Researchers have conducted a considerable number of studies before in an attempt to establish an understanding of dual diagnosis when a mental patient is affected both by psychological illness and the use of drugs and/or alcohol. This researchers have been conducted to help families with affected individuals or close friends find appropriate approaches to managing the mental disease and the abuse of the comorbid substance (Khantzian 1997). The two phenomena interact to worsen the diagnosis of each and develop serious implications on various capacities of mental, physical, and physiological functioning. Some of the affected functions in a victim of the circumstance include the ability to work, an individual’s health and safety, and the ability to have and maintain a serious relationship or relationships with other people (Schoenen 2011).
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However, the prior conducted researches have not provided enough insight to the professionals dealing with mental challenges and the experts dealing with misuse of drugs on how to effectively manage their patients and recover them from their mental challenges, particularly in cases of dual diagnosis. So, in deep view of this deficiency on better ways of treating and handling the patients of dual diagnosis, and also in thorough view of the future need to apply the findings of detailed research in informing families, friends, and mental doctors on new and effective approaches to deal with the dual diagnosis, the essence of this research virtually provides a stepping stone in the management of the mental complication and the comorbid drug or development of SUD at a particular stage in life. Moreover, conditions resulting from use of alcohol abuse (Khantzian 1997). This research finding provides insight for mental health care providers and other persons dealing with psychological treatments as they attempt to manage patients around them using better options and methods suitable for the dual diagnosis. The research identifies issues and problems encountered by the families and friends of parties affected by dual diagnosis and try to lessen the challenge of recovering the patients from their mental complications.
Recent research has provided that individuals suffering from mental illness indulge in substance abuse for reasons similar to those of other people who don’t; the reasons being to feel relaxed, to feel generally better, to feel different, to have fun, and to feel part of a peer group. Individual perceptions of the benefits of using income taxes and personal revenues. However, as much as the healthcare system in Canada is social and universal, the plan does not cater for drugs or alcohol drive many people to indulge in the use and misuse of the substance. Other people experiment with the drugs in an attempt to cope with difficult issues and problems, manage their stresses, or relieve their boredom, while others end up in drug use because of curiosity. When drugs or mental health, disease, education al impairments, and auto accidents would be on the rise. They argue that comparison of drugs with alcohol get into the body, their immediate influence usually introduces a feeling of relief from the positive manifestations and signs of mental condition, for instance, paranoia. But when people attempt to withdraw from the use of these drugs or alcohol, their action makes worse the symptoms of substance use. Those with dual diagnosis usually view and associate the use of the drugs with the process of relieving or reducing the symptoms, but they will less readily link more symptom severity to the withdrawal from the substance (Khantzian 1997).
The subject of comorbid mental and internet also promotes establishment of illegal pharmacies that may be dealing in unapproved or recalled drugs. Besides, online drug or alcohol use, commonly referred to as dual disorder, has gained significant recognition and attention ever since the year 1980. According to Kessler et al, (1996), both clinical and community studies indicate the prevalence of dual disorders. The prevalence of the disorder has been shown also by studies such as, (Scott et al & Ruijter et al, (2010). In a national study on comorbidity with a sample population of the nation, 41-65 percent of the participants with health to ensure the safety of prescribed drugs. This paper discuss the recall of tetrazepam drug use disorder of any lifetime also had developed a history of one or more mental illnesses within a lifetime (Andrews, 2010). According to the study, conduct disorder was the most common at 29 percent, the second was major depression at 27 percent which was followed by social fear (commonly known as social phobia) at 20 percent. Individuals with any lifetime background of psychological disorder had about 51 percent participants with co-occurring addictive condition or disorder; with respondents having conduct condition or personality that is anti-social (adult anti-social personality), developing 82 percent- the most prevalent SUD of a lifetime. This was followed by persons having mania at 71 percent and then those having PTSD at 45 percent. In an epidemiologic study (catchment area study), the prevalence of regulations on consumption of alcohol and usage of drugs. There should be a minimum set age limit where people can consume alcohol disorder emerged highest in a population of people having bipolar disorder, and this was at 46 percent, followed by schizophrenia at 34 percent (Schoenen 2011).
In a population of five hundred and one people requiring treatment from addictions, a considerable percentage had developed lifetime mental illness in addition to drug use, that is 78 percent and the proportion of 65 percent had developed a current mental illness. Anti-social personalities, psychosocial dysfunctions, dysthymia, social fears or phobia, and major depression were some of the common lifetime conditions. According to Schoenen (2011), of the two hundred and ninety-eight people seeking cocaine use disorder treatments, those who met lifetime mental disorder were 73 percent while those who met current mental disorder were 55.7 percent. The disorders that accounted for the rates included bipolar spectrum conditions (for instance cyclothymic personality, hypo-mania), major depression, phobia, anxiety, and anti-social disorders, etc.
Statement of the Research
The subject of comorbid mental, According to Andrews, (2010), both clinical and community studies indicate the prevalence of comorbid mental and drug or alcohol use. The prevalence of the disorder has been shown also by studies of (Cole et al. 2012, Morris et al. 2007 and Eisenberg et al. 2011). In a national study on comorbidity with a sample population of the nation, 41-65 percent of the participants with drug use disorder of any lifetime also had developed a history of one or more mental illness within a lifetime (Schoenen, J., 2011). Many types of research have been conducted in an attempt to establish an understanding of dual diagnosis when a mental patient is affected both by psychological illness and the use of drugs. However, these researches have not provided enough insight to the people dealing with mental challenges and the experts dealing with misuse of drugs on how to efficiently manage their patients and recover them from their mental challenges, particularly in cases of dual diagnosis. So, in deep view of this deficiency on better ways of treating and handling the patients of dual diagnosis, it is of the essence that this research virtually provides a stepping stone in the management process of the mental complications and the comorbid drug or alcohol abuse indicates research is done on Addressing Substance Abuse and Violence in Substance Use Disorder Treatment and Batterer Intervention Programs (2012).
Justification of the Study
This study investigated better options of managing a dual diagnosis, in an attempt to help families with affected individuals and professionals dealing with mental health find appropriate approaches to treating mental disease and the abuse of the comorbid substance. A unique trend in which the rate of development of dual diagnosis surpasses the rate of progress in its management called for this further research on the condition and to establish appropriate methods of treating and managing the patients of dual diagnosis. Dual diagnosis is an unprivileged and human miss-achievement and, therefore, patients must be treated carefully and based on properly investigated methods (Christo et al, 2012). According to recent research, it is provided that individuals who suffer psychological illnesses end up in substance abuse. They resort to using the drugs to feel relaxed, to feel better, feel different, to drug attain fun, and to feel part of a team or group. Patients’ perceptions of the benefits of using drugs push most victims to indulge in the used substance. When drugs get into the body, their immediate influence usually introduces a feeling of relief from the positive manifestations and signs of mental condition (Andrews, L. W. 2010). But when people attempt to withdraw from the use of these drugs or alcohol, their action makes worse the symptoms of substance use.
