Co‐existing mental health and substance use and alcohol difficulties – why do we persist with the term “dual diagnosis” within mental health services?

DRD4, DRD2, DAT1, and ANKK1 Genes Polymorphisms in Patients with Dual Diagnosis of Polysubstance Addictions

Background: Approximately 25–50% of people diagnosed with substance use disorder experience psychiatric disorders, and this percentage is even higher if subclinical psychopathological symptomatology is taken into consideration. ”Dual diagnosis” implies the comorbidity of two disorders (mental disorder and addiction), but in a clinical setting, numerous dual diagnoses involve multiple addictions (polysubstance use means the concurrent use of more than one psychoactive substance). Clinical observations and epidemiological studies showed that the use of stimulants in combination with other substances results in additional risks. Apart from the clinical significance of the specificity of stimulants used in combination with other substances, only non-exhaustive research on the specificity of this comorbidity has been performed to date. The aim of the study was to analyze polymorphisms of the genes (DRD4 VNTR in exon III Ex3, DRD2 rs1076560, rs1800498, rs1079597, rs6276, as well as in the PROM promoter region (rs1799732, ANKK1 Tag1A rs1800497, DAT) in a group of patients diagnosed with polysubstance use disorder, including addiction to stimulants, and the co-occurrence of specific mental disorders in a group of patients diagnosed with polysubstance use disorder, including addiction to stimulants, compared to the group of patients diagnosed with polysubstance use disorder. Methods: The study group consisted of 601 male volunteers with psychoactive substance dependence (n = 300) and non-dependent controls (n = 301). The genomic DNA was extracted from venous blood using standard procedures. Genotyping was conducted with the real-time PCR method. All computations were performed using STATISTICA 13. Results: Psychotic disorders were significantly more common in the group of males with polysubstance addiction, including addiction to stimulants, compared to the group of males with polysubstance addiction without addiction to stimulants. In our own research, different statistical significances were found in the frequency of the DRD4 Ex3 gene polymorphism: s/s was more common in the study group. Psychotic disorders were more common in people addicted to stimulants compared to people addicted to other substances. Conclusions: In our study, psychotic disorders occurred more frequently in the study group of patients with polysubstance addiction, including addiction to stimulants, compared to the control group of patients with polysubstance addiction, but with no addiction to stimulants. Different statistical significances were found in the frequency of the DRD4 Ex3 gene polymorphism: s/s was more common in the study group, while the l/l genotype was less frequent in the study group. In DRD2 PROM rs 1799732, the del allele occurred more often than the ins allele in the study group. In the DRD4 Ex3 gene polymorphism, the s allele was more common in the study group, and the l allele was less frequent. In the DRD4 Ex3 gene polymorphism for the s/s genotype, psychotic disorders and generalized anxiety were more common, while for the s/l and l/l genotype, they were less frequent. The DRD4 Ex3 polymorphism s alleles were more common for depressive episode, dysthymia, and psychotic disorders as well as generalized anxiety disorder. We see a clear genetic aspect here. However, we want to be careful and draw no definite conclusions.

Care planning and nonpharmacological interventions in a metropolitan inpatient dual diagnosis service: A retrospective exploratory study

In Australia, the terms dual diagnosis and comorbidity are commonly used, often interchangeably, to describe the experience of consumers with both mental health difficulties and difficulties with alcohol and other drug use. Consumers with comorbidity often have complex needs that require comprehensive assessment, multidisciplinary team support, and trauma-focused management. More information about the demographics of consumers admitted with comorbidity, and the documented assessed needs, care, and interventions provided, would provide the foundations for working towards improved quality and continuity of care. Therefore, the aim of this study was to explore the documentation of inpatient assessment, care, and interventions provided to people with comorbidity. The research design was a retrospective exploratory study, and data collection involved a 12-month healthcare record audit. Forty-one records were screened, and 36 consumer healthcare records were identified as eligible for inclusion in the study. Most consumers (n = 34, 94%) were admitted on an involuntary basis, and 8 (22.2%) were female. Consumers had a median length of stay of almost six months. In most healthcare records, there was no documented evidence of care planning involvement by consumers or the multidisciplinary team. There was great variance in the delivery of nonpharmacological interventions. Most consumers did not receive trauma-focused assessment or intervention, and assessment tools were often incomplete with outcome measures poorly documented. This study has demonstrated significant gaps in consumer and multidisciplinary engagement with care planning and goal setting. There was poor documentation of comprehensive assessment and nonpharmacological interventions.

