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Integrative Management of Complex Patients with High Comorbidity

  • James H. Lake
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Abstract

Common patterns of comorbidity in mental illness are described and mainstream approaches to managing complex cases with high comorbidity are reviewed. Depressed mood, anxiety, psychosis, bipolar disorder, post-traumatic stress disorder (PTSD), and other serious mental health problems often occur together (i.e., “are comorbid”) with substance abuse and medical problems. Mental health problems are also frequently comorbid with medical disorders in all age groups and may significantly impact the clinical course of medical illness and response to treatment. Complex presentations involving two or more serious mental health problems and comorbid substance abuse or a medical problem are often poorly responsive to pharmaceuticals and other Western medical treatments. Managing complex cases calls for multitiered treatment planning incorporating evidence from a wide range of Western medical and CAM modalities. There is currently no agreement within Western medicine or non-Western systems of medicine on how to manage complex cases with high comorbidity. Complex patients with serious mental health problems and comorbid substance abuse or medical problems respond better and more rapidly when managed by a team of practitioners using a collaborative care model. The methodology developed in previous chapters is expanded to address complex cases with high comorbidity including co-occurring psychiatric disorders, substance abuse and medical problems. Important clinical considerations involved in managing complex patients are reviewed. The goal of parsimony is to identify the simplest care plan that adequately addresses all medical, mental health and substance use problem(s). The uses of the evidence tables and algorithms for planning integrative mental health care involving highly comorbid cases are described. The chapter concludes with a detailed case vignette that includes the rationale for recommendations made during different phases of treatment.

Keywords

Integrative management of complex patients Patterns of comorbidity in mental illness Methodology for integrative management of complex cases 

