Integrated Treatment for Substance Use and Depression
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Mental Health: Simone Case Scenario
Dual diagnosis, co morbidity and co-occurring disorders are terms often used interchangeably to describe mental ill health and substance abuse (drugs and/or alcohol) in various combinations. These disorders may occur at the same time or one may follow the other. Even though the diseases of mental illness and drug abuse are comorbid, causality is not implied and either condition may precede the other (Fortinash and Holoday Worret, 2012). The symptoms of one condition may mask or conceal the symptoms of the other, with either condition assuming priority at any given time.
Alcohol is the most widely used drug. The National Institute for Clinical Excellence (NICE) estimated in 2011 over 24% of people in England consume alcohol levels that are potentially or actually detrimental to health. The co morbidity of depression and alcohol dependence are two of the most prevalent psychiatric disorders affecting the general population. Evidence suggests that alcohol use disorders are linked to depressive symptoms and that alcohol dependence and depressive disorders co-occur to a larger degree than expected by chance. However, it is not clear whether the depression causes alcohol problems, whether the alcohol consumption or alcohol problems caused depression, or whether both could be attributed to a third cause (Royal College of Psychiatrists, 2015).
This assignment will consider the case scenario of Simone part time social worker, aged 43 with depression and alcohol abuse. Simone lives with her three children and the intervention of choice is Cognitive Behavioural Therapy (CBT). This section will define CBT and its uses and adopt the Critical Appraisal Skills Programme (CASP) toolkit (2013) to critically evaluate and discuss two CBT research articles in treating depression and alcohol abuse to evidence why this is an appropriate intervention for Simone.
CBT is defined as 'a talking therapy that can help individuals manage their problems by changing the way they think and behave' (Frances and Robson, 1997). Commonly used to treat a range of mental health issues including depression, anxiety disorders, phobias, but also deemed valuable in treating alcohol misuse, especially as part of an overall programme of recovery. The goal of cognitive behavioural therapy is to teach the person to become aware of incidences and situations which trigger the need to drink, to learn to avoid putting themselves in these situations and to develop coping strategies to deal with other problems and behaviours which may lead to drinking. Until recently the effectiveness of CBT for comorbid alcohol had not been studied, however, the first of two research articles will now be critically evaluated and discussed below.
Developing an Integrated Treatment for Substance Use and Depression Using Cognitive Behavioural Therapy (Osilla et al, 2009) is an American qualitative research article. The research goal was to design and develop a treatment programme for delivery by substance abuse counsellors in outpatient mental health settings. This was thought to be important because earlier research had indicated the effectiveness of CBT in depression and alcoholism separately. The research developed a group based integrated 18 session treatment plan involving 3 modules (thoughts, activities and people interactions) linking mood and alcohol use and provided strategies for identifying and modifying harmful thoughts and activities. Drawing on previous studies (Hepner, Watkins, Woo and Wiseman, 2006) they involved a treatment development team including researchers, clinicians, stakeholders and CBT experts. Recruited participants (N=7; 4 male, 3 female) were already enrolled in outpatient substance misuse treatment who had met the criteria for mild depression using the 9 item Patient Health Questionnaire with scores of 5 or > (no indication given whether other people had chosen not to take part as this sample is small). Client focus groups were conducted following the group treatment sessions led by two clinical psychologists who had observed the group sessions from behind a one way mirror, thus the methodology used is entirely appropriate for addressing the research goal. The article states that the clients provided informed consent but there is no information regarding how the research was explained to participants, whether ethical approval was sought or whether ethical standards were maintained. The data analyses consisted of the researchers reviewing notes and transcripts independently from the client focus groups to select, group and label salient issues that point to the acceptability of integrated CBT. Notable points with similar concepts were categorised if different participants had said the same things on a number of occasions over a given time frame e.g. comments which stated that alcohol and mood influenced each other. Underlying themes were generated from the data and quotes were analysed and identified that fitted each of the relevant themes. Each researcher independently sorted quotes by theme and together they reached a consensus on any discrepancies.
Findings indicated that treatment was widely accepted by clients and counsellors. Clients stated that applying CBT skills help to treat both their depression and alcohol misuse whilst positively affecting other areas in their lives. Clients felt the treatment had built their confidence and the group process was helpful in learning from each other. The article produced no evidence of triangulation but stated that there were limitations to the study that affect the generalization of the results. The study evaluated a single case implementation, so future studies would be necessary to examine client views in several clinics over time with different treatment sessions in order to judge whether integrated treatment is truly acceptable and feasible given funding constraints. Clearly, integrated CBT for depression and alcohol misuse evaluated as being useful and beneficial but the research concluded that there is a need to develop more web based training or other innovative ways that effectively train substance abuse counsellors to a reasonable standard with minimal costs to provide a unified CBT approach to manage comorbid depression and alcohol misuse.
