Epidemiological Complexity in Dual Diagnosis Treatment

Dual diagnosis involves individuals suffering from comorbid substance abuse or dependence and psychotic, behavioural, affective or severe personality disorder (Lehman, 1996). Treatment for double disorders poses a treatment challenge (Levy, 1993). Ahmed suffers from a dual problem, substance abuse (smoking cannabis) and hearing voices, also termed ‘auditory verbal hallucination’ (McCarthy-Jones, 2012). Ahmed will be medically termed as a dual client, who will ‘doubly’ deny their problems and will, therefore, be difficult to enlist (Evans & Sullivan, 2012). In that context, the current analysis will explore the epidemiological issues with regard to treatment of Ahmed’s conditions.

Ahmed case will involve treatment of psychiatric and chemical dependency disorders. In this regard, it must be noted that cannabis with the main component, called A9-THC causes majority of psychotomimetic effects, such as increased anxiety and psychotic symptoms (Morgan & Curran, 2008). A study that used hair analytic techniques found individuals with A9-THC experience higher unusual experiences such as halucinations and delusions (Morgan & Curran, 2008). Ahmed’s case may fall under this category where his abuse of cannabis may be causing his auditory verbal hallucination.

A dual diagnosis of Ahmed will involve separate programmes and staff (Evans & Sullivan, 2012). There will be a psychiatric consultant and a substance expert. This will create potential problem where experts and consultants involved are not cross-trained. Ahmed may be subject to a treatment system not integrated to attend to specific categories of patients. Such treatment will follow different philosophies and sets of appointments that may leave Ahmed confused about the treatment (Evans & Sullivan, 2012).

The relationship between the use of cannabis and auditory verbal hallucination may be a complex issue. Henquet and colleagues (2010) found that the use of cannabis use was significantly associated with subsequent increases of hallucinations. They found the cannabis effects in patients associated with auditory hallucinations. The daily use of cannabis was found linked with subsequent increases in hallucinatory experiences, particularly auditory hallucinations. Patients with a psychotic disorder are more sensitive to hallucinogenic effects of cannabis than those with healthy controls (Henquet, et al., 2010). This is also suggested in secondary substance use disorder models that the patients’ biological vulnerability of psychiatric disorders can bring sensitivity to even a small amount of drugs leading to substance use disorders (Mueser, et al., 1998).

Patients with a psychotic disorder can be more sensitive to psychosis-inducing cannabis effects than healthy controls (Os, et al., 2002; D'Souza, et al., 2005). Ahmed may have a psychotic disorder making his sensitive to cannabis effects and exposed to auditory hallucinations that he is going through. This should be made known to Ahmed as he uses cannabis to self-medicate the symptoms and or/ the effects of medications. The Secondary Mental Illness Models suggest that substance use brings or causes mental illness (Rosenberg & Rosenberg, 2017). This model when applied to the association of cannabis effect and auditory hallucinations may present a complex area of diagnosis. Identifying and implementing management of dual disorders is important in case of relapses, poor treatment engagement or unsatisfactory treatment outcomes (Saddichha, et al., 2015). Ahmed’s mental health issues must be assessed as to whether they are associated with his use of cannabis. Illicit substances foreign to a person body when injected could alter neurotransmission. The persistent and dangerous use of such substances can lead to structural and functional changes in the brain (Leede-Smith & Barkus, 2013). However, research says otherwise that this only happens where there is an existing mental illness or a family history of illness. In all likelihood, heavy substance use may bring early onset and increased psychotic disorder (Rosenberg & Rosenberg, 2017).

While assessing whether or early psychotic experiences may prompt cannabis use as a means of self-medication, it was found that there was no effect of self-medication. Pre-existing psychotic symptoms do not significantly predict later cannabis use (Kuepper, et al., 2011). Research do not support self-medication models. However, in presence of accumulated multiple mental risk factors, risk of substance use disorder may increase (Mueser, et al., 1998). The use of such illicit substance, including cannabis, predates the onset of psychotic symptomatology, such as auditory verbal hallucinations. Such psychotic symptoms are reported in more than half a sample of cannabis substance abusers (Matthew J., et al., 2009). Further, the severity of such symptoms is related to the rate of substance use (Thirthalli & Benegal, 2006).

