The Experiences of Clinicians Caring for Older Adults with Dual Diagnosis: An Exploratory Study

Dual diagnosis has been identified as a significant challenge to mental health services, resulting in higher rates of psychiatric relapse and greater illness severity. Much research explores dual diagnosis in the adult mental health cohort, however little research attention has been paid to older adults with dual diagnosis. Far from being a trivial issue, preliminary studies have shown that dual diagnosis in older adults is under diagnosed and poorly identified by clinicians with few specific treatment options available. In addition, studies of the ageing baby boomer cohort demonstrate a potential for dual diagnosis presentations to increase in the coming years. This article explores the experiences of a clinical team providing care to older adults with dual diagnosis in Melbourne, Australia, through a semi-structured interview process. The participants described a number of systemic barriers to providing care to the older adults with dual diagnosis presenting to the mental health service, in addition to feeling poorly prepared and expressing a degree of clinical helplessness. Additionally, the participants described service improvement, which included a strong dual diagnosis culture in the leadership team of the mental health service and role modelling dual diagnosis competent practice among clinicians.     

Prevalence of co‐occurring alcohol and other drug use in an Australian older adult mental health service

Co‐occurring mental illness and substance use disorder, known as dual diagnosis, is a significant challenge to mental health services. Few older adult specific alcohol and other drug treatment services exist, meaning older adult mental health services may become the default treatment option for many. Evidence suggests that dual diagnosis leads to substandard treatment outcomes, including higher rates of psychiatric relapse, higher costs of care and poorer treatment engagement. This paper explores the prevalence of co‐occurring alcohol and other drug (AOD) use in an older adult community mental health service in inner Melbourne, Australia. This aim was accomplished by using a retrospective file audit of clinical intake assessments (n = 593) performed on consumers presenting to the service over a two‐year period, June 2012–2014. Of consumers presenting to the service, 15.5% (n = 92) were assessed by clinicians as having co‐occurring AOD use. Depression predominated in the dual diagnosis group as the primary mental health disorder. Dual diagnosis consumers in this sample were statistically more likely to be male and younger than their non‐dual diagnosis counterparts. A limitation of this audit was the lack of implementation of screening tools, leaving assessment to clinical judgement or the interest of the clinician. This may also explain the discrepancy between the results of this study and previous work. Although appearing to be a relatively small percentage of assessments, the results accounted for 92 individuals with complex mental health, AOD and medical issues. Poor screening procedures in a population that is traditionally difficult to assess need to be rectified to meet the future challenges inherent in the ageing baby boomer generation, changing drug use trends and extended lifespans through harm reduction initiatives and medical advancements.     

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.     

Caring for clients with dual diagnosis in rural communities in Australia: the experience of mental health professionals

This paper identifies and describes the experiences of 13 rural mental health professionals who care for clients diagnosed with a mental illness and a coexisting alcohol and other drug disorder (dual diagnosis). Dual diagnosis is a common problem which is often poorly understood and managed by mental health professionals. The effect of excessive substance use on a person's mental well-being can present as a diagnostic challenge as each condition may mask symptoms of the other. The authors utilized a phenomenological approach to discover the experiences of a group of mental health professionals working in rural communities in Victoria, Australia. Caring for clients diagnosed with dual diagnosis was found to be a complex and stressful role that involved high levels of skill and knowledge. Despite the fact that health professionals in rural areas are expected to deliver the most appropriate care to individuals with a dual diagnosis, a number of these rural health professionals have limited preparation and experience in dealing with arising clinical diagnosis issues. Clinicians experience frustration, resentment and powerlessness in their attempt to understand their clients' drug misuse whilst simultaneously endeavouring to provide a quality mental health service.     

