Diagnoses of Co-occurring Mental Illness in Works' Horsfall, Robert E Drake, Zerrin - Article Example

Article Reviews Table of Contents Article Reviews 1 Table of Contents 1 Article Reviews 1 Part 1: 2 Part II: Articles Reviewed 3 Article Reviews Part 1: Abstract This paper is a review of three research papers by different authors tied together with a common topic of dual diagnoses of co-occurring mental illness and substance abuse. All papers have an underlying focus relevant to the topic ranging from dual diagnoses in young people, adults and peer-reviewed work done on the same. While these papers focus more on approaches needed to treat dually diagnosed subjects, and do not talk on specific drugs to be sued, this review deals with critical analysis of approach as outlined by each. Introduction Dual diagnosis encompasses a wide range of illness and several substances that are abused. A number of consequences and correlates underlie living with dual diagnoses and treating dually diagnosed is as much difficult for caregivers and clinicians as are negative consequences for the diagnosed. The consequences could range from noncompliance, distorted cognition and perception, relapse, suicidal tendencies, aggression, social exclusion, and certain co-existing medical conditions. One of the primary factors for problems faced by the caregivers is lack of motivation on part of the dually-diagnosed to undergo treatment or rehabilitation. As a result of this any attempts at bringing them to a stage where treatment and other modalities can be initiated prove futile. Considerable research has gone into this aspect of dual diagnoses and different researchers have propounded different modalities that could be used in order to accomplish twin goals of convincing such people for treatment and initiating the same in a coordinated manner for desired outcomes. Modalities in isolation and also in combination have been suggested by scholars from the field, each group backing reasons for the relevance of modality being suggested. However recent body of research recommends use integrated approach to the issue and interest in the same seems to be picking pace now. Part II: Articles Reviewed Articles under review in this section are as below: Article I (Lead Article): Horsfall, J., Cleary, M., Hunt, G.E., & Walter, G. 2009, ‘Psychosocial treatments for people with co-occurring severe mental illnesses and substance use disorders (dual diagnoses): A review of the empirical literature’, Harvard Review of Psychiatry, vol. 17, no.1, pp. 24-34. Article II: Robert E. Drake, Kim T. Mueser, Mary F. Brunette. 2007. Management of persons with co-occurring severe mental illness and substance use disorder: program implications. World Psychiatry 2007;6:131-136) Article III: Zerrin A. 2009. Managing cannabis use in people with severe mental illness: what can be done? Advances in Psychiatric Treatment. 15:65-71 Article I Review The lead paper raises some pertinent issues regarding the dually diagnosed people and provides some practical ideas on how this group of people can be benefitted from more focussed programs customized on individual basis. The paper makes a specific mention of young people, under the influence of overused drugs, who have suffered first episode of psychosis. The paper suggests that early intervention in such cases can go a long way in weaning them off the polysubstance abuse exacerbations. The paper starts with an introduction of the diversity of the co-occurring substance abuse and mental illnesses. Citing the Diagnostic and Statistical Manual of Mental Disorders, the paper clearly describes four types of people who would require a combination of substance abuse and mental health services. These include the ones who can benefit from integrated and coordinated approach on account of the severity of their condition; a near disability imposed by co-occurring mental illness and substance abuse. Then it is this group of people who have been adversely affected by substance abuse and severely disabled by mental health issues, followed by the group disabled by substance abuse and adversely affected by mental health disorders. The fourth group is the one which is mildly affected by the duality of the problems and, as per the authors, can be taken care of by the general practitioners with occasional access to either substance abuse or mental health services. Horsfall et al have developed the paper in the wake of the considerable research that has been previously done on consequences of co-occurring psychosis and substance abuse disorders. But, as has been seen, studies have either been abandoned or not reached any conclusion because of small samples, often heterogeneous in nature, short follow-up periods, high attrition rates, and treatment components not clearly defined. The authors reflect a positive outlook with regard to providing treatment to such people having been dually diagnosed. They opine that treatment can either be customized or based as per individual needs and must be a combination of psychosocial and medical interventions. These include cognitive-behavioral therapy, motivational interviewing, relapse prevention, skills training, contingency management, and case management. Even though the authors have used interchangeably terms as co-occurring disorders and dual diagnoses, their real focus has been persistent and serious mental disorders illnesses like major