Psychosocial approaches to dual diagnosis

Recent research elucidates many aspects of the problem of co-occurring substance use disorder (SUD) in patients with severe mental illness, which is often termed dual diagnosis. This paper provides a brief overview of current research on the epidemiology, adverse consequences, and phenomenology of dual diagnosis, followed by a more extensive review of current approaches to services, assessment, and treatment. Accumulating evidence shows that comorbid SUD is quite common among individuals with severe mental illness and that these individuals suffer serious adverse consequences of SUD. The research further suggests that traditional, separate services for individuals with dual disorders are ineffective, and that integrated treatment programs, which combine mental health and substance abuse interventions, offer more promise. In addition to a comprehensive integration of services, successful programs include assessment, assertive case management, motivational interventions for patients who do not recognize the need for substance abuse treatment, behavioral interventions for those who are trying to attain or maintain abstinence, family interventions, housing, rehabilitation, and psychopharmacology. Further research is needed on the organization and financing of dual-diagnosis services and on specific components of the integrated treatment model, such as group treatments, family interventions, and housing approaches.     

Service use and costs of people with dual diagnosis in South London

OBJECTIVE: To compare the service use and costs of individuals who have a dual diagnosis of psychosis and substance abuse with those who have a diagnosis of psychosis but no substance abuse. METHOD: Patients with psychosis were identified and a representative sample were interviewed. Six-month service use was measured and costs calculated. Regression models were developed to predict costs from background characteristics and dual diagnosis status. RESULTS: A greater proportion of the patients with dual diagnosis used community psychiatric nurses, in-patient care and the emergency clinic. The regression analysis revealed that dual diagnosis patients had significantly higher 'core' psychiatric service costs (a difference of pound sterling 1362) and non-accommodation service costs (pound sterling 1360) than non-dual-diagnosis patients. The difference when all services were analysed was pound sterling 1046, but this was not statistically significant. CONCLUSION: Specific interventions for dual diagnosis patients should be introduced and assessed in terms of individual outcomes, service use and costs.     

Reflections on a Service User Perspective in Supporting Persons with Dual Diagnosis: the Case of Villa Voortman

Inclusive citizenship is an important concept in today’s mental health care. Still, persons with co-occurring substance use problems and psychiatric problems seem to fall through the cracks of existing (community) treatment services. At the same time, they are the persons least asked for their opinions as service users. This commentary sheds light on Villa Voortman, an innovative community-based outpatient treatment service for persons with dual diagnosis in Ghent (Belgium) that gives a central position to user perspectives in its daily practice.     

Engaging with,and understanding children whose parents have a dual diagnosis

Background: The perspective of children whose parents have a mental health and a substance use disorder (dual diagnosis) are rarely considered in either research or clinical practice. This study sought to (i) identify the issues when engaging children whose parents have a dual diagnosis into research, and (ii) present their needs and preferred supports. Method: Semi‐structured, qualitative interviews were conducted with 12 children whose parent had a dual diagnosis. Analyses involved thematic analysis, inter‐rater reliability and respondent validation. Results: Building trust with parents was crucial to gain access to children. Children described the importance of family, the secrecy around their parent’s substance abuse, and various maladaptive coping strategies. Children requested more positive times in their families and specific support for their parent’s substance abuse. Conclusion: The primacy of family in the child’s life is highlighted. The need to acknowledge and work with the individual needs of children and parents, as well as family dynamics, is indicated.     

Community integration of persons with psychiatric disabilities in supportive independent housing: a conceptual model and methodological considerations

Despite the consensus regarding community integration as a major goal of mental health policy and the emergence of supportive independent housing as a critical component of community mental health services, mental health services research has not examined the extent to which housing and service characteristics are associated with community integration of persons with psychiatric disabilities in supportive independent housing. The main goal of this paper is to propose a conceptual model of factors influencing community integration that takes into account the differential configuration of housing setting and support structure in supportive independent housing. The conceptual model encompasses a multidimensional conceptualization of community integration and considers an array of housing and service characteristics that are potentially relevant determinants of community integration. On the basis of the proposed model, this paper outlines the methodological considerations for future research with regard to measurement, research designs, and statistical models.     

