Caring for clients with dual diagnosis in rural communities in Australia: the experience of mental health professionals

Mental Health Nurses' Attitudes on Consumers with Dual Diagnosis: A Thematic Analysis

BACKGROUND

The issue of dual diagnosis continues to be a global health concern. There is a lack of empirical research on mental health nurses' attitudes toward consumers with dual diagnosis.

OBJECTIVE

This study aimed to answer the following research question: How do mental health nurses describe their attitude toward consumers with co-existing mental health and drug and alcohol problems?

DESIGN

This qualitative study employed purposive sampling to recruit participants. Semi-structured interviews were conducted to explore mental health nurses' attitudes toward consumers with dual diagnosis.

SETTING

This study focused on mental health nurses employed in mental health settings. It placed a particular emphasis on mental health nurses who had experience in caring for consumers with dual diagnosis. Seventeen mental health nurses participated in the interview.

METHODS

Interviews were transcribed verbatim and coded using NVivo™ 12 Plus software. Thematic analysis was used to generate codes and themes inductively.

RESULTS

Three major themes with a total of eight sub-themes were identified: (1) satisfaction and connection, with three subthemes; (2) combating negativity in others, with two subthemes; and (3) working to improve outcomes, with three subthemes.

CONCLUSIONS

Participants were concerned about their peers' sense of fear and frustration, stigmatized language, and lack of consistency in providing dual diagnosis training for mental health nurses. There is a need to investigate effective strategies to address mental health nurses' stigmatized attitudes, fear, and frustration toward consumers with dual diagnosis.

Caring for patients with substance use disorders: a qualitative investigation of difficulties encountered by hospital-based clinicians

Background: Caring for patients with substance use disorders (SUD) is held in low regard and many clinicians resist treating them. To address this situation, numerous research projects assessed training program gaps and professional attitudes. In contrast, this study explored the actual clinical difficulties that a variety of hospital-based professionals encounter when treating patients with SUD. Methods: Qualitative multiple method design including: (1) individual semi-structured interviews with SUD experts and educators; (2) video-elicited, cross self-confrontation interviews with clinicians working in a specialist addiction unit; (3) paired semi-structured interviews with clinicians working in non-specialist units. Participants were recruited within one university hospital. Data collected at stages (1) and (3) relied on an interview guide and were analyzed using conventional content analyses. Data collected at stage (2) consisted of discussions of video recorded clinical interviews and were analyzed based on a participatory approach. Results: Twenty-three clinicians from seven hospital units participated. Forty-four difficulties were reported that we classified into six categories: knowledge-based; moral; technical; relational; identity-related; institutional. We identified seven cross-category themes as key features of SUD clinical complexity: exacerbation of patient characteristics; multiplication of medical issues; hybridity and specificity of medical discipline; experiences of stalemate, adversity, and role reversal. Conclusions: Our study, providing a comprehensive analysis of the difficulties of caring for patients with SUD, reveals a highly challenging clinical practice for a diversity of healthcare providers. They represent a complementary approach to addressing resistance as an important feature of a complex clinical system, and valuable material to discussing professional preparedness.

For a better understanding of the relationship between caregivers and young adults living with a concomitant substance-related mental health and substance use disorder: an integrative review

Introduction

The importance of a quality relationship between young adults living with dual diagnosis and their health care providers is well documented.

Context

Although this complex phenomenon was mostly studied from an individual perspective, the results indicated the systemic nature of this relationship.

Objective

This study aims to better understand the relationship between young adults living with dual diagnosis and their health care providers, with a systemic perspective.

Method

Six data bases were consulted; manual research in gray literature and references screening enhanced the process.

Results

Of a total of 532 studies and reports identified, 44 were included in the review. Thematic data analysis was carried out, and two themes were identified: the health care system as a constraining environment; and the relationship at the heart of care.

Discussion

This study confirms the joint role played by the young adult in question and their health care provider in developing and maintaining the relationship, by acknowledging the importance of the care, of mutual confidence, and of a hierarchic relationship.

Conclusion

This integrative review provides a basis for future nursing interventions that foreground the relationship and take a systemic approach.

