Barriers to Optimal Care for Patients with Coexisting Substance Use and Mental Health Disorders

Abstract

Objective: This paper describes qualitative research that was carried out as part of a project aimed at drawing up a series of guidelines for the assessment and management for people with coexisting substance use and mental health disorders, or dual diagnosis [1].

Method: A core consultation team of 14 experts with experience in the areas of both substance use and mental health in New Zealand was established to advise on the development of eight clinical scenarios. The clinical scenarios were selected to highlight a range of real life issues in the treatment of people with coexisting substance use and mental health disorders and were presented at 12 focus groups around New Zealand. The 261 participants of the focus groups were asked to comment on what was optimal management for each of the scenarios and to identify barriers to optimal care in their region. Written notes were analysed for recurring and strongly stated themes and these comprise the results of the study.

Results: While there was marked regional variation in treatment approaches and service structures, many of the barriers to optimal care that were identified were common to all regions. The results are considered under the headings of systems issues, clinical issues and attitudes.

Conclusions: A wide variety of barriers that impede the delivery of optimal care have been identified. These range from the attitudes of individual clinicians to the structure of the systems within which they work. A system of key principles and processes for organizing treatment in a way which helps overcome these barriers is proposed.

People who suffer coexisting substance use and mental health problems often experience poor treatment outcomes across a range of outcome measures. However, outcome is strongly influenced by the combination of substance and mental disorder; ‘dual diagnosis’ is not a homogenous condition and differing combinations of substance use and mental health problems interact in different ways and lead to different outcomes. For example, moderate to heavy alcohol use is associated with the exacerbation of depressive symptoms in major depressive disorder [2], increased frequency of admissions and a higher proportion of rapid cycling in those with bipolar disorder [3–5], and increased readmissions and psychotic episodes in those with psychotic disorders [6]. Cannabis use has been associated with increased positive symptoms, increased rates of rehospitalization and a shorter time to relapse in people with schizophrenia [7], and may elevate mood and increase psychotic symptoms in people with bipolar disorder [8]. People with opioid dependence who also suffer psychiatric disorders do less well in addiction treatment and have higher rates of HIV risk-taking behaviours [9–12].

The significance of these interactions is made all the more important by their relatively high prevalence. Although a range of prevalence rates have been reported in community samples, reflecting in large part differences in methodology, rates are consistently over 25% [13, 14] and range up to 80% [15, 16].

Rates of comorbid psychiatric disorders in addiction settings also vary, but are consistently higher than those found in the general population [17–19]. Prevalence rates of alcohol and drug disorders in mental health settings are consistently reported at between 30% and 50% depending on the specific mental health diagnosis [20]. These rates are much higher when use of nicotine is included as a substance use disorder [21, 22].

A number of treatment approaches have been developed to meet the needs of people with coexisting substance use and mental health problems. One of the most common components of these approaches is treatment integration [23–25], meaning treatments that integrate mental health and substance use resources and models. Integrated treatment aims to overcome perceived barriers to treatment, but to date there have been few studies which have investigated these barriers to care in a systematic way.

Concern that people with coexisting disorders were not receiving adequate treatment in New Zealand has been highlighted in recent years by several highly public tragedies involving people with mental illness and substance use disorders. As part of a response to these concerns, the National Centre for Treatment Development (Alcohol, Drugs & Addiction) was commissioned by the Alcohol Advisory Council of New Zealand (ALAC), the Ministry of Health and the Mental Health Commission to develop guidelines for the assessment and management of people with substance use and mental health disorders. As part of this project, the authors undertook a series of focus groups throughout New Zealand, aimed at identifying the barriers that prevented patients with coexisting substance use and mental health disorders receiving optimal care. Of particular interest were those barriers that were common to most regions and services and that would allow the development of a set of general principles and guidelines for treatment. This paper outlines the methodology and findings of the focus group research in the context of the overall project.

Method

Procedure

The project was undertaken in a number of phases.

1. A core consultation team, consisting of 14 expert clinicians from mental health and alcohol drug services in New Zealand, was assembled as a prelude to a series of national focus groups. The main role of this team was to advise on the choice of scenarios to be used in the focus groups and to help outline standard treatments for each scenario.

2. Eight clinical scenarios were selected to highlight a number of key issues in real life treatment, these being the range of specific substances, the range of mental disorders, cultural issues, safety issues and the variety of treatment settings. Each clinical scenario was comprised of several parts, which followed the case through several phases of treatment. The initial part of each of the eight scenarios is outlined in Appendix I.

3. A series of 12 focus groups (see Table 1), comprised of clinicians, consumers and family members, involved with alcohol and drug or mental health agencies were organized. The size of the focus groups ranged from four to 63 participants. Overall, 261 people were involved. Each group considered one or two of the scenarios. Each scenario was presented in at least three focus groups. Those barriers to care, common to most scenarios in most regions, were identified.

Table 1.