Dual Diagnosis and Application Problems in the Use of the Construct: A Review of Literature

Dual diagnosis (DD) commonly identifies a condition of co-occurrence of substance use disorders and psychological or psychiatric disorders. Many scholars have tried to explain this phenomenon, yet no agreement has been found: methodologies of intervention and treatment are numerous, but there is no uniformity of methodology. Our work aims to search critical aspects linked to this fragmented framework, to facilitate those who use the construct of DD. We have elaborated a literary review focused on specific critical contributions to the theoretical and methodological complexity of the construct. Scopus, PubMed, and Scholar were used as search engines. Our research reveals significant problems around several thematic areas: Defining, Operative and Treatment; Economic and Policy; Pharmacological Approach; and Patients' Perspectives Issues. Consistent issues are discussed with regard to DD: innovation should start from its limits. Future research should look for alternative theoretical formulations and consequent intervention experiences to provide new perspectives.

Oxytocin and opioid addiction revisited: old drug, new applications

Opioid addiction has devastating health and socio-economic consequences, and current pharmacotherapy is limited and often accompanied by side effects, thus novel treatment is warranted. Traditionally, the neurohypophyseal peptide oxytocin (OT) is known for its effects on mediating reward, social affiliation and bonding, stress and learning and memory. There is now strong evidence that OT is a possible candidate for the treatment of drug addiction and depression-addiction co-morbidities. This review summarizes and critically discusses the preclinical evidence surrounding the consequences of pharmacological manipulation of the oxytocinergic system on opioid addiction-related processes, as well as the effects of opioids on the OT system at different stages of the addiction cycle. The mechanisms underlying the effects of OT on opioid addiction, including OT' interaction with the monoaminergic, glutamatergic, opioidergic systems and its effect on the amygdala, the hypothalamic-pituitary-adrenal axis and on memory consolidation of traumatic memories, are also reviewed. We also review clinical evidence on the effects of intranasal OT administration on opioid-dependent individuals and discuss the therapeutic potential along with the limitations that accompany OT-based pharmacotherapies. Review of these studies clearly indicates that the OT system is profoundly affected by opioid use and abstinence and points towards the OT system as an important target for developing pharmacotherapies for the treatment of opioid addiction and co-existing affective disorders, thereby preventing relapse. Therefore, there is a clear need for clinical studies assessing the efficacy of OT-based pharmacotherapies in opioid addiction.

LINKED ARTICLES

This article is part of a themed section on Emerging Areas of Opioid Pharmacology. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v175.14/issuetoc.

Introduction of a drug-detection dog programme in mental health inpatient units: A mixed-methods study of consumer, staff, and carers' perceptions

Many consumers admitted to mental health inpatient units also use illicit drugs, and some continue to do so while receiving treatment. In an attempt to curb the impact of illicit drug use, one of Australia's largest mental health services introduced a programme of drug-detection dog (DDD) searches. Our aim was to evaluate perceptions of the DDD programme among mental health consumers, staff, and carers. A mixed-methods research design using a concurrent triangulation approach was adopted, involving three focus group discussions with consumer, staff, and carer groups, and a structured survey among 94 consumers who were receiving treatment and 102 staff working in the units at the time of a DDD visit. Data were analysed using thematic analysis, and descriptive and inferential statistics. Major themes were that: (i) drug use in these units is perceived as 'prevalent' and 'destructive'; (ii) the DDD programme is 'beneficial' but 'incongruous' in a health-care setting; (iii) consumers are 'uninformed'; and (iv) consequences should be 'customized' to circumstances. Survey results corroborated qualitative themes, with the exception that although concerns about incongruity do exist, they were not prevalent and were outweighed by positive perceptions of the programme. Most perceptions were consistent between consumers and staff. However, consumers tended to think that, if found, drugs should be confiscated, whereas staff were more strongly in favour of the consumer being discharged. In conclusion, the DDD programme was seen as a positive step towards addressing drug use in mental health units. However, improved dissemination of information to consumers through verbal and written communication is required.

Worsening of health and a cessation or reduction in alcohol consumption to special occasion drinking across three decades of the life course

Background

Ex-drinkers suffer from worse health than drinkers; however, whether a worsening of health is associated with a change in drinking status from early adulthood has not been previously investigated. We assess whether a worsening of health is associated with a cessation in consumption or reduction to special occasion drinking from early adulthood to middle age.

