Clinical Handbook of Co-existing Mental Health and Drug and Alcohol Problems

Amanda Baker, Richard Velleman

• Publisher: Routledge
• Year: 2007
• ISBN:
  9781135448431
• Edition: 1
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

Co-existing mental health and drug and alcohol problems occur frequently in primary care and clinical settings. Despite this, health professionals rarely receive training in how to detect, assess and formulate interventions for co-existing problems and few clinical guidelines exist.

This Handbook provides an exciting and highly useful addition to this area. Leading clinicians from the UK, the US and Australia provide practical descriptions of assessments and interventions for co-existing problems. These will enable professionals working with co-existing problems to understand best practice and ensure that people with co-existing problems receive optimal treatment. A range of overarching approaches are covered, including:

• working within a cognitive behavioural framework;
• provision of consultation-liaison services, training and supervision;
• individual, group and family interventions; and
• working with rurally isolated populations.

The contributors also provide detailed descriptions of assessments and treatments for a range of disorders when accompanied by drug and alcohol problems, including anxiety, depression, schizophrenia, bipolar disorder and learning difficulties.

The Clinical Handbook of Co-existing Mental Health and Drug and Alcohol Problems will enhance clinicians' confidence in working with people with co-existing problems. It will prove a valuable resource for all psychologists, psychiatrists, counsellors, social workers and all those working in both primary and secondary care health settings.

Chapter 1

Co-existing mental health and drug and alcohol problems

Steps towards better treatment

Amanda Baker, Frances J. Kay-Lambkin and Terry J. Lewin

KEY POINTS

1. Co-existing mental health and drug and alcohol problems are very common in clinical practice.
2. The experience of clients with co-existing problems is likened to a huge dysfunctional traffic roundabout.
3. Screening, assessing and intervening with clients with co-existing problems must become core business for health practitioners and health services; skill in this area needs to be a fundamental capability of practitioners working within both specialist mental health and drug and alcohol services.
4. There are no clear indications for a ‘best treatment’.
5. There are indications that assessment and brief interventions are useful for some people with co-existing problems.
6. The high prevalence of co-existing problems and evidence for the utility of briefer interventions for some people implies that a ‘stepped’ model of care may be useful.

INTRODUCTION

As we show later, co-existing mental health and drug and alcohol problems (hereafter referred to as co-existing problems) are extremely common. There are four possible options for the treatment of these co-existing problems: (i) the creation of treatment ‘super centres’ to which (all) people with co-existing problems should be referred; (ii) identification of and intervention for drug and alcohol problems by mental health services; (iii) identification of and intervention for mental health problems by drug and alcohol services; or (iv) we do nothing (Manns 2003).

The last of these options has tended to be a common (but thus far ineffective) response from mental health and drug and alcohol services, and this chapter discusses some of the consequences of this approach. Doing nothing is understandable, given that mental health and drug and alcohol services have usually been run separately, health workers have generally been trained to be responsive to client presentations rather than to identify problems opportunistically, and busy clinics within mental health and drug and alcohol settings often require people to fit into existing programs and do not have the flexibility to assess for co-existing problems and tailor treatments accordingly (Baker and Hambridge 2002). Consequently, people with co-existing problems often report difficulty navigating their way through the available treatment services, sometimes falling between the cracks of the existing systems, or being shuttled from one service to another while issues of primary versus secondary aetiology or diagnosis are clarified.

We believe that doing nothing for co-existing problems is an understandable yet unacceptable approach, given the distress and confusion that such an approach engenders, and given the growing evidence base for treatments for co-existing problems, briefly reviewed later in this chapter.

So, what of the remaining three options for treatment of co-existing problems? Hall and Farrell (1997) have pointed out that the creation of a psychiatric super-specialty dealing with co-existing problems, with treatment conducted in super centres, is likely to be a very expensive approach and its effectiveness remains to be demonstrated. They suggest that options (ii) and (iii) represent better alternatives. This involves mental health and drug and alcohol clinicians screening, assessing and intervening for co-existing problems within their respective treatment settings and the development of better links between services, with clients presenting with more established problems being referred for specialist treatment. Havassy et al. (2004) found few differences between groups of clients with co-existing problems from mental health and drug and alcohol treatment settings, suggesting that treatment providers should be prepared to provide interventions for both mental health and drug and alcohol problems. How best do we progress this approach? In this chapter, we propose a new model for screening, assessing and treating co-existing problems that will hopefully empower primary care, mental health, drug and alcohol and specialist clinicians to offer services flexibly and more effectively, with acknowledgement of each other’s essential roles.

This chapter provides a context for the rest of this book by outlining some key features of co-existing problems that need to be considered before intervening, defining the nature of co-existing problems, describing the current experience of clients and clinicians, briefly reviewing the evidence base and proposing a new model of treatment delivery for co-existing problems. The chapter is based largely upon an article by the authors (Kay-Lambkin et al. 2004), and also draws upon two recent papers by Baker and Dawe (2005) and Kavanagh et al. (2003).