Nursing considerations for dual diagnosis in mental health

It is the intention of this literature review to present suggestions for nursing practice with reference to the care of the dually diagnosed. Nursing care of the dually diagnosed client is complex. Clinicians from both drug and alcohol services and mental health services have long recognized that neither service area provides adequate clinical care to those clients who have a dual diagnosis of substance abuse and mental illness. It is now > 10 years since a ground-breaking Australian study recognized this. To ascertain whether there has been improvement in the service management of clients who have a dual diagnosis, and to determine the best practice interventions in the area of mental health nursing, we undertook a review of the literature. The databases CINAHL, MEDLINE, PsycARTICLES and PsychINFO were searched and 185 articles met the inclusion criteria. From this review, it seems that gaps still remain in the provision of services and that mental health nurses might be best placed to provide integrated care to those clients who have a dual diagnosis and present to mental health services. This requires mental health nurses to have skills in substance use detection and knowledge of potential care implications for the client in the context of their substance use.     

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.     

Listening to young voices: challenges of research with adolescent mental health service users

Young people who have mental health problems and use the mental health services need to be consulted about their views regarding their experiences of care and treatment in the same way as adults do. Doing research with children and young people is relatively new but it is becoming more common and recent literature highlights a need to balance respect for their voices with responsibility for their best interests. This can be achieved by paying close attention to ethical and methodological issues throughout the course of every study. This paper reviews some of the issues involved in consultation research with adolescent mental health service users, and illustrates them with examples taken from an ongoing study into the experiences of young people in three Scottish child and adolescent mental health services.     

Mental health service utilization by African Americans and Whites: the Baltimore Epidemiologic Catchment Area Follow-Up.

OBJECTIVE: To compare mental health service utilization and its associated factors between African Americans and whites in the 1980s and 1990s. DESIGN: Household-based longitudinal study with baseline interviews in 1981 and follow-up interviews from 1993 to 1996. SETTING: The Baltimore Epidemiologic Catchment Area (ECA) Follow-Up. SUBJECTS: Subjects included 1,662 adults (590 African Americans and 1,072 whites). MAIN OUTCOME VARIABLE: Use of mental health services, defined as talking to any health professional about emotional or nervous problems or alcohol or drug-related problems within the 6 months preceding each interview. RESULTS: In 1981, crude rates of mental health service use in general medical (GM) settings and specialty mental health settings were similar for African Americans and whites (11.7%). However, after adjustment for predisposing, need, and enabling factors, individuals receiving mental health services were less likely to be African American. Mental health service use increased by 6.5% over follow-up, and African Americans were no longer less likely to report receiving any mental health services in the 1990s. African Americans were more likely than whites to report discussing mental health problems in GM settings without having seen a mental health specialist. They were less likely than whites to report use of specialty mental health services, but this finding was not statistically significant, possibly because of low rates of specialty mental health use by both race groups. Psychiatric distress was the strongest predictor of mental health service use. Attitudes positively associated with use of mental health services were more prevalent among African Americans than whites. CONCLUSIONS: Mental health service use increased in the past decade, with the greatest increase among African Americans in GM settings. Although it is possible that the racial disparity in use of specialty mental health services remains, the GM setting may offer a safety net for some mental health concerns of African Americans.     

Impact of the role of senior dual disability coordinator on the perceived self-efficacy and job satisfaction of mental health clinicians

Abstract

Purpose: This study aimed to evaluate a new service role in mental health services, namely, the senior dual disability coordinator role (SDDC) for its impact on the perceived self-efficacy of mental health clinicians in managing clients with dual disability (mental illness and acquired brain injury and/or intellectual disability) and their job satisfaction. Method: Mental health clinicians from a health service district in Queensland, Australia who contacted the SDDC for clinical consultation and liaison between July 2011 and July 2013 were asked to complete a questionnaire assessing perceived self-efficacy in working with clients with dual disability as well as their job satisfaction, prior to (T1) and following (T2) their contact with the SDDC. Results: Twenty-five clinicians completed and returned pre- and post-measure questionnaires. Self-reported knowledge of dual disability, clinical skills in dual disability, service knowledge in dual disability as well as perceived self-efficacy, and job satisfaction increased significantly from T1 to T2. There were no significant differences across professional discipline or years of service. Conclusions: The delivery of a clinical consultation liaison service as part of the role of SDDC may assist mental health clinicians with self-efficacy and job satisfaction, regardless of the number of years they have worked in the service or their professional discipline. Mental health clinicians with improved self-efficacy for working with clients with dual disability may be more likely to consider the client suitable for services through mental health and follow-up with treatment and linking the client with other identified suitable services.

