In this study we investigated the treatment of patients with SUD in Community Mental Health Centres (CMHCs) which typically treat patients with non-psychotic disorders such as anxiety disorders, non-psychotic affective disorders, adjustment difficulties and personality problems. The main findings are that, also in outpatient settings, the SUD group differs from the No SUD group in several ways not often systematically met with adequate treatment approaches.
Our first findings are that the patients in the SUD group are more often male, less often in a relationship and more often living alone. This is largely consistent with other epidemiological and clinical studies [4
], except for one study where only the gender difference was found [29
]. These findings indicate that people with SUD are a more vulnerable group. Consequently, therapists should plan treatment accordingly.
The second finding is that the SUD group has more severe morbidity as measured by the HoNOS with higher scores on five out of eleven parameters when adjusted for age, gender
and in relationship
. This means that the SUD group has more problems with aggressive behaviour, self harm, relationships, occupation and activities of daily living. It is therefore essential that these problems are targeted in their treatment plan. We found one other study targeting CMHCs with comparable measures [30
]. In this study of patients with schizophrenia in inpatient and outpatient clinics, the misuse group was found to have higher sum scores on the HoNOS compared to the non-misuse group. In addition, Fowler et al found higher mean scores on the Symptom Check List-90 revised (SCL-90R) [31
] on all sub-scores amongst the SUD group compared to the No SUD group amongst patients with schizophrenia [34
The third finding is that the SUD patients have lower prevalences of anxiety and depression compared to patients without SUD. This finding is in contrast to most studies in the field indicating a higher prevalence of most comorbid disorders in SUD patients[1
]. However, Bonsack et al found a similar pattern for anxiety and depression amongst patients in an acute psychiatric ward, but with higher prevalences for other psychiatric diagnoses amongst the SUD group compared to the No SUD group [28
]. Our finding could have several explanations. Firstly, the different CMHCs may have recruited different numbers of SUD and No SUD patients due to different catchment areas. Secondly, it could be a case of competing risks; patients with SUD need less other morbidity for referral to CMHCs; thus not reflecting the comorbidity in the general population. Thirdly, less severe mental illnesses, like anxiety and depression, with comorbid SUD may be more often referred to substance use treatment centres. This could be detrimental to outcome, as patients treated in substance abuse treatment facilities may not receive adequate attention for their comorbid psychiatric illness. Bakken et al did a six year follow-up study of substance abusers in inpatient and outpatient addiction treatment facilities. They found that the number and specific types of axis 1 and axis 2 disorders with the level of SUD at admission were all independent predictors of a high level of mental distress at follow-up [37
]. This underlines the need for good diagnostic and screening routines along with the competence to treat this comorbidity in an integrated treatment program.
The fourth and important finding is that patients with SUD in these CMHCs are treated differently. The patients in the SUD group receive less outpatient treatment compared to the No SUD group. In addition, the clinicians rate the patients in the SUD group as being treated at too low a competency level. One possible explanation might be that the therapists feel they lack the competence or the resources to treat these patients in an outpatient setting. In a phenomenological study of clinicians in mental health centres Deans et al found that the clinicians felt unprepared and that they were lacking knowledge of dual diagnosis patients [38
]. This is in accordance with other studies that describe difficulties in implementing new knowledge and guidelines regarding comorbid patients in mental health care [39
]. This highlights the need for establishing and implementing good treatment strategies for this group of patients.
Our final finding is that the patients in the SUD group have poorer outcomes in regard to recovery from psychological problems. In addition, they have poorer outcomes on three out of the remaining six items at a borderline significant level after adjustment for other variables. This is in accordance with previous findings of poorer treatment outcomes for patients with co-occurring disorders [41
] and is in line with the other findings of this paper, that is, that these patients have greater morbidity and receive less adequate help for their problems.
There are several limitations to this study. This study is part of an evaluation of the National Plan for Mental Health that was adapted to the study aims, the prevalence of SUD was measured by a composite adapted approach, and there was no structured clinical interview used to assess diagnoses. Further, the variables regarding the level of improvement from psychiatric symptoms were based on the clinicians' subjective evaluation of the patients' improvement, regardless if the clinician knew the patient for a longer or shorter period of time. Prior to the surveys in 2002 and 2005 the clinicians were trained in using the HoNOS, the AUS and the DUS while they only had optional training on case vignettes prior to the survey in 2007. However, comparing the results from 2007 with the results from 2002 in regard to the prevalence of SUD measured on the ICD-10 F10-19 diagnoses, the HoNOS, the AUS and the DUS, we found no significant differences [15
]. For further studies we would recommend to include screening procedures for SUD, i.e. the Alcohol Use Identification Test (AUDIT) [42
] and the Drug Use Identification Test (DUDIT) [43
], and valid diagnostic procedures, such as the Structured Clinical Interview for DSM-IV (SCID) [44
] or the Psychiatric Research Interview for Severe Mental disorders (PRISM) [45
]. One might also include measures like the HoNOS, the Symptom Check List (SCL-90R) or the Addiction Severity Index (ASI) [46
] to enable basic comparisons between studies. Finally, the representativeness of outpatient clinics in Norway might be questioned, both according to the prevalence and type of substance use in the catchment areas and the clinical routines in the units. It is obviously important to confirm these findings in further studies. However, the findings underline the need for targeted treatment approaches for patients comorbid with SUD in psychiatric outpatient units.