Download Management of Concurrent Mental Health and Drug and

B3: 7 Comorbidity HO3
GP Drug & Alcohol
Supplement No.11
January 1999
Management of Concurrent Mental Health and Drug and
Alcohol Problems
Martin Evans and Katie Willey
Introduction
The management of mentally ill patients who misuse
alcohol and other drugs creates significant challenges
for general practitioners.
Although not ideal, the term ‘dual diagnosis’ is used in
this supplement to indicate that a patient has a mental
illness and a co-existing, problematic substance use
condition.
Information from the Burdekin Report (1993) indicates
that there is a notable lack of communication between
health practitioners and services resulting in many
individuals with a dual diagnosis falling through gaps
in the health care system. An integrated approach,
which involves a range of health providers, including
professionals with mental health and drug and alcohol
expertise, is required for these patients.
Prevalence Rates
High proportions of individuals with a mental illness
are known to abuse alcohol and other drugs.
According to prevalence figures from a major US
study (Regier et al. 1990):


29% of all persons with a serious mental illness
also had a problem with substance abuse (twice
the population risk for alcohol and four times that
for other drugs).
47% of persons with schizophrenia also had a
problem with substance abuse (three times the
population risks for alcohol and six times that for
other drugs).

56% of persons with bipolar disorder also had a
problem with substance abuse (eleven times the
population risk for both alcohol and other drugs).

47% of persons with an alcohol disorder had a comorbid mental illness (twice the risk for the general
population).

53% of persons with another drug disorder had a
co-morbid mental illness (four times the risk for the
general population).
It was also concluded that people with mental
disorders are two to six times more likely to develop
substance abuse than the other way round.
There have been few Australian studies on the
prevalence of persons with the dual diagnosis of
mental illness and alcohol and drug misuse. A study
of acute psychiatric admissions to Rozelle Hospital,
Sydney found that 60% had a current diagnosis of
substance abuse and 66% had at least one such
lifetime diagnosis of substance abuse (Cheung 1991).
Information from a 1991/2 census of NSW community
mental health agencies indicated that 35% of patients
had a dual diagnosis (Muir et al. in press). A recent
study of community health services on the Central
Coast estimated that 1 in 3 patients seen had a dual
diagnosis (Evans 1996).
Problems associated with dual diagnosis
The problems associated with substance abuse can
have a devastating effect on the life of a person with a
mental illness and their family. Common problems as
discussed by McDermott and Pyett (1993) are:

Precipitation or exacerbation of symptoms of
mental illness;

Reduction or exaggeration of the effects of
medication;

Self medication for symptoms of mental illness;

Impulsive, aggressive or disinhibited behaviour;

Increased
attempts;

Physical health deterioration;

Lack of compliance with treatment;

Increased frequency of relapse, acute psychiatric
intervention and hospitalisation;

Homelessness;