List of focus groups and number in attendance

The choice of services and regions within which to run focus groups was determined in part by the aim to sample a range of regions and services across New Zealand and to include recognized experts within mental health services, alcohol and drug services specific dual diagnosis units, as well as consumer groups, family groups and Maori. 4. Each focus group was conducted using a predetermined procedure. An introduction explained the reasons for the focus group and outlined the design of the study. Participants were presented with a clinical scenario and asked the following questions: What would you consider was optimal management for this case? What barriers exist in your region to prevent this patient receiving optimal care? A second scenario was then presented in the same way.

FT or PR facilitated the focus groups. The facilitator would make notes during the group. The notes were then discussed between the facilitators as soon as possible after the group ended and general impressions were documented.

5. After all focus groups were completed, the written notes were analysed and the key themes or strongly stated themes highlighted.

6. Consistent themes drawn from the focus groups were then compared with the opinions of the core consultation group.

Results

The themes that were common to most groups and regions, consistent with the views of the core consultation team are reported below as the results of this study.

Overview of results

While there was variation between regions in terms of the approaches to treatment and models of service delivery for patients with coexisting substance use and mental health problems, many of the barriers to optimal care were remarkably consistent between focus groups and common to most regions. There was a consensus that the essence of optimal care was the provision of a comprehensive assessment and management plan that considered both urgent and important non-urgent issues. Furthermore, the components of this plan need to be integrated both conceptually and across services such that the plan made sense to the patient, encouraged the patient to engage with it and was easy to access all its components.

Most of the barriers that emerged appeared to be problems inherent in the mental health and alcohol and drug systems and applicable to many of the more ‘difficult to treat’ patients regardless of their diagnoses.

The findings are summarized under three main headings: systems issues, clinical issues and attitude issues (see Table 2).

Table 2.

Summary of barriers to optimal care for people with coexisting substance use and mental health problems

Issues specific to Maori

The Maori hui raised a number of broader contextual issues within which the results discussed below need to be considered. Maori expressed a widespread mistrust of the intentions of government agencies and mainstream professionals. While they were not united on the best approaches to the treatment of coexisting substance use and mental health disorders, they were clear that they needed to have control over the process which identified and implemented these and that kaupapa Maori frameworks of health needed to be considered.

Systems issues

Most of the barriers identified related to the structure and organization of services within which treatment was delivered. Participants expressed a strong belief that there were effective treatments that could not be delivered because of the nature of the services within which they worked, and that the effectiveness of the treatments they did offer were limited by the poor communication between the agencies involved.

Many participants were apprehensive that attempts to provide better care for patients with coexisting disorders would involve the establishment of dedicated dual diagnosis treatment services that would soon become swamped with work and would further increase the number of interfaces and therefore potential gaps between services.

Clinical issues

Participants were less willing to acknowledge deficits in their own clinical practice, but identified issues in the practice of others around them. It was clear, however, that only a minority of clinicians had the range of clinical skills and the knowledge base needed to assess and plan effective interventions for patients with coexisting disorders, and very few had the broad range of skills necessary to actually carry out effective interventions.

Attitude issues

Of significant concern were the problematic attitudes expressed by clinicians. It was obvious that judgemental attitudes about substance use often coloured the care that their patients received, especially from mental health services. Often patients with an alcohol and drug problem are turned away regardless of the other mental health problems they may suffer. Examples that were offered included the following:

1. A patient with psychotic symptoms believed to be due to drug use refused access to an acute psychiatric service on the grounds that their problems should be treated in an alcohol and drug service.

2. A patient with psychotic symptoms and alcohol and drug problems turned away from an alcohol and drug service on the grounds that the psychosis should be treated within mental health services.

3. A suicidal patient refused emergency mental health treatment because it was felt that the problem was alcohol and drug related and therefore ‘not the business of mental health services’.

Finally, a number of key quotes from the family and consumer groups reiterate the problems stated above:

‘They [clinicians] are abrupt when I ask questions, and resent having to make an effort.’

‘We get told that [the patient] doesn't want to be seen and they [the clinical team] can't do anything. They could try and give us advice or support but they won't.’

‘They don't listen when we express concern – we know the patient best.’

‘Continuity of care is poor – we do all the caring while our son is waiting to be seen by the next service.’

Discussion

The key aim of this study was to identify barriers that prevented patients with coexisting substance use and mental health disorders receiving optimal care, so that national guidelines for optimal care could be created. As such, those barriers common to most regions of the country were sought. It is evident from the findings of this study that a wide variety of barriers impede the delivery of optimal care. These range from the attitudes of individual clinicians to the structure of the systems within which they work and are likely to be applicable to many ‘difficult to treat’ patients regardless of whether they have coexisting substance use and mental health problems or not. Patients with coexisting disorders simply seem to expose the inherent weaknesses within mental health care in New Zealand to which all patients are to some degree subjected.

It can be argued that these barriers are probably not peculiar to New Zealand. Many of the treatment approaches for dual diagnosis established in other countries appear to have been designed to overcome a number of the barriers we have highlighted, especially those approaches that stress treatment integration and close liaison between services [23, 26].

However, the pattern of drug use in New Zealand, with its low rates of cocaine and stimulant use, and the rapid and uncoordinated development of services designed to help people with coexisting disorders has led to potential differences in the nature of coexisting disorders in this country. There have been no studies that have investigated the specific barriers to optimal care that exist in New Zealand.