Those with dual diagnosis usually view and associate the use of the drugs with the process of relieving or reducing the symptoms, but they will less readily link more symptom severity to the withdrawal from the substance (Andrews, L. W. 2010). The study was a staged process whose findings are a response to the need of bettering the management of dual diagnosis. The study entailed a research idea, the purpose of the research, and how the researcher carried out the research. The study aimed to capture and establish alternative approaches to treating and managing people with both mental challenge diagnosis and drug use diagnosis. The study was of main interest to the sampled patients of dual diagnosis. It could also be of interest to the psychiatric doctors and people dealing with drug addicts in designing and planning health interventions for the victims. The global society has several cases of dual diagnosis (Gass, J. T. 2010). The study further aimed to use its findings in driving hypothesis testing about methods of managing mental health and substance use.
The critical framework is an assemblage of various factors as demonstrated by the figure below. While the existing literature on dual diagnosis tries to explore the understanding of dual diagnosis when a mental patient is affected both by psychological illness and the use of drugs and/or alcohol, there is nonetheless insufficient research on specific issues that can provoke researchers’ limitations and lead to a concrete implementation to most of the dual disorder issues. According to this literature, researchers have conducted studies to help families with affected individuals or close friends find appropriate approaches to managing the mental disease and the abuse of the comorbid substance.
Some of the affected functions in a victim of dual diagnosis include the ability to work, an individual’s health and safety, and the ability to have and maintain a serious relationship or relationships with other people (Christo et al, 2012). For lack of thorough studies on the interventional treatment of mental illnesses, families and mental doctors are unaware of the best approaches to applying when managing patients with dual disorders. This research study, therefore, took the task of conducting detailed and comprehensive research on the matter to examine and analyze the actual situation of dual diagnosis in-depth and providing an alternative model that can be used in the management of mental health diagnosis and substance use diagnosis.
Qualitative methods were used in this study. Probability sampling was employed. The participation of all the persons involved was also ethically employed among other ethical issues. The research considered fairness and maximum cooperation of tools and methods involved. The figure below shows a framework study that demonstrates an approach that is applicable in the management of mental illnesses and treats individuals with a dual diagnosis. The philosophy applied in this model shows that drug use disorders and mental illnesses can both be managed or treated on the application of a systematic approach. The concept shows treatment methods that a recovery process of mental illnesses can use in providing valuable information regarding the method of recovering an individual from psychological disorders. The approach here can be consequently applied in developing treatment strategies for patients having dual disorders. The aspects of the concept can be applied as a template of care at various levels of a treatment-care system. The conceptual framework follows a dual diagnosis and management system of the symptoms of the dual disorders. This study evaluated this framework as a staged process of finding a response to the need of bettering the management of dual diagnosis. The study entailed the purpose of the research and how the researcher carried out the research. The study aimed to capture and establish alternative approaches to treating and managing people with both mental challenge diagnosis and drug use diagnosis. The study was of main interest to the sampled patients of dual diagnosis. The study further aimed to use its findings in driving hypothesis testing about methods of managing mental health and substance use.>
|Shared Risk Factors|
|Diagnosis and Management|
Source: Community Study by Andrews, (2010).
The research study design used was a cross-sectional study design. It was quite essential in defining dual diagnosis, getting the outcome, and examining the interventional approaches to the management of the dual disorder. According to the Diagnostic and Statistical Manual of Mental Disorders (2000), the data collection and research design employed in this research study if well used could provide valid and theoretically meaningful information that could be used for policymaking and developing programs for managing dual disorders.
This study was conducted based on different sex, ages, and environmental exposures regarding mental health and substance abuse. The participants were being urged to provide honest information as it could be used to upgrade the services offered by the mental health experts, psychologists, and friends and families in managing mental disorders. Independent variables included sex, duration of drug use, and a lifetime of mental health. Dependent variables included perception of patients, attitude, and knowledge.
Before analysis, all the available information on dual diagnosis went through a quality check process. After which the data collected was managed using databases, where the collected data was entered for further manipulation. The data were analyzed using descriptive statistics, hypothesis testing, and Stata.
The details of the respondents were treated with confidentiality. Consent of the respondents was requested before proceeding with the data collection process.
Aetiological Theories: Reasons why Individuals with Mental Health Problems use Psychoactive Substances.
Findings have shown that some models and theories have hypotheses why some individuals with They also play a major role in ensuring the good standards of the health of society members. There has been an emphasis on concerns about mental health problems are vulnerable to the misuse of psychoactive substances (Rassool, 2006). These include the self-medication hypotheses, alleviation of dysphoria (feeling bad) model, the multiple risk factor model, and super-sensitivity.
Self-medication serves as a motivation for patients to seek specific medication as a relief for a set of symptoms. Khantzian (1997) who proposed the self-medication model, suggested that individuals abuse psychoactive substances to cope with pain, mood which may consequently predispose them to their addictive behaviors. Khantzian emphasized that potential addicts are not selective of specific psychoactive substances at random, but go in for their unique effects of the substances they may enjoy. He argues that opiate users may self-medicate with opiate because of the preference of opiate being powerful in dealing with the range, aggression, and depression, and cocaine appeals to substance abusers because it relieves distress associated with hypomania, depression, and hyperactivity.
However, the evidence available does not support this hypothesis. Dixion et al., (1990) and Noordsy et al., (1991) found that no specific substances alleviate specific symptoms of a particular report in the form of table. This analysis helps in finding the adverse effects of marijuana smoking on mental health disorder. According to Schneider and Siris, (1987) the most common substances, which individuals with mental health issues use are alcohol, cannabis, nicotine, amphetamines, and hallucinogens. These substances have proven to increase the severity of positive symptoms of psychosis such as delusional beliefs, auditory and visual hallucination, and other thought disorder and cannot be used to decrease distress or alleviate such symptoms. However, the theory of self-medication has some credence. An illustration is cannabis, opiate or alcohol may decrease the agitation and anxiety connected with mental illness, while stimulant may be taken as self-medication for negative symptoms of depression. Castaneda et al., (1994) concluded that no affected by mental or emotional health disabilities. However, research evidence underpins the self-medication hypothesis as an essential reinforcer of continued substance used.
