Understanding And Treating Dual Diagnosis: Implications For Healthcare System

Causes of Dual Diagnosis

Discuss about the Improvement Of Treatment Services For Patients With Dual Diagnosis- A Qualitative Research.

The concept of dual diagnosis emerged as a significant concept in the last two decades and has since been a prominent area of research. Attempts have been made by researchers across the globe to analyze the implications of dual diagnosis for healthcare system. The subject of dual diagnosis has been denoted to be a critical one, with researchers stating that intensive research is required in this field. Dual diagnosis is described as the diagnosis made in people suffering from a mental illness or psychiatric disorder, and a substance abuse disorder. It is the dual nature of the affliction of the individuals that remains, at many instances, undiagnosed and untreated. Difficulty in treating dual diagnosis patients leads to sky-high likelihood of relapses (Rocco, Manera and Bellio 2017).

Mental illness and substance abuse are co-occurring at an alarming rate. Causes of such co-morbidity have been attributed to genetic vulnerability, self-medication, lifestyle or environment, common neural substrate and shared origins. According to de Waal et al. (2018) it has been well documented in literature that individuals who suffer from alcohol or substance abuse disorders have higher chances of suffering from a co-existing mental health illness. Such disorders can be depression, anxiety or any other condition. Studies have reported that almost 50-80% of clients who suffer from substance abuse are found to be suffering from mental illness. As per the research of Lehman and Dixon (2016) dual diagnosis is repeatedly being found to be the rule instead of the exception. A study of patients suffering from bipolar disorder and poly-substance abuse were found to be suffering from more mental illness symptoms. Patients who had alcohol dependence showed more signs of depression and those with cannabis dependence had manic symptoms when a comparison was done with individuals with no substance use disorder. The symptoms of dual diagnosis are difficult to point out. The symptoms vary greatly since a number of combinations of dual diagnosis are likely to occur. Numerous screening tools are being used for identification of the people who are at risk for substance abuse after mental disorders has been diagnosed (Ogloff et al. 2015). 

As opined by McGovern et al. (2014) the most suitable treatment option for addressing needs of dual diagnosis patients is integrated interventions. Integrated interventions refer to the delivery of care against both substance abuse and mental illness. The current notion that emerges in the clinical field is that both the issues in dual diagnosis are to be addressed simultaneously. Treatment planning is not the same for all patients, and depends of the degree to which symptoms are evident. Some of the commonly applied treatment options include detoxification, inpatient rehabilitation, supportive housing, psychotherapy and self help groups. The most important hurdle that dual diagnosis patients pass through is detoxification. As compared to outpatient detoxification, inpatient detoxification is more effective in treating patients. An individual suffering from a dependent pattern of substance abuse and experiencing any major mental illness such as depression and anxiety might benefit largely from the inpatient rehabilitation centers. Supportive houses and self-help groups have also been proven to be effective in helping patients come out of the feelings of isolation and frustrations (Stuyt 2015).

Symptoms and Challenges

Vaz and Crockford (2017) reported on dual diagnosis and stated that the frequent co-occurrence of psychiatric disorders and substance use has become a focus of concern among researchers, clinicians, and public policy makers. Beyond the usual occurrence of the dual diagnosis phenomena, much focus has been given to understand the particular patterns of dual diagnosis and the urgent necessity to engage in the development of specialized programs addressing dual diagnosis patient’s needs. Understanding the needs of persons and coming up with a proper response against the highlighted needs serves as a significant public health issue. Exacerbation of the mental illness acts as the most severe impact of substance abuse in a direct or indirect manner. Some other complications include increased aggression, risky behavior and increased chances of suicide. Further, substance abuse together with a mental illness might be associated with physical comorbidities such as diabetes, nutritional insufficiencies, cardiovascular problems and poor health conditions overall (Mcnelis 2015).