• Implications for Rehabilitation

• Dual disability (mental illness and acquired brain injury and/or intellectual disability) presents specific challenges for mental health services Specific strategies are needed to build capacity among mental health practitioners in order to meet the needs of people with dual disability and provide appropriate services.

• Introducing dual disability coordinators as a specific position within a health service district may assist to improve self-efficacy and job satisfaction of mental health practitioners assisting people with dual disability.

     

Mental illness and substance use: an Australian perspective

This paper presents a review of the literature of service trends and practice recommendations for management of those with the dual diagnosis of mental illness and substance abuse. The method for the review was to search bibliographical data bases and hand held literature published in English between 1990 and 2007. Using the search terms dual diagnosis, and co-morbidity and mental illness, 93 abstracts were selected and reviewed. The authors concluded that a collaborative approach to care with better integration of drug and alcohol services within mental health would benefit clients with a dual diagnosis. Improved education to enhance the assessment and diagnosis of this client group is also considered essential for clinicians in both mental health and alcohol and drugs services.     

Depression, Physical Health Impairment and Service Use Among Older Adults

Abstract The purposes of this study were: (1) to compare service use and need among 80 community-dwelling older adults (55 women and 25 men): and (2) to examine the influence of depression on service use and need. Participants were divided into three groups based on their depression scores (no depression, mild depression, severe depression) and compared on a wide range of services (e.g., medical services, social/recreational, transportation) typically used by older adults. There were no significant differences among the three groups for demographic characteristics and chronic illness types, but there were significant differences for physical health impairment (PHI). When controlling for PHI, significant differences were found among the groups for mental health services, psychotropic medications, number of sick days, hospitalizations, home help, frequency of transportation, social/recreational services, and sports-related activities. Mildly and severely depressed older adults used and needed more medical services than did their non-depressed cohorts, but used less of other types of services (e.g., social/recreational services). Depression was a significant predictor of social/recreational service use. and for need of mental health services, psychotropic medications, financial assistance, and assessment and referral services. A consistent pattern was found of depression influencing service use and need.     

Dual diagnosis,as described by those who experience the disorder: Using the Internet as a source of data

The complexity of providing treatment for people with dual diagnosis is well recognized. For the purpose of this paper, the World Health Organization definition of dual diagnosis was used; that is, a person diagnosed with an alcohol or drug use problem in addition to mental illness. This research explored the personal narratives of those who experience dual diagnosis using the Internet as a data source. An important consideration in using the Internet as a data source was that Web forums can offer a sense of anonymity, allowing people to share very detailed and personal information, and providing a rich source of qualitative data. The results produced five emergent themes: spiralling out of control – again!, getting help and giving support, treating both the addiction and mental illness, having meaning and being active, and being honest with self and others. The results indicate that individuals who experience dual diagnosis are often left to navigate their personal treatment requirements across two diverse systems, and were generally not satisfied with the conflictual advice received across these two systems (i.e. alcohol and other drug and mental health services). This study has produced valuable insights related to consumer‐perceived service barriers and enablers.     

Policy issues in mental health among the elderly

Americans are living longer than ever before in history. With age comes an increased risk for chronic mental health disorders. About 1 in 8 baby boomers is expected to be diagnosed with Alzheimer disease, which will amount to some ten million members of this age cohort. The prevalence of mental health disorders among the elderly is often unrecognized. One in four older adults lives with depression, anxiety disorders, or other significant psychiatric disorders. Mental health disorders are frequently comorbid in older adults, occurring with a number of common chronic illnesses such as in diabetes, cardiac disease, and arthritis. The public is becoming more aware of the aging of the population and the difficulties that are exacerbated by unmet services and limited access to mental health services. This article describes policy issues related to chronic mental health disorders and the older population. Mental health parity, a recent policy issue occurring at the national level, is discussed first followed by workforce issues specific to the discipline of nursing.     

