Evidence based interventions
in Dual Diagnosis
Ian Wilson
DD clinical nurse specialist, MMH&SCT
Teaching fellow, University of Manchester
Prevalence
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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)
Prevalence of cannabis use
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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
Dual diagnosis - Early studies
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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
The New Hampshire Research
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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
Using a multi-disciplinary approach
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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)
Controlled research studies in DD
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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
Limitations of the research
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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
Further studies
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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
Further studies
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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
Further studies
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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?
Further studies
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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?
Further Studies
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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
Further Studies
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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
Further Studies
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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
RCT to reduce cannabis use in FEP
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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?
Recovery outcomes for clients with DD
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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
“Recovery Outcomes” chosen by DD clients
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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%)
Links between cannabis & psychosis
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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)
A ‘pilot study’ in Manchester
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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
A ‘pilot study’ in Manchester
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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?
The MIDAS Trial
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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)
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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)
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The results are awaited with interest
Reviews of RCTs in ‘DD’
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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
Comparison of two reviews of
treatments for dual diagnosis
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Drake et al (2007) identified 45 controlled
studies (22 experimental & 23 ‘quasiexperimental’) 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
Comparison of two reviews of
treatments for dual diagnosis
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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 substancerelated 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
Closing the Gap – A capability
framework for dual diagnosis
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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’
Closing the Gap
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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)
Using Closing the Gap
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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
Local prevalence figures
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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%
Manchester Dual Diagnosis Service
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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 multidisciplinary DD Directory encourages jointworking and effective communication and
onward referral
Conclusion
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Most services are now only too aware of
the complex needs of ‘dually-diagnosed’
clients
Research into effective treatments for coexisting 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