A systematic review of the perceptions and attitudes of mental health nurses towards alcohol and other drug use in mental health clients

Mental and substance use disorders are leading contributing factors for the Australian non-fatal burden of disease. These disorders frequently co-occur in the mental health population, and mental health nurses are the largest group of professionals treating dual diagnosis. A comprehensive understanding of mental health nurses' attitudes and perceptions is required to inform future implementation of dual diagnosis training programs. A systematic literature review of sources derived from electronic databases including Medline, CINAHL, SCOPUS review, and PsychINFO, along with Connected Papers. Selection criteria included a focus on mental health nurses' attitudes towards dual diagnosis of mental illness and substance use. Extracted data was qualitatively synthesized. Of the 5232 articles retrieved initially, 12 were included in the review. Four themes emerged from the synthesis: drug and alcohol use among mental health consumers (seven studies), caring for dual diagnosis consumers (eight studies), role perception (six studies), and treatment optimism (five studies). Salient beliefs included substance use as a self-inflicted choice (71%) or a form of 'self-medication' (29%); a lack of willingness to provide care (75%), or a strong commitment to care (25%); greater comfort with screening and acute medical management rather than ongoing management (83%); and pessimism about treatment effectiveness (100%). Mental health nurses' beliefs and attitudes towards dual diagnosis were often negative, which is likely to result in poor quality care and treatment outcomes. However, the lack of recent studies in this research area indicates the need for up-to-date knowledge that can inform the development of training programs.

Barriers to Working with Patients Who Misuse Opioids and Physician Burnout: Implications for Medical Education

BACKGROUND

Physicians are on the front lines of the U.S. opioid epidemic, providing care in multiple treatment settings. Very little is known, however, about whether this experience has contributed to physician burnout. This information is critical for guiding efforts to expand the relatively low level of training on opioid misuse currently available in medical education.

METHODS

We surveyed 408 board-certified physicians practicing in Ohio about their experiences working with patients who misuse opioids. We also collected quantitative measures of physicians' burnout and their level of contact with this patient population. We coded and analyzed open-ended responses and calculated a partial correlation between contact and burnout, controlling for relevant factors.

RESULTS

Physicians experienced three primary barriers when working with patients who misuse opioids: inadequate knowledge and training, limited external resources and partnerships in their communities, and an incomplete context for understanding problematic patient behaviors. 70% of physicians experienced negative emotions when working with this patient population and 19% mentioned experiencing burnout specifically. Contact with patients who misuse opioids was significantly and positively associated with burnout scores.

CONCLUSIONS

Our findings underscore the need for medical educators to take a proactive approach to equipping physicians with the knowledge, skills, and resources needed to effectively work with patients who misuse opioids.

Mental Health Nurses' Attitudes towards Consumers with co-Existing Mental Health and Drug and Alcohol Problems: A Scoping Review

Consumers with co-existing mental health and drug/alcohol problems are exposed to more stigma than those with any other health problems. This scoping review aimed to systematically map the available literature regarding mental health nurses' attitudes, empathy, and caring efficacy towards consumers with a dual diagnosis. Twenty studies reported outcomes regarding nurse attitudes; however, none reported nurses' empathy or caring efficacy towards consumers with a dual diagnosis. Further research is required to advance the evidence on the impact of mental health nurses' attitudes, empathy and caring effectiveness, and the outcomes should lead to improved service delivery for consumers with a dual diagnosis.

Perceptions of professionals regarding interventions involving family members responsible for justice-involved youth with substance use disorders in Santiago, Chile

BACKGROUND

Eliciting professionals' experiences of current drug treatment programmes can lead to improvements of these youth-centred programmes through the involvement of the concerned youths' families. We explored perceived barriers amongst professionals concerning interventions incorporating parents or guardians responsible for justice-involved youth with substance use disorders.

METHODS

We conducted semi-structured in-depth interviews with fourteen female and four male professionals, each representing one of eighteen programmes under the Chilean National Drug Treatment Programme (2016-2017), who were tasked with contacting and/or intervening in the families of justice-involved youth. Subsequently, we performed traditional content analysis.

RESULTS

The professionals identified four key barriers impeding interventions: (1) parents' non-adherence to the treatment and issues relating to their role fulfilment; (2) tensions within the programme design that constrain the families' involvement in the interventions; (3) the lack of a supportive professional network offering interventions that complement drug treatment; (4) the problematic and dangerous living contexts of these families that discourage family involvement. Additionally, professionals identified intervention needs for improving treatment outcomes.

CONCLUSIONS

The negative perceptions of professionals regarding the interventions as well as families and family contexts of justice-involved youth, and the lack of support from other programmes, induced feelings of hopelessness and pessimism amongst the professionals regarding the effectiveness of the Chilean National Drug Treatment Programme. It is essential to consider professionals' perspectives not only to benefit from their expertise, but also to assess whether their perspectives may hinder the implementation of changes when attempting to innovate drug treatment modalities aimed at improving their outcomes.

“The dual diagnosis attitudes survey”: understanding the attitudinal impact of training across mental health and alcohol and drug service systems

Purpose

Anecdotal feedback obtained from alcohol and drug and mental health staff across the eastern metropolitan region of Melbourne, Australia suggests that attitudes towards working with people experiencing a dual diagnosis are becoming more positive. The purpose of this paper is to understand if dual diagnosis-specific training delivered to staff within mental health and alcohol and other drug services was a factor positively influencing attitudes.

