Integrated treatment is a global trend in health care reforms which chiefly focuses integrated and coordinated forms of care provisions. Individuals who are suffering from both mental illness and substance abuse disorder are diagnosed with co-occurring disorder. It has been found that the tendency to develop substance abuse disorder is much more in patients who are already suffering from mental illnesses like schizophrenia or PTSD than individuals who are not suffering from psychological issues (Torchalla et al. 2012) . The major reason behind this co-occurrence is that psychologically ill individuals often tend to use drugs or alcohol to cope up with the psychological trauma. Before the concept of integrated health care had arisen, heath care users suffering from co-occurring disorders are treated separately for each disorder. Patients undergoing non-integrated treatments often faced issues associated with expensive costs and unsatisfactory outcomes. Integrated treatments and therapies for people suffering from co-occurring disorders are regarded to be best since these treatments are reported to have better outcomes and are less expensive than non-integrated treatment. In this literature review, the importance of integrated treatment for health care service users are being evaluated along with the evaluation of different approaches of integrated dual diagnosis treatment. Besides that, the literature review also contains discussion about various barriers, which are hindering the integrated treatment approaches. Finally it has been concluded that, despite several number of approaches used to treat patients with CODs, integrated treatments needs more therapies and approach for complete recovery of healthcare service users.
Importance of Integrated treatment for patients suffering from mental illness and substance abuse disorder
Sterling, Chi and Hinman (2011) pointed out the importance of integrative approaches in order to co-occurring disorders and several barriers associated with the treatment of people suffering from Alcohol and Other Drug (AOD) use disorders along with Co-occurring Disorders (COD). Initially, the two above mentioned disorders were treated separately but in this era of modernizations health care professionals are providing integrated treatment for both AOD and COD since several researches have been conducted on the disadvantages of separate treatment and how integrative approaches can deliver a better result. Some of the barriers faced in the process of providing integrated health care service include various organizational factors, differences in education and training of healthcare service providers in the different fields and the stigma associated with both COD and AOD usage.
However despite these barriers, surveys have found that co-occurring mental health and substance abuse disorders, when treated separately in the past gave rise to several complications during the treatment along with high expense and poorer outcome. Earlier, health care providers used to treat patients with CODs as they would treat any other patients. However, the treatments provided were not well suited for COD patients and thus the need of integrated treatment was understood. Since then, a vast amount of researches have been conducted to provide treatment to patients suffering from all conditions and health care providers have succeeded to identify many key components that will help them to achieve this goal. In this article, various strategies of treating patients with both psychological illness and substance abuse disorder have been discussed along with the suggestion of mechanisms that will facilities greater integration. This article has also pointed out that the degree of integration required to ensure that patients with all types of severity of CODs are receiving appropriate care, is still lacking, and barriers to the implementation of integrative models are still to be eradicated completely.
Torchalla et al. (2012) stated that since the co occurrence of mental illness like PTSD and SUD has globally increased, various integrative approaches for treating these disorders simultaneously are highly required. Over the past decade, evaluation and development of several integrated treatments have shown gradual progress. In spite of the fact that integrated treatments have shown effective reduction in SUD and trauma symptoms, there is insufficient information to support integrated treatment over non integrated treatment. However, no evidence of integrated treatment as being hazardous or less effective than non-integrated treatment has been found and hence the article has suggested the use of both integrated and non integrated treatment in order to treat patients with CODs. Health care service providers who are currently considering which type of treatment is more effective may provide treatments based on the factors like program availability, treatment expenditure and the preference of the healthcare service users. This article has pointed out the requirement of more research and randomized control tries to clarify the effectiveness and efficiency of Integrated Treatment over non-integrated treatment. This research has also suggested evaluation of Integrated Treatment programs, evaluation and incorporation of exposure based paradigms, usage of suitable samples and developing innovative approaches to increase treatment engagement.
Various approaches of treating patients suffering from mental issues and substance abuse
Mueser and Gingerich 2013 states that high rates of substance abuse disorder is noticed in individual suffering from serious psychological issues like bipolar disorder, schizophrenia and severe depression. This in turn imposes a highly negative impact on their life. This article suggests various strategies for treating patients with both psychological illness and substance dependence disorder. According to the author, cognitive-behavioral therapy is an effective way to treat patient who have been diagnosis with dual issues since this therapy will teach more effective copping and interpersonal skills, social network engagement and supporting functional recovery. Social workers need to play an important role in assessing, treating and referring patients with co-occurring disorder in a good number of settings. The author solely believes that healthcare professionals themselves should solely belief in the possibility of the patients to get recovered from the co-occurring disorder, along with installing the same belief in the patient and his/her family, friends and relatives.