The above observation when read with that of Henquet and colleagues (2010) could mean two things in regard to Ahmed’s case. First, Ahmed has already had a psychotic disorder even he started smoking cannabis and that smoking cannabis has increased his auditory verbal hallucinations problems. Second, Ahmed started smoking cannabis and that has resulted to an onset of psychotic symptomatology, such as auditory verbal hallucinations. There could be a few ways of seeing his problem. One is he started smoking cannabis that causes the onset of auditory verbal hallucinations. Second is he already has psychotic issue and smoking cannabis made it worse. In regard to the second way, it could be that the cannabis he is smoking has A9-THC as the main component, and as Morgan and Curran (2098) observed, he is experiencing hallucinations as effects of cannabis abuse.

A basic assessment process covering the mental health and substance abuse diagnosis related to Ahmed will cover information necessary for treatment and its plan. Such process will provide for basic demographic and historical information of Ahmed; identify his diagnosis and impairments; identify strengths and problem areas related with his problem; and establish the stage of treatment for his mental health and substance abuse problems (Center for Substance Abuse Treatment , 2005). Three processes can be prescribed for Ahmed’s diagnosis. Firstly, it must be assessed whether or not Ahmed has an established diagnosis or been receiving an ongoing treatment. Ahmed’s case shows auditory verbal hallucinations but is not clear as to the diagnosis or treatment. This requires gathering information from collaterals. Ahmed has both cannabis abuse problem and auditory verbal hallucinations, and so this must be presumed to be valid for initial treatment planning. If there is any existing stabilizing treatment, it should be maintained. It is advisable to understand Ahmed’s history to gain more insight and knowledge about Ahmed (Center for Substance Abuse Treatment , 2005).

Substance-related syndromes is one of the reasons for a patient to complaint of hearing voices. This is the case in regard to Ahmed. However, Ahmed may also know that such hallucination is not real. Undergoing this problem may make his say things that are distressing or attacking. This will normally happen if Ahmed has a trauma history (Center for Substance Abuse Treatment , 2005). Thus, in case of co-occurring disorders, such as Ahmed’s, most of the causes are independent of substance use. It is necessary to gather information regarding prior and current diagnoses in context to mental health assessment. This will help connect past and present symptoms and particularly, symptoms with key time periods. For example, such assessment can link Ahmed’s auditory verbal hallucinations with time when he took or abstained from cannabis smoking. This approach may yield reliable information in determining whether cannabis smoking is causing or increasing his hallucination, or his hallucination is independent of his substance abuse problem (Center for Substance Abuse Treatment , 2005).

Experience of auditory verbal hallucinations are normally vivid, isolated and associated with the thought. This is a state of paranoia, where in Ahmed case, he feels that everyone is against him, and that in the past he had carried a knife for his protection (Roncero, et al., 2012). In relevance, using the Common factor models, an attempt could be made to assess whether Ahmed’s mental health and substance use disorders are caused by genetic vulnerability, or social environment or family situation (Rosenberg & Rosenberg, 2017). At the same time though, studies have also shown that there is no: i) relation between share genetic disorders and patients with substance use disorders and mental health, or ii) definitive explanation between social environment and such patients (Rosenberg & Rosenberg, 2017). Auditory hallucination can produce distress and disturbances, just like as is happening with Ahmed (Smith, et al., 2003). It requires a careful questioning to assess his strengths of belief and degree of preoccupation with the belief that everyone is against him and that he may be under a threat of being attack (Smith, et al., 2003).

In specific relevance to Ahmed’s case, it must also be assessed as to whether or not whether his problem of auditory verbal hallucination confers the risk for psychosis. Auditory hallucinations are not indicative of psychosis continuum. Biological factors including prenatal and perinatal complications and delayed developmental milestones are found associated with subsequent psychosis development (Stan, et al., 2009; Murray, et al., 2004). Also, childhood auditory hallucination is found be to develop into psychosis and is also founds to be associated with depression and anxiety (Santomi, et al., 2000; Lydia, et al., 2005). Assessing Ahmed’s condition will consider whether he has biological factors or childhood auditory hallucination in order to determine the risk of developing psychosis. Evans and Sullivan (2012) earlier recognised that a dual client ‘doubly’ denies their problems. Hence, the approach of abstinence will not work with such dual clients. It is rather suggested to tolerate a patient continued substance use and simultaneously focus on their treatment (Levy, 1993).