Design/methodology/approach

No formal evaluation assessing the impact of dual diagnosis-specific training on staff attitudes had previously occurred within this region of Australia. Access to staff on two occasions from three distinct sectors provided an opportunity to examine if and, to what degree, attitudes can be influenced by dual diagnosis-specific training. Using a co-designed attitudes survey, information was gathered from mental health and alcohol and drug staff on their attitudes to working with people with co-occurring mental health and substance use problems.

Findings

Two surveys were conducted involving 186 staff in 2012 and 110 staff in 2016. The dual diagnosis attitudes survey showed that positive attitudes to working with people experiencing a dual diagnosis were associated with recency of training. While attitudes may be improved by dual diagnosis training, these findings cannot exclude the impact of other dual diagnosis capacity building activities.

Originality/value

This study highlights the benefits of a regional partnership between mental health and alcohol and drug services and people with lived experience of dual diagnosis and the benefit of recent co-designed dual diagnosis training on longitudinally assessed worker attitudes.

Stigma, Discrimination, Treatment Effectiveness, and Policy Support: Comparing Behavior Analysts' Views on Drug Addiction and Mental Illness

Individuals with substance use disorders (SUDs) often face discrimination. A recent study found that people in the general population hold significantly more negative views toward persons with drug addiction than those with other mental illnesses (Barry et al. in Psychiatric Services, 65(10), 1269-1272, 2014). It is possible that these negative attitudes stem from the historical view of addiction as a moral shortcoming or lack of willpower. Behavior analysts' approach to behavior is guided by the underlying philosophy of behaviorism, which proposes that behavior is determined by genetic and environmental factors, as opposed to the free will of an individual. Because behavior analysts view behavior as determined and do not assign responsibility to an individual for his or her behavior, one would hypothesize that behavior analysts would not view individuals with SUDs more negatively than those with other mental disorders. This study surveyed 288 behavior analysts regarding their views on SUDs and mental disorders. Results showed that behavior analysts have significantly more negative attitudes toward people with SUDs than toward people with other mental disorders. Respondents reported a greater desire for social distance and greater acceptability of discrimination for people with SUDs than for people with mental disorders. They also reported less potential for recovery and lower support for policies to improve equity in insurance coverage and were less supportive of using government funding to improve treatment, housing, and job support for people with SUDs.

Stigma, Treatment, and Health among Stimulant Users: Life Stage as a Moderator

This 3-year study examined associations among drug use stigma, life stage, treatment utilization and health among 710 US adults using stimulants. Consistent with substance use developmental frameworks, life stage was represented by Emerging adulthood (18-25 years old, n=223), Earlymid adulthood (26-44 years old; n=384), and Older adulthood (45-61 years old; n=103). Emerging adults experienced less enacted stigma (i.e., experiences of discrimination) and perceived less public stigma (i.e., unjust treatment) over the course of the study than other life stage groups. More baseline enacted stigma was associated with more mental health and substance use treatment, whereas more baseline self stigma (i.e., negative thoughts about the self) was associated with less treatment utilization. Life stage moderated stigma-outcome associations such that substance use outcomes were worse for Emerging adults reporting more enacted stigma. Although emerging adults experienced less drug use stigma, stigma had a more negative impact on adults in this life stage.

How does a drug court experience influence student pharmacists?

INTRODUCTION

Drug court is a highly structured, community-based criminal justice alternative to imprisonment and probation that incorporates chemical dependency treatment for offenders with a substance abuse diagnosis. Drug court provides a unique learning experience for pharmacy students.

METHODS

Students from Purdue University College of Pharmacy and the University of Minnesota College of Pharmacy participated in drug court and provided written reflections regarding their experiences. Analysis of reflections explored how students' life experiences might be associated with their understanding of substance use disorder, and how the drug court experience might impact students' attitudes regarding substance use disorder as well as professional and personal development.

RESULTS

Consensual qualitative analysis of student pharmacist reflections of the drug court experience led to eleven distinct themes: description of the student experience at drug court; past experiences and exposures; past perceptions and judgments; stereotype deconstruction; empathy development; development of impartiality and fair-minded approach; situational appreciation; analytical thinking; role of the pharmacist; metacognition; and science of substance use disorder.

DISCUSSION

Colleges of pharmacy wishing to provide students with an opportunity for personal and professional development focused on substance use disorder and recovery should explore experiential learning opportunities in drug court settings.

