Assessing Comorbid Substance Use in Detained Psychiatric Patients: Issues and Instruments for Evaluating Treatment Outcome

Abstract

This review assesses the issues involved in the selection and treatment of patients comorbid for mental illness and substance misuse being treated in secure psychiatric facilities. It includes those individuals who have a history of offending and whose placement is the result of severe behavioral disturbance. The relevant issues in the assessment and treatment of these patients are reviewed and a battery of tests is suggested on the basis of their usefulness with this population in terms of their brevity, ease of administration, and for their value in planning treatment, providing motivational feedback, and monitoring change. The paucity of assessment tools developed specifically for this patient population is highlighted.

Keywords:

• comorbid substance misuse
• assessment
• treatment outcome
• forensic psychiatry
• secure psychiatric facilities
• craving

Notes

¹ The journal's style utilizes the category substance abuse as a diagnostic category. Substances are used or misused; living organisms are and can be abused. Editor's note.

² The reader is referred to Hills's criteria for causation which were developed in order to help assist researchers and clinicians determine if risk factors were causes of a particular disease or outcomes or merely associated (Hill (1965). The environment and disease: associations or causation? Proceedings of the Royal Society of Medicine 58: 295–300.). Editor's note.

³ The reader is reminded that for a diagnosis to be useful it should “offer,” minimally, three critical, necessary types of information: etiology, process, and prognosis… which are not always known. Secondly, a diagnosis, when demystified, is simply the outcome of an information gathering process to be used for decision making.

Thirdly, the underpinnings for diagnostic criteria can be theory-driven, empirically based, individual and/or systemic stakeholder bound, based upon “principles of faith,” etc. All-too-often the needs or agendas of the classifier (individuals as well as systems) are not adequately considered or noted. Lastly, whereas all diagnoses are taxonomy categories or labels, all labels are not diagnoses. The terms comorbidity or dual diagnosis are inadvertently misleading in that a person can be diagnosed for each and every area of adaptation and functioning which can result in multiple diagnoses whose usefulness needs to be assessed. Editor's note.

⁴ Treatment can be briefly and usefully defined as a planned, goal directed change process, of necessary quality, appropriateness, and conditions (endogenous and exogenous), which is bounded (culture, place, time, etc.) and can be categorized into professional-based, tradition-based, mutual-help based (AA,NA, etc.), and self-help (“natural recovery”) models. There are no unique models or techniques used with substance users- of whatever types- which aren't also used with non-substance users. In the West, with the relatively new ideology of “harm reduction” and the even newer Quality of Life (QOL) treatment-driven model there are now a new set of goals in addition to those derived from/associated with the older tradition of abstinence driven models. Editor's note.

⁵ The reader is reminded that concepts representing processes such as treatment engagement/ alliance, treatment adherence/compliance are often used in the literature without adequately noting their dimensions (linear, non-linear), their “demands,” the critical necessary conditions (endogenous as well as exogenous) which are necessary for any of them to operate (begin, continue, become anchored and integrate, change as de facto realities change, cease, etc.) or not to and whether their underpinnings are (theory-driven, empirically based, individual and/or systemic stakeholder bound, based upon “principles of faith” etc.). Secondly, they are related only to the identified patient and do not consider the treatment agent as well as agency. Editor's note.

⁶ The reader is reminded that given that one or few trials, in humans, is quite rare re complex, dynamic, multidimensional, phase/level-structured, nonlinear processes/phenomenon—which are also bounded (culture, time, place, etc.) that “lapse” or “relapse” may be a necessary dimension for initiating, sustaining, and integrating a change process. This “reinterpretation” in meaning doesn't change the “learning” aspects. Editor's note.