Legal, financial, social and daily living problems.
anxiety,
depression
and
suicide
Some groups are thought to be particularly at risk as a
result of dual diagnosis and require specific
approaches and interventions to be made (Burkstein
et al. 1989; McDermott & Pyett 1993). These special
groups are youth, women, aboriginal and homeless
persons.
Central Coast Area Health Service
GP Drug & Alcohol Supplement No. 11
Treatment approaches
Although there is considerable literature about dual
diagnosis, there is limited information about best
practice and practical guidelines for interventions.
The integrated approach to dual diagnosis treatment
combines mental health and drug and alcohol
interventions in a concurrent, unified treatment
program.
There is considerable support for the
integrated approach (Minkhoff 1991; McKelvey et al.
1989). Clenaghan et al. (1996) recommend “cross
sector collaboration by way of formal and informal
structures and networks to develop frameworks for
service delivery with likely outcomes being the
evolution of training initiatives and service
development.”
Systematic screening of patients for both disorders
and developing links between service providers for
purposes of specialist referral or conjoint management
are recommended.
The harm minimisation approach to dual diagnosis is
also strongly recommended and supported by
McDermott & Pyett (1993) and Clenaghan et al.
(1996). This approach is practised widely by drug and
alcohol services but less so by mental health services.
Harm minimisation is a patient-centred approach
which aims to reduce specific harms associated with
dual diagnosis, such as homelessness, self
medication and health problems, by specific matched
interventions. It is recognised that in many cases
abstinence from drugs may not be a realistic goal and,
in these cases, a number of non-abstinence treatment
goals are required.
January 1999
General practitioners’ roles in the care of these
patients include:
1. Identification
2. Accurate diagnosis
3. Coordination of care
4. Provision of interventions
5. Follow-up and monitoring
6. Early response to deterioration in the patient’s
clinical condition
1. Identification of dual diagnosis
Familiarity with the indicators of dual diagnosis and
the ability to identify signs and symptoms of both
mental illness and drug and alcohol conditions are the
keys to identifying a person with dual diagnosis. Carr
(1997) states that detection of substance use in a
person with schizophrenia is the first priority.
Undetected substance use may be one of the reasons
patients respond poorly to treatment.
Carr (1997) also states that it is important to
acknowledge the reasons the person is using other
substances particularly if use helps relieve distress.
Addressing the ‘margin of safety’ between the adverse
effects and desired effects in all types of drugs both
prescribed and recreational is necessary. Abstinence
should be advocated as the safest option but a harm
minimisation approach can be used as a satisfactory
compromise. Short-term goals such as controlled and
safe use and relapse prevention skills should also be
discussed with the patient and if necessary,
interpersonal and social problems should be
addressed.
Practical approaches when working with
dual diagnosis patients
Indicators of dual
alcohol assessment
Engagement and persuasion strategies have been
shown to be particularly useful in the initial contact
with patients who have a dual diagnosis. Engagement
refers to the initial development of a trusting
relationship between patient and service provider.
Persuasion refers to the process by which patients
learn how substance use affects their lives and
develop motivation to change (Osher & Kofoed 1989).
Other approaches that have been recommended by
Clenaghan et al. (1996) as guidelines for the
management of dual diagnosis include:
 Assertive outreach interventions and close
monitoring of patients;
 A comprehensive and holistic approach so that the
varied, associated problems can be addressed by
a range of strategies;
 A longitudinal perspective to treatment, which
should occur continuously over years rather than
sporadically or during crises.
A detailed account of a drug and alcohol assessment
is outlined in a previous supplement (No. 3
Assessment and Treatment of Alcohol Problems in the
General Practice Setting). In summary, a drug and
alcohol assessment involves:
 establishing current level of use, often using a
retrospective timeline which is taken by starting
with the last time a person used alcohol or other
drugs and enquire back through that day and then
to the day before and so on for seven days. The
patient is then asked if this is a typical week.
 taking a lifetime history of use through enquiring
about age at onset of regular use, changes in use
over time, periods of abstinence and problems with
withdrawal.
 assessing problems related to alcohol and other
drug use through pharmacological knowledge and
through report from the patient about problems
related to health, relationships and sexual
behaviour, work, accidents, and problems of
dependence. This includes narrowing of drinking
repertoire (type, time, amount of use becomes
more stereotyped), salience of drinking (primacy
over other activities), subjective awareness of
compulsion to drink, increased tolerance to
alcohol, repeat withdrawal symptoms, relief or
avoidance of withdrawal symptoms by further
drinking and reinstatement after abstinence.
Primary care for dual diagnosis patients
Managing a patient with concurrent mental health and
alcohol or other drug problems can be difficult due to
the complexity of clinical and social problems these
patients can experience. General practitioners play a
critical role as the primary carer in the ongoing