The Mentally Ill in Jails and Prisons: Towards an Integrated Model of Prevention

Jails and prisons have become a final destination for persons with severe mental illness in America. Addiction, homelessness, and fragmentation of services have contributed to the problem, and have underscored the need for new models of service delivery. Project Link is a university-led consortium of five community agencies in Monroe County, New York that spans healthcare, social service and criminal justice systems. The program features a mobile treatment team with a forensic psychiatrist, a dual diagnosis treatment residence, and culturally competent staff. This paper discusses the importance of service integration in preventing jail and hospital recidivism, and describes steps that Project Link has taken towards integrating healthcare, criminal justice, and social services. Results from a preliminary evaluation suggest that Project Link may be effective in reducing recidivism and in improving community adjustment among severely mentally ill patients with histories of arrest and incarceration.     

Students with Dual Diagnosis: Can School-Based Mental Health Services Play a Role?

ABSTRACT

This article describes and investigates initial findings from the Esperanza Mental Health Services (EMHS) Program, which is an intensive outpatient program that provides individual and group mental health services for students with “dual diagnosis” or developmental disabilities and co-occurring mental health problems. Previous research substantiates that the mental health needs of this population are significant, yet often go unaddressed in school settings. Preliminary outcomes for a sample of 61 children ages 4–22 suggest improvements in important school indicators, such as suspensions and absences during the year of program implementation, as well as positive changes in parent-reported mental health functioning. Lastly, parent satisfaction regarding these services and supports was high. The implications of these results for a proposed school-based mental health service delivery model within a multi-tiered system of prevention and intervention are discussed.     

Service Use and Perceived Service Effectiveness for People with Intellectual Disability and Dual Diagnosis in Israel

Introduction: Studies regarding the use of support services for persons with a dual diagnosis of intellectual disability and psychopathology are scarce; even fewer have focused on children and young adults. The aim of the present study, conducted in Israel, was to compare the use of support services and their perceived effectiveness by families of children and young adults with intellectual disability (ID) and with dual diagnosis. Methods: Data were collected from 195 family (parental) caregivers of individuals with ID or dual diagnosis, aged 10–30. Using a structured questionnaire, family caregivers reported on the use of support services and on their perceived effectiveness. Results: Findings showed that in addition to the obvious mental health services, caregivers of individuals with ID and dual diagnosis report using a range of services and resources. Caregivers of persons diagnosed only with ID perceived some of the mental health services as being more effective than did caregivers of individuals with dual diagnosis. Conclusion: We advocate for enhanced training for professionals working with individuals with dual diagnosis within all services. Furthermore, parents need to be supported in their search for services for their child and in dealing with complex situations. In addition, more research is needed to identify why individuals with dual diagnosis may not benefit from current mental health services and, in line with this, develop more effective services. Finally, we advocate for the establishment of a one-stop shop that can provide for the comprehensive needs of these individuals within one center.     

Psychopathology in dual diagnosis and non-addicted schizophrenics – are there differences?

In a previous publication we reported lifetime and 3-month prevalence estimates for substance use in two large samples of schizophrenic inpatients (Soyka et al. 1993). A subsequent analysis of psychopathological findings assessed by means of the AMDP Manual (Guy and Ban 1982) in schizophrenic inpatients of the Haar Mental State Hospital (N=447), in whom a lifetime prevalence for substance use of 42.9 % (3-month prevalence 29 %) had been reported, was performed. While the overall differences between substance using (dual diagnosis) and nonusing schizophrenics were small, dual diagnosis patients in general reported more positive symptoms, especially more intense hallucinations. These differences could basically be demonstrated in patients with current (3-month) substance use on admission but not on discharge possibly as a result of substance use. Most marked and highly significant results were found with respect to previous suicide attempts and delinquency which were more prevalent in dual diagnosis schizophrenics. Results of this study indicate that dual diagnosis patients compared to other schizophrenics represent a more disturbed patient group. Implications for the self-medication hypothesis for substance use in schizophrenia and future research in this area are discussed. Received: 8 January 2001 / Accepted: 6 September 2001     

Lesbian,Gay, Bisexual,and Transgender (LGBT) Service Members: Life After Don’t Ask,Don’t Tell

Lesbian, gay, and bisexual service members can serve openly in the military with the repeal of the Don’t Ask, Don’t Tell policy. The fate of transgender service members remains uncertain as the policy preventing them from serving in the military remains under review. The health care needs of these populations remain for the most part unknown, with total acceptance and integration in the military yet to be achieved. In this paper, we review the literature on the health care needs of lesbian, gay, bisexual, and transgender (LGBT) service members, relying heavily on what is known about LGBT civilian and veteran populations. Significant research gaps about the health care needs of LGBT service members are identified, along with recommendations for closing those gaps. In addition, recommendations for improving LGBT acceptance and integration within the military are provided.     

