Fig. 3.1
Principles and components of Integrated Dual Disorder Treatment
The complexity of the IDDT model is both its strength and its weakness. Many organisations may not be prepared or even not be able to undertake such a far-reaching change. An organisation may decide to start with integrated treatment by making choices about setting, team or interventions. The guiding principles, however, must always be kept in mind to prevent a repetition of the negative consequences of the parallel and sequential treatment approaches.
3.3 Guidelines and Initiatives on Integrated Treatment
Integrated Dual Disorder Treatment (IDDT) was developed and studied by researchers at the Dartmouth Psychiatric Research Center (PRC) of the Dartmouth Medical School. The national implementation of the model was led by the Dartmouth PRC as well, via the Substance Abuse and Mental Health Services Administration. Technical support centres (such as the Ohio Substance Abuse and Mental Illness Coordinating Center of Excellence (CCOE)) participate in these national initiatives. The original IDDT programme was supported by a comprehensive set of materials, the implementation toolkit. This toolkit includes information for all stakeholders, educational materials (workbook), and fidelity scales. The IDDT fidelity scale is an important implementation tool and is designed to guide service organisations in their implementation of IDDT, the evidence-based practice, by focusing on the processes of organisational change and clinical change. The Fidelity Scales measures adherence to the Evidence-Based Practice as described in the toolkit. This is important since high fidelity is associated with better treatment outcome (Drake et al. 2004).
When the model was brought to Europe, however, it soon became clear that the model had to be “fitted” to match specific national situations. The position of addiction care services, for instance, is much more prominent in many European countries than the USA. This results in other dynamics. On the other hand, in America group treatment and self help are much more common than in most European countries. Despite these obstacles, the basic model of integrated treatment has been adopted all over Europe.
3.3.1 National Programmes
In the USA (and Australia) the implementation of integrated dual disorder treatment is largely organised on a national or state level. This seems to be more of a challenge for the European countries. Only the United Kingdom has a National Dual Diagnosis Programme.
In the United Kingdom the National Dual Diagnosis Programme (NDDP) was established in 2004/2005. Originally within the National Institute of Mental Health in England (NIMHE), then as a programme within Care Service Improvement Partnership (CSIP) and since April 2008 part of the Improving Mental Health Care Pathways programme within the National Mental Health Development Unit (NMHDU). The main aim of the programme has been to “actively promote and support the development of improvement in commissioning and service provision for people with a dual disorder and their families and carers, and to promote and embed the philosophy of ‘mainstreaming’ across mental health services to ensure that dual disorder is seen as everyone’s business across health, social care and the criminal justice system” (Gorry and Dodd 2010).
The NDDP has commissioned the development of a range of products aimed at improving practices. Gap studies like the Dual Diagnosis Themed Review Report (DH/NIMHE 2008) made it clear that the key to many of the difficulties experienced in the care for dual disorder patients, was improving the confidence and capabilities of the mental health and drug/alcohol workforce. Attention was therefore concentrated towards training and education. A capability framework was commissioned and produced which established a structured approach to identifying core skills, values, knowledge, and attitudes needed to work with dual disorder across all care settings (Hughes 2006).
3.3.2 Expertise Centres and Consortiums
In several European countries professionals and researchers in the field of dual disorders have formed consortia, societies, or expertise centres. These differ in scope, form, and size, but all are aimed at improving the quality of care and disseminating knowledge. Although there are contacts between some of these initiatives, so far no European wide initiatives have been organised. Described below are various types of national initiatives.
PROGRESS is a UK consortium of consultant nurses in dual diagnosis and substance, and works in partnership with the above mentioned National Dual Diagnosis Programme. Its aim is to improve the support and integrated treatment for individuals who have co-existing mental health and alcohol and drug difficulties.
In 2009, the web-based national resource was launched (www.dualdiagnosis.co.uk). This website wants to provide good quality information for individuals who have a dual disorder, their families and carers, and health and social care workers providing support and treatment.
In 2010, The National Dual Diagnosis Programme commissioned PROGRESS and Coventry University to develop an innovative online awareness raising resource relating to dual disorder. This Internet-based programme is free to access and aimed at clinical staff, people who use services and their carers, and other interested parties.
In the Netherlands, the National Expertise Centre on Dual Disorders (Landelijk Expertise-centrum Dubbele Diagnose, LEDD) started its activities in 2009. LEDD is a collaboration of the Trimbos Institute (Netherlands National institute of Mental Health and Addiction) and four mental health institutions: Mentrum (part of Arkin), GGzE and the Kempen, Palier (Parnassia Bavo Group), and Delta Psychiatric Centre. LEDD is established to help addiction care, mental health institutions, and other services with the process of implementing integrated treatment, through sharing knowledge and developing methodologies. LEDD also offers technical support and guidance. The website of LEDD (www.ledd.nl) offers a platform to all those working with dual disorder. In the last years a modular training programme has been developed and closer cooperation with the coordinating addiction organisations has taken place.
