Screening and intervention for mental health problems in alcohol and other drug settings: Can training change practitioner behaviour?

Barriers and Facilitators to the Implementation of the Pathways to Comorbidity Care (PCC) Training Package for the Management of Comorbid Mental Disorders in Drug and Alcohol Settings

Background: We have previously reported that the Pathways to Comorbidity Care (PCC) training program for alcohol and other drug (AOD) clinicians improved identification of comorbidity, self-efficacy, and attitudes toward screening and monitoring of comorbidity. We aimed to identify barriers and facilitators of implementation of the PCC training program in drug and alcohol settings. Methods: The PCC training program was implemented across 6 matched sites in Australia as per (1), and 20 clinicians received training. PCC training included seminar presentations, workshops conducted by local "clinical champions," individual clinical supervision, and access to an online information portal. We examined barriers and facilitators of implementation according to the Consolidated Framework for Implementation Research. Results: Barriers included inner setting (e.g., allocated time for learning) and characteristics of individuals (e.g., resistance). Facilitators included intervention characteristics (e.g., credible sources), inner setting (e.g., leadership), and outer setting domains (e.g., patient needs). Clinical champions were identified as an important component of the implementation process. Conclusions: Barriers included limited specific allocated time for learning. A credible clinical supervisor, strong leadership engagement and an active clinical champion were found to be facilitators of the PCC training program.

Implementation of a Multi-Modal Training Program for the Management of Comorbid Mental Disorders in Drug and Alcohol Settings: Pathways to Comorbidity Care (PCC)

OBJECTIVES

We aimed to evaluate the impact of the Pathways to Comorbidity Care (PCC) training program for alcohol and other drugs (AOD) clinicians to improve the management of comorbidity.

METHODS

A controlled before-and-after study using PCC training was conducted across 6 matched sites in Australia including 35 clinicians. Controls received standard workplace training. PCC training included seminar presentations, workshops conducted by local "clinical champions," individual clinical supervision, and access to an online information portal. We examined (a) identification (screening, assessment) and treatment (treatment, referral) of comorbidity in practice (N = 10 clinical files per clinician), (b) self-efficacy, knowledge, and attitudes of clinicians.

RESULTS

Significant improvements were observed in the PCC group but not the control sites with regards to the rate of clinical files showing identification of comorbidity (+50% v -12% change from baseline, respectively; [X² (1, N = 340) = 35.29, p = .01] with only a trend for improvements in the rate of files demonstrating treatment of comorbidity [X² (1, N = 340) = 10.45, p = .06]. There were significant improvements in the PCC relative to the control group for clinician self-efficacy, F(1,33) = 6.40, p = .02 and knowledge and attitudes of comorbidity monitoring, F(1,33) = 8.745, p = .01.

CONCLUSIONS

The PCC training package may help improve identification of comorbidity, self-efficacy, and attitudes toward screening and monitoring of comorbidity in drug and alcohol settings.

Disentangling psychopathology, substance use and dependence: a factor analysis

BACKGROUND

The notion that substance use can induce symptoms of depression and anxiety is influential in clinical practice, however questions remain about the empirical support for this hypothesis.

METHODS

We analysed mental health and substance dependence screening records for 280 outpatients in addictions treatment. Item-level data for depression (PHQ-9), anxiety (GAD-7), severity of dependence (SDS) and self-reported weekly substance use were studied using factor analysis and correlations. Symptom-level associations between substance use and psychological distress symptoms were examined after controlling for underlying levels of psychopathology.

RESULTS

We obtained a two-factor solution accounting for approximately 48 % of total variance. Depression and anxiety symptoms loaded onto a single psychopathology factor. Severity of dependence (SDS) and substance use measures loaded onto a distinct but correlated factor. After controlling for latent levels of psychopathology, the only remaining symptom-level associations were impaired concentration linked to cannabis use and irritability linked to alcohol use. Dependence (SDS) was prominently associated with depressive rumination, and negatively correlated with residual anxiety symptoms related to substance use (e.g., craving).

