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Managing services that managepeople with a coexisting mental health and substanceuse disorder

Mark Welch and Julie Mooney

Objective: The Mental Health and Alcohol and Drug Services (MHADS)initiated the present study as a cross-service investigation into currentpractice and future developments in the provision of services to clients withdual disorders.

Method: A two-part study was conducted over a six-month period todetermine: 1) The fidelity to the principles of care outlined in The ServiceDelivery Guidelines for The Management of People with a CoexistingMental Health and Substance Use Disorder (2000) ( The Service DeliveryGuidelines), and 2) The barriers to following the guidelines.

Results: A number of barriers to the full implementation of the guidelineswere uncovered, principally in the areas of system issues, training and edu-cation, clinical issues, and policies and procedures.

Conclusions: Comorbidity of mental health and substance use disordersis receiving more attention in health services as awareness of the preva-lence of these problems increases and the poor outcomes from currentservice delivery models are more widely acknowledged. However, it isapparent that there is almost as much ‘comorbidity’ in the services thatprovide the care as in the population itself.

Key words: dual disorders, Drug and Alcohol Services, Mental HealthServices.

INTRODUCTION

There is a growing awareness that drug and alcohol problems oftencoexist with mental disorders1 and that the number of people withdual disorders is increasing.2 Prevalence studies sugest 30–80% of

people with mental disorders have a coexisting substance use disorder.Corresponding rates of mental disorders are reported for people withsubstance use disorders.1

Despite this, the literature addressing clinical aspects of dual disorders,from phenomenology to treatment, is not extensive. What literaturethere is suggests that people with dual disorders are more problematicto work with, frequently use emergency services, are difficult to evalu-ate and are often misdiagnosed. They are seen to be less responsive totreatment, frequently resist available services and are at high risk for sui-cide and violence.3 They also have an increased chance of developingassociated problems including legal, accommodation and financial dif-ficulties, and have increased rates of incarceration, homelessness andhousing instability.4 These characteristics thus define a heterogeneousgroup of people with special needs who pose particular problems forservice delivery systems.

Mark WelchSchool of Nursing, University of Canberra, Canberra, ACT

Julie MooneySouthern Area Health Service

Correspondence: Dr Mark Welch, School of Nursing,University of Canberra, ACT 2601, AustraliaTel: 02 6201 5104Email: Mark.Welch@canberra.edu.au

PSYCHIATRIC SERVICES

Mental Health and Alcohol and Drug Services (MHADS)currently provide a range of services for people withdual disorders, but it is questionable how well theymeet the needs of these clients. Initiatives in servicedelivery in Australia seem sporadic.5 Burdekin suggeststhat as services have become more specialised, expertiseon how to identify and manage comorbidity hasdecreased and people are repeatedly referred from oneservice to the other, or offered no service at all.6

Fariello and Scheidt assert that problems lie in the sys-tems of care with diagnosis specific programs designedto treat single disorders only.7 Thacker and Tremainesupport this, stressing the need to focus on individualsrather than diagnostic labels or compliance to rigid pro-gram boundaries if adequate services are to be provided.This may require a reconceptualisation of the issue.8

Systems of care may not be entirely to blame for thepoor outcomes. Other barriers include inadequateassessment and the lack of joint staff training to givea balanced understanding of both mental health andsubstance use needs and approaches.

No single method of treatment for people withcomorbid disorders is universally accepted, but thereis an emerging literature that models of care can belinked to poor outcomes. These include sequentialand parallel models in which mental health andalcohol and drug disorders are treated separately,either one after the other, or at the same time butwith no integration or reference to the other.

Alternatively, an integrated approach is defined asthe ‘concurrent application of core concepts andmethods from both psychiatric treatment and addic-tion treatment models’.9 It includes assertive out-reach to engage clients in treatment, intensivemanagement, individual and family substance usecounselling,10 a long-term perspective to care, posi-tive attitudes from clinicians and sound pharmaco-logical interventions.11 Jerrell and Ridgely report itleads to high rates of engagement, reduced problem-atic substance use and psychiatric symptomatologyand reduced need for hospitalisation.12 Finally,Mrazek and Haggerty assert it ensures full access to aspectrum of interventions, from health promotionand prevention, early intervention and treatment tomaintenance programs.13

In 1998 a statewide review was conducted in NSW ofcurrent service provision for clients with dual dis-orders. Wide variations in the levels and styles of ser-vice provision were found. However, it was evidentthat there was a general lack of co-ordinated carebased on a philosophy of inclusive and comprehen-sive health care. This led to the development of stateguidelines that aim to provide clear direction tohealth services.

