Special focus on depression and co-morbidity of addiction

Citation

(2012), "Special focus on depression and co-morbidity of addiction", Advances in Dual Diagnosis, Vol. 5 No. 3. https://doi.org/10.1108/add.2012.54105caa.001

Special focus on depression and co-morbidity of addiction

Article Type: Editorial From: Advances in Dual Diagnosis, Volume 5, Issue 3

Substance misuse and mental health problems (dual diagnosis) co-occur at a greater rate than chance in both clinical samples and in general population surveys (Kessler, 2004). The focus on “dual diagnosis” in research, policy and practice has been on people with serious mental health problems and co-morbid substance misuse. This in part has been a product of a series of seminal prevalence studies in the 1990s that helped to highlight the high levels of this co-morbidity, as well as the problems that accompanied this.

Weaver et al. (2003) undertook a study that sought to identify co-morbidity from both a mental health and a substance misuse perspective. In the COSMIC study, keyworkers from community mental health and substance misuse teams were invited to identify those on their case-loads who had both mental health and substance misuse problems. Following on from this screening, researchers interviewed these service users and found that in substance misuse, services 75 percent of drug users and 85 percent of alcohol users had a past year psychiatric disorder. The most common disorders in drug service users were affective and anxiety-related disorders (68 percent) followed by personality disorder (37 percent). Serious mental health problems such as schizophrenia were rare. Similar rates were found in alcohol service users. However, only 18 percent of the drug service users and 32 percent of the alcohol service users fitted the criteria for referral to mainstream mental health services (i.e. a mental health problem of sufficient severity or chronicity). Weaver and colleagues recommend that local drug and alcohol services are better supported by primary mental health and psychological therapy services to meet the mental health needs of substance misusers. A more recent study conducted in Leeds (Delgadillo et al., 2012) used the CIS-R to assess mental disorders and found that out of a sample of 103 substance misusers in treatment, 70 percent met the diagnostic criteria for common mental disorder (CMD). In addition, Delgadillo and colleagues found that only alcohol had a direct correlation with psychiatric symptoms, whereas all other substances had no relationship to psychiatric symptoms. However, severity of dependence (irrespective of substance) had a direct correlation with psychiatric symptoms; in other words, the more severe the psychiatric symptoms, the more likely the person reported severity of dependence of their drug of choice. These two studies clearly demonstrate that there is a close association between substance misuse and common mental health problems, but the nature of this link is likely to be complex and multi-factorial. More research is needed into the exploration of this co-morbidity to help understand this phenomenon in more depth.

Despite these important and significant findings, it seems that substance misuse services have been slow to rise to this challenge in terms of identifying and intervening in relation to mental health needs of substance misusers. One of the biggest barriers for substance misusers is the myth that if someone is an active user or still in treatment for substance misuse, that they are unable to therefore benefit from psychological therapies. Service users report being rejected or discharged from mental health services on the grounds of their continued use, or prescribed methadone in some cases.

However, the tide is beginning to turn as new evidence emerges that people with substance misuse issues can benefit and engage with psychological therapy for their mental health problems. The National Treatment Agency for Substance Misuse (the national body that drives the delivery of local substance misuse services in the UK) published a guidance in relation to psychosocial interventions in 2010 (Pilling et al., 2010) which provided a guide to assist in the implementation of psychosocial interventions within drug services. They acknowledged that:

co-morbid mental health problems [in substance misusers] had a negative impact on social functioning, and that many services users’ needs for treatment in this area were unmet (Pilling et al., 2010, p. 6).

In addition, in 2011, a new guidance (Increasing Access to Psychological Therapies (IAPT), 2011) was published to assist primary mental health services in England (IAPT) to accept referrals from people with current substance misuse problems for both high- and low-intensity psychological therapies.

However, there is limited research evidence into effectiveness of various psychological therapies for common mental health problems in active substance misusers. However, we do know that co-morbid mental health problems can hinder treatment progress for addiction. A one year follow up study of heroin users entering treatment by Teesson et al. (2005) found that those still suffering with major depression were less likely to be abstinent of heroin, showed an increase in heroin or poly drug use, engaged in more risky behaviours such as needle sharing and increased criminal activity.

Therefore, in summary, there is much work to be done. We need a greater understanding of the causal links between substance misuse and common mental health problems, as well as identifying effective methods of providing treatment that addresses both areas of need, and which in turn leads to better recovery outcomes for the person with the combined problems.

This special issue will highlight some of the emerging work in this area, and it is a theme we would like to revisit in future issues as well. I am delighted that we again have some international papers in this issue and this is something that we are actively pursuing, both in the marketing and commissioning of papers. I am also delighted that Jaime Delgadillo (author of the epidemiological study in Leeds previously cited) has joined us on the editorial board and had authored a paper for this issue. Jaime Delgadillo and myself are currently working on a feasibility study of psychological therapy for depression in substance misusers in Leeds and we will be publishing an update on this trial later in the year. Jaime Delgadillo’s paper addresses issues of sensitivity of routine measures of depression and anxiety in establishing depression and anxiety in substance misusers. Transient symptoms of substance misuse can affect the responses in depression and anxiety scales. Jaime Delgadillo found that conventional cut-off scores may over-estimate CMD and recommends the use of higher cut-offs in this particular population, which allows for a more reliable and conservative estimate of prevalence in this group.

We have two papers from Australia – Cameron Brown has written an interesting and thought provoking discussion paper on how approaches from 12-step and cognitive behavioural therapy can be utilised in practice. These approaches are often seen as separate and maybe even opposing, but Brown argues that using the concept of social reinforcement, that 12 step can be married to CBT in the sense that one of the aims is to gain positive reinforcement from engaging in activities that are healthy and rewarding. Capital for peer support and groups that are central to the 12 step approach fit well into this.

Penelope Mitchell has written a paper relating to young people in substance misuse treatment and their complex presentations across a range of psychosocial domains including mental health problems. Mitchell argues that there is a need to move away from a rigid manualised “one size fits all” approach to treatment and a movement towards a model of evidence-based practice that allows the clinician to use the approaches more flexibly in order to meet the unique and individual needs of the young person.

Finally we have a really interesting paper from Germany addressing a new form of addictive behaviour – video game dependency (VGD). This is associated with comorbid mental health and social problems. Bleckman and colleagues report on a biographical qualitative study of women with VGD and depression, with two case examples. This study indicates that there may be a common underlying theme of childhood trauma and social isolation. Video-gaming allows the women to connect with people all over the world “virtually” over the internet, thus satisfying a need for social interaction but also reducing the risks of face-to-face contact.

We hope you find this issue interesting and stimulating, and would welcome more submissions in this particular theme. Themes for subsequent issues will include homelessness, safeguarding, physical health and sexual risks and blood borne virus infections.