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Co-Occurring Disorders Current Evidence Based Treatments
Dr. Dawn-Elise Snipes
~	Review current research on evidence based and promising practices for Co-Occurring Disorders
~	Most people with addictions also have other co-occurring issues
~	Mood disorders
~	Pain
~	Effective treatment requires concurrent treatment of all presenting biopsychosocial issues
~	Cognitive Behavioral Therapy 
~	Addiction
~	Anxiety
~	Dementia
~	Depression
~	Eating Disorders
~	Insomnia
~	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
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.
~	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.
~	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

~	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 
~	CBT and Mindfulness are still the gold standard to address the cognitive and HPA-Axis aspects of a variety of disorders