management and continuity of care for dual diagnosis
patients.
Central Coast Area Health Service
diagnosis:
Drug
and
GP Drug & Alcohol Supplement No. 11
Indicators of dual diagnosis: Mental health
assessment
A comprehensive mental health assessment is lengthy
and involves, among other things, taking a psychiatric
history, history of current problem, family psychiatric
history and details of relevant medical conditions. The
mental state examination (MSE) is a useful tool in
assessing current mental state (Leon, Bowden &
Faber 1989).
The MSE includes assessment of:
 Appearance - does the patient look physically ill?
Is there evidence of self-neglect? Is the patient’s
dressing flamboyant or inappropriate? Is the
person well groomed or unkempt?
 Activity - a number of overt symptoms can be
observed including rigidity, anxiety, aggression,
withdrawal, disinhibition, impulsivity, suspicion,
shyness or timidity during the interview. Is the
patient’s overt behaviour consistent with what they
are saying? Does the patient make appropriate
eye contact or none at all? Does the patient
display slowness or retardation, overactivity,
agitation, excitation, awkwardness or idiosyncratic
movements or posturing and waxy flexibility?
 Mood and affect - mood is described as the
subjective feeling state of the patient, such as
elation, depression, anger, and anxiety. Variations
in mood throughout the day should be noted.
Affect is a transitory emotional expression at the
time of interview. Affect can vary in range,
intensity,
stability,
appropriateness
and
relatedness.
 Speech and language - it is important to examine
both the form of speech and the content. What is
the patient’s rate of speech? Does the patient use
words in an idiosyncratic way or invent new words
(neologisms)? Does speech flow normally? Is the
speech pressured? Is there evidence of thought
blocking, flight of ideas, evasion, loosening of
associations,
circumstantiality,
tangentiality,
perseveration, preoccupation, paucity of ideas or
over abundance of ideas?
 Thought content - is there evidence of
ruminations, obsessions, compulsions, delusional
ideas, overvalued ideas, pre-occupations or
phobias?
 Perceptual disturbances - are symptoms of
illusions (misinterpreted perceptions such as
seeing shadows as people), hallucinations
(sensory experiences without external stimulation),
depersonalisation (patient feels they have lost their
personal identity), derealisation (patient feels that
the environment is unreal) or formication (tactile
hallucination of insects crawling under skin)
present?
 Insight and judgment - the patient’s capacity to
understand his or her symptoms as abnormal
experiences and relate them to the presence of
illness.
 Neuropsychiatric evaluation - it is important to
examine cognitive functioning and check level of
consciousness, attention and concentration,
January 1999
language fluency, memory and higher cognitive
functioning.
2. Accurate diagnosis
Patients with dual mental health and drug and alcohol
problems often present with unclear diagnoses, which
inhibits effective treatment approaches being
instituted. Patients can present with a range of signs
and symptoms which need to be sorted into
differential diagnoses initially, and then further
investigated and clarified into a diagnosis which can
guide treatment. An example would be the presence
of psychotic symptoms, which may be substance
induced, may be secondary to a medical condition or
part of a schizophrenic illness. The appropriate
treatment, which would be different with each
diagnosis, will be determined by making an accurate
diagnosis. Because the GP will usually have a longterm relationship with the patient, knowledge of
individual patterns of mental illness can be included in
making an accurate diagnosis. GPs can use this
knowledge to determine the extent to which substance
use or mental illnesses are the primary issues. GPs
also have the capacity to investigate for causes of the
problems, such as screening for presence of drugs or
identifying medical conditions, which may be
causative, such as intracranial hemorrhages.
3. Coordination of care
Dual diagnosis patients often have multiple health and
social problems, thus coordinated care which
achieves the involvement of a range of relevant
service providers in the management of the dual
diagnosis patient is of clinical benefit. Involvement of
services such as Area Mental Health and Drug and
Alcohol Services either in a consultative and referral
role or as collaborating service providers is usually
necessary.
The GP is ideally placed to be the primary carer of the
patient calling on specialist services when the need
arises. An example could be when the patient does
not turn up for an appointment with the Mental Health
Team. The patient’s GP can assess the patient and if
necessary, organise urgent assertive follow up of the
patient by the mental health team to gain quick, early
control of the patient’s deteriorating clinical condition.
General health care provided by the GP will also
improve outcomes for these patients. This type of
management has been advocated as a successful
approach in the management of dual diagnosis.
(Clenaghan et al, 1996)
The support of the Area Health Service can be useful
in managing this group of patients. Involvement of
both Mental Health Services and Alcohol and Other
Drug Services would usually be included in the
management plan for a person with concurrent mental
health and drug and alcohol problems. Each service
can offer specialist expertise and support.
The Central Coast Mental Health Service and the
Alcohol and Other Drug Service are striving now to
work more cooperatively together to manage patients
with dual diagnoses. These services are working to
