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Mental Health and Substance Use: dual diagnosis Publication details, including instructions for authors and subscription information: http://www.informaworld.com/smpp/title~content=t777186830
When dual diagnosis means no diagnosis: co-occurring mental illness and problematic drug use in clients of alcohol and drug services in eastern metropolitan Melbourne Michael Cole a; Tobie Sacks b a AusAID, Australian Embassy, Bangkok b NEXUS Dual Diagnosis Service, St Vincent's Mental Health Service, Fitzroy, Australia Online Publication Date: 01 February 2008 To cite this Article: Cole, Michael and Sacks, Tobie (2008) 'When dual diagnosis means no diagnosis: co-occurring mental illness and problematic drug use in clients of alcohol and drug services in eastern metropolitan Melbourne', Mental Health and Substance Use: dual diagnosis, 1:1, 33 — 43 To link to this article: DOI: 10.1080/17523280701747289 URL: http://dx.doi.org/10.1080/17523280701747289
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Mental Health and Substance Use: dual diagnosis Vol. 1, No. 1, February 2008, 33–43
PROFESSIONAL CONCERN When dual diagnosis means no diagnosis: co-occurring mental illness and problematic drug use in clients of alcohol and drug services in eastern metropolitan Melbourne Michael Colea* and Tobie Sacksb a
AusAID, Australian Embassy, Bangkok; bNEXUS Dual Diagnosis Service, St Vincent’s Mental Health Service, Fitzroy, Australia (Accepted 19 September 2007) Background: Most previous studies examining the prevalence of co-occurring psychiatric illness and problematic substance use in Australia have been population studies or focused on clients of psychiatric services. There is little literature on the prevalence of psychiatric disorders in persons attending Alcohol and Drug Services (ADS). Aims: This study attempted to estimate the incidence of mental health disorders in people treated at two ADS in Melbourne and to describe the mental disorders with which they present. Method: 165 client records from two ADS were reviewed to determine the incidence and characteristics of psychiatric problems in people presenting for management of substance use. Results: Psychiatric diagnoses were recorded in 42% of client records but rarely substantiated by further documentation. The most common diagnoses were mood disorders (31.5%). Only 4.9% clients were diagnosed with drug-induced psychosis. Personality disorders were not recorded. While 52.7% of clients were documented as receiving psychotropic medication (other than benzodiazepines), 29.3% of those had no documentation of a psychiatric diagnosis. Twenty-three per cent of clients had documented involvement with a Psychiatric Service. Conclusion: An overall prevalence of 60% could be inferred by combining indicators from the records. Previous studies have suggested that recording of substance use in psychiatric histories is notoriously poor. This study indicates that the reverse is true, that is, psychiatric problems are poorly documented in ADS histories. Thus, the true prevalence of the problem is likely to be significantly underestimated. Keywords: alcohol; co-morbidity; drug; dual diagnosis; mental illness; substance use
Introduction Alcohol & Drug and Mental Health Services have identified the issue of dual diagnosis, or more accurately co-occurring mental illness and problematic substance use, for some time as an emerging concern. Dual diagnosis has been associated with poor treatment outcomes, poor prognoses, greater disability for the patient than either single disorder and generating larger service and social costs (Dickey & Azeni, 1996; Mueser, Drake, & Wallach, 1998).
