Dual diagnosis: management within a psychosocial context

Pharmacotherapy in dual diagnosis

The prevalence of coexisting substance misuse and psychiatric disorder (dual diagnosis, comorbidity) has increased over the past decade, and the indications are that it will continue to rise. There have simultaneously been unprecedented developments in the pharmacological treatment of alcohol, opiate and nicotine misuse. Here we evaluate the evidence on the use of some of these treatments in dual diagnosis (with psychotic, mood and anxiety disorders). The evidence base is limited by the exclusion of mental illness when pharmacological agents for substance misuse are evaluated and vice versa. We set the available information within the context of the psychosocial management of comorbid substance misuse and mental illness, and the framework for service delivery recommended by UK national policy.

Prediction of Relapse After Cognitive-Behavioral Treatment of Gambling Disorder in Individuals With Chronic Schizophrenia: A Survival Analysis

Gambling disorder (GD) in individuals with chronic schizophrenia is relevant because there are higher rates of GD in schizophrenic populations (10%) than in the nonschizophrenic population (1%-5%). In addition, these patients have more severe alcohol use disorder (i.e., meeting at least 6 of the DSM-5 11 criteria for diagnosis of this disorder), higher depression scores, a poor adherence to treatment, and more frequent use of outpatient mental health care. One of the main problems in GD is therapeutic failure (defined as three or more lapse episodes during treatment) or relapse (three or more lapse episodes in the follow-up period). Predicting a relapse of GD in individuals with chronic schizophrenia can be useful in targeting the patients for aftercare services. The main aim of this study was to estimate the time to a GD relapse (survival rate) and to evaluate some of the qualitative and quantitative variables related to a GD relapse by a survival analysis. The sample consisted of 35 patients with chronic schizophrenia and GD who were treated with pharmacological and cognitive-behavioral therapy. The therapeutic failure rate in the treatment period was 43%, and it was associated with the number of episodes of schizophrenia, the age of gambling onset, and the age of the patients. The relapse rate in the follow-up period was 32%, and it was associated with the patients' age, educational level, and weekly allowance. The implications of this study for future research are discussed.

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.

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.

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.

Combining evidence-based practices for improved behavioral outcomes: a demonstration project

This article describes a demonstration project carried out by a special team at a mental health agency serving adults with a serious psychiatric condition. The project consisted of combining the evidence-based practices of cognitive therapy, Motivational Interviewing and Stages of Change with Social Role Theory and the Chronic Care Model that were the organizing concepts of the agency's assessment and treatment program. Measures of the results of clients' improved mental health and social functioning indicated the successful use of this combination.

Can 12 step fellowship and cognitive behaviour therapy work together? A hypothesis on an integrated treatment approach for mild dual diagnosis

Purpose

The purpose of this paper is to investigate research in the field of addictions utilising CBT and 12 step fellowship methods and to create an evidence base for an integrated treatment method utilising both approaches.

Design/methodology/approach

Research on CBT and 12 step fellowships and their current applications in addiction treatment are presented. Models of severe mental illness are referenced and the use of directive and guided referrals are used as a basis to build the paper's hypothesis. A mode of action how the treatments may work together is presented.

Findings

Findings indicate that guided treatment approaches for dual diagnosis are more likely to lead to long term therapeutic gains. Discussion involves the practical implications of this treatment and its ability to create a synergistic approach.

Practical implications

Implications include the potential for streamlined treatment approaches which have the potential to increase treatment adherence and outcomes. Implications, such as the joint use of social reinforcement techniques between 12 step fellowship approaches and CBT, are also discussed.

Originality/value

There is no previous research on the application of CBT and 12 step treatment modalities working together in a structured manner. Previous work has focussed primarily on severe mental illness. The current paper aims to provide an approach to treatment which utilises several modes of treatment to create more robust treatments for people suffering from dual diagnoses.

Reflecting on the delivery of a structured alcohol and drug group in a medium‐secure forensic unit

Purpose

This review aims to discuss the planning, implementation and evaluation of a 24‐session alcohol and drug group for eight service users, based on the Behavioural Treatment for Substance Abuse in Severe and Persistent Mental Illness Model (BTSAS), delivered by a group of multi‐disciplinary staff in a medium secure forensic setting.

Design/methodology/approach

Evaluation tools were completed pre‐ and post‐group to measure attendee outcomes and perceptions of their group experience.

Findings

The group programme was well received, although adaptations to meet specific medium‐secure needs will be required for future group work.

Practical implications

The development and implementation of the group has raised awareness within the medium‐secure setting, facilitating a less punitive and more collaborative response.

Originality/value

The paper highlights interventions to support the medium‐secure setting to develop a more pragmatic bespoke response to meet alcohol and drug needs.

Dual diagnosis in a Dublin tertiary addiction centre - A cross-sectional study

OBJECTIVES

To address the relative dearth of information relating to the prevalence of psychiatric co-morbidity among attenders of community addiction facilities.

METHODS

We carried out a cross-sectional study of clients attending a Dublin-based tertiary addiction centre to assess the rates of psychiatric co-morbidity, determine the demographic and clinical variables and evaluate the level of contact with allied medical care especially primary care and community psychiatric services. Information was sourced from available patient records.

RESULTS

Forty-three per cent of the clients (n = 59), attending the service were found to have a chart diagnosis of psychiatric disorder. Only 15% of these were in contact with community psychiatric services.

CONCLUSIONS

This high rate of psychiatric co-morbidity has implications in terms of funding, training and service delivery.

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.