KEY FEATURES OF CO-EXISTING MENTAL HEALTH AND DRUG AND ALCOHOL PROBLEMS AND THEIR IMPLICATIONS FOR INTERVENTION

Kavanagh et al. (2003) have delineated several key features of co-existing problems that have fundamental implications for treatment. These include the high frequency of co-existing disorders, higher rates of co-existing problems in more intensive treatment settings, poorer physical and psychiatric outcomes among those with co-existing rather than single problems, the high functional impact of drug and alcohol use in psychosis, relationships of mutual influence rather than a clear causal pathway, inadequate service provision related to insufficient detection of co-existing problems and exclusion policies, and the possible need for different intervention strategies for different subgroups. The implications of each of these for a new intervention model are discussed below.

High frequency of co-existing problems

Of particular importance in developing a new intervention model is the high frequency of co-existing problems. The first large-scale epidemiological study to collect information on co-existing problems in the community was the United States Epidemiological Catchment Area (ECA) study of the National Institute of Mental Health (NIMH) (Regier et al. 1990). Over 20,000 interviews were conducted among community and institutional populations by five university research teams between 1980 and 1984. Among people with any lifetime mental disorder (other than a substance use disorder), over a quarter (29 per cent) had a lifetime history of one or more substance use disorders: 22 per cent had an alcohol use disorder and 15 per cent had another drug use disorder. Conversely, among individuals with a lifetime alcohol use disorder, 37 per cent had at least one other (non-substance use) mental disorder, and 53 per cent of those with a lifetime drug use disorder had at least one mental disorder other than alcohol use disorder. Of individuals with a lifetime history of alcohol disorder, 45 per cent had a coexisting mental or other drug disorder, and 72 per cent of those with any drug disorder had a co-existing mental or alcohol disorder.

The highest rates of alcohol or other drug use disorders were found among people with antisocial personality disorder (84 per cent), followed by bipolar disorder (61 per cent), schizophrenia (47 per cent), affective disorders (32 per cent) and anxiety disorders (24 per cent). Since the lifetime prevalence of affective and anxiety disorders is greater in the community (8 per cent and 15 per cent respectively) than antisocial personality disorder (3 per cent) and schizophrenia (2 per cent), their contribution to the total prevalence of coexisting problems is much greater. The most prevalent co-existing mental disorders among people with an alcohol disorder were: anxiety disorders (19 per cent), antisocial personality disorders (14 per cent), affective disorders (13 per cent) and schizophrenia (4 per cent). The most prevalent mental disorders among those with any drug use disorder were: anxiety disorders (28 per cent), affective disorders (26 per cent), antisocial personality disorder (18 per cent) and schizophrenia (7 per cent) (Regier et al. 1990).

The implication of this very large number of people in the community with common mental health and drug and alcohol problems is that relatively inexpensive, highly accessible interventions that focus on the high prevalence problems of anxiety, depression, and the use of nicotine, alcohol and cannabis are needed (Kavanagh et al. 2003). This chapter outlines how primary care and brief interventions have a major role to play in working towards better treatment of co-existing problems. In Chapter 3, David Kavanagh and Jennifer Connolly present brief motivational approaches that can be adapted to primary care settings.

Higher rates of co-existing problems in more intensive treatment settings

In the ECA study, the odds of finding a substance use disorder in those in specialist mental health disorder treatment settings were about double those of finding a substance use disorder in the non-treated population with mental disorders. Further, the odds of finding a mental disorder among those in specialty treatment for alcohol disorders and other drug disorders were 3.8 and 4.2 respectively (Regier et al. 1990). This is because individuals with multiple disorders have greater incentives to seek treatment and are found more often in treatment settings (Berkson 1946).

The implications are that interventions for co-existing problems should be the core business of health services, and skill in their delivery needs to be a fundamental capability of practitioners working within specialist mental health and drug and alcohol services (Kavanagh et al. 2003). The model of treatment in this chapter allows for both brief, primary care level interventions, most appropriate to people with high prevalence, low severity problems (e.g. depression and alcohol problems), and more intensive interventions, more appropriate for people with high severity, low prevalence presentations (e.g. schizophrenia and cannabis use). Chapter 4, on cognitive-behaviour therapy (CBT), outlines some general principles underlying the development of a case formulation specific to co-existing problems and possible CBT interventions, and subsequent chapters offer suggestions for specific mental health problems accompanied by drug and alcohol problems. Staff within specialist mental health and drug and alcohol services could and should consult with primary care staff (see Chapter 7 on consultation-liaison) and offer training (see Chapter 18 on training).