*Corresponding author. Email:
[email protected] ISSN 1752-3281 print/ISSN 1752-3273 online Ó 2008 Taylor & Francis DOI: 10.1080/17523280701747289 http://www.informaworld.com
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The Australian National Survey of Mental Health and Wellbeing (Mc Lennan, 1998) concluded that: ‘Co-morbidity in mental health and substance use disorders is highly prevalent.’ Hall, Teesson, Lynskey and Degenhardt (1998) and George and Krystal (2000) put the number of individuals with a mental illness who would also meet the DSM – IV criteria (American Psychiatric Association, 2000) for drug or alcohol abuse or dependence at some point during their lives at approximately 50%. Studies have indicated that the prevalence of co-morbid psychiatric illness and problematic substance use is significant. Mueser, Bennett and Kushner (1995) surveyed 20,000 people and found that of those diagnosed with a psychiatric disorder, 22.3% had an alcohol use disorder and 14.5% another drug use disorder as compared with 13.5% and 6.1% of people without a psychiatric problem. A similar study (Farrell et al., 2003), found that 12.2% of the nondependent population met the criteria for one or more psychiatric disorder, but this figure was more than doubled (29.6%) when the person had an alcohol dependence and more than tripled (45%) for those with a cannabis or opioid dependence. It could be suggested that a person with a substance use problem is at least twice as likely to have a mental illness as those in the general community, and a person with a mental illness is two to three times more likely to have a substance use problem than someone without a mental illness. This level of prevalence translates as high demand for service, for people with complex needs. Despite this, following their study of the epidemiology, prevention and treatment of dual diagnosis in Australia, Teesson and Proudfoot (2003), made this unambiguous statement, ‘The unmet need for treatment within this group is considerable, the lack of research is unacceptable and the person . . . is often left to fall in the gap between the relevant services.’ While there have been several studies examining the prevalence of co-morbidity in Australia, most of these have been undertaken from the psychiatric viewpoint, that is, considering the substance use of clients being treated for a mental illness at a Mental Health Service (MHS). What has not been explored is the prevalence of psychiatric disorders in persons presenting to Alcohol and Drug Services (ADS) for treatment of their substance use. This has critical implications for service planning, implementation and resourcing. This study set out to examine the frequency and type of psychiatric problems recorded in the files of clients who had presented with substance use to ADS in Melbourne. It was anticipated that this would shed some light on: . the prevalence of dual diagnosis in these services; . the characteristics of those individuals; . how these problems were assessed and documented. Methodology Services To provide a sample of clients typical of those presenting to Alcohol and Drugs Services, two ADS in the Eastern Metropolitan Region of Melbourne were selected that represented different ends of the ADS system continuum: . acute withdrawal; and . long-term residential rehabilitation. ACCESS Alcohol and Drug Service provided the only publicly funded Community Residential Drug Withdrawal Unit in the region. It offered residential withdrawal care to
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men and woman, for all substances and admitted people from 16 years of age. The service catered for clients with special needs, e.g. pregnant women, parents with ‘babesin-arms’, couples and people with psychiatric conditions. Clients stayed for an average of 6 days. The Maroondah Addictive Recovery Project (MARP) was the only publicly funded adult Residential Rehabilitation Program in the region. It provided a 24 hour staffed home where clients resided, on average, for 4 months. It was available to men and women who: . . . . .
required assistance controlling their drug and alcohol use; had undergone a withdrawal; were over 18 years of age; resided within Eastern Metropolitan Melbourne; and were willing to participate in a program of personal growth.
Welfare workers, alcohol and drug workers, and nurses staffed both services. They had protocols with local community medical practitioners for routine assessment and on-call services. File sample A retrospective file audit was undertaken using a convenience sample of 51 client files at the Rehabilitation Program and 114 at the Withdrawal Unit. Files were reviewed for indications of the presence of any mental illness or disorder. Withdrawal Unit staff advised that a sample of greater than 100 files could be obtained by selecting all clients admitted to that program during the previous three-month period. As the Rehabilitation Program serviced fewer clients for longer periods, the file audit from this service included all program residents since their current client assessment system had been introduced 15 months previously. Active files of clients who were currently resident in either service at the time of the audit were excluded as their files needed to be available to program staff at all times. Records of the initial assessment and client progress notes were examined for documentation of clients’: . . . . . . .
age; gender; drugs used; current or previous evidence of psychiatric diagnosis; who made the diagnosis; prescribed psychotropic medication; previous treatment with a psychiatrist or Mental Health Service.
Simple descriptive statistical analyses were used to present the data. Data on prescribed minor tranquillisers (benzodiazepines) use were collected but not included in the analysis. The rationale for exclusion was that whilst clients may have been prescribed the benzodiazepines for psychiatric disorders, such as anxiety, these medications are widely prescribed for many other conditions, including: . treatment of the symptoms of alcohol and other drug withdrawal; . as reduction regimens for benzodiazepine dependency; . managing behaviour problems, such as, aggressive or impulsive behaviours.