CONCLUSIONS

The drug court experience allows student pharmacist learners to gain a deeper personal understanding of substance use disorder while examining their own biases. Students reported that this experience challenges them to rethink notions of "good" and "bad" and reflect on personal preconceived views about substance use disorder and morality.

The Experiences of Older Adults with Dual Diagnosis in an Inner Melbourne Community Mental Health Service

Less is known about the experiences of older adults (65+ years of age) with co-occurring mental health and alcohol and other drug use disorders (dual diagnosis) than is known about the experiences of their younger counterparts. This exploratory qualitative study sought to interview individuals receiving case management from an inner Melbourne community mental health service to determine their experiences of living with dual diagnosis and explore their interactions with mental health and addiction treatment, and general medical services alike. Six older adults with a dual mental health and substance disorder agreed to participate in a semi-structured interview process and provided their perspectives about living with complex mental illness and alcohol and other drug use. Several key themes emerged throughout the interview process, mirroring the notion of dual diagnosis being a complex phenomenon involving a number of interrelated factors: these include medical complexity, poor service engagement and long-term use of alcohol and other drugs. Interviews also demonstrate the challenges inherent in providing care to this cohort, with the participants frequently describing their experiences with services as being fraught with difficulty. The increased understanding of the perspectives of older adults with dual diagnosis provides the foundation for further research into this population in addition to influencing future nursing care provided to this cohort.

The Experiences of Clinicians Caring for Older Adults with Dual Diagnosis: An Exploratory Study

Dual diagnosis has been identified as a significant challenge to mental health services, resulting in higher rates of psychiatric relapse and greater illness severity. Much research explores dual diagnosis in the adult mental health cohort, however little research attention has been paid to older adults with dual diagnosis. Far from being a trivial issue, preliminary studies have shown that dual diagnosis in older adults is under diagnosed and poorly identified by clinicians with few specific treatment options available. In addition, studies of the ageing baby boomer cohort demonstrate a potential for dual diagnosis presentations to increase in the coming years. This article explores the experiences of a clinical team providing care to older adults with dual diagnosis in Melbourne, Australia, through a semi-structured interview process. The participants described a number of systemic barriers to providing care to the older adults with dual diagnosis presenting to the mental health service, in addition to feeling poorly prepared and expressing a degree of clinical helplessness. Additionally, the participants described service improvement, which included a strong dual diagnosis culture in the leadership team of the mental health service and role modelling dual diagnosis competent practice among clinicians.

Maturing out, natural recovery, and dual diagnosis: What are the implications for older adult mental health services?

In 1962, Charles Winick proposed that addiction was a self-limiting process, whereby individuals stopped using substances once the stresses of life transitions ceased. The notion of maturing out, as labelled by Winick, often forms the basis of the natural recovery movement in alcohol and other drug (AOD) research, aiding the notion that older individuals either cease their substance use or fall victim to the higher mortality rates prevalent in substance-using populations. As more consumers present to adult mental health treatment settings with co-occurring substance use disorders, the idea that individuals will simply cease using AOD is outdated. Given the future challenges of an ageing population, it is prudent to explore those who fail to mature out of substance use, as well as challenge the notion that older adult mental health services rarely encounter substance-using individuals. The present study explores Winick's research in the context of an ageing population and older adult mental health services. It also ponders the proposition put forth in subsequent research that older individuals with lifelong substance use switch to substances that are easier to obtain and better tolerated by their ageing bodies.

The multifaceted vigilance - nurses' experiences of caring encounters with patients suffering from substance use disorder

BACKGROUND

Nursing care is guided by a value base focusing on promoting dignity and health by means of the caring relationship. However, previous research has revealed that negative attitudes towards 'addicted' patients, as well as these patients' behaviour, can give rise to negative emotions such as frustration and disappointment among nurses. This can contribute to a judgmental and controlling attitude towards patients. To preserve order, nursing interventions focusing on creating structure and stability could be applied in a way that challenges caring values.

AIMS AND OBJECTIVES

This study aimed to describe how nurses' working in inpatient psychiatric care experience caring encounters with patients suffering from substance use disorder (SUD).

DESIGN

This qualitative study is part of a clinical application project focusing on value-based care of patients suffering from SUD. Data were obtained during four reflective group dialogues with six nurses in a psychiatric hospital.

METHODS

The transcribed dialogues were subjected to latent qualitative content analysis.

RESULTS

The analysis facilitated the organisation of the findings into a coherent pattern. A common thread of meaning was conceptualised as a theme labelled 'the multifaceted vigilance', describing how nurses strived to deliver good care, while at the same time being vigilant towards patients' behaviour as well as their own reactions to it. Within that theme, four categories described experiences related to different challenges nurses face in caring encounters.