In Spain, the Spanish Society of Dual Disorders (Sociedad Española de Patología, SEPD) was founded in 2005. The society has over 1,600 members: multidisciplinary professionals, clinicians, and researchers. EDPS is scientifically and medically orientated and aims to promote the study and development of dual disorder treatment and areas that are related, to offer scientific and technical assistance, teaching, and research. Among the activities of SEPD are training of professionals in the field of dual disorder; disseminate and raise awareness of the problem of dual disorder among professionals, government, and society in general and taking action to reduce the double stigma in dual disorder.
The Swedish Network on Dual Diagnosis (Svenska nätverket Dubbeldiagnoser, SN-DD) is a initiative that began in 2004. The main purpose of the network is to promote the development of care that meets the needs of dual disorder patients and the thought to improve their quality of life. Other activities are the monitoring of research and development of methodology and cooperating with other networks (including user organisations), to create a consensus based on research and experience. Unlike the above mentioned initiatives, the Swedish network includes representatives from municipalities, counties, correctional and private actors operating in the health-care sector.
3.3.3 Guidelines
Several European guidelines on dual disorders have been published in the last decade, though often aimed at a specific combination of a mental health disorder and substance use. The Spanish Society of Dual Disorders (SEPD) has, for instance, published a set of seven protocols for the clinical treatment of dual disorder patients (depression, anxiety, personality disorder, ADHD, schizophrenia, bipolar disorder, and treatment of adolescents). A training programme is linked to these protocols.
In the Netherlands, in 2003 the guideline “Dubbele diagnose Dubbele hulp, Richtlijnen voor diagnostiek en behandeling” (dual diagnosis, dual help, guidelines for diagnostics and treatment) was published Ontwikkelcentrum Kwaliteit en Innovatie van Zorg 2003. This in the same year that Mueser and his colleagues published their book on integrated treatment and there are many references in the Dutch guideline to their earlier publications and studies.
The report contains instruments and guidelines for screening en diagnostics.
As far as treatment is concerned there are no actual guidelines but it offers an overview of state-of-the-art scientific insights. The guideline has not been updated since. In national multidisciplinary psychiatric guidelines, however, more and more attention is given to co-occuring alcohol- and substance abuse.
In 2002, a framework for practice around dual disorder “Dual Diagnosis Good Practice Guide” had been produced by the English Department of Health. Then in 2011, the well-known English organisation National Institute for Health and Care Excellence (NICE), published the guideline “Psychosis with coexisting substance misuse. The NICE guideline on assessment and management in adults and young people”. This is the first guideline in which NICE specifically addresses a co-occuring disorder. This guideline is relevant for adults and young people (aged 14 years and older) with psychosis and coexisting substance misuse and covers the care provided by primary, community, secondary, tertiary, and other health-care professionals.
The guideline opens with personal accounts of dual disorder patients and continues with chapters on assessment and care pathways, service delivery models, psychological and psychosocial interventions, pharmacological, and physical interventions. It concludes with a specific chapter on young people with psychosis and coexisting substance misuse.
3.4 Other Related Models
Although the most comprehensive and best researched, the IDDT model is not the only model for integrated treatment.
The Kingston Community Drug and Alcohol Team Dual Diagnosis Service (CDAT) (Lowe and Abou-Saleh 2004). This model combines interventions aimed at substance abuse with interventions based on mental health. CDAT is a multi-disciplinary team of health and social care workers that provides assessment, detoxification, care planning, residential referrals, and day programmes. It also provides information, advice, counselling support, and acupuncture for people with drug and/or alcohol problems; home visits; liaison with statutory and voluntary agencies; prescriptions (in some cases); and specialist care for children and families and those with a dual disorder.
CDAT delivers integrated treatment by providing proactive outreach and positioning a CDAT link clinician in different settings. This professional supports assessment of dual disorders attends relevant meetings; identifies cases which should be dually assessed and gives feedback on cases to relevant organisations.
Behavioural Treatment for Substance Abuse in Serious and Persistent Mental Illness (BTSAS). BTSAS (Tenhula et al. 2009) is designed to reduce drug abuse in people with severe and persistent mental illnesses (SPMI) by incorporating strategies effective for treating substance use in primary substance abusers but modifying these strategies to make them more useful for people with SPMI. BTSAS is a highly structured group intervention with groups meeting twice per week for 6 months. It is a social learning treatment that is comprised of several interrelated components:
Individual motivational interviews to discuss consequences of drug use, explore reasons for reducing use, and select a goal drug to focus on in BTSAS.
Contingency management (CM) using urinalysis to reward reductions in use or abstinence.
Collaborative goal-setting to identify specific and realistic short-term goals related to reducing drug use.
Social skills training to teach drug refusal skills, enhance non-drug social contacts, and provide success experiences that increase self-efficacy for change.
Psycho-education about the impact of drug use on individuals with SPMI, including reasons for use as well as particular dangers of use for persons with SPMI.
Relapse prevention training to help participants manage urges to use drugs and other high-risk situations, as well as lapses in use.Related posts:
Evolution of Mental Health and Addiction Care Systems in Europe
Bipolar Affective Disorders and Alcohol Dependence: Comorbidity, Consequences, and Treatment
Schizophrenia and Addiction
Mood Disorders and Addiction
Non-Substance-Related Disorders: Gambling Disorder and Internet Addiction
Dual Disorders in Adolescent Populations
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