Co-existing Mental Health and Drug and
Alcohol Problems: Steps towards better
treatment
Cutting Edge, 2010, Auckland, New Zealand,
Friday, 24th September 2010
Professor Richard Velleman
Professor of Mental Health Research,
University of Bath / Avon & Wiltshire Mental Health
Partnership NHS Trust, UK
Co-existing Mental Health and Drug and Alcohol Problems: Steps towards
better treatment
Acknowledgments:
Amanda Baker, University of Newcastle, New
South Wales, Australia
Also, in Bath, Gina Smith, Ian Dickinson
Co-existing Mental Health and Drug and Alcohol Problems: Steps towards
better treatment
Three things today:
• Huge range and high prevalence of coexisting problems;
• Screening, assessing and intervening must
become core business for health
practitioners and health services;
• Family approaches, and intensive work
with people with co-existing homelessness
as well as both mental health and
substance misuse problems, are vital.
Co-existing Mental Health and Drug and Alcohol Problems: Steps towards
better treatment
Huge range and high prevalence of co-existing
problems
One USA-based study:
• any lifetime mental disorder, 29% ALSO had a
lifetime history of some substance use
disorder:
• Conversely, any lifetime alcohol use disorder,
• 37% ALSO had at least one other mental
disorder (and 53% of those with a lifetime drug use
disorder had at least one mental disorder).
Co-existing Mental Health and Drug and Alcohol Problems: Steps towards
better treatment
If a Mental Health Disorder
• Highest rates of alcohol or other drug use
disorders were found among people with
antisocial personality disorder (84%), followed
by bipolar disorder (61%), schizophrenia
(47%), affective (32%) and anxiety disorders
(24%).
Co-existing Mental Health and Drug and Alcohol Problems: Steps towards
better treatment
If an Alcohol Disorder
• anxiety disorders (19%), antisocial personality
disorders (14%), affective disorders (13%) and
schizophrenia (4%).
If a Drug Disorder
• anxiety disorders (28%), affective disorders
(26%), antisocial personality disorder (18%)
and schizophrenia (7%).
Co-existing Mental Health and Drug and Alcohol Problems: Steps towards
better treatment
Are we hearing more about co-existing
disorders?
Yes:
• the increasing availability and accessibility of
alcohol and illicit drugs;
• deinstitutionalization of people with severe
mental health problems;
• and increasing expectations that agencies will
address co-existing problems.
Co-existing Mental Health and Drug and Alcohol Problems: Steps towards
better treatment
Clients with co-existing problems can be hard
to manage
• Clients with co-existing problems can be ‘high
impact’.
• Often present a major challenge: their
individual needs in medico-psycho-social
terms, and their collective needs in
organisational terms, are both complex and
highly demanding.
Co-existing Mental Health and Drug and Alcohol Problems: Steps towards
better treatment
Also, in economic terms: significantly higher
overall healthcare costs than those with either
substance use or mental health problems alone.
• Many of these clients will have lost touch with
(or have been discharged from) specialist
medical, psychiatric and addiction services.
• So they often pose particular difficulties for
the non-statutory sector and for primary care.
Co-existing Mental Health and Drug and Alcohol Problems: Steps towards
better treatment
This creates a paradox: the services within
which the staff are meant to have higher levels
of skill in dealing with complex problems have
tended to discharge or lose contact with these
clients,
and hence the ‘safety net’ services where staff
often have lower levels of training are the ones
that have primarily to deal with these complex
problems.
Co-existing Mental Health and Drug and Alcohol Problems: Steps towards
better treatment
In summary, co-existing problems with both
substance use, and one or more of a range of
mental health issues (anxiety, depression,
schizophrenia, bipolar disorder, etc)
• are highly prevalent,
• often begin in youth,
• and place an immense burden on individuals,
families, and society.