CONCLUSION

We suggest that this perhaps unavoidable aspect of caring encounters can be an asset. Thus, if acknowledged and subject to reflection, being vigilant could be understood as a strength enabling nurses to safeguard caring values, and to use their authority to promote patients' health and alleviate suffering.

Health-care professionals' attitudes across different hospital departments regarding alcohol-related presentations

INTRODUCTION AND AIMS

Attitudes to individuals presenting with alcohol-related issues are important in developing therapeutic relationships and applying alcohol-related interventions. This study explores staff attitudes to these individuals across a range of roles and departments.

DESIGN AND METHODS

Data were gathered from 204 staff in the Southern Health and Social Care Trust in Northern Ireland. Regression models were used to predict attitudes as measured by the Short Alcohol and Alcohol Problems Perception Questionnaire (SAAPPQ).

RESULTS

Two hundred and four people participated in the study. The sample comprised doctors, nurses, allied health professionals and other staff who had face-to-face contact with patients. Staff worked in accident and emergency (A&E), medical, surgical, addiction or psychiatry departments. Staff working in addiction and psychiatry departments had significantly higher levels of role adequacy compared with those in A&E. Staff in addictions also demonstrated higher levels of role legitimacy, motivation and role satisfaction than those in A&E. Doctors had higher role adequacy and role legitimacy than nursing staff.

DISCUSSION AND CONCLUSIONS

There are critical differences in staff attitudes to patients presenting with alcohol-related issues in a range of hospital settings; training and working in a specialist setting have a significant positive influence on staff attitudes. This suggests that further training and support would positively enhance the attitudes of staff in a variety of professional roles and across a range of hospital settings in the management of patients presenting with alcohol-related difficulties. [Iqbal N, McCambridge O, Edgar L, Young C, Shorter GW. Health-care professionals' attitudes across different hospital departments regarding alcohol-related presentations. Drug Alcohol Rev 2015;34:487-94].

Understanding how people who use illicit drugs and alcohol experience relationships with psychiatric inpatient staff

PURPOSE

Psychiatric inpatient services are often required to provide care for people with mental health difficulties who use illicit drugs or alcohol (people with coexisting difficulties). In other settings, relationships between service users and staff can be important in alleviating distress and improving outcomes. This study explored how people with coexisting difficulties experienced relationships with staff in psychiatric inpatient services to increase understanding of these relationships.

METHODS

Ten adult service users (5 male, 5 female) from eight inpatient wards participated in semi-structured interviews. All participants had mental health diagnoses, and self-reported use of illicit drugs and/or heavy alcohol consumption. Data was analysed using interpretative phenomenological analysis.

RESULTS

Analysis yielded three consistent themes: 'weighing up the risk of relationships', 'relationships intertwined with power and control' and 'seeking compassionate care'. These themes highlighted the negative impact that service users' anticipation of rejection could have upon their willingness to develop relationships with staff, and the conflict which could occur due to their perceived difference to staff. Findings also highlighted that consistent, compassionate care by staff could minimise group differences and alleviate rejection fears.

CONCLUSION

Previous experiences of rejection and power structures within psychiatric inpatient services can influence the abilities of people with coexisting difficulties to develop relationships with staff. It is, therefore, important for staff and services to demonstrate consistent care, where staff are sympathetic and show a desire to alleviate suffering and to encourage clinical approaches which foster equality and mutual understanding between staff and service users.

Healthcare professionals' regard towards working with patients with substance use disorders: comparison of primary care, general psychiatry and specialist addiction services

BACKGROUND

Healthcare professionals are crucial in access to treatment for patients with substance use disorders. However, healthcare professionals often have negative attitudes towards this patient group. Healthcare professionals' regard for working with patients with substance use disorders was examined and three sectors in which professionals are working were compared.

METHODS

General practitioners (GPs; N=180), healthcare professionals of general psychiatry (N=89) and specialists in addiction services (N=78) filled out a questionnaire in which regard for working with patients with substance use disorders was assessed. ANOVAs were used to compare the sectors and multiple linear regression analysis tested the association of regard with attribution beliefs, emotional reactions and other characteristics of healthcare professionals.

RESULTS

Regard for working with patients with substance use disorders was different between the three sectors (GPs M=42.00; general psychiatry M=48.18; addiction specialists M=55.41; p=0.00, ω(2)=0.40). Attribution of personal responsibility and feeling of anger and fear were associated with lower regard scores. More familiarity with substance use problems, higher frequency of working with this patients group and more confidence in substance abuse treatment were positively associated with regard. Social desirability bias was present and was positively related to healthcare professionals' regard.

