Marel C., Mills K.L., Kingston R. et al.
[Australian] National Drug and Alcohol Research Centre, University of New South Wales, 2016
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Updated guidelines funded by the Australian government recommend universal mental health screening for people accessing substance use services, and say that mental health issues do not pose an “insurmountable barrier” to effective substance use treatment.
Summary These guidelines aim to provide alcohol and other drug workers (including nurses, medical practitioners, psychiatrists, psychologists, counsellors and social workers) with evidence-based information to assist with the management of co-occurring or comorbid substance use and mental health conditions. The scientific evidence regarding their management and treatment has grown considerably since the guidelines were first published in 2009, so the updated and revised version reflects the most current evidence. A series of case studies has now been included to describe the key issues experienced by service users, and to demonstrate some examples of pathways through treatment. It is envisaged that these guidelines will be updated every five years.
Population estimates indicate that more than one-third of individuals with an alcohol or other drug use disorder have at least one co-occurring mental health disorder. The rate is even higher among those in alcohol and other drug treatment, although a large number of people who enter treatment displaying symptoms of mental health problems may not meet the criteria for a diagnosis of a disorder.
The primary goal of alcohol and other drug treatment services is to address clients’ substance use. In order to do so effectively, staff must take into account the broad range of issues clients present with, including their mental health. The high prevalence of mental health issues means that alcohol and other drug workers are frequently faced with the need to manage complex psychiatric symptoms or problems, which may interfere with their ability to treat clients’ susbtance use. As such, it is important that all alcohol and other drug workers are aware of the mental health symptoms clients commonly present with, and are aware of how to manage these symptoms.
It is the recommendation of these guidelines that all clients of alcohol and other drug treatment services should be screened and assessed for comorbidity as part of routine clinical care. Historically, comorbidity has not been looked for in this way, and consequently may have gone unnoticed or untreated.
Once identified, many mental health symptoms can be effectively managed while the person is undergoing alcohol and other drug treatment. The goal of management is to allow treatment to continue without mental health symptoms disrupting the process, and to retain clients in treatment who might otherwise discontinue such treatment. “Comorbidity is not an insurmountable barrier” to treating people with alcohol and other drug use disorders. Indeed, research has shown that clients with comorbid mental health conditions can benefit just as much as those without comorbid conditions from usual alcohol and other drug treatment. The treatment for specific combinations of mental health and substance use problems is under-researched. In the absence of specific research on comorbid disorders, it is recommended that best practice is to use the most effective treatments for each disorder. Both psychosocial and pharmacological interventions have been found to have some benefit in the treatment of many comorbidities.
In the past the tendency has been to establish the order of onset of the mental health and substance use issues, in an effort to identify which is the ‘primary disorder’. Although establishing the order of onset can be useful for understanding the relationship between conditions, once the comorbid conditions are present it is most likely that the relationship between them is one of “mutual influence” rather than there being a “clear causal pathway”.
In addition to engaging with mental health services, alcohol and other drug workers may need to link with a range of other services to meet clients’ needs. A broad multidisciplinary approach is recommended to address all of the issues effectively, including active referral to other services and “assertive follow-up”, consulting with the referral agency to see whether the client kept the appointment, whether assistance was provided and what progress was made.
More on the treatment of patients suffering from both substance use and mental health problems in an Effectiveness Bank hot topic.
Last revised 07 August 2016. First uploaded 23 July 2015