The proposed research is an attempt to review the present scope of dual diagnosis treatment improvement aligned with the needs identified of the patients diagnosed with such a condition. The present paper outlines a research that is to be conducted for understanding the scope of improvement in dual diagnosis treatment approaches that are comprehensive. The research proposal paper outlines the background of the study in an appropriate manner to set the foundation for research. The aims and objectives of the proposed research are articulated suitably. A rich literature review is put forward to highlight the gap existing in current literature on the concerned topic. A methodology is proposed in this regard that gives a detail of how the study would be conducted applying suitable research frameworks and designs.

Individuals with dual diagnosis are often found to be exhibiting complex needs that encompass physical support and social empowerment. The variety of needs that the patients present influence the need of bringing reforms in treatment approaches. According to Petrakis et al. (2018) apart from mental health issues and addiction, persons with dual diagnosis face a number of other problems, such as housing problems, judicial problem, social isolation, poverty and poor physical health. As a result of this, there is a strong likelihood of facing major challenges by the healthcare professionals while working with patients with dual diagnosis. Similarly, patients with dual diagnosis face a number of key challenges in accessing treatment. At present, a multidimensional and integrated treatment approach is considered for to be more than sufficient than a sequential treatment approach or a parallel treatment approach. In such programs, the emphasis is given to both psychiatric problems as well as substance abuse problems. Further, the focus of such integrated treatment options, in alignment with the updated trends in addiction and mental health care policy, is gradually shifting towards provision of support to achieve personal recovery (De Ruysscher, Vanheule and Vandevelde 2017). Such a shift is witnesses against the previous trend of providing symptoms based cure. Stabilization of patients is the prime focus in such a case. The chief factors in an effective delivery of integrated system include treatment delivery in different stages, assertive outreach, motivational approaches and provision for social support.

Effective Treatment Options

Connolly (2018) pointed out that modification in treatment approaches have emerged against the fact that treatment of such patients leads to high economic costs for the healthcare domain. Greater health burden, poor self care and exacerbation of the mental illness conspire together to lead to an overpowering augmentation in the use of health services. The high population of individuals with dual diagnosis leads to rapid utilization of healthcare resources and leads to a decrease in the capability and capacity of services to coordinate treatment options. The developments that have recently surfaced towards integrated treatment options lead to a vast range of treatment modalities. Such modalities range from pharmacological treatment and specialized therapeutic communities to self-help groups (Tirado-Munoz et al. 2018). Recent literature however point out that there are a number of treatment barriers that hamper the process of care giving for patients with dual diagnosis. These barriers are related to both structural factors such as financial constraints, organizational aspects, exclusion from care services, and to the patient’s personal features such as cultural beliefs, motivation and encouragement for treatment and self-stigma. In this regard Carra et al. (2015) stated that such challenges lead to high rates of patient dropout, loss of focus on social context in integrated services, and lack of emphasis on reducing the symptoms of the conditions.

Sterling and Hinman (2011) have highlighted the need of having an integrated approach in treating substance abuse problems and severe mental illnesses. The researchers attempted to answer there is an increased need of an integrated approach needed for dual diagnosis treatment. Despite there has been much research put into the subject, integrated support has not been made extensively accessible to clients. The reason for this are the barriers that arise while treatment is bring delivered. It has been suggested that no particular form of integrated treatment has emerged to be more powerful and effective than others. Effective integrated treatment is one where professionals work in collaboration with each other to provide interventions that are bundled together. The consumers therefore receive consistent care for treating the varied symptoms (Hesse 2009). The philosophy and approach are seamless, and the involvement of separate teams is not there anymore. Integrated systems must recognize that counseling for substance abuse and that for mental health conditions are different at the core.

Kelly and Daley (2013) in this regard mentioned that those who deliver care and those who receive care are equally vulnerable to face challenges in the course of treatment. Chances are high that patients might shift between services that focus on any one of the treatment option for substance abuse or mental illness. Uncoordinated and fragmented care services are the source of service gap for those suffering from co-occurring disorders. Integrated services, when provided appropriately, would allow for improved health on an overall basis. Further, such a form of service can ameliorate the impact of the disorders on society at large. Through helping patients gain an improved quality of life, health care providers can considerably decrease some of the costly and sinister societal concerns such as domestic violence and HIV/AIDS (Mueser and Gingerich 2013).

