Dual Diagnosis Project

Program Contact Person

Kellie Marshall


Activities/Achievements

Introduction

  • General Practitioners (GPs) are the most accessible of health care providers and in a unique position to intervene in the detection and management of comorbid mental health and substance use disorders (dual diagnosis) (McCabe & Holmwood, 2002).

  • 30% of patients presenting to General Practice have a diagnosable mental health condition (Andrews et al., 1999),

  • 12% are likely to have a dual diagnosis (Hickie et al., 2001b).

  • Many GPs fail to appropriately detect and mange patients with mental health, substance use and their comorbidity (Hickie et al., 2001a; Kessler et al., 2002).

  • The Illawarra Division of General Practice (IDGP) in partnership with the Shoalhaven Division of General Practice (SDGP) and the Illawarra Institute for Mental Health (iiMH) were funded by the Commonwealth Department of Health and Ageing under the NSW State Primary Mental Health Care Initiative – Stage 2 to develop, implement and evaluate a GP Dual Diagnosis education resource.

  • The aim of the project was to provide a pilot of an educational resource that improved the skills of General Practitioners in identification and care of patients with coexisting mental health and substance use disorder (Dual Diagnosis).

  • The process involved extensive collaboration between:

    • Illawarra and Shoalhaven Divisions of General Practice

    • Illawarra Institute for Mental Health, University of Wollongong

    • Illawarra Area Health Service (IAHS), Mental Health Integration Project, Mental Health Service and Drug, Alcohol and HIV/AIDS services

    • NSW Transcultural Mental Health Centre (TMHC)

Development

  • Project management and Reference committee members developed and determined most of the curriculum

  •  Digital Media Centre (DMC) at the University of Wollongong was contracted to support the development and design of an interactive CD-ROM based training resource

  • Five education modules were developed

    • Identification

    • Assessment

    • Motivational interviewing

    • Referral

    • Case coordination

  • Four video tape case vignettes provide continuity and context for knowledge and skills development

  • Audio GP discussants provided meta-cognitive analysis and reflection.

  • The CD-ROM was designed for GPs to use for a minimum of 8 hours – Order Form

Implementation

  • Three dissemination strategies were developed and evaluated

  • (1) GP only workshops plus CD-ROM

  • (2) Teams of Three workshops bringing together GPs, Mental Health and Drug and Alcohol Service staff plus CD-ROM

  • (3) CD-ROM only, where GPs received the CD-ROM as a stand alone product and completed it in their own time without workshop participation

  • Workshops were of 2 hours duration and strategies included

    • Introduction and demonstration of the CD-ROM

    • An interactive talk by a visiting presenter on one topic from the CD-ROM

    • Engaging participants in group problem solving around Dual Diagnosis

  • Seven workshops involving 125 participants were conducted

    • 79 were GPs

    • 28 were Illawarra Health Drug and Alcohol Service Staff

    • 18 were Illawarra Health Mental Health Service Staff

Evaluation Design

  • Evaluation involved multiple strategies and was divided into four major stages

  • Needs and Environmental Analysis (see report submitted to the Commonwealth Department of Health and Ageing 2002).

    • GP focus groups

    • Practice staff focus groups

    • Division-wide questionnaire survey (2001) with 148 GP responses

  • Division-wide questionnaire survey (2002) with 114 GP responses

    • Cross-sectional data reported

    • Comparisons provided with 2001 Division-wide survey

  • Clinical Audit

    • 5 GPs audited 100 consecutive patients each

    • Data on 508 patient consultations

  • Pre-post workshop evaluation and CD-ROM utilisation rates (70 GPs)

    • Questionnaires assessing motivational and transfer to practice factors

    • 5-week telephone follow-up to assess CD-ROM utilisation

Results

Needs and Environmental Analysis (2001 Survey)

  • 44% of GPs regularly or almost always treated Dual Diagnosis

  • 17% regularly used screening measures

  • 36% used other specialist services to support their work in DD

  • 26% regularly took on a coordinating role with DD

  • 5% used EPC items in management of DD

  • Lack of time, difficulty with access to support services and poor feedback when referrals made to support services were major barriers to care