Alleviation of Dsyhoria
This model encompasses that people with severe mental illness are liable to experience dysphoric, which makes them prone to using psychoactive substances (Birchwood et al., 1993). The motive behind using the psychoactive substances initially is for the relief of bad feelings and to help feeling good (Leshner, 1998). Dysphoric may motivate initial alcohol and substance use, consequently promoting addictive behavior.
Multiple Risk Factor Models
As noted by the Department of Health (1999), multiple risk factors such as social isolation, poor interpersonal skills, poverty, educational failure, poor cognitive skills, unhealthy neighborhood, and association with drug subcultures may motivate mentally ill patients to use psychoactive substances. However, this model has no direct evidence, but the rationale for using psychoactive substances is related to these identified factors (Noordsy et al., (1991).
The Super-Sensitivity Model
This model deals with psycho-biological vulnerability decided by a combination of genetic and environmental conditions, which interact by the stresses of the environment to either precipitate the onset of psychosis episode or trigger relapse (Mueser et al. 1995). Mueser argues that the nature of sensitivity attached to psychoactive substances enhanced vulnerability and may cause people with severe mental health prone to experiencing negative consequences, having used a relatively small amount of psychoactive substance. Studies by Drake et al., (2001), Leiberman (2000), and Corse et al., (2005) confirm . For example, the course of nation-state building that took place in the 19th and 20th century and society militarization, as well as the warlordism, are two processes that provide evidence for the model, thus, lower levels of physical dependence; trigger clinical symptoms of a low dose of amphetamine and negative clinical effects such as relapse, with small amount of alcohol or drug. According to Mueser et al. (1995), the super-sensitivity model serves as a theoretical framework in portraying how a low level of psychoactive substance can consequently result in a negative experience for individuals with severe mental illness.
Chapter 4: Findings
4.1 Preliminary Intervention
4.1.1 Introduction to Theme
The examination of dual diagnosis-treatment/ management of mental illness and comorbid substance abuse is aimed at helping individuals working in the field of the mentally challenged and those in the environment where the substance is misused. Mental illness and drug abuse as a result of comorbidity have serious impacts on the professionals working on alcohol and drug services, mental health sector, in varied agencies as well as both statutory sectors and non-statutory sector (Andrews, L. W. 2010). These findings aim to provide some overview of the assessment, diagnosis, prognosis as well as treatment, the findings will attempt to highlight the researches that have been conducted to achieve the key objectives of this theme. Several reviews have been taken that would support the existing hypothesis on the concept of dual diagnosis as well as the coexisting problems of substance abuse and mental health. In a broader sense, this chapter has critique views that have been presented on this theme and have ultimately arrived at a compromising conclusion.
4.1.2 Review of human society develops. The Evidence to Include for Each Source:
There were nine major sources included in the preliminary care theme.
Three studies were a clinical survey that focused mainly on the methodological construct for mental development in people of different ages. . For example, the course of nation-state building that took place in the 19th and 20th century and society militarization, as well as the warlordism, are two processes that provide Evidence on the methodological construct, therefore, helped in making an evidence-based decision on the assessment of the subject based on their mental development (Cole et al. 2012, Morris et al. 2007 and Eisenberg et al. 2011).
Three studies considered quasi-experiment studies, where practical experiments performed on the premises of a health facility, looking into the correlation between emotional dysfunction and personality disorder. Evidence taken from this source included the effect of drug misuse on emotional dysfunction and personality disorder for diagnosis (Kim et al. 2010, Leible et al. 2004 and Wolf et al. 2011).
Furthermore, three studies by Gratz et al. (2006), Wupperman et al. (2013), and Schulze et al. (2011)were Literature searches, which looked at the issues of mental illness and drug misuse from a neurological perspective. They were therefore very useful in the prognosis of the subject involved in the study.
These nine sources will be presented in table one as shall be indicated in the appendix.
4.13 Type of evidence and main methods
Based on the sources that were selected, there were different forms of evidence used for different methods of the study. According to Scott and Bak, M., Diest, R. v., & Ruijter, M. d. (2010), the evidence is the type of information that is obtained as the outcome of research and scientific evaluation of practice. At the preliminary care stage, which insists on several issues before the actual treatment is arrived at; there are several issues to consider. (Bewley, T. 2008) First, a few questions need to be asked. The first question is how the presence of the problems can be identified. Secondly, there is a need to ask about the exact problems to focus on, and lastly, whether these problems need to be addressed concurrently and if so, how would they be addressed. These are the questions that, if not addressed accurately, may result in poor retention of treatment as well as the outcome of the treatment.
The preliminary care stage may demand that the clinician routinely makes inquiries when they notice that patients present either mental disorder or problems related to substance use. (Fabrega, H. 2009) It is at this stage that the clinician may assume comorbidity particularly when there is a negative response to therapy directed to either mental disorder or substance abuse. On the findings of this study, and based on the precursors of comorbidity, the findings were therefore made based on two major types of evidence, which were primary and secondary evidence. Primary evidence was gathered through observational studies on the subject, while secondary evidence was gathered through literature search, using the nine major sources listed above. These types of evidence resulted in two main methods, which were quantitative research method and qualitative research method. Whilst the evidence from observational studies focused on quantitative research, the literature search was narrowed to qualitative research.
4.1.4 Main findings
Assessment is an integral part and a universal aspect of care. A clear assessment should entail the determination of history that underpins the treatment of the comorbidity. (Gass, J. T. 2010). The more detailed and focused the process of assessment is the better appreciative will be on the connection between the disorders in question, which in this paper primarily narrows to substances other than the use of alcohol. (Gass, J. T. 2010).
As noted by Petry, N. M. (2005), mental health assessment offers the practitioner the opportunity to have a detailed picture of how well a patient or client feels emotional and how accurately the patient can undertake psychiatric functions such as thinking, reasoning, and cognitive functioning. The assessment took place through clinical observation of subjects, including an interrogation session with the assistance of a clinical psychologist (Schoenen, J., 2011). As the first stage of treatment, results from the assessment of subjects showed various outcomes. The verbal test version of the Hamilton Rating Scale for Depression showed a score of 21, which is a severe state of depression (Schoenen, J., 2011). This result showed that there was a need for entry into a clinical trial (Andrews, L. W. 2010). Areas, where worse symptoms were recorded, included insomnia, anxiety, the feeling of guilt, and somatic symptoms.
