This chapter provides a discussion of current best practice and evidence regarding the management and treatment of the more common co-occurring mental disorders seen among clients of AOD services. Symptoms of mental disorders may be identified through screening and assessment processes (described in Chapter B3), or they may arise spontaneously during the client’s treatment. There is a distinction between the management of co-occurring mental health conditions and their treatment. The goal of management is to allow AOD treatment to continue without mental health symptoms disrupting the treatment process, and to retain clients in treatment who might otherwise discontinue such treatment. Without further treatment, these techniques on their own may not provide long-term relief from symptoms; however, they may allow the client’s AOD use to be treated in the interim. One advantage of managing mental health symptoms is that no diagnosis is required prior to their use (i.e., symptoms are managed rather than disorders being treated). Readers are encouraged to read Chapter A4 of these Guidelines to familiarise themselves with the signs and symptoms of mental disorders.
AOD workers have widely varying roles, knowledge and experience; therefore, it is not expected that all AOD workers should be able to implement the treatments described. We do not provide detailed information relating to the implementation of these treatment options, but rather an overview of the available options. Where appropriate, readers are referred to existing literature and resources for more detail about the use of particular interventions. This information may nonetheless be used by all AOD workers to improve their understanding of best practice, and it may encourage workers to consider further training to improve their skills in these approaches.
It should also be remembered that the provision of treatment for AOD use alone has positive effects for those with co-occurring mental disorders [97–99, 102, 864, 865]. As discussed previously, it is important to note that, for many people, symptoms of depression and anxiety will subside after a period of abstinence and stabilisation, without the need for any direct intervention [866–868]. However, if the mental health symptoms started prior to the onset of AOD use, if symptoms persist even during periods of abstinence, or if there is a family history of the particular disorder, the client may have a condition that is independent of their AOD use, which may require treatment [869].
In terms of clients’ AOD use, the goal of abstinence is usually favoured, particularly for those whose mental health conditions are exacerbated by AOD use. Abstinence is also preferred for people with more severe mental disorders (or cognitive impairment) as even low-level substance use may be problematic [132]. Those taking medications for mental health conditions (e.g., antipsychotics, antidepressants, mood stabilisers) may also find that they become intoxicated even with low levels of AOD use due to the interaction between drugs. Although abstinence is favoured, many people with co-occurring conditions prefer a goal of moderation. In order to successfully engage with the client, AOD workers should accommodate a range of treatment goals and adopt a harm reduction approach [133, 134].
It is fundamentally important to discern the client’s preferences regarding treatment for their mental health. Just because the client has sought treatment for their AOD use does not necessarily mean that they are ready to address their mental health condition. It is important that the client is not forced to undergo treatment for their mental health if they are not ready to, as this may jeopardise the therapeutic relationship. Ultimately, it is up to the client to decide whether they want to address the issue and how they would like to go about doing so.
The recommendations in this section are based on a combination of expert opinion and evidence from research. People with AOD use disorders are commonly excluded from trials of psychotherapies and pharmacotherapies for mental disorders. Some interventions have been designed for the treatment of specific co-occurring conditions; however, these interventions generally have not been well researched. In the absence of specific research on co-occurring disorders, it is generally recommended that best practice is to use the most effective treatments for each disorder. It should be noted that the research evidence is based on trials of treatments for mental disorders (see Chapter A4 for disorder descriptions); however, these treatments may also be useful for those who do not meet diagnostic criteria but experience symptoms that cause significant distress or impairment.
Psychological and pharmacological interventions have been found to have some benefit in the treatment of many co-occurring mental disorders. As mentioned in Chapter B6, it is recommended that when pharmacotherapy is used, this should be accompanied by supportive psychological interventions [870, 871]. Symptoms are less likely to return on completion of psychological treatment compared to pharmacotherapy, where relapse upon cessation is common [782]. Pharmacotherapies are beneficial, however, in helping people to manage symptoms and obtain maximum benefit from psychotherapeutic interventions.
Pharmacotherapies for mental health disorders can only be prescribed by a medical practitioner, preferably a psychiatrist. However, it is important that AOD workers establish clients’ past medication history as well as any current medications (see Chapter B3). AOD workers should also be aware of:
- Possible interaction effects between prescribed and non-prescribed substances.
- The presence of medical problems such as liver dysfunction related to long-term AOD use or hepatitis, which may be exacerbated by certain medications.
- The abuse potential of medications prescribed.
- Potential contraindications.