Ebook Dual diagnosis nursing: Part 2
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Ebook Dual diagnosis nursing: Part 2
15Dual Diagnosis In Acute In-patient SettingsJ. Gallagher & S.J. ScottIntroductionSubstance misuse in society has reached epidemic proportions and thi Ebook Dual diagnosis nursing: Part 2is increase is inevitably reflected in patients with mental health problems who are admitted to psychiatric wards (Williams & Cohen, 2000). As pointed out by Gafoor & Rassool (1998) the number of individuals who have coexisting substance misuse and psychiatric disorders within the L'K is increasing. Ebook Dual diagnosis nursing: Part 2 Krausz (1996) emphasises this point by stating that:'the coincidence of severe mental illness and addiction is and will be one of the most importantEbook Dual diagnosis nursing: Part 2
clinical challenges in psychiatry in the coming years which will also point to structural weaknesses in the treatment system between psychiatric and a15Dual Diagnosis In Acute In-patient SettingsJ. Gallagher & S.J. ScottIntroductionSubstance misuse in society has reached epidemic proportions and thi Ebook Dual diagnosis nursing: Part 2ngs (Baker, 2000) due to raised bed occupancy (up to 104%) and the changing nature of the patients served. Patients with serious mental illness and those with complex behavioural and social problems, including substance misuse, are now the norm within acute in-patient settings (Sainsbury Centre for Ebook Dual diagnosis nursing: Part 2Mental Health, 1998a). The aims of this chapter are to examine the prevalence of dual diagnosis in in-patient settings and describe theidentificationEbook Dual diagnosis nursing: Part 2
and assessment of substance misuse in acute care settings. Barriers to engagement and treatment are also discussed.In-patient settingsWithin acute in-15Dual Diagnosis In Acute In-patient SettingsJ. Gallagher & S.J. ScottIntroductionSubstance misuse in society has reached epidemic proportions and thi Ebook Dual diagnosis nursing: Part 2 is up to three times that in the average population at roughly 37% (Cantwell Ct al., 1999) and is more prevalent in younger clients (Hambrecht & Hafner, 2000). Cantor-Graae el al. (2001) reported higher lifetime prevalence rates of 40-60%. Due to this high level of co-morbidity between substance mi Ebook Dual diagnosis nursing: Part 2suse and schizophrenia, dual diagnosis is now often considered the norm rather than the exception in acute in-patient settings (Smith & Hucker, 1993).Ebook Dual diagnosis nursing: Part 2
In most studies the prevalence of cannabis use is equivalent to alcohol use at about 30-40%' (Hambrecht & Hafner, 2000) and misuse continues before a15Dual Diagnosis In Acute In-patient SettingsJ. Gallagher & S.J. ScottIntroductionSubstance misuse in society has reached epidemic proportions and thi Ebook Dual diagnosis nursing: Part 2enic male with co-morbid substance misuse, probably cannabis or alcohol.Despite this prototypical group, a heterogeneous group of patients with dual diagnosis emergesDual Diagnosis In Acute In-patient Settings 151from the major national epidemiological studies in Australia (Teesson el al., 2000) and Ebook Dual diagnosis nursing: Part 2 in the USA (Regier Ct al., 1990). Dual diagnosis patients have varied mental health problems (depression, social phobia, schizophrenia, manic depressEbook Dual diagnosis nursing: Part 2
ion and severe anxiety disorders) and misuse a number of substances (including cannabis, alcohol, amphetamines, cocaine and opiates) (Watkins el al., 15Dual Diagnosis In Acute In-patient SettingsJ. Gallagher & S.J. ScottIntroductionSubstance misuse in society has reached epidemic proportions and thi Ebook Dual diagnosis nursing: Part 2ly replicated in the UK it is likely that there is considerable overlap. This heterogeneous presentation makes it necessary to conclude that even with seemingly prototypical patients we must consider each unique patient’s pattern of mental health and substance misuse issues.The patterns of interacti Ebook Dual diagnosis nursing: Part 2on between substance misuse, mental health and social exclusion demonstrate a need for complex theoretical formulations of the individual's problems.Ebook Dual diagnosis nursing: Part 2
As with any other complex client an integrated approach to understanding is necessary (Barker, 1997; Watkins Ct al., 2001). From this position it is t15Dual Diagnosis In Acute In-patient SettingsJ. Gallagher & S.J. ScottIntroductionSubstance misuse in society has reached epidemic proportions and thi Ebook Dual diagnosis nursing: Part 2applying appropriate theory to each individual illness narrative (Barker, 2001) can a clear picture of the interaction of the biological, the personal (psychological) and the social begin to occur and the voyage to recovery commence (Stevenson & Fletcher, 2002). The assessment conducted when working Ebook Dual diagnosis nursing: Part 2 with patients with complex conditions must therefore focus on these issues as well as the tools used. A summary of the relationship between substanceEbook Dual diagnosis nursing: Part 2
