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Practice

Studies examining specific treatments for specific populations have been conducted to guide services and practitioners in their choice and allocation of treatment modalities. A major study (Project MATCH 1997) for example attempted to match individual treatments to specific substance disorders with no conclusive findings that could translate into practice. However, numerous studies (see Table 2, Page 24) have been successful in demonstrating effective combinations of substance misuse and mental health interventions in different sub groups of dually diagnosed individuals.

Table 2, Page 24, summarises relevant research that has demonstrated the feasibility of conventional mental health treatment regardless of substance misuse being present. Limitations were often evident. For instance the inconsistent descriptions of study outcomes made ‘like for like’ comparison difficult and the attrition rates were reportedly high. Whilst this latter point was not highlighted as a major research problem it could be construed as a characteristic of the client group worthy of further mention and research in itself as disengagement is a frequently reported issue of working with people who are dually diagnosed (DH 2002; SCMH 1998).

In reviewing evidence based practice in dual diagnosis I have included both demonstrably effective interventions and those that are regarded by opinion leaders as promising. Few of the reviewed studies with the exception of the ten year longitudinal

show sustained positive changes in substance use or mental health. However, the relevant elements of studies pertaining to the generating of practitioner and service user optimism, which in turn improves engagement (Mueser et al 1995b) are discussed.

Brown et al (1997), for instance delivered 8 sessions of Cognitive Behavioural Therapy (CBT) in alcohol dependence. Not only did depressive symptoms diminish but alcohol reductions appeared to have been mediated through improved mental health. This suggests alcohol treatment among people with depression requires an integral mental health intervention (CBT for depression in this case).

Further pharmacological therapy appears worthwhile, as either a singular treatment or in conjunction with others. Among alcohol dependant and depressive participants Salloum et al (1998) identified naltrexone, an anti-opioid craving compound, as reducing the frequency and strength of urges to drink alcohol which resulted in reduced consumption. No changes in depressive symptoms were significant, despite this, the sense that combinations of ‘promising’ treatments prevails. Petrakis et al

(1998) found antidepressant therapy (fluoxetine) to be ineffective among opioid using participants in a randomised controlled trial held over 12 weeks. This all reinforces the assertion by the Project MATCH (1997) researchers that individual responses to specific treatment modalities vary so extensively that predicting positive responses, or tailoring treatments may not be feasible. A heuristic approach based upon the comprehensive range of treatments, combined or singular, appears more realistic.

Research conducted by Barrowclough et al (2001) and by Haddock et al (2003) has relevance here by illustrating improvements through psychosocial measures. The Barrowclough et al study (2001) devised an integrated treatment programme of cognitive behavioural intervention, family intervention and motivational interviewing and compared it to conventional mental health treatment. Each aspect of the integrated treatment contained stress management, the teaching of communication and problem solving skills and information about illness, medication, stress and substance use. Integrated treatment demonstrated improvements in positive symptoms and reductions in drinking or drug using days. Mental health relapse rates reduced also. Interestingly those from the integrated treatment group who did relapse experienced

the same severity and duration of relapse as the non-treatment group. Generally the study conveys optimism that mental health intervention is not rendered ineffective by the presence of substance use. The study fails to isolate the power of each treatment domain however Haddock et al (2003) extended the study and were able to distinguish motivational interviewing and cognitive behavioural intervention as a probable significant pairing.

In a smaller sample of people with schizophrenia Drake et al (1993) followed up 18 participants over 4 years who were in receipt of assertive case management. Participants received behaviourally orientated substance use counselling, medication management and housing support. Whilst there was no comparison group substantial reductions in substance use occurred, with 11 sustaining abstinence for periods up to 6 months.

Combined cognitive behavioural and pharmacological therapy could be effective given the impact of antidepressants, mood stabilisers and anxiolytics even when trialled as individual treatments within dual diagnosis groups. Nunes et al (1993) found almost half of a sample with primary major depression when given imipramine improved. Eighteen of these also reduced their alcohol consumption. The study was limited by size (60 participants) and lacked follow up but an opportunity to deliver additional intervention on improvement appeared to occur.

Overall dual diagnosis treatment would appear to have a promising foundation according to the studies cited above (Table 2). The studies show effective mental health intervention despite the presence of substance misuse. They show reductions rather that discontinuation (abstinence) of substance use strongly suggestive of the need for services to adopt harm reduction approaches (DH 2002; Hulse & Tait 2002).