Co-existing Mental Health and Drug and Alcohol Problems: Steps towards
better treatment
• Co-existing problems are associated with
underachievement or failure for affected
individuals across many domains, including
academic, employment, relationship, social
and health;
• and with greater involvement with the criminal
justice system, with failed treatment attempts,
with poverty, and homelessness;
• and the risk of suicide is also high.
Co-existing Mental Health and Drug and Alcohol Problems: Steps towards
better treatment
Co-existing problems are so common that in
clinical settings, a large proportion of
presentations can be assumed to have such
problems.
Despite this, clinical services are usually
separated along mental health and drug and
alcohol lines; and clinicians have rarely been
trained in how to detect, assess and formulate
interventions for co-existing problems.
Co-existing Mental Health and Drug and Alcohol Problems: Steps towards
better treatment
So – most people with co-existing mental
health and drug and alcohol problems do
not receive optimal treatment.
Example: delay in starting treatment - clinicians
seek to establish a ‘primary’ diagnosis, often
involving referral between different services.
This is poor practice: detecting, assessing and
treating co-existing mental health and drug
and alcohol problems is the clinical
responsibility of both mental health and drug
and alcohol teams.
Co-existing Mental Health and Drug and Alcohol Problems: Steps towards
better treatment
What SHOULD HAPPEN?
• All mental health and all drug and alcohol
teams should be able to detect and assess
symptoms of problems in both domains, and
offer treatment for presenting symptoms.
• Where both mental health and drug and
alcohol problems are severe (for example, in
the case of severe depression and alcohol
dependence), I’d recommend treatment by
only one team, in consultation with specialists
in the other domain (if necessary).
Co-existing Mental Health and Drug and Alcohol Problems: Steps towards
better treatment
Terminology
• This is an area where there are many debates
about terminology, and underlying these are
issues of professional power and control.
• ‘Co-existing’ is a simple statement of fact.
• symptom-focused and problem-oriented view
of problems, not on whether or not problems
are diagnosable. My orientation is to focus on
individualized assessment and formulation.
Co-existing Mental Health and Drug and Alcohol Problems: Steps towards
better treatment
Terminology
• clumsy though it is, the term ‘co-existing
mental health and drug and alcohol problems’
carries no allegiance to any professional group
or source of institutionalised power, which is
not the case with many of the other terms in
general use at present – dual diagnosis, or comorbidity.
Co-existing Mental Health and Drug and Alcohol Problems: Steps towards
better treatment
Screening
• Because such large numbers, often undetected
• Profs must be alert to likelihood
• And get familiar with useful signs:
• Substances used for emotional regulation or side effects of medication,
• low mood or mood swings, * loss of enjoyment in activities,
• lowered functioning, * a significant shift in weight.
• Sociodemographic factors may also alert workers, including
•
•
•
•
young age; * male gender; * family history of substance misuse;
homelessness; * disruptive behaviour;
poor family relationships; * repeated hospitalisations;
and legal difficulties.
Co-existing Mental Health and Drug and Alcohol Problems: Steps towards
better treatment
Routine screening
• risk of harm to self or others
• screening for co-existing mental health and
drug and alcohol problems and related areas.
• Reluctance to discuss MH or D&A probs:
likely to prejudice the outcome .
• People reveal what they can, and do not
reveal things that may be harmful for them
Co-existing Mental Health and Drug and Alcohol Problems: Steps towards
better treatment
Screening, assessing and intervening with
clients with co-existing problems must
become core business for health practitioners
and health services;
skills in this area needs to be a fundamental
capability of practitioners working within
both specialist mental health and drug and
alcohol services.
Co-existing Mental Health and Drug and Alcohol Problems: Steps towards
better treatment
Family Work
• involving families where someone has an alcohol or
drug problems leads to better engagement and better
outcomes.
• involving families where someone has an severe
mental health problem ALSO leads to better
engagement and better outcomes.
• Not surprisingly then, family approaches can be just
as effective when applied in cases where co-existing
problems arise as they are when either problem
presents on its own.
