Professional Education in Co-occurring Disorders: Some Considerations towards Practice Development

The aims of this paper are to provide a brief overview of the types of education and training as well as a framework for co-occurring disorders courses at foundation and advanced levels. Mental health nurses encounter substance abuse problems as part of their workload and should be prepared adequately to work with individuals with the co-existence of mental health and substance abuse. However, co-occurring disorders are not often picked up by substance abuse or mental health services, indicating a need for improvement in ongoing professional development. The targeted audience for education and training in core competencies should be staff working in community mental health teams, inpatient services, assertive outreach teams, early intervention teams, crisis resolution teams, primary care, mental health services for older people, independent mental health projects, accommodation services, day care services, statutory drug and alcohol services, independent drug and alcohol service providers, and those working in hostel accommodations, housing, prison health care probation, and others in the criminal justice system. The theoretical and skills-based training will need to adopt a two-tiered approach as individuals working within mental health services will by definition need a higher emphasis on training around substance misuse and vice versa for individuals working in substance misuse services. One of the agenda items for interagency training is to challenge negative attitudes and prejudices around both mental health problems and substance misuse.     

Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) military mental health issues. Information on the wars' signature wounds: posttraumatic stress disorder and traumatic brain injury

This topic can be related to the nursing profession and the need to be better educated on military mental health. Since mood disorder, suicide, alcohol abuse, PTSD and TBI are evident in actively serving and returning service members, it is imperative to educate nurses and healthcare providers about these conditions, the available evidence-based treatments and referrals to programs for these signature OEF/OIF wounds. The authors encourage nurse educators to consider ways to include military mental health and other service-related health issues into nursing curricula and to use Veterans Administration and veterans-related healthcare facilities for clinical courses. As the wars in Afghanistan and Iraq continue into the foreseeable future, many veterans will be seen not only in VA facilities, but they will self-refer to academic and community hospitals, and psychiatric and rehabilitation centers. It is important for all nurses to be aware of the effects of PTSD, depression, suicide, substance abuse and TBI on our patients and to be effective advocates for quality care of veterans in all settings. Nurses need to advocate for screening and provision of mental health services in primary care settings. When such services are offered in primary care settings, it normalizes the care and the service member will more likely allow themselves to receive the care (Jones, 2004). All nurses must understand the price of war experienced by U.S. service members and their families, and in particular, the invisible wounds of war.     

Utilization of mental health and substance abuse services among homeless adults in Los Angeles

OBJECTIVES: Even though psychiatric disorders are disproportionately present among the homeless, little is known about the extent to which homeless people receive treatment for those problems or the factors that are associated with receiving treatment. This article examines utilization and predictors of mental health and substance abuse treatment among a community-based probability sample of homeless adults. METHODS: The data analyzed here were collected through face-to-face interviews with 1,563 homeless individuals. Bivariate analyses examined differences between homeless men and women in (1) the prevalence of major mental illnesses and substance dependence and (2) utilization of inpatient and outpatient treatment services for those with specific diagnoses. Logistic regression analyses identified predictors of mental health treatment among those with chronic mental illness and substance abuse treatment among those with recent substance dependence. RESULTS: Two-thirds of these homeless adults met criteria for chronic substance dependence, whereas 22% met criteria for chronic mental illness, with substantial overlap between those two disorders: 77% of those with chronic mental illness were also chronic substance abusers. Only one-fifth of each of those two groups reported receiving treatment for those disorders within the last 60 days. Mental health service utilization was predicted largely by factors related to need (eg, diagnosis, acknowledgment of a mental health problem), whereas substance abuse service utilization was predicted by myriad additional factors, reflecting, in part, critical differences in the organization and financing of these systems of care. CONCLUSIONS: More attention must be directed at how to better deliver appropriate mental health and substance abuse services to homeless adults.     

Access to mental health care among older adults

Many older adults experience common mental health problems that can have a negative impact on physiological health, functional status, and quality of life. Lack of access to mental health care for community-dwelling older adults is a significant problem. Busy primary care practices, few mental health professionals, inadequate problem recognition, and flaws in the health care system all contribute to restricted access to mental health care. As the population of adults 65 and older continues to grow, the need for mental health care for this group will increase. Strategies to improve access to mental health care must be targeted at the individual level, the provider level, and the system level.     