Table 2. Summary of Effectiveness in Dual Diagnosis Treatments

Mental Health Substance Intervention Reference

Depression Alcohol CBT Brown et al 1997

Alcohol 12-Step and Relapse Prevention Irvin et al 1999 Opiates Anti-depressants Nunes et al 1998 Polydrug Psychosocial Intervention Charney et al 2001 Alcohol &

opiates

Naltrexone Salloum et al 1998

Anxiety Alcohol Buspirone Tollefson et al 1992

Anxiety & PTSD

Polydrug Exposure-based CBT Foa & Meadows 1997

Schizophrenia Polydrug CBT, Family Intervention and Motivational Interviewing Barrowclough et al 2001; Haddock et al 2003 Cannabis, cocaine and alcohol

Relapse Prevention and Social Skills Training

Shaner et al 2003

Polydrug Intensive Case Management Drake et al 1993 Alcohol Naltrexone Petrakis et al 2004 Bi-polar

Affective Disorder

Polydrug Medication Management and CBT

Schmitz et al 2002

Polydrug Group Therapy Weiss et al 2000 Polydrug Anti-convulsants and mood

stabilisers

Salloum et al 2005 Cocaine and

alcohol

Mood stabilisers Longoria et al 2004 Severe Mental

Illness (SMI) (diagnosis unspecified)

Polydrug Intensive Case Management, Activity Scheduling, Patient and Family Psycho-substance Use Education, Group Therapy and Self-help

Lehman et al 1993; Drake et al 2000

Polydrug Self Management Jerrell & Ridgely 1995

Polydrug Self-Management and Recovery Training

Brooks & Penn 2003

Cannabis Contingency Management (financial incentives)

Sigmon et al 2000 Polydrug Substance Misuse Information

Packs and Motivational Interviewing

Hulse & Tait 2002

Polydrug Patient and Family Education Herman et al 2000 Polydrug Inpatient Care, Medication and

Substance Education and Relapse Prevention

Moggi et al 1999

SMI With homelessness

Polydrug Housing Support, Integrated Substance Use and Mental Health Care

Services

Service considerations are broad and varied. For example primary care, secondary mental health care, substance misuse, criminal justice, education, children’s and young person’s services; wherever the client presents it appears a response is necessary that would begin to address both conditions simultaneously. Whether that means the service will (i) complete treatment independently, (ii) work in conjunction with other services or (iii) refer elsewhere is unclear. The lack of clarity concerning which service should address which need has caused resounding problems for many service users over the last decade or so (MIND 2004; Smith & Hucker 1993).

Department of Health guidance (DH 2002) and the National Treatment Agency for Substance Misuse (2002) have examined the three prevailing themes related to service delivery in detail and ascribed models accordingly. Firstly, the issue of services either perceiving themselves, or actually being, ill equipped to treat a second condition discourages them from addressing both substance misuse and mental health problems simultaneously (Rosenheck et al 2003). In this circumstance a sequential form of treatment occurs whereby service users get passed from one service to another. This form of care is often referred to as serialised and can be problematic because the two conditions are usually interactive in nature and not independent (Mueser et al 1998). Thus treatment for one condition alone is likely to be ineffective.

The second model of joint working relies upon service users engaging with both substance misuse and mental health services in a collaborative manner. The delivery of both substance misuse and mental health interventions is conducted by two or more agencies simultaneously (Johnson 1997). Liaison between services enables care to be coordinated, however the approach can be problematic since it expects engagement by service users to be with two distinct services. This can translate into different locations, organisational, treatment and care philosophies and, most problematic, poor communication. Where this approach has been successful substance misuse and mental health staff have shared knowledge and skills during the process (Graham & Maslin 1998; Ridgely et al 1998). Furthermore they have established stronger communication links, training programmes and joint working or referral protocols

(Maslin et al 2001). UK policy expects the parallel or joint working model to lead to increased integrated practice in the future.

The third model is that of integrated treatment. Here one service, agency or team delivers both intervention types to the service user. Studies from the US have led this trend (Drake et al 2006; Granholm et al 2003) indicating that practitioners who possess the necessary repertoire of skills for both conditions achieve greater levels of engagement and success. This also ameliorates some of the risks inherent in the client group that are compounded by poor engagement and multiple agency input (DH 2006a; SCMH 1998).

These 3 models of service delivery are simplistic in their representation of the themes the literature identifies. They are concerned with structures that will improve care delivery by defining dual diagnosis and its sub groups more precisely, allocating an effective treatment and then identifying which service or services should provide it.

Three key questions regarding care and treatment appear to emerge from the literature.