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Key informant interviews At each agency the service manager, a senior clinician and another program staff were interviewed. Staff were nurses and welfare workers. These were unstructured interviews, in which, staff offered their: . observations of clients at assessment; . views of the incidence of dual diagnosis in the client population; . associated issues in assessment, treatment, and referral. Salient staff comments were noted in the discussion section, particularly those that related to the issue of personality disorder. Results Client demographics There was a slightly higher representation of men than women at each agency with 10% more men at the Rehabilitation Program (55% male and 45% female) and 12% more at the Withdrawal Unit (56% male and 44% female). The age of the Withdrawal Unit clients covered a broad band from a minimum of 16 years to a maximum of 62 years with a mean of 26.9 years. The mean age of clients at the Rehabilitation Program was older, at 34.3 years and the span was narrower, 19 years to a maximum of 54 years. Characteristics of substance use Details of substance use were thoroughly assessed and documented at both services. The incidence of amphetamine use (7.3% of the files sampled), benzodiazepines 16.4% and cannabis (54.6%) was similar at each service. Alcohol was the most commonly identified drug of abuse/dependence at the Rehabilitation Program accounting for 86.3% of client files sampled but only 42% of those who presented at the Withdrawal Unit. Opioids (e.g. Heroin and methadone) were the most commonly used drugs at the Withdrawal Unit (68.4%) but accounted for only 39.2% of clients presenting for Rehabilitation. Poly-drug use was common at both services with 50.9% of clients were using two substances and 24.2% using three or more drugs. Mental illness A definitive psychiatric diagnosis was documented in 42% of all files (28 clients of MARP—Table 1, and 42 ACCESS clients—Table 2). Many files noted more than one diagnosis with 101 psychiatric diagnoses recorded. A distinction between primary or secondary psychiatric problems was not evident from the notes. In files that recorded a diagnosis, 15.7% of diagnoses were attributed to psychiatrists, 15.7% to general practitioners, and 8.5% to Public Mental Health services. However, diagnoses were rarely substantiated by documentation from any external source including the source of referral. In 21.2% of files, diagnosis or symptoms only were recorded but there was no indication as to the criteria used or the source of the diagnosis. This factor alone suggests additional support and expertise in mental health is imperative for these services. In addition, three files simply recorded ‘suicidal’ as a file note. These files were not included in
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Table 1.
Psychiatric diagnoses as recorded in MARP file notes. MARP
Psychiatric diagnosis
Incidence
Acute anxiety Anorexia Anxiety Bulimia Depression Depression—major Depression—post natal Depression—suicidal Disassociation Drug-induced—schizoaffective disorder Drug-induced psychosis Panic attacks Panic disorder Psychosis Social phobia Total diagnosis recorded
Table 2.