References

  1. Aase, D. M., Jason, L. A., & Robinson, W. L. (2008). 12-step participation among dually-diagnosed individuals: A review of individual and contextual factors. Clinical Psychology Review, 28, 1235–1248.CrossRefGoogle Scholar
  2. Baker, A. L., Hides, L., & Lubman, D. I. (2010). Treatment of cannabis use among people with psychotic or depressive disorders: A systematic review. Journal of Clinical Psychiatry, 71, 247–254.CrossRefGoogle Scholar
  3. Barrowclough, C., Haddock, G., Wykes, T., Beardmore, R., Conrod, P., Craig, T., et al. (2010). Integrated motivational interviewing and cognitive behavioural therapy for people with psychosis and comorbid substance misuse: Randomized controlled trial. British Medical Journal, 341, c6325.CrossRefGoogle Scholar
  4. Bijl, R., de Graaf, R., Hiripi, E., Kessler, R., Kohn, R., Offord, D. R., et al. (2003). The prevalence of treated and untreated mental disorders in five countries. Health Affairs, 22(3), 122–133. Chevy Chase.CrossRefGoogle Scholar
  5. Bottlender, M., Köhler, J., & Soyka, M. (2006). [The effectiveness of psychosocial treatment approaches for alcohol dependence—A review]. [Article in German]. Fortschritte der Neurologie-Psychiatrie, 74(1), 19–31.CrossRefGoogle Scholar
  6. Bowden, C., Lecrubier, Y., Bauer, M., Goodwin, G., Greil, W., Sachs, G., et al. (2000). Maintenance therapies for classic and other forms of bipolar disorder. Journal of Affective Disorders, 59(Suppl 1), S57–S67.CrossRefGoogle Scholar
  7. Brown, R. T., Daly, B. P., & Rickel, A. U. (2007). Chronic illness in children and adolescents. Cambridge, MA: Hogrefe & Huber.Google Scholar
  8. Chandwani, K. D., Ryan, J. L., Peppone, L. J., Janelsins, M. M., Sprod, L. K., Devine, K., et al. (2012). Cancer-related stress and complementary and alternative medicine: A review. Evidence Based Complementary and Alternative Medicine, 2012, 979213.CrossRefGoogle Scholar
  9. Ciaramella, A., & Spiegel, D. (2012). Chapter 33: Psychiatric disorders among cancer patients. In T. E. Schlaepfer & C. B. Nemeroff (Eds.), Handbook of clinical neurology, Vol. 106 (3rd series): Neurobiology of psychiatric disorders. Amsterdam: Elsevier B.V..Google Scholar
  10. Cooper, D., Moisan, J., & Gregoire, J. P. (2007). Adherence to atypical antipsychotic treatment among newly treated patients: A population-based study in schizophrenia. Journal of Clinical Psychiatry, 68(6), 818–825.CrossRefGoogle Scholar
  11. Daley, D. C., & Moss, H. M. (2002). Dual disorders: Counseling clients with chemical dependency and mental illness (3rd ed.). Center City, MN: Hazelden.Google Scholar
  12. Daley, D. C., & Zuckoff, A. (1999). Improving treatment compliance: Counseling and systems strategies for substance abuse and dual disorders. Center City, MN: Hazelden.Google Scholar
  13. David, A., & Kopelman, M. (2009). Chapter 2: Neuropsychology in relation to psychiatry. In A. S. David, S. Fleminger, M. D. Kopelman, S. Lovestone, & J. D. C. Mellers (Eds.), Lishman’s Organic psychiatry: A textbook of neuropsychiatry (4th ed.). Oxford: Wiley-Blackwell.CrossRefGoogle Scholar
  14. Fals-Stewart, W., & Schafer, J. (1992). The treatment of substance abusers diagnosed with obsessive-compulsive disorder: An outcome study. Journal of Substance Abuse Treatment, 9(4), 365–370.CrossRefGoogle Scholar
  15. Forrest, K., Becker, D., Kuller, L., Wolfson, S., & Orchard, T. (2000). Are predictors of coronary heart disease and lower-extremity arterial disease in type 1 diabetes the same? A prospective study. Atherosclerosis, 148(1), 159–169.CrossRefGoogle Scholar
  16. Frank, E., Swartz, H., & Kupfer, D. (2000). Interpersonal and social rhythm therapy: Managing the chaos of bipolar disorder. Biological Psychiatry, 48(6), 593–604.CrossRefGoogle Scholar
  17. Gao, K., Chan, P. K., Verduin, M. L., Kemp, D. E., Tolliver, B. K., Ganocy, S. J., et al. (2010). Independent predictors for lifetime and recent substance use disorders in patients with rapid-cycling bipolar disorder: Focus on anxiety disorders. American Journal of Addiction, 19(5), 440–449.CrossRefGoogle Scholar
  18. Grassi, L., Caruso, R., Hammelef, K., Nanni, M., & Riba, M. (2014, February). Efficacy and safety of pharmacotherapy in cancer-related psychiatric disorders across the trajectory of cancer care: A review. International Review of Psychiatry, 26(1), 44–62.Google Scholar
  19. Green, B., Young, R., & Kavanagh, D. (2005). Cannabis use and misuse prevalence among people with psychosis. British Journal of Psychiatry, 187, 306–313.CrossRefGoogle Scholar
  20. Grella, C. E., Hser, Y. I., Joshi, V., & Rounds-Bryant, J. (2001). Drug treatment outcomes for adolescents with comorbid mental and substance use disorders. Journal of Nervous and Mental Disease, 189(6), 384–392.CrossRefGoogle Scholar