CONCLUSIONS

Health care professionals of specialist addiction services showed higher regard for working with patients with substance use disorders compared to professionals of general psychiatry services and GPs. Improvement of education and shared care models in which healthcare professionals are supported by professionals specializing in addiction might address low regard.

Dual diagnosis discourse in Victoria Australia: the responsiveness of mental health services

OBJECTIVE

In recent decades, psychiatric services have been challenged to be more responsive to patients' coexisting problems, in particular those concerning substance use. In Australia this has been referred to as a "No Wrong Door" approach. This paper explores the meanings of this move for the acute mental health sector, including attitudes toward a No Wrong Door approach to people with a dual diagnosis of mental illness and substance use disorder.  

METHODS

This qualitative study involved a review of the research literatures, analysis of policy documents, and interviews with 19 key informants in a case study of the State of Victoria, Australia.  

RESULTS

The analysis resulted in two broad themes surrounding the implications of dual diagnosis discourse for the mental health sector. The first involves progress regarding the concept of No Wrong Door with subthemes including interprofessional cultural conflicts, intersectoral professional status issues, terminology, problem definition, perspectives on serious mental illness, the role of the client, and pharmacological treatment. The second overarching theme focuses upon informants' thoughts on future directions for the sector and highlights divided opinion on the implications of dual diagnosis discourse for the mental health service and social care systems.  

CONCLUSIONS

While the perspectives on system change and multiple issues such as resource concerns and cultural clashes are presented here, the informants in this study also gave clear guidance for the future of dual diagnosis work in the mental health sector (e.g., focusing on orienting services toward consumer strengths and recovery), along with recommendations for future research. This paper contributes to the small body of qualitative research on the history and course of efforts to develop appropriate practice in mental health services with regard to patients who have substance use problems and other mental health disorders.

Barriers to collaboration in mental health services for older people: external agency views

The need for mental health services for older people living in rural areas is increasing in South Australia. Providing such care requires coordination between several types of services across government, hospital and non-government sectors. The purpose of this study was to identify barriers to collaboration from the perspective of external aged care agencies. A total of 42 responses from an online survey were qualitatively analysed. Four categories emerged, within which participants had identified barriers to collaboration: (1) awareness of services and certainty about responsibilities, in particular, a lack of awareness of which services are available; (2) referral criteria and processes, including the specific criteria needed to be eligible for these services; (3) opportunities to collaborate, with a perceived lack of formal opportunities for collaboration between individuals working across agencies; and (4) education of staff, with more joint education between agencies being recognised as having the potential to increase local knowledge and provide an opportunity for networking and relationship building, with greatest barriers experienced between mental health and social care services.

Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: systematic review

BACKGROUND

Healthcare professionals are crucial in the identification and accessibility to treatment for people with substance use disorders. Our objective was to assess health professionals' attitudes towards patients with substance use disorders and examine the consequences of these attitudes on healthcare delivery for these patients in Western countries.

METHODS

Pubmed, PsycINFO and Embase were systematically searched for articles published between 2000 and 2011. Studies evaluating health professionals' attitudes towards patients with substance use disorders and consequences of negative attitudes were included. An inclusion criterion was that studies addressed alcohol or illicit drug abuse. Reviews, commentaries and letters were excluded, as were studies originating from non-Western countries.

RESULTS

The search process yielded 1562 citations. After selection and quality assessment, 28 studies were included. Health professionals generally had a negative attitude towards patients with substance use disorders. They perceived violence, manipulation, and poor motivation as impeding factors in the healthcare delivery for these patients. Health professionals also lacked adequate education, training and support structures in working with this patient group. Negative attitudes of health professionals diminished patients' feelings of empowerment and subsequent treatment outcomes. Health professionals are less involved and have a more task-oriented approach in the delivery of healthcare, resulting in less personal engagement and diminished empathy.

CONCLUSIONS

This review indicates that negative attitudes of health professionals towards patients with substance use disorders are common and contribute to suboptimal health care for these patients. However, few studies have evaluated the consequences of health professionals' negative attitudes towards patients with substance use disorders.

A cross-sectional study of patients with and without substance use disorders in Community Mental Health Centres

BACKGROUND

Epidemiological studies have consistently established high comorbidity between psychiatric disorders and substance use disorders (SUD). This comorbidity is even more prominent when psychiatric populations are studied. Previous studies have focused on inpatient populations dominated by psychotic disorders, whereas this paper presents findings on patients in Community Mental Health Centres (CMHCs) where affective and anxiety disorders are most prominent. The purpose of this study is to compare patients in CMHCs with and without SUD in regard to differences in socio-demographic characteristics, level of morbidity, prevalence of different diagnostic categories, health services provided and the level of improvement in psychiatric symptoms.