Implementing dual diagnosis services for clients with severe mental illness

After 20 years of development and research, dual diagnosis services for clients with severe mental illness are emerging as an evidence-based practice. Effective dual diagnosis programs combine mental health and substance abuse interventions that are tailored for the complex needs of clients with comorbid disorders. The authors describe the critical components of effective programs, which include a comprehensive, long-term, staged approach to recovery; assertive outreach; motivational interventions; provision of help to clients in acquiring skills and supports to manage both illnesses and to pursue functional goals; and cultural sensitivity and competence. Many state mental health systems are implementing dual diagnosis services, but high-quality services are rare. The authors provide an overview of the numerous barriers to implementation and describe implementation strategies to overcome the barriers. Current approaches to implementing dual diagnosis programs involve organizational and financing changes at the policy level, clarity of program mission with structural changes to support dual diagnosis services, training and supervision for clinicians, and dissemination of accurate information to consumers and families to support understanding, demand, and advocacy.     

Issues in the identification of comorbidity of mental retardation and psychopathology in a multicultural context

Identification of the comorbidity of mental retardation and psychopathology in a multicultural setting raises manifold difficulties. The present study explored the sampling and identification issues implicated in estimating the prevalence of this dual diagnosis in a South African clinic sample. The relations between the prevalence of dual diagnosis and socioeconomic status, gender, and severity level of retardation were investigated. The detection rate of 4.36% was significantly lower than that of other studies. Prevalence was found to be greater in areas of high socioeconomic status, among males, and among less severely retarded individuals. Implications of these findings for cross-cultural studies and for allocation of service resources for patients with dual diagnosis are considered. Accepted: 27 August 1998     

Client-level Measures of Services Integration Among Chronically Homeless Adults

Introduction  While several major studies have examined services integration at the system or interagency level, there has been far less effort to measure the integration of services at the client-level and its correlates. Methods  This study presents three client-level measures of services integration, two objective measures, representing the proportion of needed services received and the number of outpatient services received by each client, and one subjective measure, a five-item scale measuring perceived coordination of care among clients’ service providers. Data from the evaluation of the collaborative initiative to help end chronic homelessness (CICH) are used to examine bivariate and multivariate relationships of these three client-level measures to two system-level measures of services integration, one addressing interagency services coordination/planning and the other interagency trust/respect as well as to baseline client characteristics among 734 chronically homeless adults in 11 cities. Results  Client-level measures of service integration were not strongly associated to each other or to the system-level measures, except for weak associations (r = 0.10) between one objective client measure and the system-level measure of service coordination and planning, and another between client-level use of outpatient mental health services and system-level trust and respect. Multivariate analysis showed that clients who received a greater array of needed services received more service overall and were more likely to have a diagnosis of PTSD and more medical problems, but less serious alcohol problems. Clients who reported more outpatient mental health and substance abuse visits were significantly more likely to be married, to be veterans, to have more serious drug problems, and to be dually diagnosed. Clients with more serious drug problems reported poorer coordination among their service providers on the subjective measure of client-level service integration. Conclusion  Three client-level measures of services integration were, at best, weakly associated with measures of system-level integration. Positive associations between client-level measures of integration and health status, outpatient service use and negative relationships with indicators of substance abuse suggest they may usefully represent the experiences of chronically homeless clients, even though they are not strongly related to system-level measures.     

Quality of life is not only for people served – it is also for staff: the Multi-Focal Approach

Background To date, little attention has been given to the concept of quality of life around human resources employment programmes for staff working with persons with a dual diagnosis. Method This article describes the implementation of quality of life principles to service provision for people with dual diagnosis and its application to staff training. Results This type of experiential training facilitated change in staff's attitude to, and treatment of, the people served. Conclusion Human resources development programmes should be based on the same core quality of life principles and domains that guide service delivery on the individual level.     

