Evidence based interventions in Dual Diagnosis

1
Evidence based interventions in Dual Diagnosis

• Ian Wilson
• DD clinical nurse specialist, MMHSCT
• Teaching fellow, University of Manchester

2
Prevalence

• In a study of first or recent onset of psychosis
  clients, 37 met criteria for drug or alcohol
  misuse
• After one year of treatment, 19.5 were still
  using drugs 11.7 were misusing alcohol
  (Cantwell et al 1999)
• By 2007, substance use among people with first
  episode psychosis was reported to be twice that
  of the general population Cannabis 51,
  alcohol 43 Class A drugs 55 Poly-substance
  misuse 38 (Barnett et al 2007)

3
Prevalence of cannabis use

• Green et al (2005) used data from 53 treatment
  studies 5 epidemiological studies
• Current cannabis use amongst people with
  psychosis 23 (11.3)
• Use in last 12 months 29.2 (18.8)
• Lifetime use 42.1 (22.5)
• Green et al state that epidemiological studies
  consistently report higher levels of cannabis use
  in psychosis

4
Dual diagnosis - Early studies

• Research into effective interventions for DD
  clients began in the 1980s
• They examined the application of traditional
  substance abuse interventions (12-step groups)
• They produced disappointing results, which led to
  pessimistic reviews (Ley et al (1999)
• These studies did not take into account the
  complex nature of DD issues

5
The New Hampshire Research

• Researchers in the USA began to look at the
  delivery of more comprehensive programmes
  incorporating assertive outreach long-term
  rehabilitation, to positive effect
• These projects began to utilise MI with clients
  who did not perceive or acknowledge the substance
  use or their mental health problems

6
Using a multi-disciplinary approach

• By the 1990s, projects incorporated MI, outreach,
  comprehensiveness and a long-term perspective
• However, most of these studies were uncontrolled
  and should be viewed as pilot studies (e.g.
  Detrick Stiepock 1992 Durell et al 1993)

7
Controlled research studies in DD

• Began to appear in the mid-90s
• Eight fairly recent studies with experimental or
  quasi-experimental designs support the
  effectiveness of integrated dual diagnosis
  treatments for DD clients (Godley et al 1993
  Jerrell et al 1995 Drake et al 1997 Carmichael
  et al 1998 Drake et al 1998 Ho et al 1999
  Brunette et al 2001 Barrowclough et al 2001)
• Critical components of successful trials Staged
  interventions assertive outreach MI
  counselling social support long-term
  perspective comprehensiveness cultural
  sensitivity

8
Limitations of the research

• Is the research generalisable to NHS in UK in
  2010?
• Lack of data on costs of integrated services or
  possible savings
• Lack of specificity re treatments
• Mainly directed at outpatient community
  treatments
• More research needed into effectiveness for
  specific groups

9
Further studies

• A series of studies have been undertaken to
  investigate the use of specific interventions
  (primarily MI) with people with mental health
  problems (mainly severe and enduring)
• Most of these have been RCTs
• Results from these trials vary greatly and the
  trials themselves have problems with
  methodologies, outcome measures and with
  generalisability issues

10
Further studies

• Baker et al (2002) RCT comparing one 45 minute
  session of MI with one 15 minute session of
  advice for psychiatric in-patients with
  poly-drug use
• Short term benefit for MI group at 3 months, not
  sustained at 12 month follow-up
• Small group (160), short intervention, lots of
  possible confounding variables

11
Further studies

• Hulse Tait (2003) RCT comparing one session
  of MI with a group who were given an information
  pack and a control group (TAU) psychiatric
  inpatients with alcohol problems
• No effect in two experimental groups however,
  both did better than the control
• Same methodological weaknesses as before and both
  interventions were in Australia are they
  generalisable?

12
Further studies

• Graeber et al (2003) Small RCT (30 participants
  in each group) comparing 3 sessions of MI for
  patients with sz AUD with 3 sessions of
  education
• The study relied on self-report of alcohol use
  rather than objective testing. This resulted in a
  discrepancy between reported improvement and
  observed behaviours. Methodologically weak study?

13
Further Studies

• Martino et al (2006) 44 participants in a
  pre/post test RCT using adapted MI (MMDD)
• No overall effect shown
• However, substance use reduction in cocaine using
  sub-group and not in cannabis using sub-group

14
Further Studies

• Baker et al (2006) CBT for SUD in people with
  psychotic disorders RCT
• 10- session MI CBT intervention compared with
  TAU for 130 patients
• Short-term improvement in depression and
  reduction in cannabis use

15
Further Studies

• Bellack et al (2006) RCT of a new behavioural
  treatment for drug abuse in people with SMI
• 129 stabilised outpatients with SUD SMI
• Compared BTSAS with STAR
• BTSAS was significantly more effective than STAR
  in of clean urinalysis, survival in treatment
  functioning. BTSAS reduced hospitalisation,
  money, and QOL

16
RCT to reduce cannabis use in FEP

• Cannabis use in young people with a first onset
  of psychosis is very common as high as 50
  (Green et al 2005)
• An RCT attempted to reduce cannabis use in this
  group (Edwards et al 2006)
• Patients divided into 2 groups
• 1. Received CAP 2. Received control (PE)
• Both groups improved to the same degree why?