METHODS

As part of the evaluation of the National Plan for Mental Health, all patients seen in eight CMHCs during a 4-week period in 2007 were studied (n = 2154). The CMHCs were located in rural and urban areas of Norway. The patients were diagnosed according to the ICD-10 diagnoses and assessed with the Health of the Nation Outcome Scales, the Alcohol Use Scale and the Drug Use Scale.

RESULTS

Patients with SUD in CMHCs are more frequently male, single and living alone, have more severe morbidity, less anxiety and mood disorders, less outpatient treatment and less improvement in regard to recovery from psychological symptoms compared to patients with no SUD.

CONCLUSION

CMHCs need to implement systematic screening and diagnostic procedures in order to detect the special needs of these patients and improve their treatment.

The use of the repertory grid technique to examine staff beliefs about clients with dual diagnosis

AIM

This paper reports a study exploring how individual psychiatric staff construes clients with psychosis who misuse substances.

BACKGROUND

A dual diagnosis of substance misuse is common in clients with psychosis. Previous studies have suggested that psychiatric staff feel ill-equipped to work with these clients, and hold negative views of them, affecting client care and recovery. Understanding staff attitudes can inform training and practice.

METHOD

Twelve psychiatric nursing staff working in an inpatient service for adults with enduring mental health difficulties in England were interviewed. Using a repertory grid technique, staff were asked to describe clients and acquaintances who did and did not misuse substances, themselves and colleagues.

FINDINGS

All staff made critical judgements of some clients, particularly clients with dual diagnosis, but were less judgemental towards acquaintances who misused substances. Staff who used fewer dimensions to construe people appeared to make a clear distinction between clients and non-clients. This distinction was not apparent for staff with more cognitively complex construct systems. Specific factors that could be implicated in the organization of individuals' construct systems included personal experience of services as a carer; these staff made less distinction between clients and non-clients.

CONCLUSION

Further training is needed for staff working with clients with a dual diagnosis. Training packages need to consider the personal experiences and views of staff. Reducing the boundaries between staff and clients might enable staff to better understand the actions of clients and improve client care.

Nursing considerations for dual diagnosis in mental health

It is the intention of this literature review to present suggestions for nursing practice with reference to the care of the dually diagnosed. Nursing care of the dually diagnosed client is complex. Clinicians from both drug and alcohol services and mental health services have long recognized that neither service area provides adequate clinical care to those clients who have a dual diagnosis of substance abuse and mental illness. It is now > 10 years since a ground-breaking Australian study recognized this. To ascertain whether there has been improvement in the service management of clients who have a dual diagnosis, and to determine the best practice interventions in the area of mental health nursing, we undertook a review of the literature. The databases CINAHL, MEDLINE, PsycARTICLES and PsychINFO were searched and 185 articles met the inclusion criteria. From this review, it seems that gaps still remain in the provision of services and that mental health nurses might be best placed to provide integrated care to those clients who have a dual diagnosis and present to mental health services. This requires mental health nurses to have skills in substance use detection and knowledge of potential care implications for the client in the context of their substance use.

Drug and alcohol education for consumer workers and caregivers: a pilot project assessing attitudes toward persons with mental illness and problematic substance use

With the development of peer support networks in the mental health system, formal training should be provided regarding the adverse effects of substance use. Four educational workshops were conducted with caregivers and consumer workers to increase their knowledge and confidence to support people with a dual diagnosis. Workshops were evaluated through presurvey and postsurvey. The workshops were well received, and postworkshop, participants reported fewer negative attitudes toward people with a dual diagnosis and increased understanding and knowledge regarding substance misuse. This study highlights the effectiveness of targeted workshops for caregivers and consumer workers and advocates that nurses take a more active role in educational projects involving stakeholders.

Treatment approaches for dual diagnosis clients in England

INTRODUCTION

Dual diagnosis (DD, co-occurrence of substance use and mental health problems) prevalence data in England are limited to specific regions and reported rates vary widely. Reliable information on actual service provision for dual diagnosis clients has not been collated. Thus a national survey was carried out to estimate dual diagnosis prevalence in treatment populations and describe the service provision available for this client population in drug/alcohol (DAS) and mental health services (MHS).

DESIGN

A questionnaire was sent to managers of 706 DAS and 2374 MHS. Overall, 249 (39%) DAS and 493 (23%) MHS participated in the survey.

RESULTS

In both DAS and MHS, around 32% of clients were estimated to have dual diagnosis problems. However, fewer than 50% of services reported assessing clients for both problem areas. Regarding specific treatment approaches, most services (DAS: 88%, MHS: 87%) indicated working jointly with other agencies. Significantly fewer services used joint protocols (DAS: 55%, MHS: 48%) or shared care arrangements, including access to external drug/alcohol or mental health teams (DAS: 47%, MHS: 54%). Only 25% of DAS and 17% of MHS employed dual diagnosis specialists.

