Understanding and addressing obstacles to recovery for people with a dual diagnosis

Citation

Hughes, L. and Gilchrist, G. (2013), "Understanding and addressing obstacles to recovery for people with a dual diagnosis", Advances in Dual Diagnosis, Vol. 6 No. 1. https://doi.org/10.1108/add.2013.54106aaa.001

Understanding and addressing obstacles to recovery for people with a dual diagnosis

Article Type: Editorial From: Advances in Dual Diagnosis, Volume 6, Issue 1

2012 ended with an announcement that the UK Home Affairs Select Committee were to undertake a comprehensive review of the UK Government’s 2010 drugs strategy, including assessing the impact on treatment provision following the move of functions of the National Treatment Agency (NTA) for Substance Misuse to Public Health England. The 2010 strategy has a strong emphasis on recovery from drug or alcohol misuse and the need for a culture shift from the current treatment system to a recovery system where treatment is only the first step to recovery. Such a shift requires greater engagement with housing, employment, children’s services, families, and communities (NTA, 2011). Following on from Recovery-Orientated Drug Treatment: An Interim Report (NTA, 2011), the NTA has recently published Turning Evidence into Practice: Helping Clients to Access and Engage with Mutual Aid (NTA, 2013) a guide for commissioners and providers to assist them develop their services to be more recovery orientated. One evidence based approach for enhancing recovery is the provision of mutual aid (NICE, 2007, 2011) such as peer support groups and 12-step facilitation, in addition to treatment.

The fact that comorbid problems impede recovery. Therefore, a holistic recovery approach should take into account the level of mental health problems that exist in people with substance misuse and equally, substance misuse issues need to be addressed for those with mental health problems. Ten years down the line from the Dual Diagnosis Good Practice Guidance (Department of Health, 2002), which called for more integration between substance misuse and mental health treatment services, we still operate in a system that divides drug and alcohol treatment from mental health which further exacerbates the barriers to effective treatment. In “Reflections on capacity-building initiatives in an Australian state” (pp. 24-33), Roberts et al. provide an example of how mutual cooperation at a local level can overcome some of these issues. They evaluate the impact of Australia’s “no wrong door” policy for dual diagnosis initiatives and describe barriers and enablers to integration at a case study level. They conclude by describing the challenges that remain to overcome the history of separation and cultural clashes between mental health and substance misuse services.

Similarly, in our “divided world” nurses receive little training either pre- or post-registration on management and treatment of substance misuse (O’Gara, 2005; O’Gara et al., 2005; Hughes et al., 2008). This needs to be addressed as the prevalence of alcohol is especially high in non-specialist settings such as emergency rooms and psychiatric inpatient units (Phillips and Johnson, 2003). Failure to understand the medical care required for the management of alcohol dependence can have fatal consequences. Nurse need to be able to assess and respond appropriately to alcohol withdrawals and see it as a potential medical emergency (NICE, 2011). Maruca and Diaz (pp. 14-23), “Does simulation enhance undergraduate psychiatric nursing education? A formative assessment”, present a novel education method to ensure that nurses are better trained to address dual diagnosis, and therefore ensuring that the care of such patients is evidence based.

There is a perception that people with dual diagnosis are less treatment adherent than those without substance misuse, however Marienfeld and Rosenheck dispute this in a large-scale study of veterans in the USA, “National psychotropic prescription dispensation among dually diagnosed patients” (pp. 34-44). They analysed dispensing of prescriptions and found that dually diagnosed veterans with severe mental illnesses reported greater use of mental health services, greater psychotropic prescription and more additional comorbidities than other veterans. The authors conclude by stressing the need to address overall complexity of needs among veterans.

The final paper in this issue returns to the theme of barriers to recovery. In a study of “Sub-clinical trauma in the treatment of partner violent offenders with substance dependence”, Crane et al. (pp. 5-13) highlight that substance misusing men who perpetrate intimate partner violence often have a history of trauma themselves, that may result in poorer treatment outcomes and therefore a potential difficulty in achieving recovery. The authors describe how existing treatment models could be modified to better serve individuals with co-existing mental health and substance misuse problems on their recovery journey.

Liz Hughes, Gail Gilchrist