Poorer physical and psychiatric outcomes among those with co-existing rather than single problems

Since the ECA study, three national surveys have been undertaken to establish the prevalence of co-existing substance use and mental disorders, in the US (Kessler et al. 1994, 1996), the UK (Jenkins et al. 1997) and Australia (Henderson et al. 2000). All have reported similar high rates of co-existing problems (Andrews et al. 2001). Andrews et al. (2001) have reported that coexisting problems are associated with greater disability and service use. Only half of those with co-existing problems had consulted services and of those who had not, over half reported they did not need treatment. General practitioners (GPs) were the principal caregivers, either alone or in consultation with another health professional. Andrews et al. (2001) concluded that there should be a focus on better knowledge regarding mental health and drug and alcohol use among clients and on improving the clinical competence of practitioners. Kavanagh et al. (2003) recommended that interventions should address multiple problems and employ strategies to enhance engagement and retention in treatment (see Chapter 3).

High functional impact of drug and alcohol use in psychosis

The Australian National Survey of Mental Health and Well Being (NSMHWB) provided estimates of the population-level association between psychotic symptoms and substance use (Degenhardt and Hall 2001). The majority of people who screened positively for psychosis were daily tobacco smokers and around one-quarter reported daily alcohol use and at least weekly cannabis use (Degenhardt and Hall 2001). Dependence among alcohol and cannabis users was significantly more likely among cases of psychosis than non-cases (Degenhardt and Hall 2001). There are several implications for interventions among persons at risk of psychotic illness: the mental health risks of problematical substance use needs to be more widely disseminated; more attention should be given to the physical health risks of heavy or problematical substance use (including smoking-related diseases, cognitive impairment, liver damage, cardiovascular disease, contraindications with antipsychotic medications, lowered treatment compliance, increased housing instability and homelessness); and all treatments among persons with psychotic symptoms need to address potential problematical substance abuse (Degenhardt and Hall 2001). In a UK comparison of surveys from a national household sample, a sample of institutional residents with psychiatric disorders and a national sample of the homeless population, substance-related disorders were much higher in the homeless sample than the other two samples (Farrell et al. 2003). As such, service planning also needs to consider different subsections of the population, such as homeless people (Farrell et al. 2003; see also Chapter 10 on homelessness and co-existing problems, Chapter 13 on treatment of schizophrenia and drug and alcohol problems and Chapter 14 on treatment of bipolar disorder and drug and alcohol problems).

Relationships of mutual influence rather than a clear causal pathway

Treatment services and providers tend not to be sensitive to the severity and consequences of co-existing problems among their clients, and tend to consider one problem secondary to another (Havassy et al. 2004). However, co-existing problems often appear to be in a relationship of mutual influence rather than falling neatly into primary versus secondary categories, and the relationship between disorders may change over time (Kavanagh et al. 2003; Mueser et al. 1993). For example, depression may trigger alcohol use at some times and the reverse may occur at others (Hodgkins et al. 1999). In addition, focusing on finding the primary disorder can result in treatment providers and clients becoming confused about optimal treatment, resulting in suspension of treatment plans until diagnostic clarity is reached (Westermeyer et al. 2003). It follows that a specific case formulation and treatment plan addressing factors maintaining co-existing problems should be developed (see Chapter 4). Treatment may, but not necessarily, involve attempting resolution of one problem before another, or may involve addressing co-existing problems simultaneously, depending on the case formulation.

Inadequate service provision related to insufficient detection of co-existing problems and exclusion policies

It was noted above that doing nothing to treat co-existing problems has been a dominant approach to service delivery. Efforts to detect co-existing problems and to offer interventions have been hampered by the separation of mental health services and drug and alcohol services. An evidence base for treatment has been slow to accumulate because the co-existence of mental health and drug and alcohol problems usually leads to exclusion from studies conducting research into either single disorder. Implications for the inclusion of people with co-existing problems in future research are discussed in Chapter 20.

Possible need for different intervention strategies for different subgroups

Kavanagh et al. (2003) point out that a relationship of mutual influence between mental health and drug and alcohol problems may suggest that integrated treatment would be best. However, they also point out that while the (sparse) available evidence among people with psychosis and drug and alcohol problems is supportive of an integrated approach, whether this is also the case among people with anxiety or depression and co-existing drug and alcohol problems is unclear. They suggest that different intervention strategies may be necessary in different subgroups (Kavanagh et al. 2003), an idea which the proposed model in this chapter highlights. In at least a proportion of people, mental health and co-existing drug and alcohol problems may be unrelated (Hall 1996), with the co-occurrence simply representing the coprobability of two otherw...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Contributors
• Foreword
• Preface
• Acknowledgements
• Chapter 1
• Chapter 2
• Chapter 3
• Chapter 4
• Chapter 5
• Chapter 6
• Chapter 7
• Chapter 8
• Chapter 9
• Chapter 10
• Chapter 11
• Chapter 12
• Chapter 13
• Chapter 14
• Chapter 15
• Chapter 16
• Chapter 17
• Chapter 18
• Chapter 19
• Chapter 20