Maturing out,natural recovery,and dual diagnosis: What are the implications for older adult mental health services?

In 1962, Charles Winick proposed that addiction was a self‐limiting process, whereby individuals stopped using substances once the stresses of life transitions ceased. The notion of maturing out, as labelled by Winick, often forms the basis of the natural recovery movement in alcohol and other drug (AOD) research, aiding the notion that older individuals either cease their substance use or fall victim to the higher mortality rates prevalent in substance‐using populations. As more consumers present to adult mental health treatment settings with co‐occurring substance use disorders, the idea that individuals will simply cease using AOD is outdated. Given the future challenges of an ageing population, it is prudent to explore those who fail to mature out of substance use, as well as challenge the notion that older adult mental health services rarely encounter substance‐using individuals. The present study explores Winick's research in the context of an ageing population and older adult mental health services. It also ponders the proposition put forth in subsequent research that older individuals with lifelong substance use switch to substances that are easier to obtain and better tolerated by their ageing bodies.     

Substance abuse and the hospitalized elderly

Health care professionals frequently fail to recognize and address the misuse and abuse of alcohol and drugs in the elderly. Estimates of alcohol abuse in the older adult population range from 4% to 20% in the community dwelling elderly and up to approximately 25% among hospitalized older adults (Adams & Cox, 1995; Adams & Kinney, 1995; Beresford et al., 1990). In addition, the present population of older adults consumes 2-3 times more psychoactive medications than younger age groups (Sheahan et al., 1995). The effects of alcohol and substance abuse in older adults are influenced by physical, developmental, and psychosocial changes that occur with aging. Identification of alcohol and substance abuse presents a challenge for health care providers as older adults often present with atypical symptoms. Accurate diagnosis allows for the initiation of interventions for both immediate and long-term treatment.     

Practice patterns and potential solutions to the shortage of providers of older adult mental health services

Little is known about the contribution of advanced practice nurses (APNs) to the mental health care of older adults. This study describes mental health services to older adults by APNs compared with primary care physicians, psychiatrists, psychologists, and social workers. The study uses a retrospective, cross-sectional design with a 5% national sample of 1999 Medicare outpatient claims. Bivariate statistics and multinomial logit models were used to determine differences among these mental health providers. A small proportion of the nationally available providers (10.4%) submitted claims for mental health services rendered to older adults. APNs, psychiatrists, and primary care physicians care for a disproportionate number of rural and poor older adults with complex medical/psychiatric needs compared with psychiatrists, psychologists, and social workers. APNs seem to be an untapped resource for providing mental health services to older adults. Health policy reform is needed to remove barriers to meet mental health care needs.     

The Experiences of Older Adults with Dual Diagnosis in an Inner Melbourne Community Mental Health Service

ABSTRACT

Less is known about the experiences of older adults (65+ years of age) with co-occurring mental health and alcohol and other drug use disorders (dual diagnosis) than is known about the experiences of their younger counterparts. This exploratory qualitative study sought to interview individuals receiving case management from an inner Melbourne community mental health service to determine their experiences of living with dual diagnosis and explore their interactions with mental health and addiction treatment, and general medical services alike. Six older adults with a dual mental health and substance disorder agreed to participate in a semi-structured interview process and provided their perspectives about living with complex mental illness and alcohol and other drug use.

Several key themes emerged throughout the interview process, mirroring the notion of dual diagnosis being a complex phenomenon involving a number of interrelated factors: these include medical complexity, poor service engagement and long-term use of alcohol and other drugs. Interviews also demonstrate the challenges inherent in providing care to this cohort, with the participants frequently describing their experiences with services as being fraught with difficulty. The increased understanding of the perspectives of older adults with dual diagnosis provides the foundation for further research into this population in addition to influencing future nursing care provided to this cohort.     