Organizational Development Strategies for Integrating Mental Health Services

The recent debates about health care reform have focused attention on the need to develop organized systems of care capable of delivering comprehensive services which are coordinated or integrated. Achieving service integration has emerged as a central and pressing objective in most mental health systems in response to existing difficulties with fragmentation of care. However, attempts at service integration often fail at the implementation stage as provider agencies zealously guard their organizational boundaries and struggle with each other for power and control. In this article, the authors formulate an organizational development approach to service integration that focuses on reducing the rigid maintenance of agency boundaries by developing informal networks among staff of local provider agencies. Eight strategies, drawn from the research literature on services integration and recently implemented by a local mental health authority, are described as potential tools for use by systems managers in accomplishing these goals.     

The treatment capabilities of psychiatric emergency services

The author describes the treatment capabilities of a psychiatric emergency service. Psychiatric emergency facilities have become an integral part of general hospitals and the mental health system, and are used increasingly by patients. The author defines the treatment goals of psychiatric emergency care as, (1) symptomatic relief, (2) maintenance of ongoing treatment, and (3) referral and facilitation for entering treatment. The treatment techniques include an integration of psychologic, pharmacologic, and physical management principles. The qualities needed by an emergency service clinician to work in such a setting are described. Implications for training and research are discussed.     

Addictions Services Treatment Services and Service Delivery Models for Dually Diagnosed Clients: Variations Across Mental Health and Substance AbuseProviders

This paper reports on a survey of administrators (n = 26) and staff (n = 248) in 10 mental health and 16 substance abuse programs in Los Angeles County providing services to individuals with co-occurring disorders. Although half or more of the administrators and staff reported that their programs had some degree of on-site service integration, there was a lack of agreement within most programs as to the extent of integration. Characteristics of services provided and interactions with other service providers are also examined. Future research is needed regarding the divergent perceptions of administrators and staff and their relationship to treatment outcomes.     

A case mix procedure for matching the clinical characteristics of patients with dual disorders to planned treatment and treatment costs

A procedure for matching the clinical characteristics of patients with a dual substance abuse psychiatric disorder to planned treatment resource consumption is described. The procedure uses current standards and practices within the mental health literature on dual diagnosed patients, providing an empirical basis for quality assurance, utilization review, and program evaluation. These procedures permit an empirical linking of clinical service performance to the costs of clinical resources, thereby providing a means of: (a) evaluating program costs in terms of the specific clinical characteristics of patients and (b) planning budgets based on the patients' clinical needs. The methods are sufficiently flexible so that as new clinical research recommend changes in assessment and treatment, the case mix definitions and evaluation procedures can be easily modified.     

Dual diagnosis in the suburbs: prevalence, need, and in-patient service use

  Background: Previous research has found comorbid severe mental illness and substance misuse (dual diagnosis) to be highly prevalent and to be associated with serious clinical and social problems, and increased service use in inner-city populations. The present study measures the prevalence of dual diagnosis, patterns of substance misuse, and associated in-patient use in a more demographically representative population in a suburban area of South London Method: We identified representative prevalent cases with psychotic illnesses who had been in contact with services in a geographically defined catchment area in Croydon over the previous 6 months. Cases of alcohol or substance misuse and dependence were identified through standardised interviews with patients and keyworkers, and socio- demographic and in-patient psychiatric service use data were also recorded. Results: Sixty-one of the 124 cases identified were randomly selected for interview, of whom 66% responded (N = 40). The prevalence rates of dual diagnosis (DD) observed were 33% (95% CI 18–47%) for any substance misuse, 20% (95% CI 8–32%) for alcohol misuse only, 5% (95% CI −16 to 26%) for drug misuse only, and 8% (95% CI −0.7 to 16%) for both drug and alcohol misuse. A lifetime history of any illicit drug use was observed in 35% of the sample (95% CI 20–50%). Patients who misuse alcohol and drugs were not found to be more likely to have been admitted to hospital in the previous 2 years, with little difference being observed between DD and psychosis-only patients in the mean number of in-patient admissions in this period (mean difference 0.25, 95% CI for difference −1.5 to 2.0). However, the DD patients were found to have spent on average over twice as long in hospital as other psychotic in-patients over the previous 2 years (mean difference 67.3 days, 95% CI for difference −205.9 to 71.2 days). DD patients were also found to have a greater number of unmet areas of need than the psychosis-only patients, which included accommodation, daytime activity, and social life, as well as substance misuse. Conclusions: The prevalence of substance misuse in patients with severe mental disorders in a suburban area is about as high as that for similar patients in inner-city London. While DD patients are not admitted more often than patients with psychosis alone, they have double the length of in-patient stay, which may be attributable to higher levels of unmet need. Accepted: 6 April 2000