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Management of severe mental illness and substance misuse

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VOL: 103, ISSUE: 14, PAGE NO: 28

Malcolm Watts, MA, RMN, RGN, PGCert TL, is senior lecturer, school of health, University of Northampton

There is general acceptance that 30-50% of people with severe mental illness also have problems with substance misu…


There is general acceptance that 30-50% of people with severe mental illness also have problems with substance misuse (Gibbins and Kipping, 2006).



Most people with coexisting severe mental Illness and a substance use disorder (SUD) present with a multitude of problems, which may include:



- Social problems;



- Personality disorder and criminal justice problems;



- Psychosis and alcohol-induced acute symptoms that may require intervention (such as hallucination, depression, and/or other withdrawal symptoms);



- Organic illnesses such as heart and lung diseases, liver function and anaemia, which may be due to chronic substance misuse or may be independent of the SUD.



It is more acceptable to talk about a complexity of multiple problems rather than dual diagnosis but these problems in themselves are also complicated. There is some indication that both disorders should be seen as primary and treated concurrently. The challenge for nurses is to find a term that describes this condition in a meaningful, non-prejudicial way. The analysis of many texts suggests the term ‘severe mental illness and substance use disorder’ (SMISUD) appears to be a satisfactory compromise, although there may still be concerns with this term.





Research indicates that the most common substances misused by those with severe mental illness are alcohol and cannabis (Department of Health, 2002).



People with a mental illness generally use substances for similar reasons to the rest of the population. For example, some of the reasons may include to change or elevate their mood, to reduce feelings of anxiety, increase confidence and make socialisation easier. However, there are other theories on the prominence of substance misuse among clients with a mental illness:



- To alleviate symptoms of their illness - those with schizophrenia have reported that alcohol can help with dysphoria, anxiety and insomnia;



- To reduce the side-effects of antipsychotic drugs - antipsychotic drugs are reported by some to induce feelings of emptiness, lethargy, unimaginativeness and joylessness (Gibbins and Kipping, 2006).





In order to provide effective treatment to patients, practitioners must undertake effective assessments.



Assessment of need for specific alcohol or drug treatment should take place within mental health settings (DH, 2006). A comprehensive assessment must be made of all the client’s disorders and the implications for treatment and care needs. The major areas are mental health, substance misuse, risks, social factors and criminal justice issues. There are no specific tools used for assessing an SMISUD. However, the Dual Diagnosis Good Practice Guide (DH, 2002) provides several good examples of assessment techniques.



It is important to gather as much information as possible on the person’s substance misuse and how it interacts with their mental illness (Gibbins and Kipping, 2006).



The client’s mental health assessment will use several tools and methods, as described by Gamble and Brennan (2006) including: the Health of the Nation Outcome Scales (HONOS), Beliefs about Voices Questionnaire (BAVQ), Social Functioning Scale (SFS) and investigation of any side-effects from medication.



When assessing risk it is important to remember that with this group the various risks are often higher due to the complex interaction of their mental illness and substance misuse. Several areas should be considered in the risk assessment including:



- Self-harm and suicide;



- Accident;



- Vulnerability to assault;



- Violence to others;



- Risk of being abused;



- Risk to children/families/relatives;



- Risk of self-neglect;



- Risk of relapse and of non-engagement with services;



- Implications of client’s disorders on other aspects of their life, such as financial issues, employment, social isolation and access to healthcare.



Many people become involved in the criminal justice system as a result of their drug use and this needs to be assessed. Clients may be on bail awaiting court appearance, under Drug Treatment and Testing Orders (DTTOs), Anti-Social Behaviour Orders (ASBOs) or on probation. Healthcare professionals need to know this information as there may be implications for ongoing treatment and there needs to be liaison with these services.





People with coexisting mental health and SUD should have one single care plan (DH, 2006). The care programme approach (CPA) is a good place to start but many substance misuse services in the independent sector do not use this.



Clients must be fully engaged in the care process so that a trusting relationship can be developed between practitioner and service user. The Dual Diagnosis Good Practice Guide (DH, 2002) outlines a four-stage treatment approach. The spiral model of change may also complement this (Prochaska et al, 1992).





Engagement is the first stage outlined in the DH’s treatment approach for this client group and is concerned with the building of a therapeutic relationship (Gibbins and Kipping, 2006). The approach should be non-confrontational and non-judgemental as some clients may have no recognition of any problem.



Practitioners should encourage adherence to the service and deal with the person’s immediate needs such as financial issues, accommodation, physical health and legal issues. These are often more important to the client at that time than dealing with their substance misuse.





Encouraging motivation for and exploring possibilities of behavioural change is the second stage of the DH’s treatment approach and is linked with the contemplation point in the spiral model (Prochaska et al, 1992).



Motivational interviewing is linked to this stage. Ambivalence is a key concept in understanding motivation and in this case the client can often see both positive and negative aspects of change and may prefer to maintain the status quo. Change will therefore not take place unless the client wants it.



Rollnick and Miller (1995) defined motivational interviewing as ‘directive, client-centred counselling for eliciting behaviour change by helping clients to explore and resolve ambivalence’. They described it as more focused and goal-directed than non-directive counselling, and said the counsellor takes a directive approach to the examination and resolution of ambivalence, which is its central purpose. If clients accept this approach it can provide great support through the change process.



Active treatment


The third stage of the approach involves introducing active treatment (often following several months of contact with the client). At this stage clients may ask to reduce their substance use and some may wish to stop altogether, in which case pharmacological intervention will be necessary to enable a safe detoxification. Clients will need high levels of support and detoxification should not be used without other concurrent interventions. Small and achievable intermediate goals may be set and acknowledgement of achievement will increase the person’s optimism.



Relapse prevention


When significant change has been achieved, the fourth stage involves relapse prevention and maintenance of positive changes (Gibbins and Kipping, 2006). It is important to maintain contact with the client over many months following active treatment.





SMISUD can cause anxiety in families and carers, often resulting in high emotion, which in turn negatively affects the patient’s behaviour and triggers relapse (Gibbins and Kipping, 2006). There has been recognition that early support to family and carers can make positive differences to long-term treatment (Barrowclough and Parle, 1997).





This article has provided a short insight into SMISUD, covering assessment and care planning. Treatment may be long term but there are proven manualised therapies available which, with time, care and professional competence, can prove effective.





- Understand the range and complexity of the problems experienced by clients with severe mental illness and substance use disorder



- Be aware of the various reasons for substance misuse among this group and understand how to carry out an assessment for a client



- Know about the stages to follow in treatment plans and the importance of involving family members and carers





- Outline the full range of problems that clients with SMISUD may present with and list the reasons for substance misuse



- List the main areas that should be covered in an assessment and in a risk assessment



- Describe the four-stage treatment approach outlined by the Department of Health and outline the role of nurses in each stage



This article has been double-blind peer-reviewed.

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