This approach was however not a reflection of the required guideline according to the DSM-5. The DSM-5 requires that the patient gets observed primarily through the first two Axes, which are Axis I and Axis II. From what the study reveals, the focus was perfectly on the independent psychiatric condition, which, according to the Axis I and Axis II, should take into consideration, substance-induced conditions. (Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed.). 2013).
To arrive at conclusive findings of the assessment, the study ought to have considered the screening tests. Several tools may lead to an accurate result on the screening. This would be determined by the level of severity of the use of substances, the misuse of the substance as well as the mental disorder that is in question (Isseroff, R. 2006). There is no indication that the findings relied on Psychiatric Research Interview for Substance and Mental Disorders (PRISM). PRISM is one particular assessment tool that has the ability to test both mental disorders and substance use.
At the preliminary intervention stage, the diagnosis was carried out as the second modality for intervention. The diagnosis was always prompted based on the outcome of the assessment. The type of diagnosis undertaken was the medical diagnosis and used, in conjunction with the assessment of symptoms and signs, To find the specific type of mental disorder the subject might be suffering from. As part of the medical diagnosis, a mental status examination (MSE) was carried out. The major domain of the MSE that was emphasized was the mood and affect, which showed results indicating bland effect and an intensity level of flat affect. To determine the effect, the apparent emotion is labeled by the nonverbal behaviors they display (Ḳaminer, Y., & Bukstein, O. G. 2008). Depending on the prevailing situation, these effects may be described as appropriate or inappropriate, congruent or incongruent with the networking leads to connections of bad groups. (George 1989) commented that these groups end up sharing information that has no good content of the thought (Schoenen, J. 2011). When such effects are not expressed externally and are reduced internally, then the effects may be referred to as a restricted effect (Schoenen, J. 2011).
This approach usually presents an opportunity for the clinician to obtain a detailed cross-sectional description of the mental state of the patient. The method is meant to allow the clinicians to bring together historical information and biographical information relating to the psychiatric history, to allow for a coherent plan of treatment. This method utilizes an unstructured form of observing the history of the patient, with the focus on the current symptoms (Young, M. 2010).
Several factors demand clarity in the assumptions that have been given by the diagnostic tool that was used. First, it is important to appreciate that the correct identification and appropriate evaluation of the high level of comorbidity existing between several mental disorders and drug use disorders requires a wide-ranging approach to intervention (Lessa, N., & Scanlon, W. F. 2006). As mentioned previously, this approach would depend on the existing assessment tools with a high level of accuracy to avoid misrepresentation and poor diagnosis.
Considering that there is a close relationship between the treatment for people with mental illness and the screening that they get, diagnosis need not rely on appearance features, which is the main attribute of the MSE. Some of the features that this tool has always relied on include the ages, the heights, the weights as well as the manner of dressing and grooming of the patients (Lessa, N., & Scanlon, W. F. 2006). This approach is more psychological than clinical. SME evaluates the approach the patient has towards the interview. It has proven to be widely subjective since factors such as interview situation, and the behavior and skills of the clinicians, all are put together to determine the outcome of the diagnosis. Obtain an accurate diagnosis may be a complicated matter. These findings have not been illustrated in the way that is required. The findings have not brought forth the similarities that exist between symptoms related to drug abuse like withdrawal and also those that are potentially realized by comorbid mental disorder. There should be some period of time isolated for study for those individuals who abuse drugs even after they enter treatment (Gass, J. T. 2010). This is to assist in distinguishing between the effects of withdrawal or substance intoxication and the symptoms of mental disorders. Table 2 in the index will represent the findings.
As noted by Sommer, W. H. (2013), in mental illness, and especially where it is directly related to substance abuse, the prognosis should be based on diagnosis and this should be able to tell the likely course or outcome of the medical condition. The findings of this study, reveals that the basis of prognosis was very emphatic in evidence because of the understanding that a wrong prognosis can trigger wrong and miscalculated treatment and management. As a way of ensuring an evidence-based prognosis, the prognosis was directly based on diagnosis and assessment, which had been performed using credible evidence-based sources including Hamilton Rating Scale for Depression and Mental Status Examination. From the diagnosis showing the bland effect at a flat intensity and restricted mobility, the prognosis was concluded that the subject had very high chances of recovering to a normal productive life after treatment and management (Boyd, M. 2008). The pegging order was actually placed at 85%.
There is a possibility that there was a lack of accuracy in the findings of the pegging order. The study conclusions arrived at relied on the Hamilton Rating Scale for depression which has severe pitfalls. The use of the Hamilton Rating Scale for depression has been noted among the researchers who are interested in discriminating between the active drugs and placebo or to show response to the dose among the severely depressed (Fabrega, H. 2009). The improvement in scores by the Hamilton Rating Scale for depression during its trial may do not necessarily qualify the drug as an antidepressant since the total scores would not provide adequate statistics. This suggests that the improvement would most likely be found in non-specific Hamilton Rating Scale factors such as anxiety, appetite, or sleep (Cook, C. C. 2006).
Further, based on the unscientific nature of the MSE, and with the clear understanding that SME highly depends on the experience and skills of the clinician as well as structured and screening questionnaires being subject to the interpretive bias, it follows that there is a high chance that the pegging order would be inaccurate (Cook, C. C. 2006). It is noted that all screening questionnaires always have some degree of false-negative rate, particularly in the case of individuals with their focal lesions of the hemisphere at the right. For instance, low socioeconomic standings and the cultural experience would influence would restrict the significance of SME questionnaires for screening. Unlike other exams that detail metal aspects, the screening questionnaire insensitive to delicate cognitive impairment.
The above factors have a bearing on the determination of the level of pegging order and most certainly would contribute to the high rate of 85%.
4.1.5 Evidence of Critical Appraisal.
The preliminary intervention that was rendered to the subject was appraised in two major ways. The first form of appraisal was an objective evaluation involving other stakeholders and health practitioners within the research setting. These people were presented with an appraisal form to fill out in an attempt to evaluate the entire process and how it was clinically appropriate. The second form of appraisal was a subjective appraisal, involving the direct outcome of the three processes namely assessment, diagnosis, and prognosis. It was hypothesized that a successful assessment should contribute to evidence for diagnosis, and a successful diagnosis should lead to a successful prognosis (Gass, J. T. (2010) as expected, all these areas were successfully carried out as the assessment became the direct basis for diagnosis and diagnosis for prognosis. Perhaps it would be clearer to clarify the relationship between diagnosis and prognosis. Diagnosis focuses on the identification of medical conditions using the symptoms presented by such conditions (Lessa, N., & Scanlon, W. F. 2006). It, therefore, labels such conditions. Prognosis, however, examines the prospects of recovery as well as the probable progression of the condition that has been diagnosed. The focus is on how the condition in place would affect the lifestyle of the individual. Focusing on prognosis is a reflection of the lifestyle of the individual involved (Lessa, N., & Scanlon, W. F. 2006).
