Treatment approaches for dual diagnosis clients in England

Narratives of recovery in people with coexisting mental health and alcohol misuse difficulties

Purpose

Existing literature has examined what recovery means to people with co-occurring difficulties, but does little to examine experiences of recovery as a process. The purpose of this paper is to use a narrative approach to explore the process of recovery as an individual journey in a social context. It focuses on people who use alcohol in order to explore the impact of alcohol’s specific cultural meanings on the recovery journey.

Design/methodology/approach

Ten interviews with people with coexisting mental health and alcohol misuse difficulties were conducted, audio-recorded, and transcribed. The transcriptions were analysed using narrative analysis.

Findings

Most participants’ narratives shared a three-part structure, from a traumatic past, through an episode of change, to an ongoing recovery phase. Change and recovery were attributed to several factors including flexible and practical support from services, therapeutic relationships with key professionals, and peer support. Some participants redefined themselves and their alcohol use in relation to ideas of what it is to be “normal”.

Research limitations/implications

The research excluded people who recover outside of services, replicating a shortcoming of much research in this area.

Practical implications

The value placed on professionals having specialised therapeutic skills in working with trauma highlights the need for training in this area. The role for practical and material support underlines the importance of multi-agency working.

Originality/value

The narrative methodology enables the study to draw links between personal stories of recovery and wider social influences, allowing comment on the implications for services. Further, the experiences of people with coexisting mental health and alcohol misuse difficulties have rarely been studied apart from the dual diagnosis population in general, so this paper is able to investigate the specific challenges for this population.

Delivery of a mainstreaming treatment model towards co-existing difficulties: a brief exploration of practitioners’ understanding, views and reported experiences

Purpose

– The purpose of this paper is to describe the delivery of a mainstreaming model within a public sector, mental health (National Health Service (NHS)) organisation. The model promotes the inclusivity of a spectrum of presentations from co-existing moderate anxiety and depression to severe mental disorder (psychosis) and problematic substance and alcohol use.

Design/methodology/approach

– This paper introduces the delivery of three collective approaches, termed the “three essential elements” to support a mainstreaming treatment model, facilitated by a “Dual Diagnosis Lead”. The model encompasses; a “direct access” referral pathway, joint collaboration with practitioners and the delivery of a “Dual Diagnosis” training programme. An independent evaluation was commissioned to explore eight mental health and substance misuse practitioners’ views and experiences in relation to the impact of the mainstreaming model. This paper also considers feedback from 230 course participants attending a one day “Dual Diagnosis” training programme.

Findings

– This paper suggests that practitioners may benefit from the implementation of the mainstreaming approach and the delivery of this approach could be moving “Dual Diagnosis” interventions closer to mainstream practice.

Research limitations/implications

– The limitations of the mainstreaming model are acknowledged in relation to the generalisation of practitioners’ views and reported experiences.

Originality/value

– This paper offers a description of the delivery of a mainstreaming model involving the “three essential elements”. The model provides a useful insight and demonstrates the possibilities which may be achieved when attempting to implement a mainstreaming treatment approach within mainstream mental health and drug and alcohol services.

A multi-agency evaluation of the Leeds Dual Diagnosis care co-ordination protocol

Purpose

– The purpose of this paper is to demonstrate the learning from the multi-agency evaluation of the Leeds Dual Diagnosis Care co-ordination protocol undertaken by the Leeds Dual Diagnosis (DD) Project in 2013. The evaluation aimed to identify the prevalence of people with DD accessing network member services, and to identify the standard of care network members provided for people with DD in relation to the Leeds Care Co-ordination Protocol.

Design/methodology/approach

– The evaluation adopted a service evaluation methodology and included features of real world research. Two standardised self-completion questionnaires were administered using Survey Monkey™ software.

Findings

– The majority of service could provide prevalence data however the quality of data provided was significantly impacted by the limitations of client management systems. Completion of specific DD training beyond basic awareness was generally low and many participants were confused about the different levels of training available. Standards of care varied, a substantial amount of joint working was taking place via informal pathways which relied on established relationships and trust between practitioners and services. Jointing working was often informal when people were not under the Care Programme Approach.

Research limitations/implications

– Due of the methodological choices the evaluation cannot be considered impartial. The prevalence data gathered lacks robustness and does not reflect the number of people who meet clinical threshold for DD as valid screening tools were not used by all services. The standards of care identified only reflect practitioner's personal views and do not provide a definitive answer to the standard of care being delivered. The response rate in relation to standards of care was low with large amounts of missing data negatively impacting the external validity of data gathered.

Practical implications

– The completion of this evaluation demonstrates that it is extremely challenging to undertake a multi-agency evaluation with limited resources. It has highlighted key challenges and areas for future development locally in relation to DD. The themes explored are likely to be of interest to commissioners, service managers, DD consultant nurses and anyone involved in the strategic development of DD.