The Service Delivery Guidelines has recently beenreleased and widely distributed. It examines key

questions of epidemiology, prevalence, treatmentoptions, and principles of care. Written to reflect thediversity seen in clinical practice, and to ensure thatpeople with a range of mental health and substanceuse disorders were included, it identified people withpsychotic, mood, anxiety and personality disorderswith problematic substance use as all meeting thecriteria for having dual disorders.14 The presentstudy investigated the fidelity of services in MHADSto these guidelines, and sought to identify barriers to following them. Recommendations based on thefindings, indicating how the state guidelines canbest be implemented at a local level, are included.

METHOD

The project involved attendance at staff meetings of MHADS in four rural towns in the service, with apopulation of approximately 100,000. The ServiceDelivery Guidelines were distributed to all principalstakeholders and the key points highlighted.

A number of clients with dual disorders, suitable foran in-depth case analyses were then identified by theclinicians and GPs from each of the four centres.They were used as exemplars for an in-depth analy-sis. Information for the case analysis was primarilyobtained by reviewing the documentation in clinicalfiles and by interviewing the responsible case man-agers and GPs. Other MHAD clinicians and GPs wereinterviewed or took part in general discussions inorder to obtain a wider perspective of the issues.

Interviews with clinicians

Data concerning current practice and ideas toimprove current service provision were obtained byinterviewing a group of fifteen Alcohol and DrugClinicians, twenty Mental Health Clinicians andthree GPs. There were some difficulties gainingaccess to all clinical staff in all areas (ten staff wereunavailable for comment).

The interviews with MHAD clinicians were con-ducted in a group as part of each team’s regular clin-ical meeting. This allowed for the views of a greaternumber of clinicians to be sought. A disadvantagemay be that clinicians may not have been able tospeak as freely about issues of concern as they mayhave in a private setting. The MHAD clinicians inter-viewed were of differing professional backgrounds;some had additional training in dual disorders and some had a particular interest in the area, whileothers had limited knowledge about the issue.

Individual interviews were conducted with GPs.They all expressed an interest in the area of dualdisorders and a willingness to be interviewed. A dis-advantage of this approach may be that the GPs mayalso have been disgruntled with current service pro-vision as the responses tended to highlight dissatis-faction with current practice. This may have skewedA

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the data. Considering this, and the small number ofGPs interviewed, the study can not be said to author-itatively reflect the views of all GPs working in thelocations selected for the study.

Case analysis

Principal data were obtained from conducting an in-depth case study analysis of eight selected clinicalfiles. This examined documented care and specif-ically focused on current service provision and thefidelity to The Service Delivery Guidelines.

The individual teams chose the eight files. These ref-lected what clinicians thought to be a mixture of goodpractice and practice that was problematic. The advan-tage of this approach to selection was that it gaveclinicians a chance to be part of the process and encour-aged their participation which may not have occurredif the files were chosen by the researcher. A criticismcould be that only files showing good practice mayhave been chosen. To address this, additional files wereviewed but not analysed with clinicians to reflect stan-dard practice for that service. As only eight files wereanalysed in-depth, the study may be criticised for itssmall sample size. However, it did allow for a very thor-ough analysis to be conducted that was able to investi-gate all aspects of service provision.

Interviews with case managers

Each case manager of each client was interviewed toclarify information contained in the files. If theother service, i.e. Mental Health or Alcohol andDrug, was also involved, the designated person fromthat service was also contacted to gain an under-standing of how care between the two services cur-rently operated.

The client’s GP was also contacted to gain his/herperspective on the management of the client. SevenGPs in total were contacted by telephone (one clienthad refused information to be passed onto the GP).Four returned the call and offered considerable infor-mation.

Additional information on the view of GPs wasobtained from the unpublished questionnaire con-ducted by the Alcohol and Drug/General PractitionerLiaison Officer tabled in December 2000. The ques-tionnaire was sent to all 170 GPs in the area, ofwhich 41% responded. The questionnaire posed onlyone question on dual disorders out of a total of morethan 20. The comments from this question havebeen included in the findings and aided the recom-mendations of the report.

From the case analysis, interviews and questionnairethere was sufficient information to draw out themesand consistent patterns of current service delivery.The quality of services currently provided to peoplewith dual disorders was evident when comparing

current practice to fidelity to the general principlesof care outlined in The Service Delivery Guidelines.

RESULTS

The main findings of the study, relating to the bar-riers that may prevent services from implementingthese guidelines, reflect The Service Delivery Guidelines.

Systems issues

It became clear that exclusive models of care, wherebyeach service sees itself as operating independently,exist in both MHADS. These have created barriers toaccess for GPs, consumers and their families. Far toooften, the normal channels of service access act asmechanisms of exclusion rather than inclusion.