A Randomized Controlled Trial of Cognitive Behavioural Treatment for Depression versus Relaxation Training for Alcohol – Dependent Individuals with Elevated Depressive Symptoms (Brown et al, 2011). The goal of this Rhode Island trial was to evaluate the efficacy of adding CBT versus relaxing training to partial hospital treatment for individuals misusing alcohol with elevated levels of depressive symptoms. This was deemed important because it was expected that the addition of CBT would result in reduced levels of depressive symptoms and in decreased quantity and regularity of alcohol use.166 men and women were recruited (aged 16 - 65 years) from an alcohol and drug treatment unit provided they met the Diagnostic and Statistical Manual of Disorders, Fourth Edition (2000) criteria for alcohol dependence and had a Beck Depression Inventory of 15 or more. Participants were informed about the study, consent was obtained and they were randomly assigned to receive 8 individual sessions of CBT (n = 81) or relaxation training (n = 84). The article didn't mention whether the personnel were blinded. Treatment conditions did not differ on demographics, individual alcohol consumption or depression related variables. Results indicated significant improvement in depressive and alcohol use over time for all participants. Compared with the relaxation training, the CBT group had significantly reduced levels of depressive symptoms at the 6 week follow up as measured by the Beck Depression Inventory. This effect was found to be inconsistent because there was no difference in the Modified Hamilton Rating Scale (MHRD) for Depression between conditions at that point in time or at any subsequent follow up. There was no significant in alcohol use between groups. The researchers were clearly disappointed that this study did not replicate the results of an earlier pilot study in 2007. However, plausible reasons given included the average length of hospital stay had reduced from 21.2 days to 3.9 resulting in treatment sessions being conducted in an outpatient setting making it difficult to compare results. The setting for this study was a private hospital with educated Caucasian patients and caution should be used in generalizing findings to populations with different characteristics. Interview data and treatment adherence had not been subject to reliability ratings. The need for the trial was clearly documented and further studies evaluating the efficacy of CBT in individuals with alcohol misuse and elevated depressive symptoms is required. Overall, the benefits outweighed the harm.
Depressed people with alcohol misuse like Simone have complex needs which pervade every aspect of daily life including psychiatric, psychological, education, employment and social care. Supporting someone with depression and alcohol misuse is one of the biggest challenges facing mental health services (DH, 2006).Traditionally, substance misuse and mental health services developed separately but a national drug and alcohol dependence strategy was published in December 2010 (HMG, 2010), and a mental health strategy a few months later (HMG, 2011). Both strategies acknowledge the association between mental health problems and drug and alcohol problems. Successful outcomes for both problems need early intervention and effective joint working between drug and alcohol treatment and mental health services in integrated, recovery-oriented local systems. Furthermore, a NICE guideline (2011) includes principles of care, identification and assessment in all assessment areas and principles for interventions, underpinned by best available evidence (due for review in 2015).
Regarding impact on future practice, co morbidity requires nurses to adapt multiple roles in order to achieve a comprehensive level of care. A primary diagnosis isn't necessary as both depression and alcohol misuse can be treated simultaneously. A non judgemental, person centred approach recognising that treatment will be long term is required. Good communication skills with multiple professionals and services are essential. Clinical skills include specialist alcohol misuse assessments, mental health and risk assessments, the provision of specialist advice on reduction and harm minimisation, appropriate interventions, treatment advice to other care professionals and the ability to work in a multidisciplinary team. In practice, it is not possible for nurses to be an expert in all of the skills required, however they should have a working knowledge of some. Training is required to deliver comprehensive alcohol programmes through developing skills particularly in cognitive behavioural therapy which seems to produce beneficial effects on both depression and alcohol outcomes.
Brown, A.B., Ramsey, S.E., Kahler, C.W., Palm, K.M., Monti, P.M., Abrams, D., Dubreuli,.M., Gordon,.A. and Miller.I.W. (2011) A Randomized Controlled Trial of Cognitive Behavioural Treatment for Depression versus Relaxation Training for Alcohol – Dependent Individuals with Elevated Depressive Symptoms. Journal of Studies on Alcohol and Drugs 72(2): 286-296
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