Integrated Treatment Approach

Recent research has pointed out that integrated treatment services for patients suffering from mental illness and substance abuse disorder lays the provision for treating patients having severe but low prevalence mental health disorder. This implies that dual diagnosis clients who have high rate of occurrence of mental health disorders are subjected to unsatisfactory treatment services. As a result of this, the varied needs of the clients are frequently unmet (Green et al. 2015). There has been a lack of studies that have undertaken a thorough investigation of the views and experiences of patients with dual diagnosis with high prevalence mental health needs for ensuring that the provision for treatment services are adequate for meeting their needs. It is noteworthy that research is carried out for documenting the different service needs of the patients suffering from high rate of occurrence of mental health disorder and substance abuse (Ezquiaga et al., 2017).

The rationale is that based on the findings of such research redesigning of the present models of treatment and care can be considered. Through an improved and evolved service system one can hope that the specific needs of the patients can be met adequately within a stipulated time. Reforms in service delivery process entail strong evidences that emerge from the viewpoints of the service users. Information gained from the service users would form the basis for addressing the needs as a whole, thereby resolving interdependence of issues and alleviating the effect brought about by unresolved problems (Sinha, Garg and Prakash 20018). The best way to consider changes in service and treatment delivery is to bring into limelight the perspectives and suggestions of those who are using it.

The proposed research is based on the context explained above in relation to integrated treatment for dual diagnosis patients with mental disorders and substance abuse disorder. The focus would be on dual diagnosis of substance abuse disorder including alcohol abuse and drugs abuse, and depressive disorder and anxiety disorder. The research question that would be the focus of the proposed study is as follows-

“What are the views of service users in relation to improvement of services for individuals with dual diagnosis?”

The aim of the study would be to carry out a qualitative study to understand the perspectives and opinions of service users in relation to the treatment provided to them for dual diagnosis. The objectives of the research would be as follows-

• To understand the barriers faced by clients in receiving treatment for dual diagnosis of mental health disorder and substance disorder
• To gain insight into the changes required in the treatment process delivered to patients with for dual diagnosis of mental health disorder and substance disorder
• To identify the suggestions of service users for improving treatment services for dual diagnosis of mental health disorder and substance disorder

Research Methodology

According to Staiger et al. (2011), it is well known that the persons going through alcohol or substance use (AOD) disorders are more susceptible have co-existing mental health (MH) disorder like depressive syndromes or generalised anxiety (dual diagnosis). According to Murthy and Chand (2012) mental health physicians frequently find the treatment of the patients with dual diagnosis extremely challenging and difficulty. Although nearly 50% of the patients suffering from severe mental illness are victims of substance use and vice versa, the overall treatment aspect is compounded via the lack of complete clarity in the psychological interventions, pharmacotherapy and setting of the treatment.

The main pharmacological intervention used for treating patient with dual diagnosis is the use of second generation antipsychotics. They are mostly preferred due to their negligible side-effects especially in the domain of the extrapyramidal symptoms (EPS). Kelly et al. (2012) s of the opinion that antipsychotics on the basis of theory dopaminergic action over the mesocorticolimbic pathway significantly influence substance quite different from the antipsychotic actions. Although second-generation antipsychotics are reported to be beneficial in decreasing craving for the substances, there are differences in their produced anti-craving effects between different medications (Van Dorn, Volavka and Johnson 2012). This different in response is mainly due to difference among person to person arising out of difference in the rate of occupancy of the D2 receptors and Clozapine receptors (Finn, Viveros and Marco 2012). However, there are no significant researches in the domain of how this knowledge about difference in expression of the D2 receptors is utilized while prescribing clozapine among the substance abuse individuals in order to reduce the rate of side-effects while promoting faster recovery.