Jones et al. 2011 opined that an integrated treatment approach is needed to treat patients who are suffering from both co morbid substance usage disorder and bipolar disorder. The intervention of this treatment includes motivational interviewing along with cognitive-behavioral therapy. According to the research, this treatment is acceptable and feasible since an effective reduction in substance usage has been reported in patients who are diagnosed with bipolar disorder with substance misuse. Apart from this, few evidences of improvement of impulsiveness, mood and symptoms were also found among service users.
Barrowclough et al. (2010) argued that cognitive behavioral therapy and integrated motivational interview for healthcare service users with substance misuse and psychosis are found to be effect less in terms of symptom outcomes, hospitalization and functioning. However this therapy is found to be effective in reducing the tendency of substance abuse in patients for at least one year after the complication of the therapy. According to a survey involving 327 service users, it has been found that primary outcome of the therapy was death of a good number of patients within 24 months of admission. Secondarily it has been found that the therapy was effect less on the negative consequences of substance misuse and the frequency of substance use, although, has effectively reduced substance use per day. No effects of the therapy were found on clinical outcomes like psychotic symptoms, relapses self harm and functioning.
Najavits and Hien (2013) have suggested that the Seeking Safety Model is one of the best ways to treat patients who are suffering from both Post Traumatic Stress Disorder (PTSD) and Substance Use Disorder (SUD). According to the research, implementation of several treatment models has shown positive impact on several domains, however, it has been found that the model is more effective for PTSD than SUD and hence it can be concluded that SUD is harder to treat. SS is the only treatment that has shown commendable performance by efficiently controlling both PSTD and SUD. Partial dosage of Safe seeking (SS) is more effective than complete dosage. Considering the fact that treatment of both PTSD and SUD is more time consuming than treating PTSD alone, dual treatment put emphasis on stabilization and coping and is more present focused. However, models with past-focused approaches incorporate present –focused approaches in order to treat vulnerable healthcare service uses.
Kelly and Daley (2013) opined that multiple treatments including a combination of pharmacotherapy and psychotherapy can be used to treat patients having psychological disorder along with substance abuse disorder. Considering the fact that psychological issues and substance abuse disorder are common among adults, integrated treatment for co morbidity is found to be more effective than treating each disease individually.
Green et al. 2015 suggested three crucial comprehensive themes in order to treat patients with mental and substance abuse disorders. While the first theme includes providing knowledge to the patients about the effects of drugs and alcohol for enhancing motivation and sobriety, the second theme is about how sobriety helped service users to start their psychological health recovery process. The third theme includes maintaining sobriety that helps in building self-confidence, self-efficiency, sense of personal growth and improved functioning. Apart from this, non-judgmental support from professionals, family, friends and relatives also facilitated recovery.
Wolff et al. (2012) suggested an open trial design to evaluate the efficiency of Seeking Safety Intervention for women who are diagnosed with co morbid Substance Use Disorder (SUD) and PTSD. The treatment was conducted on a group of 75 female prisoners of an approx age of 18 years old or more, who has committed violent crimes, have experienced traumas in childhood which eventually have resulted in mental illness. After the conduction of the survey, above three quarters of the total participants reported that the Seeking Safety helped them to deal with their mental illness and substance abuse disorder by enhancing their knowledge about various skills of coping.
Hesse (2009) opined that though an prominent approach, psychotherapeutic treatment for substance abuse and co morbid depression is not empirically supported and requires trial for the development of new treatment options for substance use disorders and co-morbid depression and anxiety. According to the research, nine trials of integrated treatment for both the mentioned diseases have been carried out and Meta analysis was performed for integrated treatment of depression and anxiety. It has been found out that patient’s experiences lower tendency of substance use but no improvement was reported for anxiety or depression disorder.
Hien et al. (2009) argued that treatment models that targets PTSD simultaneously or before substance abuse are the most effective treatment models and hence has proposed the mentioned course of treatment instead of courses that are offered commonly for healthcare service users patients with both psychological illness and substance abuse disorder since the commonly offered courses lack trauma-focused approaches, especially because of the high rates of trauma histories and PTSD among such healthcare service users. A survey has been conducted among 353 women who are randomly assigned for either health education group treatment or trauma focused treatment. The treatment was conducted for 1 year and a Markov Model was fit on to assess and investigate the link between improvement in substance use symptom and PTSD severity during the study’s treatment phase. As a result of the survey, it was found that patients with PTSD were showing more significant response over time, indicating PTSD improvement is subsequently associated with substance use improvement. Thus, the research concluded that integrated treatments that involve PTSD reduction are more likely to improve substance abuse disorders while there are very fewer amounts of evidences that support treatment for substance use disorder can effectively reduce mental illness issues like PTSD.According to Sacks et al. (2013), the capability of the health service provided for CODs at New York State (NYS), outpatient programs lacks satisfaction of the heath service users and hence needs improvement. In an survey conducted on 447 health care service users who were suffering from both mental illness and substance abuse disorder, it has been found that, though health care providers can assess both the disorders efficiently, less effective approaches were observed during actual delivery of treatment. The patients were assessed with the help of dual diagnosis capability indices. While commendable efficiency has been reported in staffing and assessment, issues were found in deliverance of treatment. The project concluded that due to lack of proper policies, workforce benchmarks and practice, health care service providers are unable to provide proper treatment to the health care service users.
