people.

TCAs and MAOIs may also be useful, but there is less evidence and greater side effects.

Benzodiazepines: are logic choices for anxiety and insomnia. However, they run risks of causing dependency, increasing the risk of PTSD with early treatment and causing the worsening of the symptoms when withdrawing.

Atypical antipsychotics, anticonvulsants, alpha 2 adrenergic agonists and beta blockers may help with specific symptoms.

 

Prognosis

58% recover within nine months, but 15-25% have a chronic course. outcome depends on initial symptoms severity.

 

Recovery is helped by:

  • good social support
  • absence of maladaptive copying mechanism (avoidance, denial, not talking about problems, thought suppression or rumination.
  • No further traumas, including secondary problems like physical health, disability, disfigurement, disrupted relationships, economic problems, litigation.

Reference: Oxford American Handbook of Psychiatry, American Psychiatry Association

PTSD is present in about 7.8 % of the population. The rates depend on the type of trauma. PTSD affects women >men = 2:1. PTSD sufferers are more likely to have a lower socioeconomic status, live in an inner-city or be combat veterans.

PTSD is a devastating mental illness that causes marked impairment. it develops in the aftermath of a trauma, which requires an actual or threatened death or serious injury or even just witnessed — an extremely traumatic, tragic, or terrifying event as well as a severe emotional response.

PTSD incorporates the same clusters of symptoms seen in acute stress disorder, namely intrusive recollections (nightmares -flashbacks), avoidance (emotional numbing and dissociative symptoms) and hyperarousal.

Co-morbidity: 84 % have another lifetime diagnosis. Most common Major depressive disorder, alcohol/drugs abuse or dependence, social phobia, and agoraphobia.

Diagnosis:

  • PTSD checklist
  • impact of events scale
  • Davidson trauma scale
  • Clinician administered PTSD Scale
  • Structured Interview for PTSD

Differential diagnosis:

  • Acute Stress Disorder
  • Personality disorder
  • Major depression and dysthymia
  • Complicated grief
  • Substance abuse
  • Psychosis

Gambling Disorders

Gambling disorder: is the uncontrollable urge to keep gambling despite the toll it takes on your life (relationships, work, school, health, finances, legal “theft or fraud to support your addiction”, suicide, suicide attempts or suicidal thoughts). Gambling means that you are willing to risk something you value in the hope of getting something of even greater value.

Gambling can stimulate the brain’s reward system much like drugs or alcohol can, leading to addiction. Compulsive gambling is a serious condition that can destroy lives. Although treating compulsive gambling can be challenging, many people who struggle with compulsive gambling have found help through professional treatment.

 

What Activities Are Considered Gambling?

Gambling has grown rapidly since the 1990s and is becoming a more and more popular leisure activity.

 

There are various ways to gamble, including:

  • casino games
  • bingo
  • keno
  • slot machines
  • lottery tickets
  • scratch, Nevada or pull-tab tickets
  • betting on card games, mah-jong, dominoes, horse racing, sports or games of skill
  • Internet gambling
  • stock market speculation.

 

Concepts:

 

Casual social gambling: Most people gamble casually, buying the occasional raffle or lottery ticket or occasionally visiting a casino for entertainment.

Serious social gambling: These people play regularly. It is their main form of entertainment, but it does not come before family and work.

Harmful involvement: These people are experiencing difficulties in their personal, work and social relationships.

Pathological gambling: For a small but significant number of people, gambling seriously harms all aspects of their lives. People with gambling problems this severe are unable to control the urge to gamble, despite the harm it causes. They are more likely to use gambling to escape from problems and to get relief from anxiety.

Problem Gambling:

On average, 3.5% of Canadian adults are experiencing moderate to severe gambling problems. The figure varies among the provinces as the table to the right shows:

Saskatchewan

Alberta

British Columbia

Manitoba

Ontario

Newfoundland

New Brunswick

Nova Scotia

Quebec

Prince Edward Island

3.2%

3.4%

3.4%

3.4%

4.6%

5.2%

5.9%

2.1%

1.7%

1.6%

There are common behavioral, emotional, financial and health signs of problem gambling.