misuse and mental health is presented in Table 15.1.Table 15.1 Summary OÍ the relationships between substance misuse and mental health.Stressors + ph15Dual Diagnosis In Acute In-patient SettingsJ. Gallagher & S.J. ScottIntroductionSubstance misuse in society has reached epidemic proportions and thi Ebook Dual diagnosis nursing: Part 2haotic behaviour = exclusion and labelling = hospitalisation + boredom = further substance misuse to relieve boredom and reduce medication side effects = further labelling and increasing exclusion.The problems for acute carePatients with psychosis and substance misuse problems tend to have longer st Ebook Dual diagnosis nursing: Part 2ays in hospital, have more re-admissions and are less likely to be compliant with medication and other treatments. They have increased rates of suicidEbook Dual diagnosis nursing: Part 2
e, HIV and other physical illnesses and have poorer overall social functioning. These findings highlight the need to provide more effective interventi15Dual Diagnosis In Acute In-patient SettingsJ. Gallagher & S.J. ScottIntroductionSubstance misuse in society has reached epidemic proportions and thi Ebook Dual diagnosis nursing: Part 2 el al., 2001).Despite the clear needs, this client group are not treated effectively within any setting. In-patient care focuses on 'diagnosis and control' and in terms of mental illness alone this reduces opportunities to meaningfully engage patients in their own recovery (Sainsbury Centre for Men Ebook Dual diagnosis nursing: Part 2tal Health, 1998a; Kovistocf al., 2003). Rassool (2002) suggests that services, both substance misuse and mental health, at best address the co-morbidEbook Dual diagnosis nursing: Part 2
issues separately (not integrating) and at worst ignore one aspect of the problem totally. The consequence of this is that substance misuse is often 15Dual Diagnosis In Acute In-patient SettingsJ. Gallagher & S.J. ScottIntroductionSubstance misuse in society has reached epidemic proportions and thi Ebook Dual diagnosis nursing: Part 2to militate against a holistic client focused approach.Whilst substance misuse workers traditionally use a long-term recovery perspective, accepting a relapse-recovery pattern over an extended period of time (Watkins Ct al., 2001) acute in-patient services have been increasingly franchised to treat Ebook Dual diagnosis nursing: Part 2illness and promote rapid discharge policies to ease pressure on beds (Baker, 2000). Early intervention material talks about prevention of a relapse pEbook Dual diagnosis nursing: Part 2
rofile which can worsen outcome (Birchwood el al., 2000). This means that patients who display 'revolving door' pathology and need a longer journey to15Dual Diagnosis In Acute In-patient SettingsJ. Gallagher & S.J. ScottIntroductionSubstance misuse in society has reached epidemic proportions and thi Ebook Dual diagnosis nursing: Part 2ing door and longer stay (Watkins Ct al., 2001). Further, a relapse-recovery' pattern is a central part of their journey to health (Miller & Rollnick, 2002). Conflict therefore exists between a pressure to stabilise an illness and discharge a patient on the one hand and a focus on longer term recove Ebook Dual diagnosis nursing: Part 2ry including relapse on the other.152 Dual Diagnosis NursingQualitative research into training needs in acute in-patient settings suggests that staffEbook Dual diagnosis nursing: Part 2
are motivated and keen to work with this client group but often feel unprepared when dealing with the challenges they face (Ryrie & McGowan, 1998). Ri15Dual Diagnosis In Acute In-patient SettingsJ. Gallagher & S.J. ScottIntroductionSubstance misuse in society has reached epidemic proportions and thi Ebook Dual diagnosis nursing: Part 2including low optimism and low permissiveness in mental health staff. These attitudes mean that staff will feel treatment is unlikely to succeed if substance misuse is present. This can lead to an attitude of low permissiveness and a punitive confrontational approach to drug use. Patients in this si Ebook Dual diagnosis nursing: Part 2tuation may feel excluded and stigmatised within mental health services, leading to a cycle of stigmatisation, alienation and social exclusion (Sayce,Ebook Dual diagnosis nursing: Part 2
1999; Sainsbury Centre for Mental Health, 1998b).Overall, the present system of care, the in-patient ethos and skills mix in acute in-patient provisi15Dual Diagnosis In Acute In-patient SettingsJ. Gallagher & S.J. ScottIntroductionSubstance misuse in society has reached epidemic proportions and thi Ebook Dual diagnosis nursing: Part 2els.Considering the government agendaThe Government's Dual Diagnosis Good Practice Guide (Department of Health, 2002) states that in-patient services and others such as assertive outreach must develop the skills necessary to work with both substance abuse issues as well as mental illness (Department Ebook Dual diagnosis nursing: Part 2 of Health, 2002). The document also recognises a clear need to develop integrated treatment approaches. Despite this clear distribution of responsibiEbook Dual diagnosis nursing: Part 2
lity (Department of Health, 2002) no clear guidance is given about underlying service level, and service ethos issues, although some guidance is givenGọi ngay
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