  21. Hofmann, S. G., & Smits, J. A. (2008). Cognitive-behavioral therapy for adult anxiety disorders: A meta-analysis of randomized placebo-controlled trials. Journal of Clinical Psychiatry, 69, 621–632.CrossRefGoogle Scholar
  22. Huang, Y., Kotov, R., deGirolamo, G., Preti, A., Angermayer, M., Beniet, C., et al. (2009). DSM-IV personality disorders in the WHO World Mental Health Surveys. British Journal of Psychiatry, 195(1), 46–53.CrossRefGoogle Scholar
  23. Hysing, M., Elgen, I., Gillberg, C., Lie, S. A., & Lundervold, A. J. (2007). Chronic physical illness and mental health in children. Results from a large-scale population study. Journal of Child Psychology and Psychiatry, 48(8), 785–792.CrossRefGoogle Scholar
  24. Immelt, S. (2006). Psychological adjustment in young children with chronic medical conditions. Journal of Pediatric Nursing, 21(5), 362–377.CrossRefGoogle Scholar
  25. Jacobsen, L. K., Southwick, S. M., & Kosten, T. R. (2001). Substance use disorders in patients with posttraumatic stress disorder: A review of the literature. American Journal of Psychiatry, 158, 1184–1190.CrossRefGoogle Scholar
  26. Kelly, T. M., Daley, D. C., & Douaihy, A. B. (2012). Treatment of substance abusing patients with comorbidpsychiatric disorders. Addictive Behaviors, (37), 11–24. [PubMed: 21981788].Google Scholar
  27. Kendler, K. S., Aggen, S. H., Knudsen, G. P., Roysamb, E., Neale, M. C., & Reichborn-Kjennerud, T. (2011). The structure of genetic and environmental risk factors for syndromal and subsyndromal common DSM-IV Axis I and Axis II disorders. American Journal of Psychiatry, 168(1), 29–39.CrossRefGoogle Scholar
  28. Kessler, R. C. (2004). The epidemiology of dual diagnosis. Biological Psychiatry, 56, 730–737.CrossRefGoogle Scholar
  29. Kessler, R., Chiu, W., & Demler, M. (2005). Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 617–627.CrossRefGoogle Scholar
  30. Khoury, L., Tang, Y. L., Bradley, B., Cubells, J. F., & Ressler, K. J. (2010). Substance use, childhood traumatic experience, and Posttraumatic Stress Disorder in an urban civilian population. Depression and Anxiety, 27(12), 1077–1086.CrossRefGoogle Scholar
  31. Knopman, D., Boland, L., Mosley, T., Howard, G., Liao, D., Szklo, M., et al. (2001). Atherosclerosis Risk in Communities (ARIC) Study Investigators. Cardiovascular risk factors and cognitive decline in middle-aged adults. Neurology, 56(1), 42–48.CrossRefGoogle Scholar
  32. Krueger, R., Chentsova-Dutton, Y., Markon, K., Goldberg, D., & Ormel, J. (2003). A cross-cultural study of the structure of comorbidity among common psychopathological syndromes in the general health care setting. Journal of Abnormal Psychology, 112(3), 437–447.CrossRefGoogle Scholar
  33. Lenzenweger, M. F., Lane, M. C., Loranger, A. W., & Kessler, R. C. (2007). DSM-IV personality disorders in the National Comorbidity Survey Replication. Biological Psychiatry, 62(6), 553–564.CrossRefGoogle Scholar
  34. Lexicon. (2017, June 16). What do we mean by “behavioral health integrated with primary care”? [Internet]. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from http://integrationacademy.ahrq.gov/lexicon
  35. Martinotti, G., Carli, V., Tedeschi, D., Di Giannantonio, M., Roy, A., Janiri, L., et al. (2009). Mono- and polysubstance dependent subjects differ on social factors, childhood trauma, personality, suicidal behaviour, and comorbid Axis I diagnoses. Addictive Behaviors, 34(9), 790–793.CrossRefGoogle Scholar
  36. Miklowitz, D. J., Otto, M. W., Frank, E., Reilly-Harrington, N. A., Kogan, J. N., Sachs, G. S., et al. (2007). Intensive psychosocial intervention enhances functioning in patients with bipolar depression: Results from a 9-month randomized controlled trial. American Journal of Psychiatry, 164, 1340–1347.CrossRefGoogle Scholar
  37. Moak, D. H., Anton, R. F., Latham, P. K., Voronin, K. E., Waid, R. L., & Durazo-Arvizu, R. (2003). Sertraline and cognitive behavioral therapy for depressed alcoholics: Results of a placebo-controlled trial. Journal of Clinical Psychopharmacology, 23, 553–562.CrossRefGoogle Scholar
  38. Mueser, K. T., Noordsy, D. L., Drake, R. E., & Fox, L. (2003). Integrated treatment for dual disorders: A guide to effective practice. New York, NY: Guilford Press.Google Scholar
  39. Murthy, P., & Chand, P. (2012). Treatment of dual diagnosis disorders. Current Opinion in Psychiatry, 25(3), 194–200.CrossRefGoogle Scholar
  40. Musselman, D., Betan, E., Larsen, H., & Phillips, L. (2003). Relationship of depression to diabetes types 1 and 2: Epidemiology, biology, and treatment. Biological Psychiatry, 54(3), 317–329.CrossRefGoogle Scholar
  41. National Survey of Children’s Health. (2007). Retrieved from https://pdfs.semanticscholar.org/2810/0849f76eca44b8685af6cb2ce6709c3b30eb.pdf
  42. Ortega, A. N., Huertas, S. E., Canino, G., Ramirez, R., & Rubio-Stipec, M. (2002). Childhood asthma, chronic illness and psychiatric disorders. The Journal of Nervous and Mental Disease, 190(5), 275–281.CrossRefGoogle Scholar