Both MHADS are currently designed to treat singledisorders. It is evident that both services have adeveloped tendency to see a client as someone whoeither has a primary mental disorder with a sub-stance use disorder loosely attached, or the otherway around. None of the cases examined explicitlyused diagnostic terms, indicating an inseparable andmutually dependent comorbidity, even though clin-icians recognised the condition themselves.

GPs, often the primary care, were not always keptinformed about what MHADS can provide for themand their clients. The evidence of written communi-cation indicating the results of assessment or treat-ment plans was almost without exception poor, andin some instances totally absent.

Training and education

GPs and clinicians in both MHADS often seem tolack the expertise to recognise and effectively man-age dual disorders. Few clinicians or GPs hadreceived any training specific to the assessment ortreatment of clients with a dual disorder.

Clinical issues

Service provision lacked integration and coordina-tion between the three primary care providers.Although in most of the examples case reviews wereconducted, in only one were all relevant stakehold-ers, i.e. case managers, GP, Medical Officer, client,family, involved. There was an obvious lack of for-mal interchange of information. Anecdotal evidenceindicates that informal exchange was rarely better.

Different professional orientations to treatment anda limited understanding of the respective practicesby the other service area significantly limited refer-rals between MHADS. There was a general lack ofawareness or understanding by one service of therole and practice of another. Clinicians in one ser-vice often did not know what clinicians in another,who would be seeing the same client, actually did.

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The focus of care in both MHADS was predom-inantly on treatment with little attention given toother alternative interventions, such as early inter-vention and prevention.

Comprehensive assessments that fully explored phys-ical, mental health and substance use issues wereinfrequent. Even when they were carried out, servicesuse different formats, scales and measures, evenwhen assessing the same aspect, for example mood ordrinking behaviour. As before, the exchange of infor-mation remained haphazard at best.

Policies and procedures

There were few policies and procedures between GPsand MHADS to facilitate consistent clinical practiceand to promote service links. On a practical everydaylevel, services lacked formal procedures for referral,networking and liaison.

PRINCIPAL RECOMMENDATIONS

The findings suggest recommendations for futurestudy and service development. Again, they reflectThe Service Delivery Guidelines.

Systems issues

In order to promote access and facilitate referrals,services should develop a common understandingand clear definition of the clinical term dualdisorders, evidenced based treatment protocols, ashared philosophy of care (based on client needrather than diagnosis), and a joint service responsi-bility with regard to assertive engagement, liaison,integrated models and continuity of care.

The reduction of the development of dual disordersin the general population, comprehensive strategiesfor health promotion and illness prevention, earlyintervention and identification of high-risk individ-uals and groups should be considered a priority.

Training and education

Opportunities and funding for training and clini-cal development for GPs and MHADS clinicians to improve clinical competence, assessment, andtreatment should be provided. The emphasisshould be on the co-working relationship and jointmanagement.

Clinical issues

In order to optimise clinical outcomes and reducethe long term negative effects associated with dualdisorders, services should develop a comprehensiveand integrated model of care for people with dualdisorders, including common assessment proceduresand treatment protocols, joint case conferences andco-management and Clinical Pathways. Protocolsneed to incorporate all service providers, includingGPs and MHADS.

The full establishment of clinical and managementinformation systems is necessary for service provi-sion to be evaluated for its quality and effectivenessin improving outcomes.

Policies and procedures

In order to coordinate care and improve interagencylinks, services should develop formal agreements –for example, Service Agreements or Memoranda ofUnderstanding – regarding protocols for referral,networking and liaison between GPs, MHADS andother relevant services.

CONCLUSION

It can be reasonably deduced from the study that notall is well in the systems of care for people with dualdisorders. The examination of documentary recordsand interviews with responsible clinicians and GPsclearly show many areas in which the service pro-vided does not reach the standard demanded by TheService Delivery Guidelines. In particular, the servicesoften fail to respond to coexisting mental and sub-stance use disorders that do not simply exist side by side, but act in a way that compounds and meldstheir presentation. These, of course, demand an inte-grated rather that particular and parochial response.Nevertheless, there are a significant number of strat-egies that could be implemented to improve this, butthese require the respective services to address theirown comorbidity and not just that of their clients.

ACKNOWLEDGEMENTS

The authors would like to thank the Dual Disorders Steering Committee for theirassistance and guidance with this study. Thanks also to Debbie Smith, Alcohol andDrug Liaison Officer SAHS and Tina Phillip, General Practice/Mental Health IntegratedCare Project Officer SAHS, for their assistance and support, and staff of the SAHS whogave their time to participate in the project. The study was funded by the SouthernArea Health Service (SAHS) and South East New South Wales Division of GeneralPractice (SE NSW DGP) with a grant from The Commonwealth Department of Healthand Aged Care Divisions of General Practice Program.

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