Cognitive behavioural therapy can be used to treat cannabis dependency (The European Monitoring Centre for Drugs and Drug Addiction, 2010). This therapy has resulted in modest rates of abstinence, for example over 15 % of participants in a study found continuous abstinence at a six-month follow-ups and substantial reduction in cannabis use and cannabis-related problems (Denis, et al., 2006; Roffman & Stephens, 2006). The effectiveness of this therapy is found against medication resistant problems, including hallucination and delusional belief. This therapy has cognitive and behavioural elements, which reduce patients’ conviction in their delusional beliefs (Center for Substance Abuse Treatment , 2005). It is necessary to understand specific diagnosis and particularly the stage of change. This is necessary to match intervention with the stage of change. Such interventions must be consistent with the stage of treatment for each disorder, which is cannabis dependency and auditory hallucinations in the Ahmed’s case (Center for Substance Abuse Treatment , 2005). It must assess the functional capability of Ahmed to determine his current level of impairment keeping determining periods of extended abstinence of cannabis, and his mental health stability. It must focus on strengths, skills and other supports of Ahmed regarding his general life functioning and his ability to manage his disorders. This will drive a positive treatment engagement beyond the deficits or areas to be corrected. (Center for Substance Abuse Treatment , 2005).

The recognition of strengths and skills and the functional management capabilities of Ahmed will consider other aspects of intervention. The Individualized Placement and Support model of psychiatric rehabilitation will promote better vocational outcomes for Ahmed and a positive substance abuse outcomes (Becker, et al., 2001). Ahmed, if he wants to work, can be placed in sheltered work activities depending on his strengths and preferences. This intervention can be executed even if he is actively using substances and not consistent with his medication regimens. Such an ongoing job will instil in Ahmed self-esteem and drive motivation to address his mental disorders and substance issues (Center for Substance Abuse Treatment , 2005).

The Care Act 2014 provides for duties of the local authorities to promote an integrated care and support with health services (S3). Section 9 – 13 provides for assessing needs for care and support and determining eligibility of needs. Care plan for Ahmed can be formulated around what the Public Health England and NICE guidance on dual diagnosis provides (Alcohol Policy UK, 2017; Public Health England, 2017). Local authority services must be contacted. Ahmed must be referred to secondary care mental health services. This care plan will be a multi-agency approach addressing his physical health, housing, social care, and other needs. Specialised services must be involved due to his dual diagnosis. A core coordinator must be assigned to coordinate agencies and specialists involved. A 24 hour support must be given access to Ahmed so that he can get ongoing support. The care and support must have strong focus on therapeutic approaches. Regular advice on abstinence must be provided. The entire approach is based on Care Programme Approach with coordinative care and support and Ahmed having access to an integrate care. This approach along with the intervention methods provided above will prove useful for Ahmed (Alcohol Policy UK, 2017; Public Health England, 2017). Such a care plan approach is also supported by the 2012 Health and Social Care Act, which focuses on quality of care and outcomes for patients based on a patient-centred and facilitates choice (Glover-Thomas, 2013 ).

To conclude, double disorders present double difficulties to address. Treatment and care are subject to properly determining Ahmed history and conditions so as to go beyond the apparent problem of cannabis smoking and auditory verbal hallucinations. Even if the cause of his auditory verbal hallucinations is independent of cannabis smoking, his substance abuse problem may also be associated with increasing his hallucinations. Thus, it is important that he is given an integrated care and treatment that could properly identify any earlier or current diagnosis before his substance abuse to identify the stage for introduction of proper treatment. The integrated approach must ensure a combination of treatment and recovery with focus on his abilities and skills. It must focus on therapeutic and care techniques that are patient-centred and facilitate Ahmed’s choice.

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