1. Which is the most appropriate treatment? (substitute prescribing of opiates, mental health inpatient care, outpatient cognitive behaviour therapy or housing support for example)

2. Where is the most appropriate service setting (primary care, drug service day treatment or psychiatric rehabilitation for example)

3. What is the most efficient model of service delivery (sequential, parallel or integrated)

Table 3 below (Research and Service Development Centre 1999) attempts to address these questions by allocating a lead service depending on condition severity. Where both conditions are equally serious one multi-skilled service takes responsibility and adopts an integrated approach. Regardless the CPA is cited as necessary in the effective provision and coordination of care for all those people experiencing serious mental health illness with or without substance misuse.

Table 3. Lead Agency by Severity of Substance Misuse or Mental Health Need

Key: Integrated Care = Assertive Outreach Service / Intensive Case Management. MH = Mental Health Service. SM = Substance Misuse Service.

To summarise this section it appears that service and treatment issues are both orientated around diagnosis. Treatment effectiveness research demonstrates pharmacological and psychological types are promising. This is encouraging because services could become less likely to exclude service users on the grounds that they will be unresponsive to an intervention due to the presence of a second condition. The organisation of services and their inclusion criteria, primarily diagnosis driven, are increasingly likely to consider collaborative or parallel (joint) working arrangements. This follows policy development and illustrates the formulas for decision making related to joint working and the subsequent allocation of a lead agency.

Overall services and treatments appear to be adjusting positively, through the various study findings and through policy development, to the increasing prevalence of dual diagnosis within both substance misuse and mental health services.

Chapter Summary

Dual diagnosis or co-existing mental illness and substance misuse is common throughout mental health service and substance use service settings. The prevalence is significant enough for UK Department of Health policy to recommend that services consider dual diagnosis to be the norm rather than the exception. Further to this, since the prevalence is high in both service settings, the definition of dual diagnosis must be Mental Health (MH) Substance Misuse (SM) Care

Specific / limited mental health need

Occasional / recreational substance use

MH only Specific / limited mental

health need

Frequent / dependent substance misuse

SM (lead) & MH

Moderate degree of mental health need

Occasional / recreational substance use

MH (lead) & SM

Moderate degree of mental health need

Frequent / dependent substance misuse

SM (lead) & MH Severe mental health

problems

Occasional / recreational substance use

MH only Severe mental health

problems

Frequent / dependent substance misuse

MH (lead) & SM or Integrated Care

focussed upon severe mental illness and substance misuse but has expanded to include less severe, but arguably equally distressing and costly illnesses, such as anxiety and depression.

The definition of dual diagnosis, referring to the simultaneous presence of both substance misuse and mental health problems, extends to a multifaceted model that considers the specifics of both presenting conditions as Figure 1 (Page 19) illustrates.

This review summarises the effective interventions and concludes that there is sufficient evidence to orientate aspects of intervention around harm reduction and information provision. Cognitive behavioural intervention, motivational interviewing and pharmacological therapy appear as credible models of treatment to follow. The review demonstrates that abstinence was achieved less frequently whereas significant reductions in use and consumption were observed (see Table 2, Page 24). This is strongly suggestive that the client group in general adopted harm reduction strategies rather than making wholesale change.

The issue of service provision and which service provides what intervention revealed itself as problematic but potentially solvable. Historically services had been focussed upon their core or specialist functions to the exclusion of individuals who presented with a second condition, particularly if the second condition (drug use or mental illness) was perceived to compromise treatment. Government policy has recommended services work jointly, share skills through such joint working practices and provide training to increase overall capability. Policy and research suggest also that joint working requires a lead agency to coordinate care as a way of preserving continuity; subsequently engagement issues have become very important in influencing the fundamentals of care.

Having presented the background literature, the next chapter describes the methodology I employed and how it related to meeting the specific aims of the study.

CHAPTER 3. METHODOLOGY

Introduction

The purpose of this chapter is to describe the research methodology used for the study and justify its selection. The chapter therefore contains discussions relating to research types and their applicability to the subject of enquiry and how grounded theory was finally chosen and executed.

This chapter is set out in six sections. Firstly, ‘choice of methodological approach’ which compares qualitative and quantitative research approaches and concludes with a description of grounded theory and its inherent qualities relating to social and human inquiry. Secondly, ‘the research context’ considers the practitioner-researcher role, the study context, its relevance to practice and the extent to which reflexivity was applicable. The third section, ‘research quality’ discusses various quality factors. I compare the key grounded theory tenets of fit, relevance, modifiability and workability to those of validity, reliability and generalisability; concepts found in conventional research approaches. Section four; in ‘data collection, analysis and theory development’ I outline the data collection and analysis in both procedural and theory generation terms. In addition an objective of the study, to develop educational information for services users, is examined. The fifth section presents what I did, and how, with regard to recruitment and data management. The sixth section is a discussion related to the methodology I employed and appraises the execution of my grounded theory approach.