CONCLUSIONS

Dual diagnosis clients constitute a substantial proportion of clients in both DAS and MHS in England. Despite recent policy initiatives, joint working approaches tend to remain unstructured.

Mental illness and substance use: an Australian perspective

This paper presents a review of the literature of service trends and practice recommendations for management of those with the dual diagnosis of mental illness and substance abuse. The method for the review was to search bibliographical data bases and hand held literature published in English between 1990 and 2007. Using the search terms dual diagnosis, and co-morbidity and mental illness, 93 abstracts were selected and reviewed. The authors concluded that a collaborative approach to care with better integration of drug and alcohol services within mental health would benefit clients with a dual diagnosis. Improved education to enhance the assessment and diagnosis of this client group is also considered essential for clinicians in both mental health and alcohol and drugs services.

Comorbidity of mental health and substance misuse problems: a review of workers' reported attitudes and perceptions

A comorbidity of mental health and substance misuse problems has been associated with deleterious outcomes. In the United Kingdom it has been acknowledged that people with comorbidity have often received poor care, with gaps in service provision suggesting ambivalence towards this issue. Previous reviewing authors have concluded that health professionals hold stereotypical views towards people that misuse substances, but these findings may not be directly comparable to those who work within mental health services. There is however a growing body of evidence concerning this context. The author has reviewed the literature from 1996 to 2006 to ascertain mental health professionals and allied workers attitudes and perceptions towards comorbidity, perceptions on the effectiveness of service systems, and perceptions of personal knowledge and skill in providing effective interventions. The evidence presented mainly pertains to mental health nurses, which reflects their status as the largest discipline within the mental health workforce. Overall attitudes towards comorbidity are mixed, possibly being related to contextual issues of practice and are not necessarily negative. However, there is an almost universal negative perception of deficiencies in service provision and the adequacy of training. Implications for research, development and practice are explored.

How involuntary commitment impacts on the burden of care of the family

Little research has examined how, or if, involuntary commitment has impacted on the burden experienced by the family. This paper reports a qualitative study which explored how involuntary commitment under the Mental Health Act (MHA) 2000 in Queensland, Australia impacted on families of people with mental illness. Family members of a person with a mental illness, under involuntary commitment at the time or in the previous 12 months, participated in focus groups. Thematic analysis was used to determine the themes. It was apparent from the views of the family that the use of the involuntary commitment was influenced greatly by the pressures experienced by the mental health services (MHS). The MHA did little to assist the family in gaining access to MHS. It was not until after the family made repeated attempts that they were taken seriously. Often the family had few options other than to use deceit and threats to obtain the necessary treatment required. In view of this, the inherit nature of what involuntary commitment implies for persons under it, such as refusing treatment and management difficulties, indicates the family with such an individual experience more hardship in trying to obtain assistance for that person. Thus, the MHA in Queensland has not met its goals of increasing access to MHS. Family members perceive that they were not being listened to and their concerns were not acted upon. The current culture of the MHS appears to serve, to a large degree, to estrange the family from the consumer making relationships difficult and time-consuming to repair. The mental health profession is urged to consider the culture within their workplace and move towards constructive involvement of the family.

Analysis of positive Edinburgh depression scale referrals to a consultation liaison psychiatry service in a two-year period

Antenatal depression is a depressive episode that begins in pregnancy and is often a predictor of postnatal depression. The main aim of this study was to examine the prevalence of antenatal depression and other psychiatric conditions in women referred to a consultation liaison psychiatry service because of positive scores on the Edinburgh Postnatal Depression Scale. The other aim was to review known risk factors in the women and note any significant findings. An audit of all women referred to the psychiatry team because of positive Edinburgh scores during a 2-year period was completed. Information about Edinburgh scores, clinical diagnoses at the time of the psychiatric appointment, and factors such as relationship status, domestic violence, ethnicity, and substance use was noted. According to the Diagnostic and Statistical Manual of Mental Disorders: Fourth Edition criteria: 36.5% of the women had an adjustment disorder, 13% had a major depression, 10% had dysthymia, 8% had a recurrent depressive disorder, 2% had post-traumatic stress disorder, and 2% had a borderline personality disorder. The findings demonstrated the usefulness of using a screening tool such as the Edinburgh Postnatal Depression Scale in detecting women requiring psychiatric intervention and highlighted the importance of a psychiatric interview assessment to interpret the scores of screened patients in terms of clinically relevant syndromes.