1 3 3 5 17 1 1 2 1 1 1 1 1 1 1 40
Psychiatric diagnoses as recorded in ACCESS file notes. ACCESS
Psychiatric diagnosis Alcohol-related brain injury Anorexia nervosa Anxiety disorder Bipolar affective disorder Bulimia Depression Drug-induced psychosis Dysthymia Eating disorder (unspecified) Obsessive compulsive disorder Panic attacks Paranoia Paranoid schizophrenia Post traumatic stress disorder Schizophrenia Tourette’s syndrome Total diagnosis recorded
Incidence 1 4 7 1 2 28 6 1 1 1 1 1 1 1 4 1 61
the figures for diagnosed mental disorder, which may have decreased the final prevalence figures but increased their accuracy. Surprisingly, only 4.9% (8 clients) of the total sample were diagnosed to have a Drug Induced Psychosis. This may be due to people with these conditions presenting to MHS, hospital emergency department or other services rather than ADS. Psychotic illnesses (recorded as Schizophrenia, Paranoid Schizophrenia, Paranoia and Psychosis) were recorded for seven clients (4.2%). Anxiety disorders (recorded as Anxiety Disorder, Acute
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Anxiety, Obsessive Compulsive Disorder, Panic Attacks, Panic Disorder, Social Phobia and Post Traumatic Stress Disorder) represented 20 of the entries (12.1% of the total client sample). Entries representing Disorders of Mood (Dysthymia, Depression, Post-natal Depression, Suicidal Depression and Bi-Polar Affective Disorder) were recorded in 51 (30.9%) of the clients’ files. There were 15 entries (9.1%) for Eating Disorders (recorded as Anorexia Nervosa, Anorexia, Bulimia and Unspecified Eating Disorder). One client with a diagnosis of Acquired Brain Injury, one with Dissociation and one with Tourettes Syndrome were also recorded. An unexpected result was that there were no file entries recording any of the personality disorders, as per DSM – IV-TR Axis II diagnostic categories (American Psychiatric Association, 2000). Psychotropic medication In many cases where no definitive diagnosis was recorded, a mental illness could be inferred from documentation that the client was using prescribed psychotropic medication. Of the client sample, 52.7% were documented as taking prescribed psychotropic medication other than a benzodiazepine. However, only 67.8% of these (59 clients—35.75% of the total sample) had a documented psychiatric diagnosis; conversely, 32.2% did not have any documentation of a psychiatric diagnosis but were taking a prescribed psychotropic medication (e.g. Aropax, Risperdal) that could indicate a co-existing psychiatric condition. However, from the prescription alone it is not possible to determine whether the condition was a chronic psychotic illness (e.g. schizophrenia) or whether the drug was being prescribed to control behavioural disturbance, i.e. as non-benzodiazepine tranquilliser. Prescribed benzodiazepines were recorded in 48.5% of client files. As a result, even though it may have increased the accuracy of identifying mental illness, excluding benzodiazepines from the data may have decreased the number of clients in the medication groups and the correlative prevalence data overall. Psychiatric hospital and community mental health service In many records, the only suggestion of mental illness was documentation that the client had been in a psychiatric hospital or involved with a Community MHS, e.g. the local Crisis Assessment and Treatment Team. Documents of involvement with MHS and or psychiatrist represented 25.5%. Discussion The results revealed three major indicators (as recorded in the clients’ files) of co-morbid mental health problem in clients presenting to ADS: . documentation of a psychiatric diagnosis; . use of prescribed psychotropic medication (other than a benzodiazepine); and . evidence of engagement with a public or private mental health service provider. Combining these data may provide a more accurate estimate of the prevalence of psychiatric problems (see Table 3).
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Table 3.
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Files with potential indicators of mental illness. MARP & ACCESS Combined
Number of indicators present
N
%
Single indicator only Two indicators only All three indicators Total
32 37 30 99
19.4 22.4 18.2 60.0
Ninety-nine client files (i.e. 60% of the total files) record one or more potential indicators of a psychiatric problem, i.e. a definitive psychiatric diagnosis, past or present treatment by either a private Psychiatrist or public Mental Health Service, or using a prescribed Psychiatric Medication. It has been widely commented upon by ADS providers that client characteristics differ between these two service types, and that because those seeking residential rehabilitation commonly have a more chronic drug using history and more complex needs, these clients are more likely to have co-morbid substance use and mental illness. The study results confirmed this view. The indicators suggested the dual diagnosis prevalence rate for the withdrawal service could be 53.5%, but considerably higher for rehabilitation program at 74.5%. Documented mental disorders in the acute withdrawal service files were 59% higher for men than for women. The higher representation of men at ACCESS was consistent with other studies. Ross, Glasser and Stiasny (1988), found that contrary to widespread belief, women substance abusers did not suffer a higher incidence of psychiatric disorders than men did. However, in MARP, 18 of the 28 (64%) clients with a recorded mental disorder were women. This marked disparity of gender representation between these services may be an area for further investigation. There is consistent evidence that the type of psychiatric disorders identified with substance using clients occurs with gender specific characteristics (Teesson & Proudfoot, 2003). There appears to be a correlation between gender and type of psychiatric disorders with the files in this study showing women generally have a much higher incidence of anxiety, affective and eating disorders. Women accounted for 14 out of 15 of those with an eating disorder recorded. Other authors (Hall, 1996; Hall et al., 1998; Ross et al., 1988; Westreich, Guedj, Galanter & Baird, 1997) have noted that substance-using women have a characteristically higher incidence of anxiety, affective and eating disorders than substance using men or other non-using women. Conversely, men were twice as likely, as women, to have a psychotic disorder (men accounted for 10 of the 15 psychotic disorders recorded). The distinction between highest risk rather than highest frequency diagnoses has implications for service provision since the greatest numbers of people in the population with co-morbidity are those with the most commonly occurring disorders, i.e. anxiety or depression (Teesson & Proudfoot, 2003). However, the greatest increased risk in Axis I disorders is seen in psychoses (Regier et al., 1990). These people are more likely to show significant functional deficits from substance use, even at relatively low levels of intake (Drake & Wallach, 1993; Drake, Osher, & Wallach, 1989; Mueser et al., 1995). Consistent with other studies on ADS populations (Virgo, Bennett, Higgins, Bennett, & Thomas, 2001) depression was the most common psychiatric co-morbidity for both men and women in these ADS. Depression frequently co-occurred with anxiety and eating
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disorders. Seventy per cent of clients with one or more mental disorder recorded had a diagnosis of depression. Often no differentiation as to the type or severity of the depression was documented. However, staff suggested that these clients usually presented with mild to moderate uncomplicated depressions as it is common practice for ADS to refer clients with severe depression or depression with psychotic features to MHS. The combination of data, by taking into account either contact with a MHS, prescription of psychotropic medication or documentation of a psychiatric diagnosis, indicated a much higher incidence of co-morbidity than was recorded by diagnosis alone. Thus the figure of 60% was consistent with research into prevalence of co-morbidity that suggests approximately half (35–65%) of those with a mental illness will have a history of substance use disorder (Buckley, 1999; Hall, 1996; Hall et al., 1998; McDermott & Pyett, 1993; Morris & Wise, 1992; Mueser et al., 1995). It was a unanimous opinion by staff of both agencies that the actual frequency of co-existing problems in the client populations was far more common than was recorded. The actual incidence of co-morbidity among ADS consumers appears to be substantially higher than that documented at assessment as a diagnosed psychiatric comorbidity. Milling, Faulker and Craig (1994) and Wolford et al. (1999) concluded that those with co-morbid psychiatric and substance use disorders often did not have their conditions recognised or diagnosed. This lack of documentation maybe due to a number of reasons: . . . .
clients not disclosing; difficulties by the referring practitioner in making a diagnosis; under identification by staff at assessment; other factors, e.g. consistency with practices in documentation.
Assessment process The recorded psychiatric history was often dependent upon clients self-reporting, or less often, by information provided by a referring agency. It is difficult to conclude how significant client self-report is in the quality of data. There appears to be differences between what is found in the literature and what was reported by staff, for example, Wolford et al. (1999), indicated that self-report is more reliable than using a combination of demographic variables, clinical variables, medical exams, laboratory tests, and collateral reports. Bradizza and Stasiewiz (1997) describe using several sources of information including the patient’s record, a brief patient interview, and an interview with the patient’s family and caseworker, as the first step in assessing dual diagnosis. In interviews, staff stated that clients were sometimes reluctant to disclose a psychiatric disorder out of concern that this would exclude them from ADS. In the initial assessment at MARP, 14 clients answered in the affirmative to the question ‘Have you been diagnosed with a psychiatric condition?’ However, 18 female and 10 male client files (55% of this services sample) recorded a psychiatric diagnosis. It is worth noting that this information was often recorded in the case notes at a later stage in the clients’ residence, that is, after the initial assessment. While MARP and ACCESS staff are specialists in alcohol and drug treatment, they did not have psychiatric training and did not perform a mental state examination as part of the assessment. Morris and Wise (1992) suggest that programs without multi-disciplinary staffing have poorer outcomes with dual diagnosis because they are at a considerable disadvantage in being able to adequately diagnose clients, and to develop effective