Methods

Multinomial logistic regression assessing whether a change in self-reported limiting longstanding illness (LLI) was associated with ceasing alcohol consumption, or a reduction to special occasion drinking compared with being a persistent drinker from age 23 in separate models at ages 33, 42, and 50. All models adjusted for sex, poor psychosocial health, education, marital status, and children in the household. Sample included participants from Great Britain followed longitudinally in the National Child Development Study from ages 23 to 33 (N = 5,529), 42 (N = 4,787), and 50 (N = 4,476).

Results

Developing an LLI from the previous wave was associated with ceasing alcohol consumption at ages 33 (odds ratio [ORs] = 2.71, 95% confidence interval [CI] = 1.16–4.93), 42 (OR = 2.44, 95%CI = 1.24–4.81), and 50 (OR = 3.33, 95%CI = 1.56–7.12) and a reduction to special occasion drinking at ages 42 (OR = 2.04, 95%CI = 1.40–2.99) and 50 (OR = 2.04, 95%CI = 1.18–3.53). Having a persistent LLI across 2 waves increased the odds of ceasing consumption at ages 42 (OR = 3.22, 95%CI = 1.06–9.77) and 50 (OR = 4.03, 95%CI = 1.72–9.44) and reducing consumption to special occasion drinking at ages 33 (OR = 3.27, 95%CI = 1.34–8.01) and 42 (OR = 2.25, 95%CI = 1.23–4.50). Persistent drinkers at older ages had the best overall health suffering less from previous poor health compared with those who reduced or ceased consumption at an earlier time point.

Conclusions

Developing an LLI was associated with a cessation in alcohol consumption and a reduction in consumption to special occasion drinking from early adulthood. Persistent drinkers who drank at least till 50 were the healthiest overall. Health selection is likely to influence nondrinking across the life course.

A Qualitative Exploration of U.K. Prisoners’ Experiences of Substance Misuse and Mental Health Difficulties, and the Breaking Free Health and Justice Interventions

This qualitative study explored prisoners’ lived experiences of substance use and mental health difficulties and aimed to examine perceived links between these two areas and how they might be associated with recovery during engagement with the Breaking Free Health and Justice (BFHJ) treatment programs. Interviews were conducted with 32 prisoners receiving treatment for substance use in North-West England. Emerging from prisoners’ interviews were themes relating to difficult life experiences from childhood into adulthood, how these experiences played a role in the emergence of their multiple and complex difficulties, their treatment experiences, and how their current involvement with the criminal justice system acted as a catalyst for positive change, including engagement with the BFHJ programs. This study identified the roles of substance use and mental health difficulties in the lives of participants, identified how their multiple and complex difficulties might be addressed, and provided insights into prisoners’ interpretations of their life experiences.

Understanding How People with Mental Health Difficulties Experience Substance Use

BACKGROUND

Quantitative studies dominate research exploring reasons for substance use and experiences of substance use by people with mental health difficulties. This limits the depth of understanding which can be gained about these experiences.

OBJECTIVES

In the present article, we synthesized current qualitative research in this area to provide enhanced theoretical knowledge of these experiences.

METHODS

Following a systematic literature search, we identified 12 studies which explored how people with mental health difficulties experienced using substances, and which met additional inclusion criterion. We used Noblit and Hare's metaethnographic approach to qualitatively synthesize these studies.

RESULTS

Synthesis led to the development of two themes; "substance use mediates acceptance and social inclusion" and "substance use provides perceived opportunities for control and power."

CONCLUSIONS/IMPORTANCE

The findings suggest that in the studies reviewed people's motivation for substance use was embedded in social and psychological contexts. It indicated that substance use could provide perceived benefits such as mediating the impact of mental health stigma, enabling the development of alternative identities, increasing their sense of power and providing opportunities for social inclusion. Mental health and substance use workers should therefore aim to develop alternative opportunities for people with co-occurring disorders to gain such benefits, and seek to challenge mental health stigma.

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.

The 10 most important debates surrounding dual diagnosis

Purpose

– It is more than 30 years since attention turned to the issue of the relationship between substance use and mental health. The purpose of this paper is to reflect on the progress to date that has been made in advancing the knowledge and understanding.

Design/methodology/approach

– The author has drawn on the available literature, identifying key contributions from a variety of fields which have helped to shape the understanding of the issues in relation to dual diagnosis. The ten themes are not presented in order of importance.

Findings

– Achievements have been made in attracting the attention of clinicians, researchers, policy makers and commissioners to this issue. Overall the author is left with a clearer understanding of what treatments are not effective and the challenges of determining what is.

Originality/value

– This paper seeks to instigate a discussion about where the collective knowledge stands on this important and challenging area of practice and research.