While this study only sampled a small proportion of alcohol and drug and mental health workers in New Zealand, one of its strengths was the wide range of services and regions covered. There was impressive consistency between groups regarding most of the barriers that were identified, especially from a systems perspective. However, there were also significant regional differences in the structure of services, the way they interacted and what had been tried to remedy the problem of service fragmentation. The need to develop a set of national clinical guidelines [1] meant that the study focused on common issues at the expense of the more specific regional barriers, which nevertheless remain important.

Several of the important barriers to optimal care involve the nature of the systems within which treatments occur and as such are difficult to overcome at a clinical level. A separate set of recommendations was therefore produced for the Ministry of Health with the expectation that changes on a systems level will need support and leadership at a governmental level. Similarly, clinical guidelines are unlikely to overcome barriers to optimal care that emanate from the attitudes and beliefs of clinicians. At best, such guidelines can only suggest strategies to minimize the impact of these.

To provide a structure for organizing treatment for people with coexisting mental health and substance use disorders five key principles of treatment and five key processes were developed out of the findings of this research and will be discussed in more depth in a subsequent paper. The aims of these principles are to remind clinicians of their primary responsibility to ensure the patients safety regardless of the appropriateness of the patient for the service they present to, to encourage a method of assessment and management planning that is both comprehensive and internally consistent, and to emphasize the need for coordinated strategies by which treatment can be integrated across paradigms and services. The five key principles are described briefly below and strategies for implementing them are outlined in Table 3.

Table 3.

Strategies for implementing the five key principles of treatment to consider when intervening with people who have coexisting mental health and substance use disorders

Five key principles of treatment

1. Safety

Ensuring the safety of the patient and others that may be at risk takes precedence over all other decisions. It is relevant at this point to stress the need for cultural safety, and for all clinicians involved in the care of the patient to recognize the limits of their expertise, to take responsibility for increasing their cultural skills and to involve appropriate health workers to address these issues.

2. Stabilization

Once safety is ensured, any acute issues that interfere with further treatment need to be stabilized. Such issues include acute intoxication and withdrawal, psychotic symptoms, psychosocial crises, severe anxiety or depressive symptoms or a combination of these.

3. Comprehensive assessment and treatment planning

A comprehensive assessment and treatment plan is a dynamic process that begins with the patient's first contact and is reviewed continually throughout the course of treatment. It aims to assess and integrate all relevant areas of a patient's life, and sets the direction of further treatment. It should be undertaken by a clinician trained in either mental health or alcohol and drug assessment.

4. Clinical case management

Once the patient is stable and a comprehensive assessment has given rise to a comprehensive treatment plan, clinical case management becomes the focus for ongoing treatment.

5. Treatment integration

Treatment integration aims to integrate the conceptual models and treatments for substance use and mental health problems into a coherent package that is easy for the patient to access and understand.

In addition to the 5 key principles mentioned previously, there are several other processes that should be considered.

1. Conceptual frameworks

The complexity of the problems people with coexisting mental health and substance use disorders present with means that a range of treatment approaches are often indicated, many originating from different theoretical paradigms. Using approaches that are conceptually compatible is important when trying to put together an integrated treatment package. Models that appear to fit neatly together include the following:

A ‘disease’ model; using diagnoses and interventions, evidence-based interventions targeting these.

The Engagement-persuasion model.

Motivational Interviewing approaches.

Various Cognitive–behavioural approaches, including Relapse Prevention and skills training.

Twelve-step approaches, while widely used, do not fit as well with the other models mentioned due to their emphasis on complete abstinence from psychoactive substances (often including prescribed psychotropic medications) and the admission of powerlessness over problems. They certainly have a place, however, for those people who are attracted to them.

2. Clinical responsibility

Maintenance of a clear line of clinical responsibility at all times while in treatment.

3. Therapeutic alliance

Throughout the treatment process, consideration must be given to fostering the therapeutic alliance between patient and clinician. This may be facilitated by the use of non-confrontational, empathic and motivational approaches with special emphasis being given to the engagement phase of the Engagement-persuasion model mentioned previously [27].

4. Cultural issues

Cultural needs for Australian Aborigine, New Zealand Maori and Pacific Nations peoples. Clinicians need to have access to and work alongside trained health workers specializing in the cultural needs of these groups, and should have sufficient knowledge to allow their effective utilization while at the same time work within the limits of their expertise.

5. Treatment issues for special needs groups

There are several groups who may not engage well in treatment unless their special needs are met, and the general principles of treatment need to be elaborated upon to take this into account. Of particular importance are the following:

The specific needs of patients living in rural areas.

Specific needs of gay people.

Gender-specific needs.

As mentioned, these clinical guidelines may help clinicians overcome some of the barriers to optimal care experienced by people with coexisting substance use and mental health disorders. The range of barriers we have identified extend well beyond the purely clinical. Improvements in the delivery of clinical care will have limited impact on the overall quality of treatment unless efforts are also made to address those barriers that emanate from systems and clinicians attitudes.