The relationship between diagnosis and prognosis is a mutually exclusive concept and yet a closer look may reveal that they are directly related (Radoilska, L. 2012). It is not certain that a successful diagnosis can lead to a successful prognosis. Diagnosis will highly depend on the examination tool used. Prognosis, however, would depend on the direction of life intended by the people around the patience. It is however clear that sometimes a good diagnosis would prepare the patient and the other social capital to arrange for plans on how they would lead their lifestyle. This makes a successful diagnosis, a precursor to a successful prognosis.
4.1.6 Link to Research Question
The pre-intervention care that is given in the forms of assessment, diagnosis, and prognosis can be directly linked to the research question that was posed in the earlier part of the study. Earlier, the question of ‘how people with both a mental health problem and substance misuse (co-morbidity) can be treated’ was asked. Quite related, it will be noted that for any effective treatment to start, Clinicians have the obligation of ensuring that they conduct appropriate assessment and diagnosis to ensure appropriate treatment. It is for these reasons that pre-intervention care in the forms of assessment, diagnosis, and prognosis are very necessary. The author considers it essential for caregivers to be conversant with the outcome of the assessment that has led to the development of the diagnosis, before offering any form of treatment or intervention. This is important because as noted by Andrews, L. W. (2010) caregiver to have a very accurate measure of the situation so that treatment can also be accurate as desired by the patient.
4.1.7 Link to next piece of evidence
The next piece of evidence, which focuses on treatment, shall deal more with the primary forms of evidence. This means that a lot of observational studies on the subject shall be carried out at the treatment stage of the intervention. The link that the pre-intervention care has with the observational studies on the subject is that it makes it possible for the caregiver to have a quantitative perspective of the situation at hand that needs to be treated. By quantitative, reference is made to the fact that the caregiver can have accurate measures that have to do with variables such as the duration of the problem, the extent of mental breakdown and substance use, any previous case of care, and existing deficiencies with the patient. Considering that mental health and substance misuse, the focus of this kind of comorbidity needs to be evaluated quantitatively rather than in an imaginative way.
4.2.1 Introduction to Theme
This section of the findings deals with the treatment that was given to the patient who was suffering the case of co-morbidity of mental health and substance misuse. By treatment, mention is being made to the application of professional health interventions to patients with the hope that the patient will be able to experience the improved state of health and wellbeing (Schoenen, J. 2011). The theme of treatment is seeking to do two major things at the same time. In the first instance, the treatment is looking into the issue of improving the state of health, which focuses on mental health improvement. There is also the need to achieve improvement in general wellbeing, which focuses on psychological improvement in the patient’s attitude towards the use of a substance.
4.2.2 Review of Evidence to Include for Each Source:
Another set of nine secondary sources of evidence was gathered to be reviewed under the theme of treatment. These nine sources were totally different from those that were used in the case of pre-intervention care.
In three studies that considered nonclinical panic attacks, anxiety sensitivity, and emotion regulation difficulties (Tull et al. 2009, Mennin et al. 2009, Novick-Kline et al. 2011) they suggested that these problems which are directly related to the current study sought to use nonmedicinal approaches to tackle the various health problems that were identified.
Another three studies by Cloire et al. (2010), Tull et al. (2007), and Cloire et al. (2012) focussed on specific cases of mental health problems. In this case, however, medications were combined with therapy.
Three studies aimed at finding the effectiveness of specific medication in the combined cases of mental health problems and substance misuse (Cloitre et al. 2012, Baker et al. 2004 and Cooper et al. 2009).
Table 3 in the appendix will indicate the sources.
4.23 Type Of Evidence and Main Methods
Even though there were some levels of secondary evidence used at the treatment level, which was part of the intervention level, much emphasis on evidence was put on primary evidence. Over here, different methods of primary evidence were gathered. Some of the evidence was an observational study of the patient and clinical outcomes of medication. This means that there were two major areas of focus in terms of evidence aimed at achieving evidence-based nursing practice (Young, M. 2010). The first of these focused directly on outcomes that were identified through primary research from the patient, and the second was on the clinical outcome, based on a well-calculated measure of care delivered to the patient.
4.24 Main Findings
Treatment of the co-morbidity situation made up mental health problem and substance misuse comprised the use of different approaches, some of which were clinical and medicinal, others of which were nonclinical and non-medicinal. The key findings that were made after each form of treatment have been given below.
Several psychiatric medications have been noted to be useful in the medication of addiction problems. An example is during the process of withdrawal as well as for the symptoms that occur as a result of psychotic issues (Young, M. 2010). Others are also useful in the cases of anxiety disorder and depression (Strauss, J. S., & Carpenter, W. T. 2009). Pharmacological treatment also reduces the rate of consumption of substances which ultimately would result in addiction and the overall outcome. However, skilled medication specifically under the supervision of a professional may be required in the instances of acute withdrawal and intoxication. In the case of the co-occurring mental disorders, opiate, alcohol, psycho-stimulant and nicotine pharmacotherapies may be used to undertake a careful assessment (Strauss, J. S., & Carpenter, W. T. 2009).
- Therapy – e.g. Cognitive Behavioural Therapy (CBT), Dialectical Behavioural Therapy (DBT), and Complementary Alternative Therapy (CAT).
Findings indicate that in the whole life of people, at least one out of four people would suffer mental health problems. It is grounded on these arguments that a necessary comprehensive evidence-based program that would ensure accessibility of treatment, that indiscriminate the severity of a range of disorders (Stewart, S. H., & Conrod, P. J. 2008).
There has been increasing appreciation of Cognitive Behavioural Therapy (CBT). Largely, these have been contributed by the 2007 involvement of Improving Access to Psychological Therapies (IAPT), a program which was meant to improve people’s care particularly those who were suffering from anxiety disorder and depression. There has been wide use of CBT for acute care to enhance patients’ life quality, especially those with mental health problems. Several CBT therapies known as the third wave has also been developed, including acceptance and commitment therapy, dialectical behavior therapy as well as mindfulness (Stewart, S. H., & Conrod, P. J. 2008).