Originality/value

– The evaluation has generated information which is of practical significance to local commissioners and Leeds DD Network Members. The knowledge and learning from this evaluation has subsequently been used by the Leeds DD Strategy Group to inform the new action plan for the DD Project, the re-commissioning of substance misuse services and the new mental health framework being developed for Leeds.

Severe and enduring mental health problems within an established substance misuse treatment partnership

Aims and method The study reports findings of an investigation into the presence of severe and enduring mental health problems within the four statutory and non-statutory teams of an established substance misuse treatment partnership.

Results Of a total of 772 clients in the four teams surveyed, 69 (8.9%) were identified as having severe and enduring mental health problems and problem substance use in the past 12 months. Alcohol was the most prevalent substance used by this predominantly male group. Different rates were found across the four teams, with higher numbers in the non-statutory teams. The clients displayed significant levels of self-harm and suicide risk and were responsible for 131 acute service contacts over the past 12 months.

Clinical implications Clients with severe and enduring mental health problems engaged with substance misuse services display high levels of complex need. It is important to identify the best and most effective service response to this group.

Convergent validity of the ASAM criteria in co-occurring disorders

OBJECTIVE

The complexity of substance use and psychiatric disorders demands thorough assessment of patients for integrated services. We tested the convergent validity of the software version of the American Society of Addiction Medicine (ASAM) second edition-revised criteria for patient placement by examining the software's ability to discriminate based on a variety of demographic and clinical factors.

METHODS

This prospective naturalistic multi-site study examined the software's assignment of patients to three types of treatment (addiction only services, dual diagnosis capable, and dual diagnosis enhanced) and whether these assignments indicated an ability to discriminate between patients with and without dual diagnosis based on clinical characteristics and severity. Ten addiction treatment clinics spanning three counties participated, and both patients and ASAM assessors were kept blind to the ASAM recommendation. Patients were assigned to their respective treatment options based on routine assessment by clinicians at intake, which they had in addition to the ASAM interview. Three months after treatment initiation a follow-up interview with ASAM was conducted.

RESULTS

There were 261 patients in the study, 96 (36.7%) were assigned to addiction only services, 42 (16.1%) to dual diagnosis capable, and 123 (47.1%) to dual diagnosis enhanced. Patients assigned to the two dual diagnosis groups were significantly more likely to be younger and have fewer years of work than other patients. There were significant differences in history of inpatient and outpatient psychiatric treatment across groups. For example, a larger percentage of those in addiction only services had never been in inpatient treatment, while more of those in the two dual diagnosis groups had three or more inpatient stays. Despite similar alcohol and drug severity scores, patients recommended by the software for dual diagnosis enhanced programs showed a gradient of significantly higher psychiatric (p <.001), legal (p <.04), and family (p <.001) Addiction Severity Index composite scores at baseline than patients in dual diagnosis capable and addiction only services.

CONCLUSIONS

RESULTS show a high prevalence of co-occurring program recommendations with statistically significant and clinically meaningful differences between patient groups. The convergent validity of the revised version of ASAM Criteria Software is supported by these results.

Implementation and evaluation of brief depression and anxiety screening in clients contacting a drug and alcohol service

INTRODUCTION AND AIMS

High prevalence mental health (HPMH) comorbidity is common in clients seeking alcohol and other drug (AOD) treatment yet can remain undetected. Although research has reported on the introduction of screening into AOD services, little research has reported on the processes surrounding the introduction or evaluated its effectiveness. This study reports on the implementation and evaluation of brief anxiety and depression screening within a specialised, publicly funded AOD service in South-East Victoria.

DESIGN AND METHODS

Study one examined the implementation of standardised HPMH screening with 114 adult clients (Mean age=35.49, SD=9.53; 64% male) telephoning an AOD service over a 5week period. Measures included severity of HPMH problems, AOD use, care plans and referrals. Study two used semistructured interviews with nine staff/managers to evaluate the effectiveness of screening and its impact on service delivery.

RESULTS

Ninety-four per cent of clients were identified at risk of anxiety or depression. Most care plans incorporated counselling, and concurrent referrals commonly involved a general practitioner. Staff and management found systematic screening increased identification and understanding of comorbid issues and enhanced client interaction but impacted on resource requirements.

DISCUSSION AND CONCLUSIONS

Most AOD treatment seekers were identified HPMH comorbid and care plans generally included counselling. Adjunctive referrals were more common for severely depressed clients. Screening was effective and enhanced client rapport. Evaluations revealed low confidence in treating HPMH issues in-house. Training may increase worker confidence in managing mental health interventions with subclinical cases, enhancing services' ability to move towards dual diagnosis capability.