McFarling et al. (2011) have pointed out several numbers of stigmas that are associated with substance abuse and psychological health in military setting which are creating barriers for treating individuals with this issue and various challenges faced by health care professionals when they tries to reduce the stigma . Military culture greatly influences attitudes of individuals towards the patients which hinder the treatment. Beside that health care professionals face various challenges during treating reserved personnel. In these articles the authors have suggested the requirement of various policies to irradiate the barriers along with enhancing military culture, education and leadership that will eventually bring about the desired change.
According to Barriers to Providing Mental Health Medication to the Homeless Mentally Ill Population (2016), people who are homeless are likely to have more choric mental and physical issues along with higher tendency to substance abuse compared to the general population. Excessive usage of drugs can severely affect an homeless individual and can even impair his ability to maintain physical and mental health. Considering the fact that individuals without proper accommodation do not posses insurance coverage and are unable to engage health care provider in their community, it is difficult to provide them with preventive care and proper medication. These barriers compelled individuals without proper accommodation to approach health care services only when their psychological or physical condition has worsened to the point of emergency service center visit.
From the above literature review, it can be understood that integrated treatment for patient suffering from both substance abuse and psychological disorders, is crucial since several evidences of its effectiveness has been found through various researches. According to researchers, the co-occurrence of substance abuse disorders and mental illness in individuals are increasing and patients who are being treated separately are showing less improvement when compared to patients who are being given integrated treatment (Sterling, Chi and Hinman 2011). However, enough evidences of the effectiveness of integrated treatments over non-integrated treatments are still to be discovered (Torchalla et al. 2012). Several researches have been conducted on various approaches for treating patients with both psychological and substance abuse disorders. While according to some researchers, cognitive-behavioral therapy is regarded as the most effective ways to treat health care service users suffering from the above-mentioned co-occurring disorders, others state that motivational interviewing along with cognitive-behavioral therapy is needed to effectively reduce the co occurring disorders (Mueser and Gingerich 2013; Hien et al. (2009 ).
Several researches have also being conducted on the efficiency of Seeking Safety treatment, pharmacotherapy and psychotherapy. Evidences of how trauma focused treatment can eventually improve substance abuse disorders in women who are admitted as outpatients for CODs have also been found through research. However, need of more researches is evident since, enough evidences of patients getting recovered from both mental illness and substance abuse disorders simultaneously, are not found till now. Though remarkable amount of improvement in substance abuse disorder is seen in patients, very few number of health care service users have reported to get recovered from mental illness and substance abuse disorders simultaneously with the help of integrated treatment. Apart from this, researches have been conducted on various barriers associated with the treatment of (Co-Occurring Disorders) CODs, which include stigmas associated with the above mentioned disorders and inefficiency in providing medication and therapies to homeless individuals (Providing Mental Health Medication to the Homeless Mentally Ill Population 2016). However, fewer researches have been conducted on other barriers that show up while providing integrated treatment to healthcare service users. Besides that very few researches are conducted on finding the remedies of the barriers that are hindering the treatment process.
Conclusion
From the above literature review, it can be concluded that, though a good number of approaches are being used globally, to provide integrated treatment to healthcare service users with both mental illness and substance use disorders, very few evidences are reported where a patient gets cured from both the disorders simultaneously. While some therapies are reported to reduce mental illness effectively, other therapies are effective only I substance abuse reduction. A majority of integrated treatments are efficiently reducing substance abuse disorders whereas, the effect of integrated treatments and therapies on mental illness of the patients is very low. Hence more researches are required to invent therapies that can efficiently and simultaneously reduce both psychological and substance abuse disorders. Besides that, several challenges are recognized which are creating barriers for providing efficient integrated treatment to patients suffering from CODs. Hence more researches are required to eradicate the barriers that are hindering the process of integrated treatment. The above mentioned challenges recognized in this literature review, provide the scope of further researches in fields that needs to be improved.
References:
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