Under numerous contemporary settings of treatment, the mental health and substance use services are procured in a separate manner. Therefore patients with dual diagnosis are asked to get treated with in one system for one type of disorder and then referred to anther system for another type of disorder (Baigent 2012). Sometimes two different sets of experts for example mental health and the substance abuse experts evaluate such dual diagnosis patients independently. Baigent (2012)is of the opinion that such models delay the overall process of initiation of the accurate interventions and at the same time increase the overall burden of the healthcare resources. On contrary, multidisciplinary “integrated treatment approach” has same healthcare professionals working under one setting to procure both mental health along with substance use interventions. Such interventions are mostly tailor made for patients with dual diagnosis. This type of integrated treatment approach employs the application of medicines for both mental health and substance use along with co-ordinated psychotherapy and psychological treatments for mental health illness and substance use matching with the motivation of the patients. However, Morrens et al. (2011) highlighted that under an integrated set-up there at times occurs lack of individualized plan. Morrens et al. (2011) also highlighted that under integrated setup there occurs delay in response during the crises. The reason behind this is lack of adequate manpower under the integrated step-up high rate of work-pressure which delays individualised attention.

Other important non-pharmacological interventions include cognitive behavioural therapy and motivational therapy. Cognitive behavioural therapy (CBT) denotes one of the popular therapeutic approaches that can be effectively applied to a variety of different psychological problems (Murthy and Chand 2012). The meta-analysis conducted by Hofmann et al. (2012) highlighted that CBT is extremely beneficial for anxiety disorders, somatoform disorders, bulimia, anger control problems and other general stress related issues. However, Ehde, Dillworth and Turner (2014) is of the opinion that under an integrated step for the treatment of the patients dual diagnosis, it is seen that CBT therapy is applied as a whole to a mass of patients with substance use disorder and suffering from mental illness like schizophrenia, major psychotic disorders, severe depression, bipolar disorders, eating disorders, anxiety disorders, personality disorders, aggression, anger, general stress and criminal behaviours. Such that the outcome is not same with every patients and thereby causing a delay in cure process among the patients whose mental health complications are not compatible with the approach of the CBT. Cash (2012) is of the opinion that the majority of the service provides for the dual diagnosis, lacks the ability to adapt themselves properly with the individual circumstances with the clients and thereby leading to the procurement of the therapy plan in a generalized approach in spite of claiming to provide a bespoke therapy plan.

In the domain of lack of bespoke approach towards the treatment of the patients with dual diagnosis is further highlighted by Elwyn et al. (2014). Elwyn et al. (2014) is o the opinion that there lacks significant gaps in the proper education among the service givers towards procuring patient centred care and thereby generation increase in the length of hospital stay among the patients with dual diagnosis and delay in proper cure. Elwyn et al. (2014) stated that procurement of the patient centred care mainly demands different approaches, which varies accordingly with the clinical situations. Elwyn et al. (2014) emphasized over the motivational interviewing along with shared decision making to procure appropriate and well-described methods to successfully accomplish patient-centred care under the context of situations where significant medical evidences supports specific behavioural changes and the best suited actions is solely dependent on the patients preferences. However, numerous clinical consultations may demand elements of both the approaches (Elwyn et al. 2014).

Generation According to the research conducted by Van Boekel et al. (2013), healthcare professionals are important in the proper identifications and accessibility of the treatment for the people suffering from substance use disorders. However, the attitudes of the healthcare professionals nurture negative attitudes towards the patients with substance use disorders. This contributes towards the generation of suboptimal care for these patients along with delay in the overall outcomes. Van Boekel et al. (2013) highlighted that perceived violence, manipulation along with poor motivation are the main impending factors towards the comprehensive healthcare delivery towards patients. Negative attitudes of the healthcare professional destroy the feelings of the patients towards empowerment and successful outcomes of the treatment. Healthcare professionals are also less involved and mostly prefer more task-oriented approach in procuring healthcare to the patients with substance abuse and this result in reduction in the overall personal engagement along with diminished empathy (Van Boekel et al. 2013). Van Boekel et al. (2013) recommended that proper building and maintaining relationships with the client along with addressing the complex mental health issues of the person beyond illness would be helpful in managing the situations in an effective manner and thereby helping in the fast disease recovery.