‘The group was the only therapy which supported my needs,because it helped me feel normal and I was able to speak out with a voice’: A qualitative study of an integrated group treatment for dual diagnosis service users within a community mental health setting

Whilst the evidence for the efficacy of treatment interventions for individuals with dual diagnosis has been developing in recent decades, little is known about individual perceptions and the personal benefits of attending integrated treatment programmes within this population group. A qualitative methodology, Interpretive phenomenological analysis, was used to investigate the experiences of individuals with a range of complex mental health and coexisting substance misuse problems who took part in a psychoeducational group (PEG) programme. This comprised of social support and therapeutic peer group relationship facilitation. Semi‐structured interviews were undertaken with 15 service users who successfully participated in this treatment programme. Findings identify the complexity of the therapeutic process and understanding of the treatment from the service users perspective. This included the importance of forming meaningful therapeutic relationships as an influential factor in countering a range of distressing and incompatible environmental and situational stressors, such as self‐regulatory control, self‐awareness of a need for change and the importance of integrated treatment in reducing the sense of stigma and exclusion linked with using mental health services. The study findings support the use of integrated treatment programmes in mental health services with a dual diagnosis population group.     

Dual diagnosis: an exploratory qualitative study of staff perceptions of substance misuse among the mentally ill in Northern India

Dual diagnosis is well recognized as a significant clinical problem. It is associated with poor outcomes, staff difficulties, and management problems. This exploratory study investigated the extent and clinical correlates of dual diagnosis and traditional substance use among the mentally ill by interviewing staff from several substance misuse and mental health services in Northern India, using a semi-structured interview schedule and focus groups. Dual diagnosis was seen as a common problem according to staff interviewed from substance misuse and mental health services, although types of substance use reported were different than in western studies. Traditional substance use (the use of substances in distinct cultural, religious, and social settings that is not prohibited, such as khat or betel nut) also was reported as common among those with dual diagnosis. Substance misuse among the mentally ill is common in Northern India. Opportunities exist for informing mental health nursing practice about "traditional" substance use.     

DUAL DIAGNOSIS: AN EXPLORATORY QUALITATIVE STUDY OF STAFF PERCEPTIONS OF SUBSTANCE MISUSE AMONG THE MENTALLY ILL IN NORTHERN INDIA

Dual diagnosis is well recognized as a significant clinical problem. It is associated with poor outcomes, staff difficulties, and management problems. This exploratory study investigated the extent and clinical correlates of dual diagnosis and traditional substance use among the mentally ill by interviewing staff from several substance misuse and mental health services in Northern India, using a semi-structured interview schedule and focus groups. Dual diagnosis was seen as a common problem according to staff interviewed from substance misuse and mental health services, although types of substance use reported were different than in western studies. Traditional substance use (the use of substances in distinct cultural, religious, and social settings that is not prohibited, such as khat or betel nut) also was reported as common among those with dual diagnosis. Substance misuse among the mentally ill is common in Northern India. Opportunities exist for informing mental health nursing practice about “traditional” substance use.     

The Matrix Model of dual diagnosis service delivery

The Matrix Model is essentially a strategy for managing dual diagnosis across a range of agencies. It is a way of implementing partnership working across services and commissioning structures. The Matrix Model was born out of hard experience at the coalface of dual diagnosis treatment at a tier four service in Bristol. A very common experience, which many may recognize, was that clients with complex mental health and addiction needs were being sent from 'pillar to post' in their treatment. Things needed to change. Here is a method of how things can change. Briefly, professionals in the drug/alcohol and mental health fields co-locate, working with clients in each other's workspaces. In doing this, they create nodes of integration. These nodes of integration link through parallel-working to create a matrix. Outcome and key recommendation is that professionals in the drug/alcohol and mental health fields co-locate in each other's agencies, adopting an assertive outreach approach to working with dual diagnosis/complex-needs clients.     

The Experience of Mental Health Service Use for African American Mothers and Youth

Little is known about African American families’ experiences with mental health services. A purposive sample of 40 dyads of African American youth (aged 13 to 19) and their mothers participated in a cross-sectional qualitative research design using semi-structured interviews that elicited information about their past experiences and satisfaction with mental health services. Though rarely received, group and family therapy were perceived favorably. However, both mothers and youth reported dissatisfaction centered on medication and lack of professionalism, confidentiality, and concern by providers. The failure of mental health services providers to meet basic standards of quality and professionalism may explain the low rate of service use by African Americans.