  • About 90% of GPs used a computer in their practice

Division-wide survey 2002

  • Comparisons between 2001 and 2002 survey revealed significant decreases in

    • Provision of counselling for DD

    • Use of screening devices

    • Use of specialist support network

    • Use of EPC items

Clinical Audit

  • Screening/Assessment

    • 50% of cases GPs asked at least one mental health screening question

    • Screening suggested possibility of at least one disorder in 38% of cases

    • Depression (47%) and anxiety (41%) were screened more often than substance abuse (35%)

    • Depression (26%) and anxiety (25%) received positive screen more frequently than substance abuse (16%)

    • Symptom checklists or other assessment tools were used in only 7% of positive screen cases

    • Only 3% of all cases were thought to have a dual diagnosis

    • Depression (14%) and anxiety (12%) were more often found to require treatment than substance abuse (7%)

  • Treatment/Management

    • Depression

      • 77% received pharmacological treatment

      • 66% received psychological treatment

      • 33% received treatment for physical health problems

      • 27% referred to mental health services

    • Anxiety

      • 58% received pharmacological treatment

      • 63% received psychological treatment

      • 35% received treatment for physical health problems

      • 20% referred to mental health services

    • Substance abuse

      • 12% received pharmacological treatment

      • 58% received psychological treatment

      • 39% received treatment for physical health problems

      • 15% referred to drug and alcohol services

  • No GPs intended to use a care plan or case conference in the management of these patients and for only two patients was there an intention by a GP to use the 3 Step Mental Health Process.

Pre-post workshop evaluation and CD-ROM utilisation rates

  • 70 GPs received the CD-ROM, consented to evaluation and were contacted at telephone follow-up

  • Pre-workshop measures indicated GPs participating in Dual Diagnosis training were confident and engaged in good practices in the assessment and management of DD more than the general Division-wide sample of GPs

  • After the workshops 95% of GPs were

    • highly motivated to learn more about dual diagnosis

    • motivated to use the CD-ROM

    • intended to use the CD-ROM

    • intended to transfer what they learned into practice

  • At 5-week telephone follow-up

    • Only 31% of GPs had used the CD-ROM

    • The CD-ROM was used for an average of 71 minutes

    • 76% of GPs who had not yet used the CD-ROM, intended to do so

    • Self-efficacy and motivational variables did not predict CD-ROM use

    • Mode of delivery (workshop, teams of 3, CD-only) did not predict CD-ROM use

Conclusions

  • GPs do not detect as many patients with dual diagnosis needs as prior research suggests present to General Practice

  • There appear to be lower "actual" rates of detection and treatment than found with GP self report

  • GPs need skill particularly in screening, assessment and treatment of substance abuse problems

  • Checklists and other tools to support assessment are rarely used

  • The use of EPC items and the 3-step mental health process is extremely low

  • Without specific interventions, GP counselling and referral to specialist support services for DD show risk of decreasing

  • Advertising and recruitment strategies used attracted approximately a quarter of all GPs to undertake some aspect of training in Dual Diagnosis

  • Workshops were able to enhance high levels of motivation and intention to use the CD-ROM

  • Despite high levels of motivation only one third of GPs actually used the CD-ROM and to a much lower extent than desirable

  • Those who used the CD-ROM indicated that they found it helpful

Recommendations

  • The evaluation indicated high need for ongoing education in dual diagnosis therefore continued development and national rollout of the CD-ROM training resources recommended

  • Independent review and evaluation suggests the need for an enhanced version of the CD-ROM education resource with priority for re-scripted and videotaped case studies with clearer examples of "ideal" practice.

  • A high priority should be an enhanced and more structured learning plan to improve CD-ROM utilisation rates

  • Development of information systems and reporting to enhance continuing education management, learning outcome assessment and evaluation of national dissemination strategy

Request CD – Dual Diagnosis CD Order Form