Thus from the above review of literature it can be easily highlighted that the majority of the research that have been conducted over the interventions of the people with dual diagnosis is mainly concentrated over the side-effects of the treatments and lacks of the personalised approach of the treatment. All these pitfalls in the treatment plan for the patients with dual diagnosis are mainly drawn over the perspective of the service providers or the healthcare professionals. There are no significant discussion and research plan done from the perspectives of the of the service users. One study conducted by Benaiges, Prat and Adan (2012) mainly highlights how the lack of proper treatment for the patients with the dual diagnosis affects the quality of the life of the service users. Moreover, that study was based on a quantitative approach and is biased as it is only composed of male participants. Brett et al. (2014) is of the opinion that the recording of the responses of the service users is the principal way towards the proper accomplishments of the successful generation of an effective therapy plan. Brett et al. (2014) further stated that since the service users are in the direct representatives towards the successful outcomes of the therapy plan, their views and the subsequent recommendation will help in the generation of effective personalized approach for the proper treatment of the patients with dual diagnosis.  

According to Bernard (2011) the research mainly encompass the methodologies which will be used in order to frame the overall process of research conduction while maintaining proper focus over the research gap. The selection of proper methods mostly depends on the aims and objectives of the research along with the appropriate selection of the methodology which in turn will assist in deducing proper findings of the research.

As opined by Bergh and Ketchen (2011), there are different types of research philosophies like interpretivism, positivism and realism. This research will follow positivism research philosophy. Berh and Ketchen (2011) stated that positivism research philosophy is appropriate for qualitative research approach and assists in explaining the data in a scientific manner along with the logical data representation.

As opined by Crowther and Lancaster (2012), research approach can be subdivided into two different types and this includes deductive and inductive research approach. In this research, the author will use deductive research approach for formulating the hypothesis of theoretical framework. The proper framing of the hypothesis will help in the establishment of the relationships between the research objectives.

According to Ellis and Levy (2012), there are different types of research design like explanatory, exploratory and descriptive style research design. In this research, author will employ descriptive style research design. This particular research design will help the researcher to comprehensively describe the cause and effect relationships generated in the subsequent themes. With this research design, the researcher will generalize the overall presentation of the research and thus evaluating the research problems. In this study, the researcher will make use semi-structured interview with open-ended questionnaire that will be developed specifically by the author after effective review of literature. The research design will enable authentic validation of the information while maintaining the clarity of the research (Leedy and Ormrod 2012).

According to Truscott et al. (2012), data collection is an integral part of the research as it helps in proper analysis of the research topic. Nature of data collection is of two types, quantitative data collection and qualitative data collection. Here the researcher will employ qualitative mode of data collection. Miles, Huberman and Saldana have opined that qualitative mode of data collection does not employ the use of statistical methods to quantify the results. It progress the research under natural settings with an initiative to interpret the process in term of inherent meaning which people bring to it (Sandelowski 2000). There are various ways of collecting data in qualitative research in order to capture multiple realities and thus obtaining an in-depth analysis of human experience. Some of the important mode of data collection procedure for qualitative research is interviews focus groups and observations. In this research, the author will employ semi-structured interviews directed towards 10 individuals of dual diagnosis who are the service users of mental health and substance abuse. According to Galletta (2013), semi-structured interview is the most common method employed in social science and nursing research. Semi-structured interview is different from structured interview. Structured interview are mostly based on close ended questions which restricts the interviewee from diverting out of the topic. Semi-structured interview is based on open-ended questionnaire which provides avenues to create fresh new ideas during interview sessions. The interviewer conducting a semi-structured interview has a proper framework of specific themes that are required to be explored. Semi-structured interview also enables the respondents the freedom to express their views in their own terms and thereby helping the researcher to generate comparable data. Thus via selecting semi-structured interview as a mode of qualitative data collection will help the researcher to analyse the experience of individuals with dual diagnosis about the available service for mental health and substance abuse. In this research, the interview will be guided through an indicative schedule through 3 open-ended questions (questions provided below) and the duration of the interview will be 30 to 45 minutes. The entire response of each participant will be recorded digitally and some portion of the verbal communication will also be documented by interviewer manually (Kallio et al. 2016). The digitally recorded audio will be transcribed after the interview process via a transcriptionist and the generated transcript will be cross checked by the audio and respective respondents in order to maintain clarity of the research.