Central Coast Area Health Service
GP Drug & Alcohol Supplement No. 11
January 1999
more effectively treat the patients who previously fell
between the gaps.
that can result in high levels of distress and disruption
to the patient’s life.
4. Provision of interventions
6. Early response to deterioration in the
patient’s clinical condition
There are a number of drug and alcohol interventions
that are known to be effective, including relapse
prevention strategies, controlled drinking programs
and motivational interviewing (Mattick & Jarvis 1993).
These interventions should also be used with patients
who have dual diagnoses. Although these
interventions are not likely to be effective for patients
with unstable psychiatric presentations, they are
appropriate for patients who have relatively stable
presentations and some degree of insight.
Psychosocial treatment of psychiatric conditions
includes provision of education about psychiatric
disorders, signs of early relapse, the benefits of
treatment, and how to identify symptoms early. It also
includes rehabilitation of patients through, for
example, social skills and living skills training. These
approaches should be applied to patients with dual
drug and alcohol and mental health problems.
5. Follow-up and monitoring
Close monitoring and follow-up have been advocated
as one of the most effective strategies in the
management of patients with dual diagnosis. They
provide the opportunity to identify early any variations
in mental state and degrees of substance use, and
also improve compliance with psychiatric medication.
They also provide continuous care for these clients in
comparison to crisis driven and acute episodic care
Patients will dual diagnosis often has a number of
health, social and interpersonal problems exacerbated
by both mental illness and substance use. Because
GPs are in a position to regularly follow-up these
clients they are well placed to monitor deterioration in
the patient’s clinical condition. Once recognised, the
GP can increase the frequency of contact, increase or
change medication as required, or facilitate entry into
other services before the condition worsens.
Prevention of an acute episode and admission to
hospital is the optimal result ensuring as little
disruption to the patient’s life as possible.
_________
The Mental Health Service can be contacted on
02 43 203 500 24 hours a day, 7 days a week.
The Alcohol and Other Drug intake service can be
contacted by patients on 02 43 202 637
between 8.00-5.00 pm on weekdays.
Information and advice for GPs about the
management of patients with alcohol and other drug
problems can be obtained through the Drug and
Alcohol Clinical Advisory Service on 0413 276 177.
Please note this service is to be obtained by health
professionals only.
References
Burdekin, B., Guilfoyle, M. & Hall, D. (1993). Human rights and mental illness. Report of the national inquiry into human rights of
people with mental illness. Australian Government Publishing Service: Canberra.
Burkstein, O., Brent, D. & Kaminer, Y. (1989). Co-morbidity of substance abuse and other psychiatric disorders in adolescents.
American Journal of Psychiatry, 146: 1131-1141.
Carr, V.J. (1997). The role of the general practitioner in the treatment of schizophrenia: specific issues. Medical Journal of Australia,
166, 3: 143-146
Cheung, R. (1991). The detection of psychoactive substance use in acute admissions : a pilot study, dissertation for R.A.N.Z.C.P.
Fellowship.
Clenaghan, P., Rosen, A., Van Bysterveld, M., Friel, O. & Spilsburg G. (1996). Developing effective strategies for people with a
serious mental illness and problematic substance use. Royal North Shore Hospital and Community Mental Health and Drug and
Alcohol Services, Sydney.
Evans, M. (1996). Identifying the needs of community mental health workers in managing clients who misuse alcohol and other
drugs. Central Coast Area Health Service.
Hall, W. & Farrell, M. (1997). Co-morbidity between substance use and other mental disorders. National Drug and Alcohol Research
Centre, Sydney.
Leon, R.L., Bowden, C.L. and Faber, R.A. (1989). The psychiatric interview, history and mental state examination. In Kaplan, H.I and
Sadock, B.J. (Eds) Comprehensive Textbook of Psychiatry/V, Volume 1, 5th Edition. Williams and Williams: Baltimore. Chapter 9.1.
Mattick, R. & Jarvis, T. (1993). An outline for the management of alcohol problems : quality assurance project.
Government Publishing Service : Canberra.
Australian
McDermott, F. & Pyett, P. (1995). Not welcome anywhere - people who have both a serious psychiatric disorder and problematic
drug or alcohol use. Victorian Community Managed Mental Health Services: Melbourne.
McKelvey, M., Kane, J. & Kellison, K. (1989). Substance abuse and mental illness. Journal of Psychosocial Nursing and Mental
Health Services, 25 (1), 20-25.
Minkoff, K. (1991). Program components of a comprehensive integrated care system for serious mentally ill patients with substance
disorders. New Directions for Mental Health Services, 50, 13-27.
Muir, C., Flaherty, B. & Ross, J. (In press). Census of community drug and alcohol clients, NSW 1991 & 1992. Drug and Alcohol
Directorate, Sydney.
Osher, F. & Kofoed, L. (1989). Treatment of patients with psychiatric and psychoactive substance abuse disorders. Hospital and
Community Psychiatry, 40, 1925-1030.
Central Coast Area Health Service
GP Drug & Alcohol Supplement No. 11
January 1999
Regier, D., Farmer, M., Rae, D., Goodwin, F., Judd, L., Keith, S. & Locke, B. (1990). Co-morbidity of mental disorders with alcohol
and other drug abuse - Results from the E.C.A. study. Journal of the American Medical Association, 264, 2511-2518.
Central Coast Area Health Service