- Family & Carers
Individuals with comorbidity disorders always have the urge just like other normal people in society to live a normal life (Radoilska, L. 2012). They need to be supported to ensure that they get integrated into society. Efforts are made by members of the families and individuals in the society to give them such help. Some of the members of the society are specialists in the lines of comorbidity. When these comorbidity patients face challenges with access to treatment, they depend on these specialists to help them.
Principles of Treatment
Relevant experience and adequate resources are needed for accurate assessment and treatment. According to Mercer-McFadden (1997), an integrated program of treating dual diagnosis is important because it is considered evidence-based and it has shown good outcomes in controlled studies, and its absence is linked with predicted failure. Drake et al., (2001) described nine principles of treating individuals with mental health problems with substance misuse. These principles are applied in most settings as a shared care framework. See appendix…
Individuals with dual diagnoses may have a poorer tendency of engaging with treatment services or disengaging from treatment due to poor attendance of appointments. A more assertive approach will encourage supervision focus towards the reinstatement of engagement with the appropriate agencies (Rassool, 2006). People with dual diagnoses will get practical help with basic needs from the outreach team such as housing, state, or welfare benefit and developing a trusting relationship before participating in treatment. This approach enables the clients to gain access to services and foster a needed relationship and consistent treatment regime.
Treatment programs with individuals with a dual diagnosis should incorporate initial intensive supervision at least three times a week to develop therapeutic relationships and engaging the client in other intervention strategies. Monitoring people with dual diagnoses closely must be made on the mental state of clients and their compliance with prescribed medications such as antipsychotics, methadone, and antidepressants (Rossool, 2006).
Treatment is centered on integrated care pathways in which there is concurrent and coordinated treatment. The care program approach (CPA) would facilitate a better liaison between mental health and substance misuse services and other agencies. Virtual teams can be formed across teams and organizations and this has advantages of flexibility but lacks the cohesion of the single physical team (Checinski, 2002). A key worker for people with clients with a dual diagnosis would enable the coordination of the network of care and treatment required.
Clients with mental health and comorbid substance misuse often have complex needs in their lives. Drake et al. (2001) state that, for clients with dual diagnosis to learn to lead a life that is symptoms-free and abstain from their lifestyle to achieve a sustainable life, demands a transformation of some aspects of their lives. For example, habit, friends, stress management, activities, and housing. This means that addressing living skills, vocational and interpersonal skills, routine screening such as cervical smears, dental, ophthalmology, and engaging in clinical treatment may enhance recovery.
Stable living situation
Linking the client with housing services and associations are important in the provision of accommodation for clients. Appropriate housing for the client group may be necessary for the overall support system, because dual diagnosis clients who live in hostels or night shelters may be exposed to individuals with alcohol and/or drug environment.
Flexibility with Specialization
Findings have shown that when clients are motivated to manage their illness, there is the need for them to develop the skills and all the necessary support to control the symptoms and pursue an abstinent lifestyle (Mueser et al. 1998). However, when there is a directive ‘counseling’ and confrontational challenges, it may counter-productivity and increase the risk of disengagement which consequently impair recovery. Under this, practitioners have to re-evaluate and modify therapeutic approaches to effectively engage clients with a dual diagnosis. To illustrate this, there is the necessity of the practitioners to modify previous beliefs, learn new skills and approaches. In a situation where the client with dual diagnosis exhibit clearly self-abusive behavior, especially when it involves illicit psychoactive substances, healthcare staff deal with it in a suppressive and moralistic manner. However, not at least all nurses, probably out of a sense of frustration or inadequacy about their ability to effect any change.
Stages of Treatment
According to Rassool (2006), treatment of individuals with dual diagnosis proceeds in stages such as persuasion, engagement, active treatment, and prevention of relapse. However, in a clinical practice treatment does not often proceed in a linear pathway. Each individual differs from the other and may typically enter the cycle of change and move through the stages intermittently. Individuals will move between the stages and specific intervention is required in a specific stage.
It is relevant to realize that mental illness and substance misuse are chronic relapsing condition and treatment occurs over years rather than episodically or during a crisis.
Individuals with dual diagnosis are liable to feeling hopeless about their future due to combining effects and consequences of both conditions. This may be understood as having a lack of motivation to engage in treatment. However, practitioners need to view motivation as a dynamic process that can either undermine or enhance by different therapeutic approaches and techniques.
4.31 Introduction to Theme
Comorbidity that comes as a result of mental disorder and substance use disorder is a rampant situation in society (Cook, C. C. 2006).In its entirety, there is considerable heterogeneity within subgroups regarding both the nature and characteristics of a causal connection between the two disorders (Cook, C. C. 2006). Any assessment and management of the comorbidity need to appreciate that the problem should be addressed in both the community aspect and the specific subgroups including individuals with psychosis (Fabrega, H. 2009).In this section, there was a narrow research base from which some recommendations should have been drawn, though there was a considerable foundation for the introductory conclusion. This section of the study attempted to review existing evidence and further made suggestion for the management of comorbidity.
4.32 Review of evidence to include for each source:
Evidence regarding the management of comorbidity has taken varied perspectives (Fabrega, H. 2009). Several approaches encompassed the management of comorbidity. There are several aspects that this study has tried to examine about the management of comorbidity.
4.33 Type of Evidence and Main Methods
Several pieces of evidence had been reviewed to illustrate the management of comorbidity. There is a high frequency between several mental disorders and substance use. This is mostly in settings with high-intensity treatment, and often, there is the involvement of the use of multiple substances. There is a similarity between predictive factors for comorbidity, particularly those that relate to illegal drugs and those that are generally found in the community, including, young age, male gender, marital status, and lower educational level.
4.34 Main Findings
The findings from the evidence that has been realized from the study reveal that managing comorbidity requires intervention for substance abuse and mental illness. This should be observed through rehabilitation and treatments (Gass, J. T. 2010). Treatment of comorbidity is psychological interventions and medications related to the intervention. Rehabilitation of such individuals is always meant to equip the patient with coping skills with their conditions (Gass, J. T. 2010). There is always a considerable overlap between medication and rehabilitation as a process of intervention.