1. What is your experience in availing service for mental health and substance abuse
2. What are your views in accessing barriers of the treatment?
3. How services can be improve overall to meet their needs

The researcher here will employ random and stratified sampling technique. According to Berg and Ketchen (2011), this will help the researcher to select the prospective respondents from particular focus group. The main selection criteria that will be followed during selecting the main participants for the focus group interview include

1. Age above 18 years
2. Suffering from dual diagnosis for the past 1 year
3. Dual diagnosis will mainly include substance abuse (alcohol or substance use disorder) and mental health problems (depressive disorders and/or generalised anxiety)
4. Service users of both mental health and substance abuse rehabilitation

The researcher here will utilise thematic data analysis. According to Clarke and Braun (2014), the strategy of thematic analysis is mainly employed for the majority of the qualitative research without providing notable highlight about how the entire process helps to decrease the data into workable theme and emerging summary. In other words, it can be said that the process of thematic analysis is a method for identification, analysis, reporting of generated themes from collected data. It is a form of descriptive method which reduces the information into meaningful themes.  It is frequently used in qualitative data analysis method for its flexibility in accommodating vast majority of research questions and research topics. The main steps that will be used for the thematic analysis of data include compiling, disassembling, reassembling, interpreting and concluding.

The first ethical consideration that should be taken into account is getting approval from the Nursing and Midwifery Council local ethics committee to access the service users of dual diagnosis. After getting the approval, an official letter will be sent to the co-ordinator of the service provider of dual diagnosis seeking permission to contact with the potential service users. The co-ordinator of the overall program will be then asked to circulate emails to each of the service users (more than a year) stating the set-up of the research along with rationale and scope of the study. The contact details of the concerned researcher will be included at the end of email so that the willing participants can ask questions to research directly about further information in the overall process of the study. The interested candidates will then be asked to reply to the mail directly. Interested candidates will then have a face-to-face conversation with the researcher about the further process and rationale of the research. After that, if they are satisfied and are willing to participate, they will be asked to sign a consent form. No participants will be forced to participate in the interview and will be given full liberty to leave the process at any point of time in the research, be it after, within and before the conduction of the interview. They are not required to cite any prior justification for their sudden withdrawal. They will also be informed that if they are not willing to participate in the interview process, it will not impact on their overall therapy process. The time schedule and venue of the study will solely depend as per the convenience and availability of the participants. The research is unlikely to cause any form of psychological distress. However, the researcher will also make sure that the associated risk of psychological distress will be negligible during the study. If any of the respondents becomes distressed emotionally, during the process of interview, the interview will be discontinued immediately. After the end of the interview, the participants will be provided ample time for discusses any further queries associated with the interview process. Moreover, the official transcript will sent to each of the respondents and will only be used for the research after their final approval of typed transcript (Scott and Garner 2013).

In order to maintain the confidentiality of the research process, the researcher will not disclose the names of the interviewee in the final interview transcript and any pseudo names will be used to discriminate between one individual with others. The signed consent obtained from the participants before initiation of the interview process will be stored separately in locked shelves and the written records of the interview will be locked separately in another cabinet. All the materials will be kept secured for 10 years after the interview conduction. All the audio recordings along with the transcript will be encrypted in the personal computers of the respective participants and the same will be erases completely following the final transcription (Sandelowski 2000).

Conclusion

Thus from the above discussion, it can be concluded that this qualitative research will follow thematic analysis with deductive research approach, positivism research philosophy and descriptive style research design. Under the thematic analysis, this research will employ the weapon of semi-structured interview and will perform thematic data analysis.

Task	Week 1	Week 2	Week 3	Week 4	Week 5	Week 6	Week 7	Week 8	Week 9
Review of literature	ü
Gaining ethical approval		ü
Selection of the participants		ü
Conducting interview			ü
Transcript preparation				ü
Generation of themes					ü
Analysis of the themes						ü
Conclusion							ü
Recommendation							ü	ü
Final layout of the assignment									ü

 

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