The effectiveness of nurse practitioner care for patients with mental health conditions in primary care settings: A systematic review

BackgroundThe nurse practitioner (NP) workforce is key to meeting the demand for mental health services in primary care settings.PurposeThe purpose of this study is to synthesize the evidence focused on the effectiveness of NP care for patients with mental health conditions in primary care settings, particularly focused on primary care NPs and psychiatric mental health NPs and patients with anxiety, depression, and substance use disorders.MethodsStudies published since 2014 in the United States studying NP care of patients with anxiety, depression, or substance use disorders in primary care settings were included.FindingsSeventeen studies were included. Four high-quality studies showed that NP evidence-based care and prescribing were comparable to that of physicians. Seven low-quality studies suggest that NP-led collaborative care is associated with reduced symptoms.DiscussionMore high-quality evidence is needed to determine the effectiveness of NP care for patients with mental health conditions in primary care settings.     

Managing high-acuity-depressed adults in primary care

Purpose: To identify strategies for managing high-acuity-depressed adults in primary care settings. Patients who do not achieve remission with initial treatment, patients at risk for suicide, and patients with co-occurring substance use disorders are specifically addressed.
Data sources: Scientific literature and evidence-based practice guidelines.
Conclusion: Accurate diagnosis is best accomplished using screening instruments as an adjunct to a thorough history and assessment. The goal of interventions is remission of symptoms as opposed to a partial response. Patient preferences regarding choice of intervention must be considered. Initial pharmacotherapy must include adequate doses and a trial of adequate duration. Patients who do not respond to two medication trials are at risk for suicide and/or have a co-occurring substance use disorder may require: (a) a combination of medications coupled with psychotherapy; or (b) referral to mental health specialists to achieve the best outcomes.
Implications for practice: High-acuity patients with mental health needs will continue to be seen in primary care settings. Through educational preparation and a patient-centered focus, advanced practice nurses in primary care settings are in an optimal position to set a high standard of care for complex mental health patients.     

Models of mental health care for older adults: a review of the literature

Aim.  This paper reviews literature that draws on models of mental health care for older adults.
Background.  It is predicted that as a consequence of the aging of the population the incidence of mental health disorders, common in older populations, will also rise. Many such disorders can be successfully managed if detected early. Assessment and management requires collaboration between health professionals who are skilled and educated in the management of older adults with mental illness and the use of models of care appropriate to this population.
Results.  The paucity of research in this area is demonstrated.
Conclusion.  The need for mental health nurses to challenge current models of mental health care for older adults is identified so that they take on an expanded and developed specialist role in care of older adults with mental illness.     

Dual Diagnosis in Older Adults: A Review

Dual diagnosis is associated with frequent relapse, poor treatment engagement and overall unsatisfactory treatment outcomes. A comprehensive review of the contemporary literature examining this issue was conducted, finding a paucity of literature concerning dual diagnosis in older adults. Of the literature appraised for this review, a number of studies examined US Veteran's Affairs populations, which were largely male. Studies concerning older mental health populations were scarce. During the literature search, a number of background studies that influenced contemporary research regarding dual diagnosis in older adults were found; these studies were examined regarding their contribution to contemporary paradigms concerning older adults with co-occurring mental illness and substance use disorders. This review presents the results of the contemporary literature concerning dual diagnosis in older adults. Several recurring themes emerge from the literature, including the notion of a statistically small population that, in absolute terms, represents a sizeable number of individuals coming to the attention of aged mental health services in the future. Additionally, the potential for under-diagnosis in this cohort is highlighted, potentially creating a hidden population of older adults with dual diagnosis.     

Prison health care: a review of the literature

The prison population is increasing and the health problems of prisoners are considerable. Prison is designed with punishment, correction and rehabilitation to the community in mind and these goals may conflict with the aims of health care. A literature review showed that the main issues in prison health care are mental health, substance abuse and communicable diseases. Women prisoners and older prisoners have needs which are distinct from other prisoners. Health promotion and the health of the community outside prisons are desirable aims of prison health care. The delivery of effective health care to prisoners is dependent upon partnership between health and prison services and telemedicine is one possible mode of delivery.     

