National Amphetamine-Type Stimulant Strategy Background Paper: Monograph Series No. 69
5.8 Managing co-occurring mental health and amphetamine-type stimulant problems
- Acknowledgements
- Abbreviations
- List of Tables
- List of Figures
Chapter 1: Introduction- Chapter 2 Setting the Context
- Chapter 3: Effects of Amphetamine-Type Stimulants
- Chapter 4: Prevention and Harm Reduction
Chapter 5: Treatment and Service Provision- 5.1 Amphetamine-type stimulant treatment presentations
- 5.2 Initial engagement
- 5.3 Treatment access and retention
- 5.4 Withdrawal management
- 5.5 Psychosocial interventions
- 5.6 Pharmacotherapy
- 5.7 Other interventions
- 5.8 Managing co-occurring mental health and amphetamine-type stimulant problems
- 5.9 Workforce development
- 5.10 Summary
- Chapter 6: Law Enforcement
- Appendix 1
- Appendix 2
Consideration of the co-occurrence of ATS use and mental health problems, as outlined in Chapter 3, has many implications for treatment. Differential diagnosis depends on the temporal and possible causal relationship between the issues and can be challenging for clinicians (Baker & Dawe, 2005). It is often easier to create the categories than it is to accurately identify the temporal relationship. ATS use may contribute to the development of mental health problems, or be a means of managing a pre-existing psychological difficulty,09 or the two problems may have common underlying causes. Thus, people can experience both drug-induced and drug-independent psychological issues (Bakken, Landheim &
Vaglum, 2003).
It is worth considering some of the co-existing mental health problems. Amphetamine users have higher rates of affective disorders such as anxiety and depression, psychosis, self-mutilation and self-harm, paranoia, hostility, agitation and aggression (Baker, Lee & Jenner 2004). To illustrate, Hall and colleagues (1996) interviewed a sample of 301 regular amphetamine users about their experiences of psychological symptoms prior to, and subsequent to, initiation of amphetamine use. Psychological morbidity was implicated in 44% of the sample according to scores on the General Health Questionnaire. The most commonly reported symptoms were depression (79%), anxiety (76%) and paranoia (52%), with all these symptoms increasing in prevalence after the onset of amphetamine use.
In their review of the literature, Baker and Dawe (2005) identified only a small number of studies that investigated co-occurring psychological problems among amphetamine users. The research to date suggested that anxiety disorders were more likely to follow the onset of amphetamine use than to precede it, but the evidence was less clear in regards to the temporal sequence of depressive symptoms. Again they found that depression and anxiety are the most common co-occurring psychological problems found in amphetamine users (Baker & Dawe, 2005). Determination as to whether these conditions are distinct from ATS use is complicated by the frequent presence of agitation and anxiety during amphetamine intoxication, and low mood, sleep difficulties and psychomotor retardation during amphetamine withdrawal (American Psychiatric Association, 2000). Dawe and McKetin (2004) suggested that diagnosis of amphetamine-induced anxiety disorder or amphetamineinduced affective disorder involves identification of the occurrence of symptoms following a substantial period of amphetamine use and remittance after 2 weeks.
Dyer and Cruickshank (2005) conducted a series of studies investigating the prevalence of depression and other psychological problems among patients receiving treatment for methamphetamine dependence. A study of individuals entering the inpatient treatment unit found that 46% had been previously diagnosed with an Axis I disorder, with depression diagnosed in 35% of patients. A second study administering the Beck Depression Inventory-II found that the average score for methamphetamine dependent patients was in the moderate range of depression and similar to that of psychiatric outpatients with clinical depression.
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More recently, Gonsalves and colleagues (2007) collected data from a Midwestern dual diagnosis substance abuse facility in the United States to determine if predictors of methamphetamine use could be identified. The total sample of 281 admissions included 93 participants who met criteria for methamphetamine abuse or dependence and were only using methamphetamine. Of these participants, 18% had a diagnosed anxiety disorder, 12% a depressive disorder and 6.5% a psychotic disorder. Fourteen possible predictors were analysed and nine were found to be significant associated with primary methamphetamine use: gender, age, race, legal status, anxiety diagnosis, previous treatment, emotional abuse, level of care and program completion.
Given the prevalence of a range of co-occurring psychological problems, there is a need for clinical staff to be adequately trained and skilled to manage such presentations. The need to develop the capacity of the workforce in this regard was noted in the written submission received from NDARC: Both paranoia and other psychiatric conditions (e.g., depression, personality disorders) are common among dependent methamphetamine users seeking drug treatment. High levels of depression impede positive drug treatment outcomes, while agitation and paranoia can impede treatment progress. Continued training of health workers in the accurate assessment and diagnosis of such comorbidity among methamphetamine users attending treatment is essential. Likewise, the provision of an integrated model of care, addressing mental health and substance use issues, is critical to ensure adequate care for dependent methamphetamine users.
A number of researchers have found that integrating treatment for mental health and drug problems has better outcomes than more disaggregated approaches (e.g., see Barrowclough et al., 2001). In a recent review McKetin (2004) suggested the principles described in Teesson and Burns (2001) be used to integrate treatment provision. These included the need for treatment services to respond to diverse co-morbid conditions, the need to build more effective strategies to engage and retain people in treatment, and the need to adequately resource services (mental health and drug specialist) to work effectively in case management, referral, liaison and collaboration. However, McKetin (2004) also noted:
- …there is a paucity of research on the effectiveness of diagnosing and treating comorbid conditions among psychostimulant users and … Consequently it is not possible to recommend any specific interventions for comorbid conditions at this point, although a general recommendation would be to encourage diagnosis and integrated treatment of comorbid conditions among psychostimulant users (p.168).
The Victorian Government recently released the Dual Diagnosis: Key Directions and Priorities for Service Development. This policy is designed to improve Alcohol and Other Drug (AOD) and Mental Health Services recognition of and effective responses to cooccurring substance use and mental health disorders. The policy is based on outcomes from the Dual Diagnosis Forum that brought together specialist mental health and drug and alcohol service providers and stakeholders, consumers and carers. The policy incorporates the following key issues: dual diagnosis and assessment is a ‘core business’ within specialist mental health and drug and alcohol services; relationships need to be systematically developed within and across sectors to improve outcomes; and, a ‘no wrong door’ service system be developed for consumers with co-occurring disorders.
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Projects currently underway in Australia to address issues of comorbidity include:
- Trials of stepped care approach and computer-based CBT for ATS users with co-morbid depression currently being conducted in Newcastle;
- NSW Health has planned new initiatives that include funding to address issues of comorbidity. It aims for better integration of mental health services with drug and alcohol services and trialling new interventions, including a trial of methamphetamine treatments;
- Queensland Health’s Mental Health Services has funded 13 new dual diagnosis positions to increase the capacity of both mental health and alcohol and drug services to respond to people with dual diagnosis; and
- A trial of an integrated intervention for methamphetamine users with symptoms of depression is being conducted by researchers at Turning Point, University of Newcastle, National Drug Research Institute (NDRI) and NDARC.