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treatment plans and referral strategies than adequately staffed programs. UK and USA studies indicate that, ‘. . . recording of substance misuse histories in psychiatric patients are notoriously poor’ (Phillips, 1999), and it would seem from this study that psychiatric histories in ADS clients are similarly poorly recorded. Personality disorders During the course of this project, all staff interviewed expressed particular concern that clients with personality disorders were not being diagnosed and appropriately managed. A common theme to these concerns was that all staff interviewed believed that a majority of clients in their services had undiagnosed personality disorders. These observations are consistent with findings of a number of researchers, for example, Swartz (1999) found 58– 65% of young adults hospitalised for a Substance Use Disorder met the criteria for Borderline Personality Disorder; Hall (1996) stated Anti-Social Personality Disorders predominate in men with substance use disorders. Blume (1989) found Axis II diagnoses are present in alcohol and other drug dependent patient populations at higher prevalence rates than in the public. According to Andrews, Issakidis and Slade (2001), people with a dual diagnosis do not tend to rate a personality disorder as a major concern for them, which suggests they are less likely to report it as a problem. In addition, it may be that these disorders are either less clearly understood by drug treatment and other clinicians or more difficult to diagnose in the short term. However, it is of interest that there was not a single documented diagnosis of a personality disorder in any of the files audited in this study. This suggests that the deficiency in the documentation of diagnosis of personality disorders, and other psychiatric disorders, may be due to a diagnosis not being made prior to ADS assessment, or the lack of mental health expertise available to clients within ADS. Limitations The accuracy of client file data in this study was limited due to incomplete assessment and documentation processes. Some loss of data during the study impeded further detail and refinement in analysis and reporting. Moreover, the information primarily sourced from client self-report may have some affect on validity and reliability. A larger sample size, drawn from a broader group of agencies, may have provided greater accuracy and more detail on the incidence of co-morbidity. Given the findings regarding assessment and documentation, it would have better informed the study to know more about the staff who had performed and documented the assessments, such as: their number, qualifications, experience, additional training and perceptions of role adequacy and role legitimacy. Conclusion A documented psychiatric diagnosis was found in 42% of files sampled taken from two ADS, Acute Withdrawal and the Residential Rehabilitation. However, when combined with other indicators, utilisation of MHS and prescription of psychotropic medication, the suggested incidence of co-morbidity is 60% of the client sample. This is likely to be an underestimate because a number of files were excluded due to records being imprecise or unreliable. Staff of both agencies stated they considered the frequency of clients with comorbidity was considerably greater than was recorded.
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There appears to be a significant disparity between the actual incidence of comorbidity among ADS clients and what is documented in files. Previous studies have suggested that recording of substance use in psychiatric histories is notoriously poor. This study indicates that the reverse is also true in that psychiatric problems are poorly documented in ADS histories. Since the prevalence of co-morbidity changes according to the type and circumstances of assessment (Silva De Lima, Lorea, & Carpena, 2002), improvements in assessment and documentation should result in greater accuracy of prevalence data on dual diagnosis in ADS. Moreover, it is evident from the study that the term dual diagnosis is a misnomer for ADS clients, as it appears the likelihood of ADS clients with co-morbidity having accurate psychiatric diagnoses is unacceptably low. Implications and recommendations This study points to weaknesses in assessment and diagnosis of those with co-morbidity within the ADS system. Service could be improved through: . a review of ADS file documentation policies and practices as regards client mental health with training and assistance as required for ADS staff; . the provision of training and development of protocols for ADS staff in mental state examination; . the development of formal service protocols for ADS to access specialist MHS for the provision of secondary consultation for clients with co-morbidity; and . the development of formal service pathways and protocols between ADS and local MHS and private psychiatrists for assessment, referral and release of information. In addition, and more specifically, the issue of prevalence of personality disorders among clients within ADS is an area of research that should be further investigated. Acknowledgements We wish to acknowledge the support and encouragement we received from the staff of the Maroondah Addictions Recovery Project and ACCESS Alcohol and Drug Services.
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