  43. Otto, M. W., Smits, J. A., & Reese, H. E. (2004). Cognitive-behavioral therapy for the treatment of anxiety disorders. Journal of Clinical Psychiatry, 65, 34–41.PubMedGoogle Scholar
  44. Raic, M. (2017). Depression and heart diseases: Leading health problems. Psychiatria Danubina, 29(Suppl. 4), 770–777.PubMedGoogle Scholar
  45. Randall, C. L., Thomas, S., & Thevos, A. K. (2001). Concurrent alcoholism and social anxiety disorder: A first step toward developing effective treatments. Alcoholism, Clinical and Experimental Research, 25, 210–220.CrossRefGoogle Scholar
  46. Reeve, J., Blakeman, T., Freeman, G. K., Green, L. A., James, P. A., Lucassen, P., et al. (2013). Generalist solutions to complex problems: Generating practice-based evidence-the example of managing multimorbidity. BMC Family Practice, 14, 112–120.CrossRefGoogle Scholar
  47. Schafer, I., & Najavits, L. M. (2007). Clinical challenges in the treatment of patients with posttraumatic stress disorder and substance abuse. Current Opinion on Psychiatry, 20, 614–618.CrossRefGoogle Scholar
  48. Schneier, F. R., Foose, T. E., Hasin, D. S., Heimberg, R. G., Liu, S. M., Grant, B. F., et al. (2010). Social anxiety disorder and alcohol use disorder comorbidity in the National Epidemiologic Survey on Alcohol and Related Conditions. Psychological Medicine, 40, 977–988.CrossRefGoogle Scholar
  49. Sheidow, A. J., McCart, M., Zajac, K., & Davis, M. (2012). Prevalence and impact of substance use among emerging adults with serious mental health conditions. Psychiatric Rehabilitation Journal, 35(3), 235–243.CrossRefGoogle Scholar
  50. Stewart, R. E., & Chambless, D. L. (2009). Cognitive-behavioral therapy for adult anxiety disorders in clinical practice: A meta-analysis of effectiveness studies. Journal of Consulting and Clinical Psychology, 77, 595–606.CrossRefGoogle Scholar
  51. Strachan, M., Frier, B., & Deary, I. (2003). Type 2 diabetes and cognitive impairment. Diabetic Medicine, 20(1), 1–2.CrossRefGoogle Scholar
  52. Swendsen, J., Conway, K. P., Degenhardt, L., Glantz, M., Jin, R., Merikangas, K. R., et al. (2010). Mental disorders as risk factors for substance use, abuse and dependence: Results from the 10-year follow-up of the National Comorbidity Survey. Addiction, 105(6), 1117–1128.CrossRefGoogle Scholar
  53. Testa, A., Giannuzzi, R., Sollazzo, F., Petrongolo, L., & Bernardini, L. (2013). Psychiatric emergencies (part II): Psychiatric disorders coexisting with organic diseases. European Review for Medical and Pharmacological Sciences, 17(Suppl. 1), 65–85.PubMedGoogle Scholar
  54. Tiet, Q. Q., & Mausbach, B. (2007). Treatments for patients with dual diagnosis: A review. Alcoholism: Clinical and Experimental Research, 31, 513–536.Google Scholar
  55. van Oudheusden, L., Meynen, G., & van Balkom, A. (2015). [Psychiatric comorbidity: Theoretical and clinical dilemmas]. Tijdschrift voor Psychiatrie, 57(9), 664–671.Google Scholar
  56. Weiss, R. D., Griffin, M. L., Jaffee, W. B., Bender, R. E., Graff, F. S., Gallop, R. J., et al. (2009). A “community friendly” version of integrated group therapy for patients with bipolar disorder and substance dependence: A randomized controlled trial. Drug and Alcohol Dependence, 104(3), 212–219.CrossRefGoogle Scholar
  57. Weiss, R. D., Kolodziej, M., Griffin, M. L., Najavits, L. M., Jacobson, L. M., & Greenfield, S. F. (2004). Substance use and perceived symptom improvement among patients with bipolar disorder and substance dependence. Journal of Affective Disorders, 79(1–3), 279–283.CrossRefGoogle Scholar
  58. Wesa, K., & Culliton, P. (2004). Recommendations and guidelines regarding the preferred research protocol for investigating the impact of an optimal healing environment on patients with substance abuse. Journal of Alternative and Complementary Medicine, 10(Suppl. 1), S193–S199.CrossRefGoogle Scholar
  59. Williams, L. B., Laffelt, L. M., & Hood, K. K. (2009). Diabetes-specific family conflict and psychological distress in paediatric type 1 diabetes. Diabetic Medicine, 26(9), 908–914.CrossRefGoogle Scholar
  60. Wu, N. S., Schairer, L. C., Dellor, E., & Grella, C. (2010). Childhood trauma and health outcomes in adults with comorbid substance abuse and mental health disorders. Addictive Behaviors, 35(1), 68–71.CrossRefGoogle Scholar
  61. Yohannes, A., Willgoss, T., Baldwin, R., & Connolly, M. (2010, December). Depression and anxiety in chronic heart failure and chronic obstructive pulmonary disease: Prevalence, relevance, clinical implications and management principles. International Journal of Geriatric Psychiatry, 25(12), 1209–1221.Google Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • James H. Lake
    • 1
  1. 1.Center for Integrative MedicineUniversity of Arizona College of MedicineTucsonUSA

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