Treatment approaches and outcomes
People with a co-occurring AOD and mental health problem may have worse impairment, a more trying course of illness and are more difficult to treat than people with a singular problem.12
Research shows people with a dual diagnosis may also have poorer treatment outcomes.25
However, emerging evidence has clearly demonstrated that individuals with dual diagnosis benefit equally from treatment as those without comorbid conditions,25 both in terms of their physical and mental health and AOD use, including those with severe mental health disorders.26
This highlights the importance of treating both conditions simultaneously.25 AOD workers and service providers should deliver sound treatment for AOD issues, despite the clinical complexity.
While the conditions of both groups improve with treatment, people with a dual diagnosis may be at higher risk of continuing to use AOD and having poorer levels of functioning following treatment compared to people without a dual diagnosis.26
However, people with dual diagnosis do benefit from treatment, which can result in reductions in AOD use and improvements in overall health, including the symptoms of a mental health condition.1
Screening
A key focus for practitioners should be supporting prevention efforts through holistic screening and early intervention.
Effective screening to assist dual diagnosis is critical.
The high prevalence of mental health disorders of between 47-95 per cent (particularly mood and anxiety disorders) in substance use treatment settings highlights the need for clinicians to effectively screen and assess for these disorders as part of standard clinical care.27
While clinical tools for screening, assessing and responding to presentations for mental health conditions and AOD use disorder are already available,12 the high prevalence rate reinforces the need for clinicians and health practitioners to be familiar with evidence‐based management and treatment strategies.27
Single condition treatment
Co-morbid patients and clients usually have their health problems dealt with singly. This often results in one condition going untreated, which can - in turn - jeopardise their recovery from the treated condition.
When one co-occurring condition is not identified, the resultant misdiagnosis will confuse and frustrate clinician and patient alike.
For example, the treatment of psychosis is often overlooked because the onset of psychosis and the onset of drug use typically occurs during adolescence and early adulthood.28
Conversely, the psychomimetic qualities of many drugs can result in a person being wrongly diagnosed for a drug-induced psychosis when they present for the first time.24
Misdiagnosis delays proper treatment with adverse consequences for the eventual outcome.24
Concurrent treatment
The current evidence-based guidelines in Australia suggest that the integrated treatment of mental health and AOD use disorders is best practice.29
Concurrent treatment of anxiety and substance use problems is difficult, and some experts advise it may be efficacious to treat the AOD use disorder first, as anxiety symptoms often cease or reduce markedly when problematic drug use is discontinued.28
This, however, presents a challenge for clinical staff as some patients in psychiatric services prefer their anxiety and depression be treated, without addressing their AOD use.28
Staff involved in treating AOD dependence need to include treatment of psychiatric disorders for co-morbid clients. Psychiatric staff similarly need the capacity to introduce AOD treatments into mental health service programs.28
Treatment of people with co-occurring problems will require the training of general practitioners and staff in alcohol and other drug services and in mental health services.
Standardised and manualised treatment packages for the range of co-occurring AOD and mental health conditions in primary care and specialised service settings would expedite those developments.28
Unfortunately, as little research has been conducted into treating co-morbid conditions there is a lack of evidence about effective treatment interventions.28
The idea of combining treatment for multiple disorders has considerable appeal and presents a number of advantages over sequential or parallel approaches.30 Further research and evaluation is necessary to confirm that these approaches lead to significantly better outcomes for individuals and their families30.
Where possible, integrated treatment by a single service assists in ensuring consistent, focussed treatment, enabling the complex relationship between conditions to be understood by treating practitioners.30
This single point of engagement:
- lessens the burden on the individual
- mitigates potential communication problems and conflicting approaches to treatment
- reduces the chance of people falling between the gaps when it comes to treatment.22
Where this single service approach is not possible, individuals need to access different services to have their respective needs meet.
When this is the case, there is a need for specialist health services to improve their collaboration and coordination between each other, ensuring that the most appropriate communication, treatment and supports are available to individuals seeking help, in a timely, safe and effective way.26
While each individual’s experiences and needs will be different, most people will be likely to require support from a number of different services which may have varying levels of interconnection with each other.
This need underscores the importance of services adopting a ‘no wrong door’ policy to ensure that people always receive appropriate treatment and support – especially when multiple organisations are involved.
Defining success in treatment
There is no single definition of success for either AOD treatment, or for the treatment of a mental health condition.
Each individual is the expert on their own goals.
Care should be taken to not oversimplify the diversity of people with mental health conditions, or their goals in seeking treatment or support.31
Determining what recovery means to the individual can help ensure treatment is appropriately tailored.31
For some people who use alcohol or drugs, abstinence from AOD is neither achievable or desirable – they may seek instead to reduce, or feel in control of, their use. If this is the case, health practitioners can provide evidence-based advice and resources to help individuals engage in low risk substance use and information on the associated harms and support.
Stigma
For individuals experiencing substance use disorders or dual diagnosis, the evident lack of treatment is partly due to stigmatisation, because a person’s experience of dependence is often regarded as ‘personal choice or moral failure’.8, 32
Stigma is a mark of disgrace that sets members of the stigmatised group apart, marking them as less valuable than other members of society.
A person who is stigmatised is not seen as a full and complex human being – they are judged first and foremost based on their stigmatised traits.
People experiencing an AOD dependence or a mental health condition are often stereotyped as being dangerous and unpredictable and may be considered ‘to blame’ for experiencing a dependence.8
When a person starts to believe these things about themselves, they can experience shame, low self-esteem, and feel unable to succeed or accomplish goals.8
Stigma stops people asking for help.8
The stigma associated with both AOD use and mental health can lead to people denying their symptoms or feeling as if they cannot seek treatment.3
In this way, stigma can contribute to worse health outcomes amongst people who are stigmatised.8
Being afraid to seek treatment or unwilling to tell health care practitioners about either mental health symptoms or the use of alcohol and other drugs can mean that people aren’t getting the care and support they need.
Health care practitioners have a key role to play in reducing the stigmas associated with alcohol and other drug use and mental health conditions.
Health professionals can help reduce stigma by using person-first language. Learn more about the ‘Power of Words’ around AOD.