Integrated Treatment of Dual Diagnosis

This assignment delves into the complex field of integrated treatment for individuals with co-occurring mental health disorders and substance use disorders (dual diagnosis). It examines various psychosocial therapies, including motivational interviewing, cognitive-behavioral therapy, and exposure-based treatments, highlighting their effectiveness in addressing both conditions simultaneously. The assignment also discusses the challenges of stigma and the importance of comprehensive care models that consider the interplay between mental health, substance abuse, and social determinants of well-being.

Running head: LITERATURE REVIEW
Literature Review
Name of the Student
Name of the University
Author note

1LITERATURE REVIEW
Introduction
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.
Literature Review
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

2LITERATURE REVIEW
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.

3LITERATURE REVIEW
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

4LITERATURE REVIEW
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.

5LITERATURE REVIEW
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.

6LITERATURE REVIEW
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.
Barriers of treating patients with both psychological illness and substance abuse disorder
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.

7LITERATURE REVIEW
Discussion
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

8LITERATURE REVIEW
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.

9LITERATURE REVIEW
Reference List:
Barriers to Providing Mental Health Medication to the Homeless Mentally Ill Population. (2016).
11th ed. [ebook] Available at:
http://file:///C:/Users/LAPTOP_MP168/Downloads/SunsetItem11Report.pdf [Accessed 6 Jan.
2018].
Barrowclough, C., Haddock, G., Wykes, T., Beardmore, R., Conrod, P., Craig, T., Davies, L.,
Dunn, G., Eisner, E., Lewis, S. and Moring, J., 2010. Integrated motivational interviewing and
cognitive behavioural therapy for people with psychosis and comorbid substance misuse:
randomised controlled trial. BMJ, 341, p.c6325.
Green, C.A., Yarborough, M.T., Polen, M.R., Janoff, S.L. and Yarborough, B.J.H., 2015. Dual
recovery among people with serious mental illnesses and substance problems: a qualitative
analysis. Journal of dual diagnosis, 11(1), pp.33-41.
Hesse, M., 2009. Integrated psychological treatment for substance use and co-morbid anxiety or
depression vs. treatment for substance use alone. A systematic review of the published
literature. BMC psychiatry, 9(1), p.6.
Hien, D.A., Jiang, H., Campbell, A.N., Hu, M.C., Miele, G.M., Cohen, L.R., Brigham, G.S.,
Capstick, C., Kulaga, A., Robinson, J. and Suarez-Morales, L., 2009. Do treatment
improvements in PTSD severity affect substance use outcomes? A secondary analysis from a
randomized clinical trial in NIDA's Clinical Trials Network. American Journal of
Psychiatry, 167(1), pp.95-101.
Horsfall, J., Cleary, M., Hunt, G.E. and Walter, G., 2009. Psychosocial treatments for people
with co-occurring severe mental illnesses and substance use disorders (dual diagnosis): A review
of empirical evidence. Harvard review of psychiatry, 17(1), pp.24-34.
Jones, S.H., Barrowclough, C., Allott, R., Day, C., Earnshaw, P. and Wilson, I., 2011. Integrated
motivational interviewing and cognitive–behavioural therapy for bipolar disorder with comorbid
substance use. Clinical psychology & psychotherapy, 18(5), pp.426-437.

10LITERATURE REVIEW
Kelly, T.M. and Daley, D.C., 2013. Integrated treatment of substance use and psychiatric
disorders. Social work in public health, 28(3-4), pp.388-406.
McFarling, L., D'angelo, M., Drain, M., Gibbs, D.A. and Rae Olmsted, K.L., 2011. Stigma as a
barrier to substance abuse and mental health treatment. Military Psychology, 23(1), p.1.
Mills, K.L., Teesson, M., Back, S.E., Brady, K.T., Baker, A.L., Hopwood, S., Sannibale, C.,
Barrett, E.L., Merz, S., Rosenfeld, J. and Ewer, P.L., 2012. Integrated exposure-based therapy
for co-occurring posttraumatic stress disorder and substance dependence: a randomized
controlled trial. Jama, 308(7), pp.690-699.
Mueser, K.T. and Gingerich, S., 2013. Treatment of co-occurring psychotic and substance use
disorders. Social work in public health, 28(3-4), pp.424-439.
Najavits, L.M. and Hien, D., 2013. Helping vulnerable populations: A comprehensive review of
the treatment outcome literature on substance use disorder and PTSD. Journal of clinical
psychology, 69(5), pp.433-479.
Sacks, S., Chaple, M., Sirikantraporn, J., Sacks, J.Y., Knickman, J. and Martinez, J., 2013.
Improving the capability to provide integrated mental health and substance abuse services in a
state system of outpatient care. Journal of Substance Abuse Treatment, 44(5), pp.488-493.
Sterling, S., Chi, F. and Hinman, A., 2011. Integrating care for people with co-occurring alcohol
and other drug, medical, and mental health conditions. Alcohol Research & Health, 33(4), p.338.
Torchalla, I., Nosen, L., Rostam, H. and Allen, P., 2012. Integrated treatment programs for
individuals with concurrent substance use disorders and trauma experiences: A systematic
review and meta-analysis. Journal of substance abuse treatment, 42(1), pp.65-77.
Wolff, N., Frueh, B.C., Shi, J. and Schumann, B.E., 2012. Effectiveness of cognitive–behavioral
trauma treatment for incarcerated women with mental illnesses and substance abuse
disorders. Journal of anxiety disorders, 26(7), pp.703-710.