Fraser Todd

Barriers to optimal care for patients with coexisting substance use and mental health disorders.

Objective: This paper describes qualitative research that was carried out as part of a project aimed at drawing up a series of guidelines for the assessment and management for people with coexisting substance use and mental health disorders, or dual diagnosis [1]. Method: A core consultation team of 14 experts with experience in the areas of both substance use and mental health in New Zealand was established to advise on the development of eight clinical scenarios. The clinical scenarios were selected to highlight a range of real life issues in the treatment of people with coexisting substance use and mental health disorders and were presented at 12 focus groups around New Zealand. The 261 participants of the focus groups were asked to comment on what was optimal management for each of the scenarios and to identify barriers to optimal care in their region. Written notes were analysed for recurring and strongly stated themes and these comprise the results of the study. Results: While there was marked regional variation in treatment approaches and service structures, many of the barriers to optimal care that were identified were common to all regions. The results are considered under the headings of systems issues, clinical issues and attitudes. Conclusions: A wide variety of barriers that impede the delivery of optimal care have been identified. These range from the attitudes of individual clinicians to the structure of the systems within which they work. A system of key principles and processes for organizing treatment in a way which helps overcome these barriers is proposed.

Drug use and Addiction: Evolutionary Perspective

Drug use creates a significant amount of harm in modern societies. From an evolutionary perspective, the pervasive use of drugs and the ongoing risk of drug addiction can be explained in terms of the action of drugs on evolved motivational–emotional systems. Addiction arises through interaction of these evolutionarily ancient systems, designed to promote the pursuit of natural rewards, and contemporary environments where purified and potent forms of drugs are readily available. This evolutionary analysis is extended to account for developmental patterns in problem drug use, and to explain the existence of behavioural addictions, such as problem gambling. The paper concludes by considering some of the clinical and public policy implications of the evolutionary perspective presented.

DSM-5 alcoholism: A 60-year perspective

Alcohol continues to be the western world’s favourite recreational drug, use of which induces a compelling state of anxiolytic euphoria for several hours in most people. Overuse of alcohol is associated with a range of negative health and social consequences. These consequences relate to both the highly intoxicating and aggressogenic nature of alcohol in the short-term (Parrott and Zeichner, 2002), and toxicity from chronic overuse, with about half of alcohol deaths due to acute effects and the other half chronic illness (Connor et al., 2005), including cancers, which account for at least 25% of all alcohol-related deaths. Alcoholism has been the most commonly used term to describe the behavioural pattern of alcohol overuse in clinical practice. We use the term ‘alcoholism’ here to encompass the series of changes in formal diagnostic systems over the past 60 years since the publication of the Diagnostic and Statistical Manual of Mental Disorders, First Edition (DSM-I) in 1952. From DSM-I to DSM-IV there have been two main shifts in diagnostic conception of alcoholism (Sellman, 1994); DSM-5 represents a third, which is a return to the 1960s unitary formulation of alcoholism (Figure 1).

CLINICIAN BELIEFS AND PRACTICES RELATED TO INCREASING RESPONSIVITY TO THE NEEDS OF MAORI WITH ALCOHOL AND DRUG PROBLEMS

Culturally responsive treatments are often cited as essential for successfully addressing substance use-associated problems in indigenous and other ethnicgroups. However, there has been little investigation of the support for this assertion among alcohol and drug-user treatment workers, or how it might translate into clinical practice. The current paper reports on the results of a survey of the New Zealand alcohol and drug-user treatment field, which canvassed these issues. Eighty-six percent of respondents advocated adjustment of clinical practice when working with Maori. Two key strategies were referral to specialist Maori groups or individuals and/or contacting/meeting with whanau (family). Comparisons were made between respondents who referred clients on and those who provided intervention themselves. Implications of results, limitations and future research are discussed.