An on‐site health home for homeless men in addiction recovery

Patients with comorbid substance abuse, mental health disorders, and chronic health conditions face difficult challenges when attempting to access health care. A large gospel rescue mission developed an onsite wellness center, based on an integrated, embedded practice health home model, to promote health care access among homeless men in addiction recovery. The center model integrated primary care with behavioral health, specialty care referrals, and wellness services to address the multifaceted needs of the population. Standardized health care performance measures and resident and staff feedback support the effectiveness of the model in promoting improved health care access and treatment adherence. Future directions for program expansion include infrastructure development, expanded community outreach, and evaluation of effectiveness of the onsite health home through systematic program evaluation and research.     

Community mental health services for the underserved: a culturally specific model

Underutilization of community mental health services by minorities has been an ongoing concern in the field of mental health. Many agencies are mainstream and ethnocentric in their services to culturally diverse clients, resulting in color-blind treatment approaches. During the era of civil rights, the concept of difference was used to exclude groups of individuals, families, and communities from access to resources. However, ethnicity does matter and make a difference. This article will address the need for culturally relevant services for African-American clients with the dual diagnosis of substance abuse and mental illness. The intent is to provide mental health care providers with a culturally specific model that will render culturally relevant and culturally competent services to individuals from diverse cultural backgrounds.     

An Innovative Model for Conducting a Participatory Community Health Assessment

Accurate information is needed to facilitate health equity in underserved communities. This community-based participatory study asked residents about the meaning of mental health, their perceptions of community mental health needs, barriers to accessing mental health care, and acceptability of mental health services that are integrated in primary health clinics. Forty-five primarily African-American residents from urban communities participated in focus groups. Findings revealed high prevalence of substance abuse, depression, crime, and stigma about mental illness, with multiple access barriers. Participants were receptive to mental health care integrated in primary care, if others did not know they were receiving mental health care.     

Community perceptions of mental health needs in an underserved minority neighborhood

Accurate information is needed to facilitate health equity in underserved communities. This community-based participatory study asked residents about the meaning of mental health, their perceptions of community mental health needs, barriers to accessing mental health care, and acceptability of mental health services that are integrated in primary health clinics. Forty-five primarily African-American residents from urban communities participated in focus groups. Findings revealed high prevalence of substance abuse, depression, crime, and stigma about mental illness, with multiple access barriers. Participants were receptive to mental health care integrated in primary care, if others did not know they were receiving mental health care.     

Barriers and Facilitators of Hispanic Older Adult Mental Health Service Utilization in the USA

Mental health providers in the USA encounter the challenge and opportunity to engage the rapidly growing population of Hispanic older adults in evidence-based mental health treatments. This population underutilizes mental health services, despite comparable or slightly higher rates of mental illness compared with non-Hispanic White older adults. This review identified barriers and facilitators of mental health service use by Hispanic older adults in the USA to identify practice, policy, and research implications. Hispanic older adults face multiple compounding barriers to mental health service use. Issues related to identification of needs, availability of services, accessibility of services, and acceptability of mental healthcare treatment are discussed.     

Continuous medical education (CME) of general practitioners (GP) in primary health care settings in the field of identification and diagnosis of alcoholism

Institute of Public Health of Serbia (IPHS) is developing new function related to better monitoring of alcohol related diseases and injuries, actions focusing on alcohol as a lifestyle related factor using integrated strategic approaches for both population and individual risk reduction. In that regard the long term objective of the IPHS is to study, monitor, promote and safeguard public health--from the point of view of mental health and alcohol abuse--by means of research, development and the provision of expert services. Starting point in the aforementioned need for the capacity building in the area of mental health and alcohol abuse is the Program of education of general practitioners (GPs) in primary health care settings for identification and diagnosis of alcoholism. This is because GPs have the widest contact with the general population. Their education related to recognition of alcohol abuse and appropriate diagnostic tools application is first, but very important step in providing direction of the health service and other sectors for problem solving and would bring the largest benefit for the whole population. In the year 2010 National program against alcohol abuse and alcoholism will be developed. Program of education of GPs is very important complementary activity which outcome will have great impact on the National program implementation.