Recent reviews have addressed the increased development of intervention which is psychologically oriented for those with comorbidity. The most recent review picked on 45 independent clinical trials that were controlled. Despite the errors as a result of the methodology, it was evident that; there was an inconsistency on evidence that would support individual psychotherapy intervention. Secondly, the evidence suggested that reduction of substance use and improvement of outcome in other areas was more witnessed in circumstances where the intervention was peer-oriented with the assistance of professionals. Thirdly, the evidence had indicated that contingency management had given a bearing of being effective in reducing substance use, though this area has not been studied comprehensively (Ḳaminer, Y., & Bukstein, O. G. 2008).
Other findings suggested that long term residential intervention, despite its heterogeneity of the models, works perfectly in reducing the use of substances while improving other outcomes, especially for the patients who are homeless and those who are have not positively responded to the outpatient services. In another study, it was found that intensive case management, which includes assertive community treatment improved consistently, community tenure, and residential stability (Ḳaminer, Y., & Bukstein, O. G. 2008). Other interventions like poverty on America’s families:Assessing our research knowledge”. Journal of family psycho-education and self-programs worked successfully in the management of comorbidity.
Since the mid-1970s, scientific research shows that treatment of drug abuse can be able to help drug-abusing offenders to consider a change of attitude, behaviors as well as beliefs (Ḳaminer, Y., & Bukstein, O. G. 2008). This may also help the substance abusers avoid relapse and other crime-related behaviors. Legal pressure has been used in the past to help individuals get into the treatment process and also ensures that they stay in the treatment program. Once individuals get into the treatment program, even if they never wanted in the first place, they would eventually find themselves involved in the program (Lessa, N., & Scanlon, W. F. 2006).
Substance abuse that is not treated in most cases adds problems to the communities, which may include violent property crime, expenses to the prisons, court costs, abuse of children and neglect, problems with the child support, welfare and foster care cost, reduction of productivity, victimization, and unemployment (Lessa, N., & Scanlon, W. F. 2006).
Policies and Government Policies
Several policies have been developed to deal with comorbidity depending on which who is addressing the matter. The medical field has its own policy on how to handle comorbidity. Psychologists have their own views while legal aspects of individual countries have also developed legislation that demands special treatment to the patients (Young, M. 2010).
There is large documentation of comorbidity within the community and the clinical settings that indicate that comorbidity has a very clear connection with disability (Young, M. 2010). In a study conducted in Australia, respondents who suffered comorbidity reported a significant rate of disability, service utilization, and distress. This trend increased in almost a linear level, whenever the number of disorders increased. What still raises the question is what if critical information that would help shape the strategy to business models and onto tactics. Long range planning of treatment is missing out from the researches that have been conducted (Young, M. 2010)? In the previous studies, it was clear that successive comorbidity, which is the presence of more than two disorders, may be useful in analyzing the risk factors associated with the comorbidity, service utilization, or disability.
Detoxification in Patient
There are several alcohol withdrawal episodes, which take place without any pharmacological or medical treatment (Isseroff, R. 2006). In such circumstances, there is a need to strike a balance between giving the patient just enough medication to minimize withdrawal symptoms and just giving medication unnecessarily. There should also be a consideration of the cases of withdrawal symptoms and the complications that may be experienced as a result (Isseroff, R. 2006). When there is a successive alcohol withdrawal, then this may be associated with increased severity of withdrawal complications as well as cognitive impairment. There is a need to consider the goals intended before engaging in detoxification as a management measure (Isseroff, R. 2006).
- Society Views on Treatment
Several myths have been developed surrounding the treatment of patients with comorbidity disorders. This varies from one society to another (Young, M. 2010).
4.35 Evidence of Critical Appraisal
In an interview survey, assessment of the mental health status was conducted on the use of Quick Personality Assessment Schedule (QPAS) (Kessler et al, 1996), CPRS – Pathological Rating Scale (Cole et al. 2012, Morris et al. 2007 and Eisenberg et al. 2011) and their scales for rating depression and anxiety (Andrews, 2010), for instance, and anxiety disorders (BS 1979- Brief Scale).
Research psychiatrists in the study assessed patients for psychosis in drug or substance use group on the application of the Operational Checklist for Psychiatric Disorders (OCPD) and this was based on a review of a case-note (Cole et al. 2012, Morris et al. 2007 and Eisenberg et al. 2011). A specificity analysis was done using information from the patient interview to ensure a rating of psychosis that is conservative.
Synthesis Of Main Findings
There has been growing interest across the globe to research dual diagnosis, especially in the United Kingdom and as well across Europe. The interest has increased day by day even though many studies on dual diagnosis have been carried out in the US. It is noted, however, that majority of these research studies are conducted by medical researchers and the social work has contributed very little to the research. When research findings are generalized into the issues of mental health, the outcome may end up into experiences such as stigmatization, isolation, and exclusion from social life, and maybe provision of poor services to particular groups of victims of dual diagnosis.
Essentially, the families of the affected and their friends or care persons may lack the voice in the existing literature of the research conducted and this has been noted in a previously done Scottish study. Practice guides and handbooks, among many other toolkits, have been developed by service-user and non-statutory organizations. Such companies include Rethink, Mind, and Turning Point. Research findings have provided better insight for mental health care services as they attempt to manage patients using better alternative options and methods suitable for the dual diagnosis. The study has identified well issues and problems encountered by the families and friends of the people affected by dual diagnosis and try to lessen the challenge of recovering the patients from their mental complications. Additionally, research has provided evidence that the use of drugs or substances, as well as intoxication and harmful use, and substance withdrawal and drug dependence may result in symptoms of mental illnesses.
Mental challenges or psychiatric disorders have also been discovered to contribute to substance use and substance addiction. Substance misuse in most cases has presented with anxiety, depression, attention deficit, hyperactivity, schizophrenia, eating, and even post-traumatic stress. According to Kessler et al., (1996), both clinical and community studies indicate the prevalence of dual disorders. The prevalence of the disorder has been shown also by studies such as, (Scott et al & Ruijter et al, (2010).
This study presents an alternative integrated model that can be used to manage mental illnesses and treat individuals with a dual diagnosis. The model is derived from illness management initiatives that are based on research permitting common language use or philosophy of management for all cases of co-occurring disorders. The philosophy behind this model emphasizes that drug use disorders and mental illnesses can both be managed or treated on the application of the Disease and Recovery Model. The model explains treatment phases that are parallel and implies that the recovery process of mental illnesses based on clinical experience can provide valuable information regarding the method of recovering an individual from other disorders (Gass, J. T. 2010).