17
Recovery outcomes for clients with DD

• Xie et al (2005) reported 3 year recovery
  outcomes for long-term DD clients with very
  positive results
• Drake et al (2006) reported 10 year outcomes for
  130 clients from the New Hampshire Study
• They also used 6 recovery outcomes identified
  as positive by DD clients
• Participants improved steadily over 10 years in
  the outcome domains of symptoms, substance abuse,
  institutionalisation, functional status QOL

18
Recovery Outcomes chosen by DD clients

• Controlling symptoms of psychosis (62.7)
• Remission from substance abuse (62.5)
• Living independently (56.8)
• Competitive employment (41.4)
• Social contacts with non-substance users (48.9)
• Overall life satisfaction (58.3)

19
Links between cannabis psychosis

• There is still considerable uncertainty about the
  role of substance use as a causative factor for
  mental illness
• However, there is a growing evidence base to
  indicate that cannabis use is a risk factor for
  schizophrenia, particularly in people with a
  pre-existing vulnerability (Arseneault 2002 van
  Os (2002) Zammit (2002)

20
A pilot study in Manchester

• An RCT carried out in Manchester that utilised an
  integrated cognitive behaviourally oriented
  service for DD clients produced positive results
  on a number of outcomes (Barrowclough et al 2001)
  
• They used interventions that had proved
  successful in treating the two disorders
  independently, combined into an integrative
  treatment by specialist workers
• They used MI, CBT FI, all adapted for DD

21
A pilot study in Manchester

• The results were a significant improvement in
  patients general functioning, an improvement in
  positive symptoms and in symptom exacerbation and
  an increase in the percent of days of abstinence
  from drugs or alcohol over the 12 month period
  from baseline to follow-up
• This led to a successful bid to the MRC for an
  even larger multi-site trial The MIDAS study
• However, one component of the original trials was
  dropped what why?

22
The MIDAS Trial

• With a sample size of 327 and a follow-up of 2
  years, the MIDAS trial is, to date, the largest
  RCT for people with psychosis substance use
• It evaluates an integrated MI CBT client
  therapy. A descriptive review of the development
  of the trail has been published (Barrowclough et
  al 2006)
• Whist the outcomes of the study are not yet
  available, data on recruitment and retention
  indicate that attrition rates were low and the
  majority of participants received a substantial
  number of therapy sessions
• Sample characteristics are in line with
  epidemiological studies and representative of the
  clients found in mental health services
  (Barrowclough et al 2009)
• The results are awaited with interest

23
Reviews of RCTs in DD

• Brunette et al (2004), Drake et al (2004), Mueser
  et al (2005), Drake et al (2007) Tiet and
  Mausbach (2007) have all provided wide ranging
  reviews of the growing evidence base for
  efficacious interventions in DD
• They indicate varying levels of optimism for
  treatment outcomes

24
Comparison of two reviews of treatments for dual
diagnosis

• Drake et al (2007) identified 45 controlled
  studies (22 experimental 23 quasi-experimental
  ) of psychosocial DD interventions
• Three types of interventions showed consistent
  positive effects on substance misuse group
  counselling, contingency management residential
  DD treatment
• Case management (AOT) enhances community tenure.
  Legal interventions increase treatment
  participation

25
Comparison of two reviews of treatments for dual
diagnosis

• Tien Mausbach (2007) reviewed 59 studies (36 of
  them RCTs) of both psychosocial medication DD
  interventions
• No treatment was identified as efficacious for
  both psychiatric disorders and substance-related
  disorders
• Existing efficacious treatments for reducing
  psychiatric symptoms also tend to work in DD
  populations and existing efficacious treatments
  for reducing substance use also reduce use in DD
  populations
• However, the efficacy of integrated treatments is
  still unclear

26
Closing the Gap A capability framework for dual
diagnosis

• To assist in the implementation of the MH PIG for
  DD (DOH 2002), The Centre for Clinical Academic
  Workforce Innovation have produced Closing the
  Gap
• The framework is divided into three sections
  values and attitudes knowledge and skills and
  practice development. Each capability has three
  levels core generalist and specialist
• Its aim is to establish core competencies for all
  staff who work with clients with a DD

27
Closing the Gap

• This document complements other indicators of
  service and clinical development The Knowledge
  Skills Framework (2003) The National
  Occupational Standards for Mental Health (MHNOS,
  2004) The Capable Practitioner Framework (2001)
  The Ten Essential Shared Capabilities (SCMH/NIMHE
  2004) The Drug Alcohol National Occupational
  Standards (DANOS, 2004)

28
Using Closing the Gap

• The authors of this document recommend that it
  can be used to ensure effective working for
  people with DD in several ways
• To enhance training by mapping it to explicit
  appropriate competencies
• To assess the capabilities of individual workers
  via clinical supervision
• To devise job descriptions at all levels and
  across professional boundaries

29
Local prevalence figures

• Prevalence rates across Manchester Mental Health
  and Social Care Trust (Holland and Schultz 2006)
  showed some wide variations in the rates of dual
  diagnosis among clients from different parts of
  the service
• Psychiatric intensive care units (PICUs) - 90
• Assertive outreach team 71
• Inpatient wards 56
• Acute home treatment team 12
• Community mental health teams (CMHTs) -prevalence
  rates of between 10 75 - why so large a
  difference?
• Substance use services 59

30
Manchester Dual Diagnosis Service

• In response to the increase in DD clients, MDDS
  was launched in 2004 to offer training, support,
  service development, research and city-wide
  clinics
• An integrated care pathway clearly describes how
  the clinical service operates
• A city-wide multi-agency and multi-disciplinary
  DD Directory encourages joint-working and
  effective communication and onward referral

31
Conclusion

• Most services are now only too aware of the
  complex needs of dually-diagnosed clients
• Research into effective treatments for
  co-existing substance misuse and mental health
  problems is, as yet, inconclusive
• However there have been some positive
  developments that reflect client and carer need
  rather than traditional service priorities