CONCLUSIONS

Overall, this analysis supports a psychological understanding of comorbidity; with dependence, craving, negative reinforcement and rumination as key variables.

Acceptability of mental health screening in routine addictions treatment

OBJECTIVE

The objective was to investigate patients' views on the application of case finding and screening methods for common mental disorders in an addiction treatment service.

METHOD

Qualitative thematic analysis of semistructured interviews with a purposive sample of 19 participants. Participants took part in diagnostic assessments (Revised Clinical Interview Schedule, CIS-R) and completed brief screening questionnaires for depression (Patient Health Questionnaire, PHQ-9) and anxiety (Generalized Anxiety Disorder Scale, GAD-7).

RESULTS

Patients generally favored the use of screening questionnaires to detect psychological problems, to monitor changes in symptoms and to facilitate targeted and specialist treatment. On the whole, respondents seemed to find such methods familiar and easy to use. The need for staff support was strongly emphasized, both to deal with the emotional impact of screening and to overcome accessibility and literacy problems. Good therapeutic rapport with practitioners came across as an important factor that influences patients' willingness to discuss psychological problems. Patient readiness and the timeliness of assessments were additional factors influencing acceptability. Participants discussed how psychological problems and substance misuse are associated in complex ways, often resulting in discrimination, poor recognition of such problems and limited access to treatment.

CONCLUSIONS

Mental health screening is generally acceptable to patients and can help to identify comorbid mental disorders in order to provide appropriate support and treatment.

Evaluation of a Culturally Adapted Training in Indigenous Mental Health and Wellbeing for the Alcohol and Other Drug Workforce

Indigenous Australians have high rates of mental illness comorbid with substance misuse. The complex needs of this client group create challenges for the alcohol and other drug (AOD) workforce. This paper describes the outcomes of an Indigenous-specific “Yarning about Mental Health” training for the AOD workforce to strengthen knowledge and skills in mental health approaches and in their engagement with Indigenous clients. The training provides culturally adapted strategies and tools for understanding mental health, promoting wellbeing, and delivering brief interventions in the substance misuse setting. A nonexperimental evaluation which incorporated pre-post questionnaires was conducted with workshop participants attending one of four trainings. The training was perceived to be highly appropriate and helpful in participants’ work with Indigenous AOD clients. There was significant improvement in confidence and knowledge related to Indigenous mental health and wellbeing and qualitative data supported these positive outcomes. This study supports the need to blend Indigenous concepts of health and wellbeing with non-Indigenous ways of understanding and treating illness in order to develop services which are appropriate to Indigenous peoples. It also suggests research is required to understand whether self-reported increases in knowledge and confidence can translate into behavioural changes in participants' teaching and practice of culturally competent care and to improved client outcomes.

Dual diagnosis capability after an AOD workforce initiative

Purpose

Dissemination of good practice information to practitioners is one of the great challenges of the substance abuse treatment sector. The authors' understanding of the process by which research is translated is limited, but a whole of workforce approach is considered best practice. This paper aims to examine organisational change as a result of a workforce capacity‐building program over six months.

Design/methodology/approach

A total of 195 staff (nine service managers, 39 supervisors and 147 clinicians) in 13 alcohol and other drug (AOD) services across Australia participated in mental health screening and brief intervention training using PsyCheck. PsyCheck is designed to detect and address common mental health symptoms among drug treatment clients. The Dual Diagnosis Capability in Addiction Treatment (DDCAT) index was used to measure capacity before and after training.

Findings

There was no significant difference between baseline and follow‐up DDCAT scores; however, the level of PsyCheck implementation indicated improvement in DDCAT scores.

Practical implications

The results show that where organisations implement the program successfully, capacity improves; where the program is not well implemented, capacity reduces. Successful implementers report a number of common elements: the screening tool was implemented into routine assessment; there was a single onsite “champion” supporting the implementation; and they worked with the staff and persisted with the implementation even where there was initial worker resistance.

Originality/value

This paper provides the opportunity to assess workforce capacity building and the feasibility of utilising the DCCAT to measure co‐occurring mental health and substance use disorders in Australian AOD services.