depression, schizophrenia, and psychotic illness along with drug use. Making use of empirical evidence on the topic, the paper flows with complete ease; knitting in the process many aspects of the subject and suggesting ideas at each step while discussing issues. The best part of the paper is that while it builds on reliable scientific information and first class journal references, it raises the point of treatment issues that caregivers encounter in cases of dual diagnoses. The major issue with such people is that they have no or little motivation to change; something that prompts authors to suggest motivation as one of the basic psychosocial model to get this group of people initiated to. Citing developers of the model, DiClemente and Prochaska, the authors advocate use of five stages as propounded by the model to change, which are, "precontemplation, contemplation, preparation, action, and maintenance". As analysed above, the paper not only throws open storehouse of scientific evidence to the reader, it also intersperses it with real, practical suggestions on how dually diagnosed can be helped through psychosocial and medical interventions on either individual or group basis. Jason Craig’s case can be discussed in the light of this paper. His 10-year old psychotic episodes-substance abuse co-occurrence has left him distraught with every therapy. But that is only until the welfare worker, Kylie, meets him and "convinces" him to see the counsellor at the Alcohol and Other Drugs (AOD) service. After some time when Craig says Kylie “opened his eyes”, it could actually be taken as an instance of motivational model at work, followed by treatment which Craig is ready to take. Article II Review The article by Drake et al focuses specifically on adult co-occurring substance rate of abuse disorders citing high rate of around 50 percent of the incidence in this population. This is a typical review paper that follows the usual path of introduction, treatments provided and general outcome got from the intervention. The general premise on which authors base the paper is that treatment systems followed on either parallel or separate modalities are not easily accessible, tailored or integrated. The authors are of the opinion that recent integrated interventions for adults with co-occurring illnesses are aimed at only improving quality of life and adjustments and amelioration of substance abuse. Then paper is brought up on 25 year old history of co-occurring illnesses and considers the population as heterogeneous in nature based on severity and type of disorders and substance abuse apart from many other factors involving different types of support and psychosocial skills. It considers providing services to this group of people as fraught with dilemmas as, according to authors, people with co-occurring illnesses are not finding it easy to access treatments required for either proper amelioration of abuse or adjustments in quality of life. The authors paint a gloomy view on psychosocial interventions, even though they accept that this field vis-a-vis dual diagnoses is rapidly developing. They are of the opinion that despite 45 controlled trials having been conducted on these interventions the evidence got is inconsistent, and certain factors that are essential for successful implementation of these interventions are missing as a result of which these interventions have been found as inconsistently effective. Furthermore, they suggest that these interventions lacks clear guidelines pertaining to philosophy, mission, comprehensive reorganization, active leadership, longitudinal supervision and training, and quality improvement. Quoting 3 year follow-ups done on co-occurring disorders and referring to steady improvements, the authors are of the opinion that there has been only little longitudinal evidence that could support their use. One astonishing observation of the paper is that people suffering from co-occurring illnesses find, on their own, recovery cut-offs and outcomes, based on intermediates like taking up competitive jobs, living independently, being in constant touch with friends not part of the substance abuse circle, showing positive outlook towards life and controlling symptoms. This point by the authors needs critical analysis and actually comes as a strange observation with regard to people who actually have got to a stage where they find little or no meaning in life. In the same breath the authors suggest steps must be taken to turn into dual recovery programs all mental health programs. In this regard the authors urge the medical community to do further research on the subject keeping greater standardization in mind. In what appears to be a review which has been written just for the sake of writing one, this paper does not make any value-additions to the pool of knowledge already available on dual diagnoses and the amount of work that is done on the same. In fact, the paper does not raise any issues that need scientific address. Craig’s case cannot be discussed in the light of this paper, not even on the psychosocial front. The paper leaves more questions than what it answers. Craig needs a positive thing to change, this paper presents a pessimistic outlook. Article III Review The paper by Zerrin Atakan has narrowed down the topic of co-occurring mental illness and substance abuse to the use of cannabis. This is because, as author says, 50 percent of