The model discussed here can be a stepping stone for developing treatment strategies for patients having dual disorders. The aspects of the model can be applied as a template of care at various levels of a well-managed treatment-care system. In clinical management that is individualized appropriately, the model can be used in the development of practice guidelines. Designing an effective and complete integrated method of care also requires this template in which every component of an integrated system executes an important role in the delivery of accurately matched management or treatment. The model implies that dual disorders’ prevalence calls for competency in dual diagnosis throughout the treatment system. Variability of the disorders also invites the need for treatment competency. The care system of the Disease and Recovery Model proposes that the best approach to the inefficient treatment of dual disorders not only relies on the development of special programs but also establishes advanced approaches and systems in which all the special programs in it are anticipated to attain this treatment competency (Christo et al, 2012).
Limitations of Study and Evidence
The study design of this dual diagnosis study and the quality of data and procedures involved in the research were inconsistent. The dual diagnosis study was expensive to carry out and needed to be done within a short period of time to complement the available resources. To convince participants in participating in the process required expansive skills because some of them declined to respond for various reasons. Consequently, most studies have failed to provide concrete solutions to most dual disorder issues. This dual diagnosis study has researched the clinical approaches for management and developing programs. Numerous programs have developed globally to accomplish the management of dual diagnosis for patients severely affected by mental disorders; however, very few of the programs have managed to accomplish the implementation of their intended services for individuals with mental illnesses.
There have been no specific research studies conducted to strategize on how to finance, reorganize, contract, and attain relevant training relevant to the services of dual disorders. The process of developing policy has been impeded by deficiencies of data on the integrated cost of services related to dual diagnosis. Lack of specificity has also emerged as a limitation of the study of dual diagnosis management with various interventions differing across several studies and no consensus reached on better and specific ways to provide individual and group treatment, counseling, housing, interventions of families and friends, and medications among other components, First Household Survey on Drug Abuse, (Eisenberg et al. 2011).
Recommendation for Practice
An interventional program should have its first purpose as to involve users of its services in the abstinence process or reduction. If this goal is achieved, a remarkable reduction in mental illnesses and symptoms would be seen. Factors that are evident in research and other literature that can be part of the management process include the need for the following:-
- An approach that is flexible and empathetic, does not confront and is person-centered, and does not judge. This would be essential in keeping an effective program during the intervention.
- Establishing motivation and developing optimism in dealing with drug challenges and other related problems.
- Understanding the history of mental and drug disorders.
- Giving priority to solving the problem
The disease and Recovery Model can be applied in the treatment phases of a recovery process of mental illness based on clinical experience can provide valuable information regarding the process of recovering an individual from other disorders (Andrews, 2010). The design can as well establish a foundation for developing treatment strategies for patients having dual disorders. The aspects of the design can be used at various levels of a well-managed care system. In clinical management that is individualized appropriately, the design can be used in the development of practice guidelines, handbooks, and many other toolkits.
Designing an effective and complete integrated process of mental health care requires a design with a template in which every component of the integrated system executes an important role in the delivery of accurately matched management. The model implies that dual disorders’ prevalence calls for competency in dual diagnosis throughout the treatment system. Variability of the psychiatric disorders also invites the need for treatment competency.
The care system of the Disease and Recovery Model proposes that the best appropriate and efficient treatment of dual disorders relies on the development of special programs. It relies also on establishing advanced approaches and systems in which all the special programs in it are anticipated to attain this treatment competency (Andrews, 2010). A dual diagnosis study presents an alternative integrated model that can be used to manage mental illnesses and treat individuals with dual diagnoses. The design is derived from disease management initiatives that are based on research permitting common language use or philosophy of management for all cases of co-occurring disorders. The philosophy behind this model emphasizes that drug use disorders and mental illnesses can both be managed or treated on the use of the Disease and Recovery Model.
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|Sources||Type of study||Evidence included|
|Cole PM, Martin SE and Dennis TA. (2012)|
Morris AS, Silk JS, Steinberg L, et al. (2007)
Eisenberg N, Cumberland A, Spinrad TL, et al. (2011)
|Clinical survey||These 3 studies focused mainly on the methodological construct for mental development in people of different ages. Evidence on the methodological construct, therefore, helped in making evidence-based decisions on the assessment of the subject based on their mental developmental variables|
|Kim J, and Cicchetti D (2010)|
Leible TL and Snell WE Jr. (2004)
Wolff S, Stiglmayr C, Bretz HJ, et al. (2011)
|Quasi-experiment||The 3 studies were practical experiments performed in the premises of a health facility, looking into the correlation between emotional dysfunction and personality disorder. Evidence taken from this source included the effect of drug misuse on emotional dysfunction and personality disorder for diagnosis.|
|Gratz KL, Rosenthal MZ, Tull MT, et al. (2006)|
Wupperman P, Neumann CS, Whitman JB and Axelrod SR. (2013)
Schulze L, Domes G, Kru¨ ger A, et al. (2011)
|Literature search||These studies looked at the issues of mental illness and drug misuse from a neurological perspective. They were therefore very useful in the prognosis of the subject involved in the study.|
|Type of effect||Intensity of effect||Mobility of effect||Implication of intensity|
|Bland affect||Flat affect||restricted affect||The patient may be suffering from depression, schizophrenia, or post-traumatic stress disorder (quote).|
|Sources||Type of Study||Evidence included|
|Tull MT, Stipelman BA, Salters-Pedneault K, Gratz KL. (2009)|
Mennin DS, Heimberg RG, Turk CL, Fresco DM. (2009)
Novick-Kline P, Turk CL, Mennin DS, et al. (2011)
|Action research||These three sources were action research meant to identify specific cases of nonclinical panic attacks, panic disorder, anxiety sensitivity, and emotion regulation difficulties within a non-clinical setting. These problems, which are directly related to the current study sought to use non-medicinal approaches to tackle the various health problems that were identified.|
|Cloitre M, Miranda R, Stovall-McClough KC, Han H. (2010)|
Tull MT, Barrett HM, McMillan ES, Roemer L. A (2007)
Staiger P, Melville F, Hides L, et al. (2009)
|Case study||As a case study, the researchers focused on specific patients with specific cases of mental health problems. This source was therefore necessary for this study as the study also focuses largely on the problem of mental health. In this case, however, medications were combined with therapy.|
|Cloitre M, Koenen KC, Cohen LR, Han H. (2012)|
Baker TB, Piper ME, McCarthy DE, et al. (2004)
Cooper ML, Frone MR, Russell M, Mudar P. (2009)
|Quasi-experiment||These were various quasi-experiments, aimed at finding the effectiveness of specific medication in combined cases of mental health problems and substance misuse.|
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