Co-existing Mental Health and Drug and Alcohol Problems: Steps towards
better treatment
The Stress-Strain-Coping-Support modal
Family
members
are
stressed
due to the
impact of
a
relative’s
substance
misuse
Strain:
usually
physical
and
psycholo
gical
health
problems
How the family
member copes with
(responds to) the
situation
and
The level and quality
of social support
available to the family
member
Family member
involvement with the
client
Family member
stressors
Client
outcomes
Family member
well-being
Family member
involvement in the
treatment
Conceptual framework for studying family involvement with adults with co-occurring substance
and mental disorders (Townsend, Biegel, Ishler, Wieder & Rini, 2006)
Co-existing Mental Health and Drug and Alcohol Problems: Steps towards
better treatment
• Many of the ideas and skills utilized in one set of
approaches are the same as those utilized in the other
set.
• Where differences, an opportunity to produce a
family intervention using the best of both.
• Motivational Interviewing (Miller/Rollnick)
• Prochaska and DiClemente Cycle of Change
• Tolerant family environments
• Attributions
• Expressed Emotion (over-involvement and
criticality)
Co-existing Mental Health and Drug and Alcohol Problems: Steps towards
better treatment
family interventions work best if they utilise all
three of
• an education process (helping the family members and
the client understand better what is happening to the client)
• the P & DiC Cycle of Change,
• motivational interviewing.
Process: promoting awareness of family
interventions; referral; initial meeting;
assessments; education; problem solving/ goal
setting; evaluation; and booster sessions.
Co-existing Mental Health and Drug and Alcohol Problems: Steps towards
better treatment
Co-existing Homelessness
• homeless people have higher rates of both MH
and substance misuse problems AND less
access to services and other resources.
• a model of care: designated, well trained and
well supervised workers, work effectively
across the various domains of mental health,
substance misuse, and housing
Co-existing Mental Health and Drug and Alcohol Problems: Steps towards
better treatment
The main elements
• holistic (and pragmatic) view of targets
• very high levels of skill in engagement.
• Assessment should follow a similar process as
for other clients; but individual barriers and
organizational issues tto be addressed.
• treatment can and should draw from all four
relevant areas: substance misuse; mental
health generally; assertive outreach in
particular; and housing.
Co-existing Mental Health and Drug and Alcohol Problems: Steps towards
better treatment
Gerry
• 35 year old man, separated from and out of touch
with his family.
• Recently been released from prison for theft.
• Extremely challenging and chaotic poly-drug user
(heroin, alcohol, nicotine and other drugs, injecting
where he could),
• Sleeping rough
• Experiencing psychotic symptoms.
• Begging, shoplifting, theft, burglary
Co-existing Mental Health and Drug and Alcohol Problems: Steps towards
better treatment
• very difficult to engage; extremely distrustful;
• gradually began to talk and allowed Ian to support
him.
• Night Shelter, primary health care check-up.
• very long history of rejecting interactions with care
and helping services.
• anti-psychotic medication.
• Ian: more overt therapeutic work, on both mental
health difficulties, and his substance misuse.
Co-existing Mental Health and Drug and Alcohol Problems: Steps towards
better treatment
Prioritizing the Therapeutic Work
• Once Gerry had engaged sufficiently with the worker
and the service such that initial physical health
concerns and florid psychotic symptoms could be
controlled, the worker was able to start to talk in
more depth with Gerry about his concerns.
• Gerry had already made significant progress, even to
get to this point. Initially, distrustful, rather paranoid,
not willing to enter ‘the system’ – the night shelter,
the primary care team, and so on.
• Even to start to talk about MH or substance misuse,
was a huge step.
Co-existing Mental Health and Drug and Alcohol Problems: Steps towards
better treatment
• “I'd like to be working, I would like to have contact
with my children and I would like somewhere to live,
just somewhere that I'm not feeling that if I meet
someone in the wrong mood around me I can't be
kicked out. That’s what I want, that is all, I'm not
asking for much. Maybe I would ask for a bit of help
to maybe look at things that have gone on in my life
in the past.”