people suffering from mental illness use cannabis during the illness or at any point of time in their lives. The main focus of the paper is treatment models that have been employed in the past for dual diagnoses, have been tried recently, and can be used in future for better outcomes, expectations and quality of life in these people. In order to explain the point the author begins with the explanation of a "specially designed service" that was started in the USA and later replicated in the UK. It is noteworthy that at either countries substance abuse and mental illnesses have been treated separately; the modalities, to some extent, determined by philosophy, treatment strategies, and culture of the places. The author explains, in a very methodological manner, three service models that have been sued so far; named as serial treatment, parallel treatment, and integrated treatment. As the terms suggest, serial treatment picks up one problem at a time and generally moves to the second one after the first has been corrected; parallel treatment picks both problems at a time, though each by different teams; and integrated treatment model picks up both problems at a time but both are handled by the same team. The author suggests that the latter is of high efficacy and provides better outcomes, but only in case the whole model is diligently and scientifically integrated with staff capable of and trained in both issues of mental illness and substance abuse. backed by remarkable research and evidence the author rues the fact that people with co-occurring illnesses are denied psychological intervention, but clarifies that the reason behind it could more be lack of resources to do so rather than anything else. The paper advocates motivational interviewing as part of psychological intervention and suggests it can go a long way in developing patient-tailored treatment programmes. The first and foremost benefit of any such intervention is that it strengthens the subject's resolve to get better which is the founding principle of any treatment modality initiated. It is not the caregivers that have treatment goals to meet, the patients too can have them. The author says each individual’s expectations from the modality used on him can be different. One patient may want to reduce damage done by substance abuse, like from cannabis, and another subject may want to give it up in its entirety. Sensed motivational level in each individual the teams from integrated approach can further tailor-make the intervention. In other words, one-treatment-fits-all concept cannot be applied to difficult subject of co-occurring conditions. The paper is an excellent piece of research and reflection. It clearly outlines the need for a coherent, integrated and intelligent approach to treating the co-occurring conditions and makes lack of proper assessment, educational campaigns, and successful interventions responsible for paucity of favourable outcomes on the issue. Craig’s case fit into the realm for this paper and he fits into the integrated approach as suggested by the author. Kylie, as a matter of fact, seems to have approached him through the same intention. Part III: Concluding Summary and Directions The three articles deal with the same topic of co-occurring mental illness and substance abuse. All three of them approach a common topic differently. The first article seems to be flowing from a chapter of a book and takes in its stride a lot of information relevant to the topic, issues that pertain to it, and solutions that could be provided. The central idea behind each discussion is how to handle dual diagnoses and what can be called a better modality and why from another. Focusing mainly on young people, the article suggests use of combination therapies stemming from both psychosocial and medical interventions in order to expect better outcomes. The second article is bookish in nature and does not provide any solid substance, except summarizing stray research previously done, on the subject. Even though the article was published recently (2007) the information contained in it conveys its antiquity. It is raw, and not as would be expected of a research paper. It grossly contrasts the level of information contained in the other two articles and the knowledge that they impart and it would not be apt to use it as a reference material for any case scenario, like that of Craig. Compiled on the basis of sound scientific knowledge, the third article is a caregiver’s treat, particularly one who deals with co-occurring conditions of mental illness and substance abuse. It creates optimism when it says substance abuse cannot be handled by use of pharmacokinetics alone. It is important for caregivers of such conditions to incorporate integrated approach involving social skills for better results. In an unbiased, non-partial manner it recommends further extensive research for the benefit of people with dual diagnoses. My opinion seconds the one coming from the third article and aided by the information given in the first. To help people with dual diagnoses integrated approach must be relied up more than pharmacological-only approach and both issues must be handled simultaneously and by the same team. I am also of the opinion that wider, positive social involvement based on subject’s cultural backgrounds can boost willingness of dually diagnosed people to get better and live a happy life. Read More