Behavioural signs

  • thinks about gambling all the time
  • steals money to gamble
  • is gone for long periods of time.
  • has conflicts with other people over money
  • stops doing things individual previously enjoyed
  • they start missing family events and neglecting a child’s basic care
  • changes patterns of sleep, eating or sex
  • ignores self-care, work, school or family tasks
  • uses alcohol or other drugs more often

 

Emotional signs

  • withdraws from family and friends
  • has difficulty paying attention
  • has mood swings and anger
  • complains of restlessness
  • seems depressed or suicidal.

Financial signs

  • borrows money or asks for salary advances
  • takes a second job without a change in finances
  • cashes in savings accounts, RRSPs or insurance plans
  • has family members who complain that valuables and appliances are disappearing or that money is missing from a bank account or wallet.

 

Health signs

  • headaches
  • gastrointestinal problems
  • difficulty sleeping
  • overeating or loss of appetite.

Causes

Compulsive gambling may result from a combination of biological, genetic and environmental factors.

 

Risk factors

  • Mental health disorders. ADHD, Anxiety. Depression, Personality, Substance use, and bipolar disorders.
  • younger and middle-aged people. Gambling during childhood or the teenage years increases the risk of developing compulsive gambling.
  • more common in men than women.
  • Family influence.the chances are greater
  • Medications used to treat Parkinson’s disease and restless legs syndrome.dopamine agonists have a rare side effect that may result in compulsive behaviors.
  • Certain personality characteristics.Being highly competitive, a workaholic, impulsive, restless or easily bored may increase your risk of compulsive gambling.
  • Have an early big win (leading to false expectation of future wins)
  • Have easy access to their preferred form of gambling
  • Hold mistaken beliefs about the odds of winning
  • Have had a recent divorce, job loss, retirement or death of a loved on
  • Tie their self-esteem to gambling wins or losses

The more factors that apply, the more likely a person is to develop a gambling problem.

 

Prevention

Although there is no proven way to prevent a gambling problem, educational programs that target individuals and groups at increased risk may be helpful. If you have risk factors for compulsive gambling, consider avoiding gambling in any form, people who gamble and places where gambling occurs. Get treatment at the earliest sign of a problem to help prevent gambling from becoming worse.

 

Diagnosis

To evaluate your problem with gambling, your doctor or mental health professional will likely:

  • Ask questions related to your gambling habits.
  • Review your medical information.
  • Do a psychiatric assessment. Depending on your signs and symptoms, you may be evaluated for mental health disorders that are sometimes related to excessive gambling.
  • Use the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).The DSM-5, published by the American Psychiatric Association, lists criteria for the diagnosis of gambling disorder.

 

Treatment

A major component of treatment is working on acknowledging that you are a compulsive gambler. If your family or your employer pressured you into therapy, you may find yourself resisting treatment. But treating a gambling problem can help you regain a sense of control and perhaps help heal damaged relationships or finances.

 

Therapy

Behavior therapy (uses systematic exposure to the behavior you want to unlearn and teaches you skills to reduce your urge to gamble) or cognitive behavioral therapy (focuses on identifying unhealthy, irrational and negative beliefs and replacing them with healthy, positive ones). Family therapy may also be beneficial.

 

Medications

Anti-depressants and mood stabilizers may help problems that often go along with compulsive gambling such as depression, OCD or ADHD. Some antidepressants may be effective in reducing gambling behavior. Medications called narcotic antagonists, are useful in treating substance abuse, and may help treat compulsive gambling.

 

Self-help groups

Some people find that talking with others who have a gambling problem may be a helpful part of treatment such as Gambler’s Anonymous and other resources.

Treatment for compulsive gambling may involve an outpatient program, inpatient program or a residential treatment program, depending on your needs and resources. Treatment for substance abuse, depression, anxiety or any other mental health disorder may be part of your treatment plan for compulsive gambling. In addition, credit and debt counselling services must be included to fix a financial situation, healing family relations and restoring trust between partners.

***Adapted from CAMH and Mayo clinic.