Gilchrist, G. (2012), "Improving access, assessment and treatment response for substance abusers with co-occurring mental health problems", Advances in Dual Diagnosis, Vol. 5 No. 1. https://doi.org/10.1108/add.2012.54105aaa.001Download as .RIS
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Improving access, assessment and treatment response for substance abusers with co-occurring mental health problems
Article Type: Editorial From: Advances in Dual Diagnosis, Volume 5, Issue 1
In the UK, the need to improve access to substance abuse treatment and the difficulty in accessing mental health services for problem substance abusers has recently been highlighted (NICE, 2011). “Mainstreaming” of integrated care delivered within mental health services for patients with “dual-diagnosis” has been recommended (DH, 2002). However, such mainstreaming is only suggested for substance abusers with severe and enduring mental health problems. The most common mental disorders experienced by substance abusers are depression and anxiety (Torrens et al., 2011). Changing Habits (Care Services Improvement Partnership, 2006) recognises the need to improve access to treatment for those experiencing the co-occurrence of substance abuse and common mental health problems, and the “Dual Diagnosis Good Practice Guidance” (DH, 2002) recommends that mental health services should “work closely with specialist substance misuse services to ensure that care is well co-ordinated”.
Indeed, the King’s Fund and the Centre for Mental Health report Long-term Conditions and Mental Health: The Cost of Co-morbidities (Naylor et al., 2012) published a recently stressed the relationship between long-term physical health conditions and co-occurring mental health problems that frequently resulted in poorer health outcomes and reduced quality of life for such patients. While the report does not consider substance abuse, the argument remains the same; that the management of people with long-term conditions could be enhanced by “integrating mental health support with primary care and chronic disease management programmes”.
The first paper in the current issue describes substance abuse treatment access barriers identified by substance abuse treatment service users, and staff from specialist addiction services, general psychiatry and primary care in Barcelona, Spain. In this large qualitative study, Fonseca et al. (pages 5-14) describe the main barriers to accessing treatment; including patient’s lack of motivation, stigma, negative staff attitudes, and the need to raise the awareness about services. Staff highlighted the need for integration and co-ordination of mental health and addiction treatment sectors, and collaboration and joint working among specialist addiction, general psychiatry and primary care sectors to improve access, identification and management of those with co-occurring disorders. The authors also highlighted the need for joint referral protocols between specialist addiction and mental health sectors to improve access for patients with co-occurring disorders.
In the second paper of this issue, Hughes et al. (pages 15-22) ask “is the mental health workforce equipped and supported to meet complex needs?” They conducted a survey among acute mental health staff in four NHS Regional Acute Services in Coventry, England to identify workforce development issues. Findings in relation to managing patients with co-occurring drug and alcohol disorders are presented. Deficits around assessment and the need for training in therapeutic skills to effectively manage such patients are described.
The importance of access and assessment for patients with co-occurring mental health and substance abuse disorders is also prominent in the third paper. Mental health services may exclude substance abusers without a primary mental health disorder, however, the diagnosis of primary versus secondary disorders or independent versus substance-induced disorders is complicated (Torrens et al., 2011). In Melbourne, Australia, Lee et al. (pages 23-31) examined the temporal sequencing of methamphetamine use and the onset of mental health problems among a sample of dependent methamphetamine users and discuss the implications for treatment for this group. They found that of those who had a mental health diagnosis or had been in treatment for mental health problems, these problems began around a year after regular methamphetamine use for the majority (72 per cent). Interestingly, those receiving treatment for their mental health engaged in treatment for methamphetamine use earlier; thus highlighting the potential usefulness of co-ordination and integration of mental health and substance abuse treatment in enhancing recognition and treatment access for patients with co-occurring disorders. The authors believe there is limited evidence “outside the area of psychotic disorders that suggest integrated treatment is an effective model and […] suggest that a stepped care model is more appropriate” (Kay-Lambkin et al., 2010).
Finally in the last paper in this issue, Walls and Hamilton (pages 32-37) outline the difficulties with current assessment tools for use with Deaf people who have a co-occurring mental health and substance abuse problem including: problems of cognition, with understanding of concepts and with material not being accessible in an appropriate format for deaf people. The authors describe the cognitive-behavioural integrated treatment model (Graham and Copello, 2004) as a potentially suitable interview to working with deaf patients. They comment that this semi-structured interview process is “flexible and allows discussion of terms and concepts. It also allows the use of various media, e.g. pictures, etc. to explore ideas. This is more suitable to work with Deaf individuals, especially those with minimal language skills”.
I would like to take this opportunity to invite readers to submit papers to Advances in Dual Diagnosis. We are currently preparing special issues on gender, and on treatment approaches for common mental disorders among substance abusers and would welcome manuscripts in these areas.
Care Services Improvement Partnership (2006), Changing Habits, North West Development Centre, London
Department of Health (2002), Mental Health Policy Implementation Guide: Dual Diagnosis Good Practice Guide, DH, London
Graham, H. and Copello, A. (2004), Cognitive-behavioural Integrated Treatment (C-BIT): A Treatment Manual for Substance Misuse in People with Severe Mental Health Problems, Wiley, Hoboken, NJ
Kay-Lambkin, F., Baker, A., McKetin, R. and Lee, N. (2010), “Stepping through treatment: reflections on an adaptive treatment strategy among methamphetamine users with depression”, Drug and Alcohol Review, Vol. 29, pp. 475–82
National Institute for Clinical Excellence (2011), “NICE clinical guideline 115”, Alcohol-use Disorders. Diagnosis, Assessment and Management of Harmful Drinking and Alcohol Dependence, National Institute for Health and Clinical Excellence, London
Naylor, C., Parsonage, M., McDaid, D., Knapp, M., Fossey, M. and Galea, A. (2012), Long-term Conditions and Mental Health: The Cost of Co-morbidities, The King’s Fund and Centre for Mental Health, London
Torrens, M., Gilchrist, G. and Domingo, A. (2011), “Psychiatric comorbidity in illicit drug users: substance induced versus independent disorders”, Drug and Alcohol Dependence, Vol. 113, pp. 147–56