• actual ‘sessions’ between Ian and Gerry, in private,
without interruption.
Co-existing Mental Health and Drug and Alcohol Problems: Steps towards
better treatment
Drug and Alcohol Work
• methadone prescription ; oral, daily supervised
consumption.
• injecting behaviour; .gradually weaning off.
• alcohol and cannabis use : much more difficult .
Gradual opening of issues, working on concerns re
money, shoplifting, and fear of returning to prison;
and relationship between use of cannabis and
exacerbation of psychotic symptoms.
Co-existing Mental Health and Drug and Alcohol Problems: Steps towards
better treatment
Mental Health Work
• paranoid; severe anxiety and associated agitation and
aggression; depression.
A number of psychosocial interventions:
• taking ‘time out’ when felt defensively aggressive,
and asking staff for help.
• early symptom recognition and control,
• medication management,
• CBT work on unhelpful thoughts,
• thought stopping and control,
• relapse prevention.
Co-existing Mental Health and Drug and Alcohol Problems: Steps towards
better treatment
Housing Work
• Accompanying Gerry to the Housing Department,
helping him fill in a housing application form.; letters
to the Housing Department explaining Gerry's
vulnerability :
• eventually he was offered suitable accommodation.
• Help in accessing furniture for his new flat via a
furniture donation service.; helping fill in a
Community Care Grant form for essential items such
as a fridge and a cooker
• Visiting him at home to ensure he was coping.
Co-existing Mental Health and Drug and Alcohol Problems: Steps towards
better treatment
The Role of the Past
• Much of his first 16 years being moved from one
institution to another; father: severe alcohol problem;
Gerry: disruptive and difficult at a young age.
• Parents found him difficult to cope with; child
protection concerns re domestic violence.
• At 11, into care, cycle of abuse and emotional neglect
continued; series of children's homes, assessment
centres and secure units; age 15 sniffing glue and
stealing cars; at 17, into a flat but impossible to cope
and began staying on friends' floors and sleeping
rough.
Co-existing Mental Health and Drug and Alcohol Problems: Steps towards
better treatment
• both psychiatric services and prison.
• long-term relationship, 2 children, but fell
apart : no contact with partner or children for
many years; no contact with family of origin
since aged 16.
• Ian explored these past experiences ; started to
help Gerry formulate some explanations for
himself, as to why things had gone wrong, and
how these were related to his current
difficulties.
Co-existing Mental Health and Drug and Alcohol Problems: Steps towards
better treatment
Outcomes
• Gerry: still maintaining his tenancy; mental health
and substance misuse are now stable. He says that the
therapeutic work that Ian and others helped him with,
have ‘given me a reason to get up in the morning’.
• volunteers at a related project; developed skills; feels
‘100 per cent more confident’.
• thinking about topping up his electrician’s training ;
• not yet made contact with either family, but is still
actively considering this.
Co-existing Mental Health and Drug and Alcohol Problems: Steps towards
better treatment
Key Factors in Successfully Helping Gerry.
• Liaison between Ian and other staff /services; strong,
consistent;facilitated effective multi-agency approach
• no need to refer on to other services: ‘1-stop shop’
• Ian: high quality and regular support and supervision;
excellent training; understood and could utilise a
range of psycho-social interventions: CBT, MI,
relapse management, and medication management.
• very lengthy engagement period, where Ian
persevered even though Gerry was adamant he didn’t
want help.
Co-existing Mental Health and Drug and Alcohol Problems: Steps towards
better treatment
• Show huge range and high prevalence of coexisting problems;
• Show how and why Screening, assessing and
intervening must become core business for
health practitioners and health services;
• Shown something about how useful Family
approaches are in this area
• and demonstrated how intensive work with
people with co-existing homelessness as well as
both mental health and substance misuse
problems, can be immensely helpful.